Citation Nr: 22013293 Decision Date: 03/09/22 Archive Date: 03/09/22 DOCKET NO. 15-24 665 DATE: March 9, 2022 ORDER Entitlement to service connection for a respiratory disorder to include asthma is denied. REMANDED Entitlement to service connection for a right hip disorder, to include as secondary to service-connected lumbar spine degenerative disc disease, right knee degenerative joint disease, right knee strain, and right knee lateral instability (jointly right knee disability), and right and left knee shin splints, is remanded. Entitlement to service connection for a left hip disorder, to include as secondary to service-connected lumbar spine degenerative disc disease, right knee disability, and right and left knee shin splints, is remanded. Entitlement to service connection for diabetes mellitus, type II, is remanded. Entitlement to service connection for residuals of a cerebral vascular accident, to include as secondary to diabetes mellitus, type II, is remanded. Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus, type II, is remanded. Entitlement to service connection for a liver disorder, to include as secondary to diabetes mellitus, type II, and/or medications prescribed for service-connected orthopedic disabilities, is remanded. Entitlement to service connection for peripheral neuropathy (PN) of the bilateral upper extremities (BUE), as secondary to diabetes mellitus, type II, is remanded. Entitlement to service connection for PN of the bilateral lower extremities (BLE), as secondary to diabetes mellitus, type II, is remanded. Entitlement to service connection for a bilateral eye disorder, as secondary to diabetes mellitus, type II, is remanded. FINDING OF FACT The evidence of record persuasively weighs against finding that asthma began during active service or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for respiratory disorder to include asthma are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1987 to September 1991. The Veteran is not a Persian Gulf veteran as defined by VA. 38 C.F.R. § 3.317(e)(1), (2). The Veteran's service personnel records show that although he had almost two years of foreign service, that service was in Germany. See Military Personnel Record (February 2021); Certificate of Release or Discharge From Active Duty (May 2014). Moreover, the Veteran has stated he was never sent to the Persian Gulf. See VA 231-4138 Statement In Support of Claim (June 2000). This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2018, the Veteran testified before a Veterans Law Judge (VLJ). A hearing transcript is associated with the record. See Hearing Transcript (August 2018). In November 2021, the Veteran was advised that the VLJ who held the hearing had retired and that he was entitled to have another hearing. See BVA Letter (November 2021). The Veteran requested that the appeal be adjudicated without an additional hearing. See Hearing Request (December 2021). This appeal was remanded in May 2020. See BVA Decision (May 2020). In additional to the issues indicated above, the issue of entitlement to service connection for a psychiatric disorder was remanded. See BVA Decision (May 2020). During remand status, a June 2021 rating decision granted service connection for PTSD, effective July 21, 2014, the date of the Veteran's service connection claim. See Rating Decision (June 2021). As the benefit sought has been granted in full, there remains no matter for the Board's consideration. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997) (noting that a grant of service connection extinguishes appeals before the Board). The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. In the 2020 remand, the Board directed the RO to obtain a VA examination and opinion regarding the Veteran's asthma. See BVA Decision (May 2020). The Board requested that the Veteran's Gulf War service be verified and etiological opinions be obtained regarding direct service connection and whether there was a respiratory disorder due to Gulf War service. See BVA Decision (May 2020). Although an examination was conducted and opinions were provided, the examiner did not address whether a respiratory disorder was due to Gulf War service. See C&P Exam (March 2021); C&P Exam (June 2021); C&P Exam (August 2021). The Board finds, however, that there has been substantial compliance with the prior remand, as on remand, the RO confirmed that the Veteran had no Persian Gulf service. See Military Personnel Record (February 2021). Accordingly, consideration of the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 as a basis for service connection are not applicable and, thus, related opinions are not necessary. The Board may thus proceed to adjudicate the issue of service connection for a respiratory disorder. 1. Entitlement to service connection for a respiratory disorder is denied. The Veteran contends that he had breathing issues during service, was treated with an inhaler, and developed asthma thereafter. See VA 21-4138 Statement In Support of Claim (June 1999); Third Party Correspondence (July 2002). He has also asserted that his body began breaking down after taking experimental medication at his military entrance processing station. See Hearing Transcript (August 2018); VA 231-4138 Statement In Support of Claim (June 2000). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Board concludes that service connection is not warranted because the evidence of record persuasively weighs against finding that asthma began during active service, or is otherwise related to an in-service injury or disease. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). A March 2021 VA examination report noted a diagnosis of asthma. See C&P Exam (March 2021). Second, the Board finds that there was an in-service event but no diagnosis or manifestation of a chronic disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran's entrance examination and report of medical history were silent for asthma or other respiratory concerns. See STR Medical (May 2014). A February 1989 chest x-ray indicated there were no abnormalities. An August 1991 x-ray reported lungs within normal limits. See STR Medical (May 2014). In an August 1991 service discharge Report of Medical History, the Veteran denied asthma but reported shortness of breath. In the Notes section of this document, a clinician appeared to indicate the Veteran went to sick call for this, but received no medication. See STR - Medical (May 2014). The corresponding Report of Medical Examination noted a normal clinical evaluation of the lungs and chest. See STR Medical (May 2014). Thus, there are in-service symptoms of shortness of breath but no diagnosis or notations of a chronic disability. To the extent that the Veteran is asserting that his asthma is due to experimental medication or shots given to him at his military entrance processing station, the Board does not find this allegation probative. The Veteran is competent to report such an incident. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (noting that a lay witness is competent to report to factual matters of which he or she has first-hand knowledge). The Board finds, however, that this assertion is not credible as there is a lack of evidence of such medication or shots in either the service treatment or personnel records, and that the Veteran did not make this allegation in his prior 2002 claim for service connection for asthma, or until the hearing in 2018. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that the credibility of a witness may be impeached by a showing of interest, bias, inconsistent statements, consistency with other evidence, and demeanor), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Third, the Board finds that the evidence of record does not support a finding that asthma is related to active service or that it has existed since service. Post-service discharge, a November 1991 VA examination noted no wheezing and present breath sounds. See VA Examination (January 1992). In a May 1994 private treatment record, the Veteran denied shortness of breath. See Medical Treatment Record Non-Government Facility (February 2002). In a March 1998 private medical record, it was noted that the Veteran had high blood pressure and diabetes, but the box for asthma was left unchecked. See Medical Treatment Record Government Facility (December 2019). In a 1996 medical record, the Veteran denied asthma as part of his health history. See Medical Treatment Record Government Facility (December 2019). VA treatment records do not contain mention of asthma or respiratory issues until 1999. In January 1999, the Veteran reported a history of dyspnea on hills and stairs. Pulmonary function testing was done and the clinician noted possible asthma. See Medical Treatment Record Government Facility (July 1999). Other medical records dated in July and October 1999 noted asthma. See Medical Treatment Record Government Facility (December 1999). Since that time, the Veteran's medical records have continued to substantiate a diagnosis of asthma. See CAPRI (September 2021); Medical Treatment Record Non-Government Facility (August 2018). Thus, it appears that the onset of asthma began in approximately 1999, or 8 years post-service discharge. This gap in time weighs against service connection. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of disorder). A March 2021 VA examination and opinion were obtained. See C&P Exam (March 2021). The clinician opined that it was less likely as not that asthma was related to service, reasoning that the Veteran's in-service respiratory conditions appeared to be acute, and asthma was not present until many years after service discharge. See C&P Exam (March 2021). In a June 2021 addendum opinion, the clinician opined that asthma was less likely as not incurred in or caused by the in-service shortness of breath, reasoning that the lungs were normal on separation examination. The clinician also found there was no objective evidence of a chronic respiratory condition manifested during active duty that has required continuous care and treatment. See C&P Exam (June 2021). In August 2021, the clinician again provided a negative nexus opinion and indicated that the prior rationale should be disregarded. See C&P Exam (August 2021). The clinician reasoned that although shortness of breath was reported during service and at separation, a chronic asthma condition was not noted during service because two mentions do not constitute chronicity, that shortness of breath does not necessarily indicate an asthma condition is present, and that the first mention of asthma symptoms came in 1999. See C&P Exam (August 2021). The Board assigns significant probative value to the 2021 examination and opinions. Although the June 2021 addendum opinion appeared to require chronicity of care, which is not required for service connection, the VA clinician provided a later adequate and probative rationale. See 38 C.F.R. § 3.303(d) (noting that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service). The clinician opined that there was not a chronic condition during service, and that the length of time in between discharge and diagnosis indicated that asthma was not otherwise related to the in-service shortness of breath. See C&P Exam (August 2021). Taking the March 2021 and August 2021 opinions together, the Board finds that these opinions are based upon an accurate review of the Veteran's medical history and provide a supporting explanation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in determining probative value of a medical opinion is whether the examiner was informed of the relevant facts); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). Although the Veteran has testified that his asthma is due to service, the Board finds that his opinion is not competent evidence. The Veteran is competent to report breathing problems in service and asthma after service, but he is not competent to determine that these in-service symptoms were manifestations of asthma or otherwise caused a later diagnosis of asthma. The issue is medically complex, as it requires knowledge of the symptoms of asthma versus acute respiratory illnesses and diseases of the respiratory system. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the VA medical opinions of record. Accordingly, the claim is denied. As the evidence of record persuasively weighs against the claims, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307 (Fed. Cir. Dec. 17, 2021); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a right hip disorder is remanded. 2. Entitlement to service connection for a left hip disorder is remanded. The Veteran contends that his left and right hip disorders are due to his service-connected back disability, right knee disability, and bilateral shin splints. See VA 21-4138 (September 2011); VA 21-4138 (May 2001). Alternatively, he has asserted that the hip disorders have existed since service. See Hearing Transcript (August 2018). The Board finds that remand is necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Generally, a medical opinion should address the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). Congenital or developmental defects automatically rebut the presumption of soundness and are therefore considered to have pre-existed service. 38 C.F.R. §§ 3.303(c), 4.9. Defects are defined as structural or inherent abnormalities or conditions which are more or less stationary in nature. VAOPGCPREC 82-90 (July 18, 1990). Service connection is generally precluded by regulation for such defects, because they are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9, 4.127. However, VA's Office of General Counsel has distinguished between congenital or developmental defects (for which service connection is precluded by regulation) and congenital or hereditary diseases (for which service connection may be granted if the disease initially manifested in or was aggravated by service). VAOPGCPREC 82-90, VAOPGCPREC 67-90. A defect differs from a disease in that a defect is "more or less stationary in nature," while a disease is "capable of improving or deteriorating." VAOPGCPREC 82-90. A congenital defect can still be subject to superimposed disease or injury. VAOPGCPREC 82-90. If such superimposed disease or injury does occur, service connection may be warranted for the resulting disability. VAOPGCPREC 82-90. However, if a Veteran suffers from a congenital disease, as opposed to a defect, VA cannot simply assume that, because of its congenital nature, the disease must have preexisted service. That is, the presumption of soundness still applies to congenital diseases that are not noted at entry. Quirin v. Shinseki, 22 Vet. App. 390, 396-97 (2009). Since the presumption of soundness at entrance attaches, VA must show by clear and unmistakable evidence that the congenital disease preexisted service. Monroe v. Brown, 4 Vet. App. 513, 515 (1993). Existence of a congenital hereditary disease under 38 C.F.R. § 3.303(c) does not always rebut the presumption of soundness, and that service connection may be granted for congenital hereditary diseases which either first manifest themselves during service or which preexist service and progressed at an abnormally high rate during service. VAOPGCPREC 67-90; 55 Fed. Reg. 43, 253 (1990). In short, service connection is available for congenital diseases (but not defects) that are aggravated in service. Quirin, 22 Vet. App. at 394. In cases where the appellant seeks service connection for a congenital condition, the Board must indicate whether the condition is a disease or defect and discuss the presumption of soundness. Quirin, 22 Vet. App. at 394-97. It follows that in such cases where a congenital condition is at issue, a VA medical opinion may be needed to determine whether the condition is a disease or defect, whether the presumption of soundness has been rebutted and, if so, whether there was aggravation during service. Quirin, 22 Vet. App. at 395. Here, a November 1991 VA examination was conducted. The Veteran reported no recurrence of left hip pain after an inservice injury. See VA Examination (January 1992). The examiner found the left hip was asymptomatic. A left hip x-ray noted there was no evidence of fracture, dislocation, or bone or joint pathology. See VA Examination (January 1992). A January 2011 VA examination was conducted. The examiner noted normal examination of the right and left hips with somatic complaints and thus opined that the hips were less likely as not related to his lumbar spine disability. The examiner noted that the Veteran's gait is not of a degree to cause any biomechanical imbalance of gait or increased stresses upon the bilateral hips. See VA Examination (January 2011). A January 2012 VA examination was conducted. The Veteran reported left hip pain that began in 2005 and right hip pain since service. The examiner reviewed the prior VA examinations reports and medical records and disagreed with the finding in the 2011 VA examination report that the hip complaints did not begin until 2010. The diagnosis was femoral acetabular impingement (FAI) of the bilateral hips. The examiner noted that FAI can lead to hip arthritis and is developmental and that symptoms may occur after injury or repetitive stress. The examiner then opined that there is thus no indication at all that the current hip condition is related to or caused by the lumbar spine disability. The relationship of the FAI and hip pain and their relationship to the military service is speculative at best, noting that complaints of pain did not occur until 2003. See VA Examination (January 2012). A March 2021 VA examination was conducted. Two opinions were provided. First, the examiner opined that they were unable to determine without resorting to mere speculation if the Veteran's current hip conditions are a direct result of active service, reasoning in part that left hip pain was not noted until 2010 and right hip pain was not noted until 2005. See C&P Exam (March 2021). The examiner also opined that the hip disorders were not due to service-connected disabilities, noting that there is no evidence in the medical literature to support the claim that bilateral shin splints, bilateral pes planus, medial compartment degenerative joint disease, right knee, lumbar spine DDD, or lumbar spondylosis worsens or aggravates the osteoarthritis due to FAI/os acetabuli in the veteran's bilateral hips. As part of both opinions, the examiner noted that the os acetabuli likely caused the Veteran's FAI and osteoarthritis, and that the os acetabuli was either developmental or acquired. See C&P Exam (March 2021). As there are differing legal standards for service connection for congenital or developmental diseases and defects, new opinions are necessary to clarify if these diagnoses are congenital defects or diseases. Additionally, the explanation for the negative secondary opinion is inadequate because the examiner merely cited a lack of supporting medical literature, but did not address facts specific to the Veteran, such as whether his gait was altered due to the orthopedic disabilities. Furthermore, no opinion has considered two pieces of relevant evidence: (1) A recent left hip x-ray report showed old punctate fracture fragments in the region of the left hip joint (Medical Treatment Record Non-Government Facility (May 2021)) (2) a March 1991 STR in which the clinician noted the Veteran's hip pain was probably due to his flat feet. See STR Medical (May 2014). Thus, addendum opinions are required to address the appropriate service connection theories and to address all relevant evidence of record. 3. Entitlement to service connection for a liver disorder is remanded. The Veteran contends that his liver disorder is due to the use of opioids or pain medication for his service-connected disabilities. See VA 21-526EZ, Fully Developed Claim (July 2014); Hearing Transcript (August 2018). The evidence suggests there may be a relationship between a liver disorder and diabetes mellitus, type II. See Medical Treatment Record Government Facility September 2011). The Board finds that remand is warranted for a medical opinion. The RO did not provide the Veteran with an examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, there is evidence of recurrent symptoms of liver disability. An April 2002 ultrasound showed an abnormal liver function test, noting a history of diabetes mellitus and hypertension. See Medical Treatment Record Government Facility (September 2011). A May 2010 VA ultrasound report impression was abnormal liver acoustic texture, consistent with fatty infiltration. See Medical Treatment Record Government Facility (September 2011). A May 2011 VA record indicated elevated liver enzymes that may have normalized when the Veteran decreased alcohol consumption. See CAPRI (April 2015). November 2015 VA records showed abnormal liver testing. See CAPRI (March 2016). June 2016 VA records noted liver function tests were within normal limits. See CAPRI (September 2021). Other 2016 VA records, however, note elevated liver enzymes. See CAPRI (September 2021). The evidence also shows evidence that diabetes mellitus type II or medications taken for his orthopedic disabilities might impact his liver condition. The Veteran is service-connected for multiple orthopedic disabilities, including lumbar spine degenerative joint disease, bilateral pes planus, right and left lower extremity radiculopathy, right knee degenerative joint disease, right knee strain, and right knee instability. See Rating Decision Codesheet (June 2021). Medical records indicate the Veteran has been prescribed opioid pain medication. See CAPRI (September 2021). In 2011, it was noted that the Veteran's medication was being changed to protect the liver. See CAPRI (September 2021). A 2002 VA record noted abnormal liver function test probably secondary to diabetes mellitus. See CAPRI (September 2021). A November 2015 VA record contained a statement from a clinician that the abnormal liver testing may be contributed to by the high glucose levels also present. See CAPRI (March 2016). Because there is evidence of recurrent liver symptoms and an indication that the symptoms may be associated with medications for service-connected disabilities or to disabilities that may be service-connected, remand for a VA examination is required. 4. Entitlement to service connection for diabetes mellitus, type II, is remanded. The Veteran contends that his diabetes mellitus, type II, was diagnosed during active duty. See Hearing Transcript (August 2018). The Board finds that remand is warranted for an adequate opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical rationale based solely on general medical literature without discussing the specific facts pertaining to a veteran's condition or individual circumstances is inadequate. Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Here, a March 2021 opinion and June 2021 addendum opinion were obtained on remand. See C&P Exam (March 2021); C&P Exam (June 2021). The March 2021 VA examiner checked the box noting that diabetes mellitus was not related to service, but then stated that a nexus had been established. The examiner reasoned that although the Veteran was not diagnosed with diabetes during service, he had a documented thirty pound weight gain while in service, was diagnosed with diabetes mellitus in 1994, only three years after service discharge, and it was well documented that being overweight and obesity are causes of type 2 diabetes. See C&P Exam (March 2021). Based on the conflicting nexus statements, the RO sought clarification. The June 2021 VA examiner opined that diabetes mellitus was not related to service, reasoning that although weight gain was a risk factor, it did not equate to causation. See C&P Exam (June 2021). That examiner noted that diabetes mellitus was not noted on the service discharge examination and appeared to state that it was not diagnosed until 1998. See C&P Exam (June 2021). T The Board finds that there are now conflicting opinions of record, each of which are inadequate for adjudicative purposes. First, the March 2021 opinion noted medical literature, but did not address factors specific to the Veteran, to include any other risk factors. Second, the June 2021 opinion appeared to place the diagnosis of DM in 1998, although it is unclear, but diabetes mellitus was of record as early as 1993. See Medical Treatment Record Non-Government Facility (February 2002). Finally, neither opinion addressed an in-service May 1989 blood draw that noted low glucose. See Medical Treatment Record Non-Government Facility (February 2002). Given the above, a new addendum opinion is necessary to resolve the noted incongruities. See Barr, supra. 5. Entitlement to service connection for residuals of a cerebral vascular accident is remanded. 6. Entitlement to service connection for hypertension is remanded. 7. Entitlement to service connection for PN of the BUE is remanded. 8. Entitlement to service connection for PN of the BLE is remanded. 9. Entitlement to service connection for a bilateral eye disorder is remanded. The Veteran contends, or the evidence suggests, that these disabilities are related to his diabetes. See VA 21-4138 Statement In Support of Claim (November 2017); VA 21-4138 Statement In Support of Claim (November 2003); Hearing Transcript (August 2018); Medical Treatment Record - Non-Government Facility (December 2019); Medical Treatment Record - Non-Government Facility (October 2018); Medical Treatment Record Non-Government Facility (August 2018); Medical Treatment Record Government Facility (September 2011). The Board finds that remand is thus warranted because diabetes mellitus is remanded herein; if that disability were to be service-connected, the conditions could also be service-connected if there is evidence of a relationship between them. These issues are therefore inextricably intertwined with the remanded issue of diabetes mellitus. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). The matters are REMANDED for the following action: 1. Obtain an etiological opinion regarding the Veteran's right hip and left hip disorders. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with the diagnosed bilateral hip disorders. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician should provide the following opinions, with supporting rationale, as to: Congenital/Developmental a) Whether the Veteran's os acetabuli and FAI are congenital diseases or defects. If these are not congenital or development, address question (d). b) For each congenital defect, was it subject to a superimposed disease or injury during service, to include FAI or osteoarthritis? c) For each congenital disease, was it at least as likely as not that it (1) had onset in service, or (2) is otherwise related to an in-service injury, event, or disease, to include the left hip during service. Consider whether in-service symptoms of left hip pain at least as likely as not represent the onset of os acetabuli, FAI, and/or osteoarthritis in service and indicate whether such symptoms are more likely than not due to other causesexplain. Direct Service Connection d) Whether the Veteran's right and left hip os acetabuli, FAI, and/or osteoarthritis at least as likely as not (1) had onset in service, or (2) are otherwise related to an in-service injury, event, or disease. Consider whether in-service symptoms of left hip pain at least as likely as not represent the onset of os acetabuli, FAI, and/or osteoarthritis in service and indicate whether such symptoms are more likely than not due to other causesexplain. Secondary Service Connection e) Whether the Veteran's right and left hip os acetabuli, FAI, and/or osteoarthritis are at least as likely as not (1) proximately due to service-connected lumbar spine degenerative joint disease, bilateral pes planus, right and left lower extremity radiculopathy, right knee degenerative joint disease, right knee lateral instability, and left and right shin splints, or (2) aggravated beyond natural progression by these service-connected orthopedic disabilities. Provide a rationale that deals with causation and aggravation as independent concepts. Consider the following evidence of record: i) relevant STRs including an April 1991 left hip x-ray that showed os acetabuli both hips, and a March 1991 record in which a clinician stated that hip pain was probably due to flat feet; ii) the November 1991 VA examination report and x-ray report; iii) the January 2011, January 2012, and March 2021 VA examination reports; and iv) a March 2021 private medical record that noted an x-ray showed old punctate fracture fragments in the left hip. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): If any medical history is rejected, a complete explanation is required. NOTE (3): An adequate medical opinion may not be predicated solely on the absence of literature supporting causation or aggravation without discussing those facts specific to this Veteran. 2. Obtain an addendum etiological opinion for diabetes mellitus, type II. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with the diagnosed diabetes mellitus. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician should provide an opinion, with supporting rationale, as to: Whether the Veteran's diabetes mellitus at least as likely as not (1) had its onset in service, or (2) is otherwise related to an in-service injury, event, or disease. Consider (1) whether the in-service 30-pound weight gain at least as likely as not represents the onset or beginnings of diabetes mellitus during service, despite the lack of a diagnosis until 1993explain. (2) a May 1989 STR in which it was noted that a blood draw showed low glucose. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): If any medical history is rejected, a complete explanation is required. 3. Schedule the Veteran for a VA examination for a liver disorder. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with any diagnosed liver disorder. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician should provide the following opinions, with supporting rationale: a) Is there a liver disorder present at any time from 2014 to the present? b) Whether a diagnosed liver disorder is at least as likely as not (1) proximately due to medications prescribed for service-connected disabilities, including lumbar spine degenerative joint disease, bilateral pes planus, right and left lower extremity radiculopathy, right knee degenerative joint disease, right knee lateral instability, and left and right shin splints, or (2) aggravated beyond its natural progression by medications for these service-connected disabilities. Provide a rationale that deals with causation and aggravation as independent concepts. c) Whether a diagnosed liver disorder is at least as likely as not (1) proximately due to diabetes mellitus, or (2) aggravated beyond its natural progression by diabetes mellitus. Provide a rationale that deals with causation and aggravation as independent concepts. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of literature supporting causation or aggravation without discussing those facts specific to this Veteran. NOTE (2): If any medical history is rejected, a complete explanation is required. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.M., 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.