Citation Nr: 22013131 Decision Date: 03/08/22 Archive Date: 03/08/22 DOCKET NO. 18-09 790 DATE: March 8, 2022 REMANDED Entitlement to service connection for acute myelogenous leukemia is remanded. Entitlement to service connection for a vaginal disorder is remanded. Entitlement to service connection for a left breast disorder, to include fibrocystic breast disease, is remanded. Entitlement to service connection for hypertension (claimed as high blood pressure) is remanded. Entitlement to service connection for lung condition is remanded. Entitlement to service connection for a dental disorder, to include periodontal disease (pyorrhea), and to include a claim of entitlement to VA outpatient dental treatment, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1983 to November 1984, and from January 2006 to February 2012, according to the DD Form 214's of record. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2017 rating decision. In October 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. On the service-connection claim form filed in May 2016, the Veteran listed three periods of service: from August 1979 to November 1984, from November 1984 to January 2006, and from January 2006 to February 2012. She stated on her notice of disagreement (NOD) of August 2017 that she had active duty service in the Air Force from August 1979 to November 1984, and that she had active duty and inactive duty every year from 1985 to 2005, when she returned to active service. A service personnel record indicates that the Veteran initially entered military service in February 1979 and that her "AFR high year of tenure date" is March 1, 2012. The retirement date is listed as "15 Nov" [sic]. The total active military service is "120024." The "type duty codes" are listed only for various service periods between November 2000 and November 2009. It appears that the Veteran had service in the Air Force Reserve at various times between 1984 or 1985 and 2006, which may include active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). For periods of ACDUTRA, service connection may be warranted if the claimed disability arose from a disease or injury incurred or aggravated in the line of duty. 38 U.S.C. § 101 (24)(b). For periods of INACDUTRA, service connection may be warranted if the claimed disability arose from an injury incurred or aggravated in line of duty; or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. 38 U.S.C. § 101(24)(c). The current record does not indicate the exact dates of the Veteran's periods of ACDUTRA and INACDUTRA for all relevant service periods. Therefore, the Board will remand in order for the service dates to be verified. The agency of original jurisdiction (AOJ) must attempt to verify the Veteran's specific dates of ACDUTRA and INACDUTRA to order to ascertain whether the claimed disabilities can be attributed to a disease or injury of a period of ACDUTRA or INACDUTRA. Furthermore, with respect to the pending service-connection claims listed below, the Board will remand for further evidentiary development. 38 C.F.R. § 19.9(a). VA has a duty to assist in retrieving relevant records from a Federal department or agency unless further attempts would be futile. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). It is not apparent upon the current record that VA has attempted to obtain the complete service records of the Veteran's service, to include all verified periods of ACDUTRA and INACDUTRA in the Air Force Reserve. In general, service connection will be granted upon adequate evidence of a present disability, in-service incurrence or aggravation of a disease or injury, and a nexus between the present disability and the in-service disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted on a secondary basis for disability which is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to, or the result of, a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service-connected. 38 C.F.R. § 3.310(b). The Veteran's DD Form 214 indicates that she served in Iraq and Qatar from June to December of 2009. Service connection may be granted to a Persian Gulf War veteran if there is a qualifying chronic disability which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and the symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A qualifying chronic disability means a chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, or any diagnosed illness that VA determines in regulations warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2). Under 38 C.F.R. § 3.320, relating to claims based on exposure to particulate matter, a veteran who has a qualifying period of service shall be presumed to have been exposed to fine, particulate matter during such service, unless there is affirmative evidence to establish that he or she was not exposed to fine, particulate matter during that service. With respect to claims based on exposure to particulate matter, the chronic diseases of asthma, rhinitis, and sinusitis, to include rhinosinusitis, shall be service-connected even though there is no evidence of such disease during the period of service if it becomes manifest to any degree (including non- compensable) within 10 years from the date of separation from military service that includes a qualifying period of service. 38 C.F.R. § 3.320(a)(1). The presumption is rebuttable. 38 C.F.R. § 3.320(b). The Board is precluded from making its own medical conclusions. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). In this case, a Gulf War examination is needed to adjudicate the Veteran's claims. The scope of the claims includes any disability that may reasonably be encompassed by the Veteran's description of the claims, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). To date, the Veteran has not been afforded a VA Gulf War protocol examination to determine whether any of her symptoms are related either to known diagnoses or to an undiagnosed or unexplained chronic multi-symptom illness. The Board will remand in order for the Veteran to be scheduled for a Gulf War medical examination to address the possibility of an undiagnosed illness or medically unexplained, chronic, multi-symptom illness related to the Veteran's claimed disorders of leukemia, vaginal disorder, fibrocystic breast disease, hypertension, lung disorder, and a dental disorder, based on her status as a Persian Gulf War veteran. 1. Entitlement to service connection for acute myelogenous leukemia. In May 2016, the Veteran filed a service-connection claim for leukemia. A rating decision of January 2017 denied service connection for acute myelogenous leukemia. The Veteran filed a NOD in August 2017 and VA Form 9 in February 2018. In testifying before the Board, the Veteran stated that she was diagnosed with leukemia in 2014 and began treatment within two weeks. She attributed her leukemia to exposure to environmental hazards while serving in Iraq. She cited the fact that a fellow service member, who did the same job at the same time as she had in Iraq, died in 2018 of leukemia diagnosed that year. The Veteran also made the general statement that leukemia and chemotherapy changed how her body functions. In November 2016, the Veteran underwent a VA examination for hematologic and lymphatic conditions, including leukemia. A 2014 diagnosis of acute myelogenous leukemia (AML) was noted. The 2014 diagnosis was made over 2 years after the Veteran left active service. The examiner's review of the service treatment records revealed no diagnosis or treatment for leukemia during active military service. The VA examiner characterized the status of the lymphatic condition as in remission, with the most recent treatment having occurred in May 2015. The Veteran reported that there had been multiple complications during treatment. She was hospitalized from May to July in 2012 and was found to have a liver abscess, for which she was treated with outpatient antibiotics. Bone marrow aspiration and biopsy occurred in July 2016, and there was no evidence of AML. The Veteran was being seen by her doctor every two months. No nexus opinion was requested or offered by the November 2016 VA examiner. A rating decision of January 2017 denied service connection for a liver abscess. The Veteran did not appeal. As indicated above, the Board will remand for verification and records of all ACDUTRA and INACDUTRA service. A remand is also needed for a VA examination as to determine the likelihood that the Veteran's leukemia is related to environmental exposures during her Gulf War service. 2. Entitlement to service connection for a vaginal disorder. A May 2016 claim of entitlement to service connection claim for a vaginal condition was denied by a rating decision of January 2017. The Veteran appealed by filing a NOD in August 2017 and VA Form 9 in February 2018. The Veteran testified before the Board that a vaginal disorder was found and treated while on active duty. She did not identify any current problem. In November 2016, the Veteran underwent a VA examination for gynecological conditions. A 1986 diagnosis of cervical dysplasia was noted. The Veteran reported to the examiner that she had had an abnormal Pap smear in the 1990s during service, which was followed by cryotherapy. The subsequent Pap tests were noted to have been normal, including the most recent one in 2016. Medical records showed a Class 2 Pap mild dysplasia in March 1986, a negative cervical biopsy in February 1987, with cryotherapy performed for four months as follow-up. No nexus opinion was requested or provided by the examiner. The VA examination report found the Veteran to have no current symptoms related to a gynecological condition, including any disease, injury, or adhesion of the female reproductive organs, including the vagina. However, the assessment of a VA treatment record of September 2015 is atrophic vaginitis. An April 2016 VA treatment record also lists atrophic vaginitis as an active problem. A VA examination and medical opinion must be adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The November 2016 VA examination report for gynecological conditions is not adequate, because no consideration was given to the September 2015 assessment of atrophic vaginitis. The requirement of a "current disability" is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal. Service connection may be awarded even though the disability resolves prior to adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran alleged broadly at the Board hearing that her leukemia, and the treatment of it, changed her body and how it functions. To the extent that she has raised a theory of secondary service connection, the claim relating to a vaginal disorder is inextricably intertwined with the remanded leukemia claim and must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Furthermore, as explained above, the Board determines that a Gulf War examination is needed to adequately adjudicate the Veteran's service-connection claims. The Board will also remand for verification and records of all ACDUTRA and INACDUTRA service. 3. Entitlement to service connection for fibrocystic breast disease. In May 2016, the Veteran filed a service-connection claim for "breast condition, left." A rating decision of January 2017 denied service connection for fibrocystic breast disease (claimed as left breast mass condition). The Veteran filed a NOD in August 2017 and VA Form 9 in February 2018. The Veteran testified before the Board that she was initially diagnosed with, and treated for, fibrocystic breast disease in 1987 when she was a Reservist on active duty. Surgery was performed to remove a mass, and scar tissue that built up from the surgery. She also stated that two more masses were subsequently discovered and are being watched. The Veteran has a mammogram every six months. She believes the flack vest with metal plates that she wore for six months during service in Iraq may have caused her breast disorder. Her military occupational specialty included "security force journeyman," as listed on the DD Form 214. In November 2016, the Veteran underwent a VA examination for breast conditions and disorders. A 1987 diagnosis of benign left breast cyst, S/P lumpectomy, was noted. The examiner's review of service treatment records showed a biopsy of the left breast in December 1987 was negative. There was also a benign left breast cyst in 1989. Mammograms in August 2001 and January 2004 were normal. The VA examiner found that the neoplasm of the breast was benign, not malignant, and that there were no past or current metastases. The status is "watchful waiting," with the Veteran was not undergoing current treatment. As a result of the biopsy of the left breast, there is a scar that measures 3 cm. in length and 0.5 cm. in width, located in the upper outer quadrant of the left breast UOQ. In an addendum of December 2016, the examiner noted that there was no diagnosis of female sexual arousal disorder (FSAD). In December 2016, the Veteran again underwent a VA examination for breast conditions and disorders. A 1987 diagnosis of fibrocystic breast disease was noted by the examiner. The Veteran reports no change from the November 2016 examination, although she reported having occasional pain in the left lateral breast area. A negative nexus opinion was obtained in January 2017. In the examiner's opinion, it is less likely than not that the Veteran's fibrocystic breast disease was incurred during active service. The rationale was that she was diagnosed in 1987, three years after separation from the first active-duty service period and 19 years before the second period of active duty service. The Board will remand for a VA medical opinion as to the likelihood that the Veteran's fibrocystic breast disease was caused by the flack vest worn during service. The Veteran has also alleged broadly that her leukemia, and the treatment of it, changed her body and how it functions. To the extent that she has raised a theory of secondary service connection, the claim relating to a left breast disorder is inextricably intertwined with the remanded leukemia claim and must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Furthermore, as explained above, the Board determines that a Gulf War examination is needed to adequately adjudicate the Veteran's service-connection claims. The Board will also remand for verification and records of all ACDUTRA and INACDUTRA service 4. Entitlement to service connection for hypertension. In May 2016, the Veteran filed a service-connection claim for high blood pressure and for hypertension. A rating decision of January 2017 denied service connection for hypertension (claimed as high blood pressure). The Veteran filed a NOD in August 2017 and VA Form 9 in February 2018. For certain chronic diseases shown as such in service (or within the presumptive period under 38 C.F.R. § 3.307) so as to permit a finding that the disorder was incurred during service or within the presumptive period, subsequent manifestations of the same chronic disease at a later date, however remote, are service-connected. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.303(b), 3.307, 3.309. For the listed chronic diseases, service connection may be established by a continuity of symptomatology since service. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Hypertension is one of the listed chronic disease. The potential applicability of the presumption does not limit a claimant in establishing service connection by adequate evidence of actual causation. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). A VA treatment record of April 2016 lists benign essential hypertension as one of the Veteran's active problems. Hypertension is defined as persistently high arterial blood pressure. See Dorland's Illustrated Medical Dictionary 635 (26th ed. 1981). For VA purposes, hypertension means that the diastolic pressure is predominantly 90 or greater, and isolated systolic hypertension means that the systolic pressure is predominantly 160 or greater with a diastolic pressure of less than 90. 38 C.F.R. § 4.104, Diagnostic Code 7101. The Board construes the Veteran's claim (as did the agency of original jurisdiction (AOJ)) as relating to one claimed disability of hypertension, as opposed to both hypertension and high blood pressure as distinct disabilities. The Veteran's testimony before the Board, and the fact that her NOD of August 2017 references "hypertension (high blood pressure)," suggests that she also contemplates one claim at issue, not two. In testifying before the Board, the Veteran alleged that she was diagnosed during service with hypertension, which has continued from that time. She believes that in-service stress and the environmental exposure of burn pits in Iraq aggravated the hypertension that had already had an in-service onset. The Veteran stated on the NOD of August 2017 that she was not given a physical examination upon her military retirement in 2012. As a layperson, she is competent to report her experienced symptoms and a contemporaneous medical diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). Upon examination in September 1984, the Veteran's blood pressure was 118/72. In September 1988, the reading was 102/78. In September 1988 and August 1992, the Veteran answered "yes" as to the form question concerning any past or current high or low blood pressure. A dental record of December 1991 notes the following dentist's comment: "BP Pt. taken off BCP. BP now being monitored." In a dental record of September 1997, the dentist's comment was "HBP no meds.; fainting from blood sugar controls by diet." The Veteran's blood pressure was measured as 162/79. For a medical questionnaire of November 2002, she answered negatively when asked whether she had been told during the last year that she had high blood pressure. A service treatment record of June 2010 notes "elevated blood pressure" of 150/79. In November 2016, the Veteran underwent a VA examination for hypertension. It was noted as medical history that, while the Veteran reports having several elevated blood pressure readings during service, a review of the service treatment records (STRs) indicates that she was not diagnosed with hypertension during service. The examiner determined that the Veteran was not diagnosed with hypertension until "well after leaving service." However, the report listed the date of diagnosis as "unknown." No nexus opinion was requested or provided by the VA examiner. The Board will remand for a VA nexus opinion. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The remarks of the November 2016 VA examiner are inadequate as a nexus opinion in that the examiner contradictorily indicated that the diagnosis date of the Veteran's hypertension is both "unknown" and was made "well after leaving service." By alleging that her leukemia and treatment changed her body and bodily functions, the Veteran arguably raises a theory of secondary service connection as to all her service connection claims other than that of leukemia. Accordingly, the hypertension claim is inextricably intertwined with the remanded leukemia claim and must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Furthermore, as explained above, the Board determines that a Gulf War examination is needed to adequately adjudicate the Veteran's service- connection claims. The Board will also remand for verification and records of all ACDUTRA and INACDUTRA service 5. Entitlement to service connection for a lung disorder. In May 2016, the Veteran filed a service-connection claim for "lung condition," which was denied by a rating decision of January 2017. The Veteran filed a NOD in August 2017 and VA Form 9 in February 2018. The Veteran testified before the Board that she has a current lung disorder caused by environmental exposures and poor air quality during her Iraq service, including burn pits, dust storms, and open sewage pits. She alleged that her breathing problems began during service and have recurred to the present. For a VA psychiatric evaluation of April 2015, however, she stated that, upon returning from Iraq, she had some breathing problems that resolved without requiring treatment. The Veteran also told the clinician at that time that she had had one surgery since the beginning of chemotherapy to address pleurisy by the placement of a small shunt, which she noted to have been a complete success. As a layperson, the Veteran is competent to report her experienced symptoms and a contemporaneous medical diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). In November 2016, the Veteran underwent a VA examination for respiratory conditions other than tuberculosis and sleep apnea. A 2015 diagnosis of pleural effusions, S/P VATS with pleurodesis, was noted. The Veteran reported that she developed pleural effusions after chemotherapy starting in 2015, and that fluid was drained from the left lung three times, ending with VATS pleurodesis to the left lung in February 2015. There had been no effusions since pleurodesis, and there were no current complaints. According to the examiner, the operation report was not available but was noted in a hematology note of February 2016. After reviewing the STRs, the examiner found no diagnosis or treatment for lung conditions during active military service. A dental record of July 2010 notes that the Veteran was taking Sudafed for seasonal allergies. The Board takes notes that, generally, pleurodesis is a medical procedure that uses chemicals or drugs to cause inflammation and adhesion between the layers of the pleura (a thin layer of tissue that covers the lungs and lines the interior wall of the chest cavity), thereby preventing the buildup of fluid in the pleural cavity. See www.cancer.gov/publications/dictionaries/cancer-terms/def/pleurodesis (National Cancer Institute website). A VA examination and medical opinion must be adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The November 2016 VA examination report is not adequate, because no consideration was given to the fact that the Veteran took Sudafed for seasonal allergies during service. No nexus opinion was requested or provided by the VA examiner. The Board will remand for a VA nexus opinion. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Furthermore, the Veteran arguably raises a theory of secondary service connection as to her lung claim by alleging broadly that her leukemia and treatment changed her body and bodily functions. Accordingly, the claim relating to a lung disorder is inextricably intertwined with the remanded leukemia claim and must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180 (1991). As explained above, the Board has also determined that a Gulf War examination is needed to adequately adjudicate the Veteran's service- connection claims. The Board will also remand for verification and records of all ACDUTRA and INACDUTRA service. 6. Entitlement to service connection for a dental disorder, to include periodontal disease (pyorrhea), and to include a claim of entitlement to VA outpatient dental treatment. In May 2016, the Veteran filed a service-connection claim for periodontal disease (pyorrhea), which was denied by a rating decision of January 2017. The Veteran appealed by filing a NOD in August 2017 and VA Form 9 in February 2018. The Veteran testified before the Board that she had no issues with her teeth prior to active duty, that periodontal disease was found during active duty prior to her service in Iraq, and that a cleaning program for periodontal disease, which involving scaling, was started during service. She alleged that poor water quality at Keesler Air Force base, where she was stationed, may have affected her teeth. She further maintained that the poor quality of the water in Kirkuk, Iraq aggravated the periodontal disease that had already begun during her active service. In the NOD filed in August 2017, she alleged that periodontal disease was identified, treated, and documented in her STRs from 2005 to 2012. As a layperson, the Veteran is competent to report her experienced symptoms and a contemporaneous medical diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). In November 2016, the Veteran underwent a VA examination for dental and oral conditions. No response was given in the Medical/Dental History section of the report. Periodontal disease was diagnosed, and the "evidence comment" was that the Veteran has a history of periodontal disease. No other diagnosis or finding was made. Under current VA regulations, compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150, such as impairment or loss of the mandible, loss of a portion of the ramus, loss of the coronoid process, loss of the hard palate and impairment or loss of a portion of the maxilla. Compensation is available for loss of teeth that is due to loss of substance of body of maxilla or mandible due to trauma or disease such as osteomyelitis, but not periodontal disease. Otherwise, a veteran may be entitled to service connection for dental conditions including treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease, for the sole purposes of receiving VA outpatient dental services and treatment, if certain criteria are met. 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 17.161. A claim for service connection for a dental disorder is also considered to be a claim for VA outpatient dental treatment. See Mays v. Brown, 5 Vet. App. 302 (1993). Thus, adjudication of the Veteran's claim for service connection must also include consideration of service connection for the purpose of establishing eligibility for outpatient dental treatment as provided in 38 C.F.R. § 17.161. The issue on appeal has been recharacterized to include entitlement for treatment purposes. Under 38 C.F.R. § 17.161, outpatient dental treatment may be authorized by the Chief, Dental Service, in accordance with applicable provisions. A claimant must fit into a "class" as defined in 38 C.F.R. § 17.161 in order to be eligible for outpatient dental treatment. Class IV is defined as those whose service-connected disabilities are rated at 100 percent by schedular evaluation or who are entitled to the 100-percent rate by reason of individual unemployability. 38 C.F.R. § 17.161(h). Whether the Veteran falls into Class IV depends on the resolution of the remanded service-connection claims. In this regard, the dental claim is inextricably intertwined with the remanded service-connection claims and must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180 (1991). No nexus opinion was requested or provided by the VA examiner. The Board is not competent to formulate an independent medical opinion, whether favorable or unfavorable. See Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991). The Board will remand for a VA medical opinion as to the likelihood that the Veteran at least as likely as not falls within a defined class, as defined under 38 C.F.R. § 17.161, upon which eligibility for outpatient dental treatment may be based. As explained above, the Board has also determined that a Gulf War examination is needed to adequately adjudicate the Veteran's service- connection claims. The Board will also remand for verification and records of all ACDUTRA and INACDUTRA service. The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Undertake appropriate development to associate with the record any outstanding VA treatment records and any outstanding and identified private medical records that are pertinent to the remanded issues. All efforts to obtain outstanding records should be documented in the claims file. 3. Undertake appropriate development to verify all periods of the Veteran's service, to include all periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). All available reports/records, including service treatment records, corresponding to the Veteran's service, to include ACDUTRA and INACDUTRA periods, must be associated with the claims folder. Efforts to locate the reports/records must continue until it is reasonably certain that they do not exist or that further efforts to obtain them would be futile. A summary that identifies the Veteran's periods of service must be provided in a VA memorandum to be associated with the claims folder. If the requested verification is not possible, it should be so stated in a memorandum, along with a description of the extent to which verification was attempted. 4. Schedule the Veteran for a Gulf War examination by an appropriate clinician to determine the nature and etiology of the Veteran's claimed leukemia, fibrocystic breast disease, hypertension, lung condition, periodontal disease, and vaginal condition. Any current VA Gulf War examination guidelines must be followed. All indicated tests must be performed, and all findings reported in detail, as appropriate. The VA examiner must opine as to whether signs and symptoms relating to the following claimed disorders at least as likely as not are attributable to a known clinical diagnosis or a manifestation of an undiagnosed illness: a. Leukemia; b. Vaginal condition; c. Fibrocystic breast disease; d. Hypertension; e. Lung condition; and f. Periodontal disease. The examiner must also opine as to whether any of the claimed conditions (leukemia, vaginal condition, fibrocystic breast disease, hypertension, lung condition, and periodontal disease) at least as likely as not: a. Is caused, aggravated, or otherwise related to an in- service injury, disease, or event, to include periods of ACDUTRA and INACDUTRA, and to include Gulf War environmental exposure; b. Had its inception during service; c. Manifested during active service or within one year after discharge from service; d. Was noted during service or within one year after discharge from service such that the condition was not shown to be chronic at that time or a diagnosis of chronicity could be legitimately questioned, and there was a continuity of the same symptomatology since service; or e. Is proximately due to, or aggravated beyond its natural progression by, a service-connected disability or any other disorder for which service connection is sought, to include medication or treatment for a service-connected disability or other disorder. Notify the examiner that, regardless of whether an evidentiary presumption has been established for a diagnosed disorder, consideration must still be given to the likelihood of actual causation by an in- service disease, injury, or event. Notify the examiner that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is at least so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. Notify the examiner that the Veteran, as a layperson, is competent attest to matters based on personal knowledge, not medical expertise, as they come to a person through his or her senses, including observable or experienced symptoms. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A rationale is required for all opinions in the report. 5. Obtain an opinion from an appropriate clinician to determine the nature and etiology of any vaginal disorder at any time since the Veteran's claim was filed in May 2016, even if now resolved. A further VA examination may be scheduled if needed to provide an adequate medical opinion. The clinician must offer an opinion as to whether any such disorder at least as likely as not: a. Is caused, aggravated, or otherwise related to an in-service injury, disease, or event, to include periods of ACDUTRA and INACDUTRA, and to include Gulf War environmental exposure; b. Had its inception during service; or c. Is proximately due to, or aggravated beyond its natural progression by, leukemia or treatment for leukemia, or by any other disorder for which service connection is sought, to include treatment for such other disorder. Notify the clinician that, regardless of whether an evidentiary presumption has been established for a diagnosed disorder, consideration must still be given to the likelihood of actual causation by an in- service disease, injury, or event. Notify the clinician that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is at least so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. Notify the clinician that the Veteran, as a layperson, is competent to attest to matters based on personal knowledge, not medical expertise, as they come to a person through his or her senses, including observable or experienced symptoms. If the clinician cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the clinician shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A rationale is required for all opinions in the report. 6. Obtain an opinion from an appropriate clinician to determine the nature and etiology of any left breast disorder, to include fibrocystic breast disease, at any time since the Veteran's claim was filed in May 2016, even if now resolved. A further VA examination may be scheduled if needed to provide an adequate medical opinion. The clinician must offer an opinion as to whether any such disorder at least as likely as not: a. Is caused, aggravated, or otherwise related to an in-service injury, disease, or event, to include periods of ACDUTRA and INACDUTRA, Gulf War environmental exposure, and the Veteran's use of a flack vest during service; b. Had its inception during service; c. Manifested during active service or within one year after discharge from service; d. Was noted during service such that the condition was not shown to be chronic at that time or a diagnosis of chronicity could be legitimately questioned, and there was a continuity of the same symptomatology since service; or e. Is proximately due to, or aggravated beyond its natural progression by, leukemia or treatment for leukemia, or by any other disorder for which service connection is sought, to include treatment for such other disorder. Notify the clinician that, regardless of whether an evidentiary presumption has been established for a diagnosed disorder, consideration must still be given to the likelihood of actual causation by an in-service disease, injury, or event. Notify the clinician that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is at least so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. Notify the clinician that the Veteran, as a layperson, is competent to attest to matters based on personal knowledge, not medical expertise, as they come to a person through his or her senses, including observable or experienced symptoms. If the clinician cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the clinician shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A rationale is required for all opinions in the report. 7. Obtain an opinion from an appropriate clinician to determine the nature and etiology of hypertension at any time since the Veteran's claim was filed in May 2016, even if now resolved. A further VA examination may be scheduled if needed to provide an adequate medical opinion. The clinician must offer an opinion as to whether any such disorder at least as likely as not: a. Is caused, aggravated, or otherwise related to an in-service injury, disease, or event, to include periods of ACDUTRA and INACDUTRA, high blood pressure readings during service, and Gulf War environmental exposure; b. Had its inception during service; c. Manifested during active service or within one year after discharge from service; d. Was noted during service such that the condition was not shown to be chronic at that time or a diagnosis of chronicity could be legitimately questioned, and there was a continuity of the same symptomatology since service; or e. Is proximately due to, or aggravated beyond its natural progression by, leukemia or treatment for leukemia, or by any other disorder for which service connection is sought, to include treatment for such other disorder. Notify the clinician that, regardless of whether an evidentiary presumption has been established for a diagnosed disorder, consideration must still be given to the likelihood of actual causation by an in- service disease, injury, or event. Notify the clinician that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is at least so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. Notify the clinician that the Veteran, as a layperson, is competent to attest to matters based on personal knowledge, not medical expertise, as they come to a person through his or her senses, including observable or experienced symptoms. If the clinician cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the clinician shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A rationale is required for all opinions in the report. 8. Obtain an opinion from an appropriate clinician to determine the nature and etiology of any lung disorder at any time since the Veteran's claim was filed in May 2016, even if now resolved. A further VA examination may be scheduled if needed to provide an adequate medical opinion. The clinician must offer an opinion as to whether any such disorder at least as likely as not: a. Is caused, aggravated, or otherwise related to an in-service injury, disease, or event, to include periods of ACDUTRA and INACDUTRA, Gulf War environmental exposure, an in-service record of Sudafed taken for seasonal allergies, and the Veteran's competent report of breathing problems that began during service and have recurred to the present; b. Had its inception during service; c. Manifested during active service or within one year after discharge from service; d. Was noted during service such that the condition was not shown to be chronic at that time or a diagnosis of chronicity could be legitimately questioned, and there was a continuity of the same symptomatology since service; or e. Is proximately due to, or aggravated beyond its natural progression by, leukemia or treatment for leukemia, or by any other disorder for which service connection is sought, to include treatment for such other disorder. Notify the clinician that, regardless of whether an evidentiary presumption has been established for a diagnosed disorder, consideration must still be given to the likelihood of actual causation by an in- service disease, injury, or event. Notify the clinician that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is at least so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. Notify the clinician that the Veteran, as a layperson, is competent to attest to matters based on personal knowledge, not medical expertise, as they come to a person through his or her senses, including observable or experienced symptoms. If the clinician cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the clinician shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A rationale is required for all opinions in the report. 9. Obtain an opinion from an appropriate clinician to determine whether the Veteran meets certain medical criteria relating to eligibility for VA outpatient dental treatment. A further VA examination may be scheduled if needed to provide an adequate medical opinion. The clinician must offer an opinion as to whether the Veteran, based on her dental history, at least as likely as not: a. Has a non-compensable dental condition or disability shown to have been in existence at the time of a discharge from active service in the Persian Gulf era and after September 30, 1981, and the certificate of discharge or release does not bear a certification that the Veteran was provided, within the 90-day period immediately before discharge, a complete dental examination (including dental X-rays) and all appropriate dental treatment indicated by the examination to be needed, and a VA dental examination was completed within six months of discharge or release unless delayed through no fault of the Veteran; b. Has a dental condition professionally determined to be aggravating disability from an associated service-connected condition or disability, and the dental condition has a direct and material detrimental effect upon the associated basic condition or disability; c. Is participating in VA's Vocational Rehabilitation and Employment Program (Chapter 31) and needs dental services for any of the reasons enumerated in § 38 C.F.R. § 17.47(g), relating to hospital care, medical services, and nursing home care; or d. Is scheduled for admission or otherwise receiving care and services under 38 U.S.C. Chapter 17 (Hospital, Nursing Home, Domiciliary, and Medical Care) and outpatient dental care that is medically necessary, i.e., is for a dental condition clinically determined to be complicating a medical condition currently under treatment. Notify the clinician that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is at least so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. Notify the clinician that the Veteran, as a layperson, is competent to attest to matters based on personal knowledge, not medical expertise, as they come to a person through his or her senses, including observable or experienced symptoms. If the clinician cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the clinician shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A rationale is required for all opinions in the report. 10. Readjudicate the remanded issues. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Steven D. Najarian, 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.