Citation Nr: 21042463 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-34 282 DATE: July 13, 2021 ORDER Entitlement to service connection for hypertension, to include as due to herbicide exposure, to include as due herbicide exposure, including Agent Orange, is denied. Entitlement to service connection for a skin condition, to include as due to herbicide exposure, to include as due herbicide exposure, including Agent Orange, is denied. Entitlement to service connection for a right knee cyst, to include as due to herbicide exposure, to include as due herbicide exposure, including Agent Orange, is denied. Entitlement to service connection for an upper extremity nerve condition, to include as due to herbicide exposure, to include as due herbicide exposure, including Agent Orange, is denied. REMANDED Entitlement to service connection for kidney condition, to include as due to herbicide exposure, to include as due herbicide exposure, including Agent Orange, is remanded. Entitlement to service connection for erectile dysfunction, to include as due to herbicide exposure, to include as due herbicide exposure, including Agent Orange, is remanded. Entitlement to service connection for right groin cyst, to include as due to herbicide exposure, to include as due herbicide exposure, including Agent Orange, is remanded. Entitlement to service connection for hand tremors, to include as due to herbicide exposure, to include as due herbicide exposure, including Agent Orange, is remanded. FINDINGS OF FACT 1. The Veteran's current hypertension was not incurred during or his period of active service; any current hypertension is unrelated to service. 2. The Veteran does not have a chronic skin condition. 3. The Veteran does not have a current disability manifested as a chronic right knee cyst. 4. The Veteran does not have a current disability manifested as a chronic peripheral nerve condition of the upper extremities. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2021). 2. The criteria for service connection for a skin condition are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2021). 3. The criteria for service connection for right knee cyst are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2021). 4. The criteria for service connection for a peripheral nerve condition of the upper extremities are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from December 1968 to July 1970, to include service in the Republic of Vietnam. In December 2018, the Veteran testified before the undersigned at a central Board hearing. A transcript of that hearing is of record. The Veteran's claims were previously before the Board in April 2019 but were remanded for further development. Specifically, the Veteran's claims were returned to the Agency of Original Jurisdiction with directives to obtain additional VA treatment records. Additional VA treatment records were associated with his claims file. In addition, the Veteran was to be scheduled for VA examinations to determine the etiology of his claimed disabilities. The Veteran was sent a November 2019 VA correspondence requesting that he provide any additional evidence regarding his claims for service connection. He underwent VA examinations in November 2019, and medical opinions were obtained. He was examined in person and opinions were then provided that addressed the remand directives. Because the Veteran was not found to have a right knee cyst, a skin condition, and an upper extremity nerve condition, etiology opinions were not necessary. The November 2019 hypertension opinion is inadequate because it was based on incorrect facts. The December 2020 hypertension opinion is adequate because it was not based on incorrect facts and it addressed whether the Veteran's hypertension was due to herbicide exposure. There has been substantial compliance with the remand instructions for the claims being decided. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The third step of this inquiry requires the Board to weigh the probative value of the evidence in light of the entirety of the record. Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). SERVICE CONNECTION A veteran who had active service in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975, will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. See 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307 (a)(6)(iii). The Veteran served in the Republic of Vietnam during the above stated period. He is presumed to have been exposed to herbicide agents. The conditions and diseases set forth in 38 C.F.R. § 3.309(e) shall be service connected if the Veteran was exposed to an herbicide agent during active service, even though there is no record of such disease during service, and provided further that the requirements of 38 C.F.R. § 3.307(d) are satisfied. Notably, the Veteran's diagnoses of hypertension, a skin condition, an orthotic cyst on the right knee, and upper extremity nerve pain are not diseases covered by 38 C.F.R. § 3.309(e). He does not have peripheral neuropathy, early onset or otherwise. Accordingly, presumptive service connection for the Veteran's claimed disabilities are not warranted. When service connection for a particular disease may not be granted on a presumptive basis, the Veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In addition, where a veteran asserts entitlement to a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When a chronic disease manifests to a degree of 10 percent or more within 1 year from the date of separation from service, that disease is presumptively service-connected. 38 C.F.R. §§ 3.303(b), 3.307(a)(3). The Veteran's hypertension is a chronic disease as defined by 38 C.F.R. § 3.309(a). When a disease is first diagnosed after service, service connection is warranted for that condition if the competent evidence shows it was incurred in service. 38 C.F.R. § 3.303(d). 1. Entitlement to service connection for hypertension, to include as due to herbicide exposure, to include Agent Orange The Veteran's current diagnosis of hypertension was confirmed in a November 2019 hypertension examination. The November 2019 hypertension examination notes that the Veteran's hypertension was initially diagnosed in 2012. At the examination, the Veteran stated he was told he was hypertensive by a primary care physician in the 1990s. At a December 2018 Board hearing, the Veteran testified that he was originally diagnosed for hypertension and began taking medication approximately 10 years prior. An Agent Orange program note from September 2009 notes that the Veteran reported a diagnosis of hypertension and that he had been on drug therapy for the prior "6 or 7 years." Following and in-person examination of the Veteran and review of his pertinent medical history, the VA November 2019 hypertension examiner determined it was less likely than not that the Veteran's hypertension was caused by his period of active service. The examiner noted that the Veteran was not diagnosed with hypertension until 2012, and there was no evidence of chronicity of care since the Veteran's completion of active service. The Board finds this opinion to be inadequate as the conclusion that the Veteran was not diagnosed with hypertension until 2012 is directly refuted by the September 2009 Agent Orange program note indicating a diagnosis of hypertension. The November 2019 medical opinion is assigned no probative value. An addendum medical opinion obtained in November 2020 also determined it was less likely than not that the Veteran's hypertension was caused by his period of active service. The examiner reasoned that the Veteran's service treatment records (STRs) were silent for complaints of or treatment for hypertension. Regarding herbicides, the examiner stated that although recent studies showed an association with hypertension and veterans assigned to the Chemical corps who had high exposure to herbicides, there was "no association" with veterans who had other military occupational specialties. The examiner further noted that studies show that 90 percent of adults over the age of 55 "will develop hypertension eventually" whether they were exposed to Agent Orange or not. The Veteran's military occupational specialty does not show that he served in the Chemical corps, nor has he so asserted. The examiner's opinion is well-reasoned and persuasive, and is afforded high probative value. Additionally, the probative evidence of record does not establish that the Veteran's hypertension was diagnosed within a year of his completion of service. As noted above, the Veteran was not diagnosed until at least two decades after his completion of service. He asserts that he was diagnosed as early as 1990. Moreover, the probative medical evidence does not establish a continuity of symptomatology for his hypertension since his completion of active service in 1970 because per his own report he was diagnosed more than one year after service. Accordingly, the provisions of presumptive service connection do not apply. See 38 C.F.R. § 3.303(b), (c). The Board acknowledges the Veteran's contention that his current hypertension was caused by his period of active service, including exposure to herbicide agents. Lay persons are competent to provide opinions on some medical issues. Kahana, 24 Vet. App. at 435. However, determining the etiology of the Veteran's hypertension requires medical inquiry into the Veteran's anatomical and physiological functioning. With regard to the specific issue in this case, whether his hypertension was caused by his active service, falls outside the realm of knowledge of the Veteran in this case. See Jandreau, 492 F.3d at 1377 n.4. Such internal processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. As a result, the probative value of his lay assertions is low. The conclusion of the November 2020 medical opinion is of significantly more probative value. In May 2020, the Veteran submitted a page from the January/February 2020 issue of DAV Magazine with an editor's note stating that a 2016 report by the National Academy of Medicine determined there is scientific evidence linking hypertension to Agent Orange exposure. Treatise evidence can, in some circumstances, constitute competent medical evidence. 38 C.F.R. § 3.159(a)(1). It can provide important support when combined with an opinion of a medical professional if the article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based on objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998). In this case, there is no supporting medical evidence that the general principles cited in the magazine excerpt are related to the specific situation of the Veteran. Mattern v. West, 12 Vet. App. 222, 228 (1999). The magazine excerpt only references a report regarding Agent Orange and hypertension and does not apply medical principles to the specific facts of the Veteran's case. It is also not accompanied by the opinion of a medical professional. Accordingly, no probative value is assigned to the Veteran's treatise evidence. The Board concludes that the preponderance of the evidence is against the claim for service connection for the Veteran's hypertension. The benefit of the doubt rule therefore does not apply, and service connection for this disability is not warranted. 2. Entitlement to service connection for a skin condition The Veteran claims entitlement to service connection for a skin condition. At a December 2018 Board hearing, the Veteran testified to having a skin condition on both hands. The Veteran's VA treatment records note a history of dermatitis. A March 2017 VA treatment record notes a rash on the Veteran's bicep. However, a November 2017 VA treatment note specifically states that atopic dermatitis was resolved and did not require further treatment. A VA treatment record from September 2009 notes the Veteran had diagnosed eczema on the back of his hands and neck. However, this is years outside of the appeal period. In a November 2019 Skin Diseases examination, the Veteran was not diagnosed with a skin condition, to include dermatitis or eczema. Further, the Veteran denied having any skin conditions. Based on the probative evidence of record, the Board finds that a chronic skin condition has not been established. Although he had dermatitis during the appeal period from March 2017 to November 2017, the preponderance of the evidence is against a finding that this condition was chronic during the appeal period. It lasted for at most eight months out of an appeal period that began in October 2011 when he filed his claim. Accordingly, entitlement to service connection is not warranted. The Board concludes that the preponderance of the evidence is against the claim for service connection for the Veteran's claimed skin condition. The benefit of the doubt rule therefore does not apply, and service connection for this disability is not warranted. 3. Entitlement to service connection for a right knee cyst The Veteran claims entitlement to service connection for a right knee cyst. At a December 2018 Board hearing, the Veteran testified to having a cyst on the right knee that he incurred approximately 20 years previous. In a February 2012 statement, the Veteran reported a history of right knee cysts. In a November 2019 Skin Diseases examination, the Veteran was not diagnosed with right knee cyst. Further, the Veteran denied having any right knee cyst. The Veteran's VA treatment records did not note a right knee cyst. Based on the probative evidence of record, the Board finds that a current, chronic right knee cyst has not been established. As noted above, in the absence of proof of a current disability, there can be no valid claim. Boyer, 210 F.3d at 1353 (Fed. Cir. 2000); Brammer, 3 Vet. App. at 225 (1992). Accordingly, entitlement to service connection is not warranted. The Board concludes that the preponderance of the evidence is against the claim for service connection for the Veteran's claimed right knee cyst. The benefit of the doubt rule therefore does not apply, and service connection for this disability is not warranted. 4. Entitlement to service connection for upper extremity nerve condition The Veteran claims entitlement to service connection for upper extremity nerve pain. The Veteran's STRs are silent for complaints of upper extremity nerve pain during his period of active service. In addition, the Veteran's VA treatment records are silent for a diagnosis of a peripheral nerve condition of the upper extremities. In a November 2019 Peripheral Nerve Conditions examination, the Veteran was not diagnosed with a peripheral nerve condition. The Veteran's had no symptoms attributable to a peripheral nerve condition, no muscle atrophy, no strength loss, and normal deep tendon reflex of the upper extremities. The Veteran has not submitted any private medical evidence establishing a peripheral nerve condition of the upper extremities. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich, 104 F. 3d at 1332. In the absence of proof of a current disability, there can be no valid claim. Boyer, 210 F.3d at 1353; Brammer, 3 Vet. App. at 225. Based on the probative medical evidence of record, the Board finds that the Veteran does not have a current diagnosis of a peripheral nerve condition of the upper extremities. Accordingly, entitlement to service connection is not warranted. The Board concludes that the preponderance of the evidence is against the claim for service connection for the Veteran's claimed peripheral nerve conditions of the upper extremities. The benefit of the doubt rule therefore does not apply, and service connection for this disability is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a kidney condition The Veteran underwent a VA examination for kidney conditions in November 2019. The examiner noted that a kidney cyst was diagnosed in 2012, but stated that he was unable to confirm whether there was a kidney cyst based on available records. At the examination, the Veteran told the examiner he was going to have an ultrasound shortly after the examination. He underwent an ultrasound in December 2019. In September 2020, an addendum opinion was provided after an examiner reviewed the ultrasound report. The examiner stated that the ultrasound did not reveal any renal cysts, but that the left kidney had a kidney stone. The scope of the Veteran's claim covers his kidney stone, and the Board has recategorized the issue as entitlement to service connection for a kidney condition rather than for a kidney cyst. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). An addendum opinion is needed regarding the Veteran's kidney stone. 2. Entitlement to service connection for erectile dysfunction The Veteran's current diagnosis of erectile dysfunction was confirmed in a November 2019 male reproductive organ conditions examination. The examiner stated that the Veteran's erectile dysfunction was initially diagnosed in 2012. The Veteran reported that he was told of his erectile dysfunction by a primary care physician in the 2000s. At his December 2018 Board hearing, the Veteran testified that he was originally diagnosed for erectile dysfunction approximately 25 years prior. In a February 2012 statement, the Veteran reported that he had seen numerous private physicians for erectile dysfunction over the "in past 30 to 40 years." A VA treatment record notes a diagnosis of erectile dysfunction in December 2009. Following and in-person examination of the Veteran and review of his pertinent medical history, the VA examiner determined it was less likely than not that the Veteran's erectile dysfunction was caused by his period of active service. The examiner noted that the Veteran's claims file did not establish a history of erectile dysfunction. The examiner opinioned that the Veteran's erectile dysfunction was a result of his age or possibly a side-effect of medication used to treat hypertension. An addendum opinion obtained in November 2020 noted stated that the Veteran's STRs were negative for complaints of or treatment for erectile dysfunction. The opinion further stated there was no credible medical evidence to support a causal link between herbicide exposure and erectile dysfunction. However, neither the November 2019 medical opinion, or the November 2020 medical opinion, address the Veteran's statements that his erectile dysfunction began anywhere from 25 to 40 years prior to the November 2019 VA examination, or that a December 2009 VA treatment record noted a diagnosis of erectile dysfunction. A medical opinion is inadequate if the examiner's rationale fails to account for pertinent evidence, to include competent lay statements describing symptoms of the disability at issue. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331,1335 (Fed. Cir. 2006) (noting that "lay evidence is one type of evidence that must be considered, if submitted, when a veteran's claim seeks disability benefits"). Accordingly, the Board finds that the November 2019 and November 2020 medical opinions are inadequate for purposes of determining service connection. An additional VA addendum opinion is necessary to comprehensively evaluate the Veteran's claim for service connection for erectile dysfunction. 3. Entitlement to service connection for cyst on right groin The Veteran's cyst on the right groin was verified at a November VA skin conditions examination. The November 2019 examination report noted that the Veteran's right groin cyst began in 2010. In a December 2018 Board hearing, the Veteran testified that the cyst began 15 years ago. A November 2019 medical opinion concluded it was less likely than not that the Veteran's cyst on the right groin was not incurred during or caused by his period of active service. The opinion reasoned, "[h]e was diagnosed with benign neoplasm of right scrotum sac in which there is not visible skin abnormalities to the area." An addendum medical opinion obtained in November 2020 stated, "[a]ll available medical records were reviewed. There is no credible medical evidence to support a causal link between herbicide exposure and benign skin lesions. A nexus is not established." The Board finds that the November 2019 and November 2020 medical opinions are not adequate for determining service connection. The opinions do not consider or discuss the Veteran's testimony regarding the history of his cyst of the right groin. As noted above, a medical opinion is inadequate if the examiner's rationale fails to account for pertinent evidence, to include competent lay statements describing symptoms of the disability at issue. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331,1335 (Fed. Cir. 2006) (noting that "lay evidence is one type of evidence that must be considered, if submitted, when a veteran's claim seeks disability benefits"). Additionally, the medical opinions contain no rationale as to why the Veteran's right groin cyst was not directly related to his period of active service. Conclusory, contradictory, or incomplete analysis will render a medical opinion inadequate. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). Accordingly, the Board finds that an additional addendum medical opinion is necessary to comprehensively evaluate the Veteran's claim for service connection. 4. Entitlement to service connection for hand tremors The Veteran's hand tremors were verified in a November 2019 peripheral nerve conditions examination. In a December 2018 Board hearing, the Veteran testified that the hand tremors began during his active service but became stronger 20 years ago, after his completion of active service. A November 2019 medical opinion concluded it was less likely than not that the Veteran's tremors were not incurred during or caused by his period of active service. The opinion reasoned, "[s]ymptoms are subjective only. Objective exam is normal. There is no objective evidence of a chronic condition. A nexus has not been established." The Board finds that the opinion is inadequate because it is contradicted by the November 2019 peripheral nerve examination noting that the Veteran has a diagnosis of hand tremors. An addendum medical opinion obtained in November 2020 stated, "[t]he [V]eteran has [diagnosis] of essential tremor, since 2015. There is no evidence of any issue with his median nerve as peripheral nerve DBQ dated [November 4, 2019] and the VA neuro evaluation dated [July 31, 2016] show normal. While the pathophysiology is not fully understood it is largely genetic. There is no evidence of a causal link to herbicide exposure. A nexus is not established." The Board finds that the November 2020 medical opinion is not adequate for determining service connection. The opinion does not consider or discuss the Veteran's testimony regarding the history of his tremors beginning during active service or worsening that occurred approximately 20 years ago. As noted above, a medical opinion is inadequate if the examiner's rationale fails to account for pertinent evidence, to include competent lay statements describing symptoms of the disability at issue. See Barr, 21 Vet. App. at 311; see also Buchanan, 451 F.3d at 1335. Accordingly, the Board finds that an additional addendum medical opinion is necessary to comprehensively evaluate the Veteran's claim for service connection. The matters are REMANDED for the following action: 1. Provide the Veteran's claims file to a qualified clinician to provide an addendum opinion regarding his kidney stone. The entire claims file and a copy of this remand must be made available to the clinician. A new examination is only required if deemed necessary by the clinician. The clinician must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's kidney stone began during active service, or is related to an incident of service, to include exposure to Agent Orange. It is insufficient for the clinician to provide a negative opinion merely because kidney stones are not on the presumption list for exposure to herbicide agents. The clinician must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the clinician must state this and provide a rationale for such conclusion. 2. Provide the Veteran's claims file to a qualified clinician to provide an opinion for the Veteran's erectile dysfunction. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's erectile dysfunction began during active service, or is related to an incident of service, to include exposure to Agent Orange. It is insufficient for the clinician to provide a negative opinion merely because erectile dysfunction is not on the presumption list for exposure to herbicide agents. The clinician's opinion should consider the Veteran's December 2018 testimony that his erectile dysfunction began 25 years ago and his February 2012 statement that his erectile dysfunction has existed for 30 to 40 years. The clinician must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the clinician must state this and provide a rationale for such conclusion. 3. Provide the Veteran's claims file to a qualified clinician to provide an addendum opinion for the Veteran's cyst on the right groin. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's cyst on the right groin began during active service, or is related to an incident of service, to include exposure to Agent Orange. It is insufficient for the clinician to provide a negative opinion merely because right groin cysts are not on the presumption list for exposure to herbicide agents. The clinician's opinion should consider the Veteran's December 2018 testimony that cyst on the right groin began 15 years ago and has persisted since. The clinician must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the clinician must state this and provide a rationale for such conclusion. 4. Provide the Veteran's claims file to a qualified clinician to provide an addendum opinion for the Veteran's hand tremors. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hand tremors began during active service, or are related to an incident of service, to include exposure to Agent Orange. It is insufficient for the clinician to provide a negative opinion merely because the Veteran's hand tremors are not on the presumption list for exposure to herbicide agents. The clinician's opinion should consider the Veteran's December 2018 testimony that his hand tremors began during his active service and worsened about 20 years ago. The hand tremors have persisted since the Veteran completed his active service. The clinician must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the clinician must state this and provide a rationale for such conclusion. 5. After all completed development, the AOJ should then readjudicate the claim. If the benefits sought on appeal are not granted, the Veteran and his representative should be provided a Supplemental Statement of the Case and afforded the requisite opportunity to respond before the case is returned to the Board. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Riordan, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.