Citation Nr: 22014091 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 14-28 641A DATE: March 11, 2022 ORDER The claim of entitlement to service connection for a cervical spine disorder is denied. The claim of entitlement to service connection for bilateral hearing loss is denied. REMANDED The claim of entitlement to a disability rating in excess of 10 percent for angioedema is remanded. The claim of entitlement to service connection for a psychiatric disorder is remanded. The claim of entitlement to service connection for erectile dysfunction is remanded. The claim of entitlement to service connection for a low back disorder is remanded. The claim of entitlement to service connection for a bilateral knee disorder is remanded. The claim of entitlement to service connection for a memory disorder is remanded. The claim of entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's cervical spine disorder did not originate in service or within one year thereafter and is not otherwise etiologically related to service. 2. A bilateral hearing loss disability has not been present during the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for a cervical spine disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 2. The criteria for establishing entitlement to service connection for bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Army from October 1977 to October 1981 and from October 1990 to April 1991. Service Connection Service connection may be granted for 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. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease, injury, or event and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis and bilateral hearings loss, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258, 271 (2015). Service connection may be granted to a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability resulting from an undiagnosed illness, or from a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders) that is defined by a cluster of signs or symptoms, or resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed below, or from any diagnosed illness which the Secretary determines in regulations prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection. The symptoms must 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. By history, physical examination and laboratory tests, the disability cannot be attributed to any known clinical diagnosis. Objective indications of chronic disability include both "signs" in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The signs and symptoms which may be manifestations of undiagnosed illness or a medically unexplained chronic multisymptom illness include, but are not limited to: (1) fatigue, (2) signs or symptoms involving the skin, (3) headaches, (4) muscle pain, (5) joint pain, (6) neurologic signs or symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the respiratory system (upper or lower), (9) sleep disturbance, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, and (13) menstrual disorders. 38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317. A review of the Veteran's service personnel records confirm that he had service in the Southwest Asia theater of operations during the Persian Gulf War. As such, he is a Persian Gulf veteran. See 38 C.F.R. § 3.317 (e). In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (finding service connection presupposes a current diagnosis of the condition claimed). The requirement that a current disability be present is satisfied, "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim... even though the disability resolves prior to the Secretary's adjudication of the claim." McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). For the purpose of applying the laws administered by VA, impaired hearing will be considered a disability when the auditory threshold for any of the frequencies of 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. 1. Entitlement to service connection for a cervical spine disorder. The Veteran seeks service connection for a cervical spine disorder. The Veteran's service treatment records are silent for complaints of or treatment for a cervical spine disorder. The Veteran's April 1991 separation examination showed that his neck and spine were clinically normal. On the report of medical history, the Veteran denied swollen or painful joints. A September 1997 VA general examination report indicated that the Veteran's musculoskeletal system was normal. A November 1998 VA joints examination report documented the Veteran's complaint of neck pain that started four years prior. However, at the time of the examination the Veteran denied cervical spine pain. The cervical spine examination was negative. A January 2001 x-ray of the cervical spine revealed minimal cervical spondylosis. November 2011 VA treatment records showed that he injured his cervical spine in September 2011. He reported that a heavy box landed on his posterior neck area, which immediately resulted in intense pain at the neck area with radiation to the left arm. An x-ray showed left C5-C6 paracentral disc protrusion with neural foramen encroachment. The Veteran was afforded a VA examination in December 2019. The diagnosis was cervical spondylosis. The Veteran reported that his cervical spine disorder was related to service. The examiner opined that the Veteran's cervical spine disorder was not related to service. The rationale was that there was no evidence of a cervical spine disorder during service or within a year of service. The Veteran was also afforded a VA cervical spine examination in April 2021. The diagnoses were degenerative arthritis and cervical strain. The Veteran reported cervical region pain and decreased range of motion since 1990. The examiner found that the Veteran's cervical spine disorder was less likely than not related to service. The examiner acknowledged the Veteran's symptoms of pain since 1990, however, it was noted that the Veteran had multiple visits for neck pain after service and no evidence of a cervical spine disorder during service. In an August 2021 VA medical opinion, the reviewing examiner opined that there was no evidence to support that the cervical spine disorder was diagnosed during service or as a result of service. The reviewing examiner also found that his cervical spine disorder is a chronic multi-symptom illness with a partially understood etiology. The examiner found that the cervical spine disorder was less likely than not related to specific exposure events during service in the Persian Gulf. It was explained that there was no correlation between the cervical spine disorder and service in the Persian Gulf. Initially, the Board finds that the Veteran is not entitled to presumptive service connection under 38 C.F.R. § 3.317. The Veteran's cervical spine pain has been attributed to a diagnosis of degenerative arthritis of the cervical spine and cervical strain. As such, it is not an undiagnosed illness for which service connection may be awarded under 38 C.F.R. § 3.317. The Board also concludes that, while the Veteran has a current diagnosis of a cervical spine disorder, the evidence weighs persuasively against finding that the Veteran's cervical spine disorder began during service or is otherwise related to an in-service injury, event, or disease. The earliest record documenting cervical spine complaints was dated in November 1998 and at that time he stated that his symptoms started in 1994. Such evidence indicates that the Veteran's cervical spine disorder started after service. Additionally, there is no competent medical evidence in the record that links his cervical spine disorder to military service. In this regard, the only competent medical opinion of record addressing the etiology of his cervical spine disorder was provided by the December 2019, April 2021, and August 2021 VA examiners. The Board affords significant probative value to the VA medical opinions as they were based on an accurate medical history and provided explanations that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Also, there is no medical opinion of record to contradict the VA medical opinions and the Veteran has not submitted competent medical evidence relating his cervical spine disorder to service. With regard to whether arthritis was shown during service or within one year of separation, the Board finds that such a diagnosis was not shown. To determine that a chronic disease was "shown in service," the disease identity must be established and the diagnosis not subject to legitimate question. 38 C.F.R. § 3.303 (b); Walker, 708 F.3d at 1331. The evidence does not show that the Veteran had arthritis or any other cervical spine disorder at the time he separated from service or within one year thereafter. Arthritis must be objectively confirmed by x-ray. 38 C.F.R. § 4.71, Diagnostic Code 5003. Thus, the Veteran is not entitled to service connection for arthritis of the cervical spine on a presumptive basis, either as a chronic disease during service or within one year of service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a); Walker, 708 F.3d 1335 -37. Therefore, chronicity is not established in service or within a year of separation. Furthermore, the evidence does not establish continuity of symptomatology since service. 38 C.F.R. § 3.303 (b). In this regard, the medical evidence does not document any complaints, treatment, or diagnosis of a cervical spine disorder for years after his military service. The Board also finds that the Veteran's statements regarding the presence of his cervical spine symptoms during service are not credible. During the November 1998 VA examination, the Veteran reported that his cervical spine symptoms began in 1994. During the November 1998 VA examination, the Veteran did not mention that his cervical spine disorder started during service, and he denied seeking in-service treatment for cervical spine symptoms. As such, the Board finds that the Veteran's report of cervical spine symptoms during service are not credible. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (finding that in weighing credibility, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant). The Board acknowledges the Veteran's lay statements that his current cervical spine disorder is related to service. Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, the diagnosis and etiology of a cervical spine disorder, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The questions of diagnosis and etiology in this case go beyond a simple and immediately observable cause-and-effect relationship, particularly considering the delayed onset of the disorder. Based on the foregoing, the Board finds that the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for a cervical spine disorder is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for bilateral hearing loss. The Veteran contends that he is entitled to service connection for bilateral hearing loss. The Veteran initially underwent a VA examination in connection with his claim of entitlement to service connection for bilateral hearing loss in January 2013. Speech discrimination scores and pure tone thresholds, in decibels (dB), were as follows: Jan. 2013 HERTZ 500 1000 2000 3000 4000 CNC RIGHT 20 20 20 25 25 96% LEFT 20 25 20 25 25 96% VA treatment records include a June 2015 audiology report. Speech discrimination scores and pure tone thresholds, in decibels (dB), were as follows: June 2015 HERTZ 500 1000 2000 3000 4000 CNC RIGHT 20 20 25 20 25 96% LEFT 20 20 15 35 25 96% The Veteran was afforded another VA examination in December 2019. Speech discrimination scores and pure tone thresholds, in decibels (dB), were as follows: Dec. 2019 HERTZ 500 1000 2000 3000 4000 CNC RIGHT 10 15 10 15 15 100% LEFT 10 10 10 10 15 100% The Veteran was afforded another VA examination in March 2021. Speech discrimination scores and pure tone thresholds, in decibels (dB), were as follows: Mar. 2021 HERTZ 500 1000 2000 3000 4000 CNC RIGHT 15 10 15 15 15 100% LEFT 15 15 15 25 25 100% The Board finds that the competent evidence of record does not establish the presence of a bilateral hearing loss disability, as defined by 38 C.F.R. § 3.385, at any time during the pendency of this claim. Significantly, the audiology findings throughout the appeal period did not show a bilateral hearing loss disability for VA purposes. Therefore, even when considering the Veteran's reported symptoms and functional impairment, the Board must conclude that service connection for bilateral hearing loss is not warranted because the competent evidence does not show a bilateral hearing loss disability for VA compensation purposes. See 38 C.F.R. § 3.385. Without a finding of a current disability, service connection is not warranted. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). REASONS FOR REMAND 1. The claim of entitlement to a disability rating in excess of 10 percent for angioedema is remanded. The Veteran's angioedema is currently rated pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7825 for chronic urticaria. According to MedlinePlus, urticaria is also known as hives and is defined as "red and sometimes itchy bumps on your skin." See Hives, MedlinePlus Medical Encyclopedia, https://medlineplus.gov/hives.html (last visited February 28, 2022). Angioedema is defined as "swelling that is similar to hives, but the swelling is under the skin instead of on the surface." See https://medlineplus.gov/ency/article/000846.htm (last visited February 28, 2022). Angioneurotic edema is rated pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7118. The May 2011 VA examination report documented recurrent episodes of swelling of the knees, ankles, hands, or elbows, accompanied by itching that lasted for three weeks each month. The diagnosis was angioedema. The December 2019 VA skin diseases examination report included diagnoses of angioedema and urticaria. He reported itchy, red rashes and areas of edema that mostly occurred between February and June. The examiner noted that the Veteran used corticosteroids or other immunosuppressive medications, as well as antihistamines as treatment for urticaria/angioedema. The Veteran was afforded a VA artery and vein conditions examination in April 2021. The diagnosis was angioedema. It was noted that the Veteran had chronic urticaria and angioedema on the face, feet, neck, and trunk. The examiner checked the box for angioneurotic edema, but later clarified that none of the options in the diagnosis section was correct for the Veteran's condition of angioedema, therefore, the closest selection was chosen. Consequently, the examiner did not provide information required to rate the Veteran's disorder under Diagnostic Code 7118, for angioneurotic edema. The examiner explained that angioedema is "the rapid edema, or swelling, of the area beneath the skin or mucosa...The swelling happens because fluid accumulates. It tends to affect areas with loose areas of tissue, especially the face and throat, as well as the limbs and genitals." The examiner also stated that there was no change in the established diagnosis of angioedema. As noted above, angioedema differs from urticaria in that the swelling is under the skin, while urticaria involves hives that are on the skin. The April 2021 VA examiner indicated that the Veteran's angioedema was close to angioneurotic edema. As such, the evidence suggests that the Veteran's angioedema may be rated by analogy to Diagnostic Code 7118 for angioneurotic edema. As the VA examinations do not include the information needed to rate the Veteran's angioedema under Diagnostic Code 7118, the Board finds that a remand is required. Additionally, the December 2019 VA examination report also noted scalp psoriasis, hemangioma, and neurofibroma. The examiner should note whether such findings are associated with the service-connected angioedema. 2. The claim of entitlement to service connection for a psychiatric disorder is remanded. The Board finds that the December 2019 VA medical opinion is inadequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Specifically, the examiner found that the Veteran's psychiatric disorder was not directly related to service. The rationale was that the service treatment records, a November 1998 VA mental health examination, and a February 2005 VA treatment record were negative for a psychiatric disorder. The examiner also stated that the Veteran sought psychiatric care in 2010 and received a diagnosis of depression, but a stressor was not identified. It does not appear that the VA examiner fully considered the medical evidence. The November 2010 VA note documented the Veterans report that he was prescribed medication for "nerves" during the 2000s. An April 2011 VA treatment record noted that the Veteran started to reexperience war-related traumatic memories when a significant number of his coworkers returned from the war. The Veteran learned techniques to better cope with flashbacks and to lower the frequency of nightmares. An August 2011 VA psychiatric note indicated that witnessing young servicemembers return from Iraq triggered the Veteran's depressive symptoms that were previously in remission. He reported war-related nightmares and flashbacks that started 10 years prior. The Veteran reported that he was involved in five altercations during service due to racism and language barriers. He stated that he was hazed and had to learn to defend himself. The Veteran believed that his early military experiences changed his personality and contributed to the difficulties that he experienced since service. He also reported that he witnessed multiple traumatic experiences in Iraq. In September 2011, the Veteran reported flashbacks about accidents and deaths he witnessed during his deployment. As it does not appear that the VA examiner fully considered the VA treatment records and the Veteran's lay statements, a remand is required to obtain another medical opinion. 3. The claim of entitlement to service connection for erectile dysfunction is remanded. The Board finds that the December 2019 and April 2021 VA medical opinions are inadequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312. The December 2019 VA examiner opined that the Veteran's erectile dysfunction was not directly related to service. In support of the opinion, the examiner stated that there was no evidence of erectile dysfunction during service and he was first evaluated for the disorder in 2011. However, the record contains an October 1998 VA treatment record showing that the Veteran complained of impotence and was given a provisional diagnosis of erectile dysfunction. With respect to the April 2021 VA medical opinion, the examiner did not provide an opinion as to whether the Veteran's erectile dysfunction was aggravated by his service-connected angioedema. Accordingly, a remand is required for addendum opinions. 4. The claim of entitlement to service connection for a low back disorder is remanded. The Board finds that the January 2013, December 2019, April 2021, and August 2021 VA medical opinions are inadequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312. The January 2013, December 2019, and August 2021 VA examiners found that the Veteran's low back disorder was less likely than not directly related to service. In support of the opinion, the January 2013 and December 2019 VA examiners acknowledged the Veteran's in-service treatment for low back pain in 1985 and 1987 and found that the next complaint of low back pain was in 2003. Similarly, the August 2021 VA examiner found that the first post-service complaint of low back pain was in 2003 and added that the Veteran's low back disorder was related to aging and a 2011 injury. However, VA treatment records showed complaints of low back pain in February 1998, June 1998, and October 1998. A November 1998 VA examination report documented the Veteran's complaint of low back pain that started four years ago. Therefore, the Board finds that the unfavorable opinions were based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (medical opinion based on inaccurate factual basis not probative). Additionally, the April 2021 examiner did not provide an opinion as to whether the Veteran's low back disorder was aggravated by his service-connected angioedema. Accordingly, a remand is required for addendum opinions. 5. The claim of entitlement to service connection for a bilateral knee disorder is remanded. The Board finds that a remand is required to obtain another VA medical opinion. The Veteran was afforded a VA examination in December 2019. The Veteran reported knee pain since service. The examiner opined that the Veteran's knee disorder was less likely than not incurred in or caused by service. The rationale was that there was no evidence of any knee injuries during service or within a year of service. The December 2019 VA medical opinion is inadequate because the examiner relied on the absence of evidence in concluding that there was no in-service injury or condition. See Buchanon v. Nicholson, 451 F.3d 1331, 1336, 1337 (Fed. Cir. 2006) (holding that the Board may not rely on a medical opinion in which it is determined that a Veteran's lay statements lack credibility solely because they are not corroborated by contemporaneous medical records). The Veteran was afforded another VA knees examination in April 2021. The Veteran reported knee pain during and after his Gulf War service. He also reported a knee injury following a fall at work. The examiner provided an unfavorable opinion. The rationale was that the Veteran's knee disorders started after service and a post-service work injury. It was noted that there was no evidence of a bilateral knee disorder during service. A VA medical opinion was provided in August 2021. The examiner found that the Veteran's knee disorder was at least as likely as not related to service. The examiner stated that the records supported evidence of pain, left knee contusion, and degenerative knee conditions during service. The examiner also found that the Veteran's knee disorder was at least as likely as not due to wear and tear injuries of service. It was noted that the Veteran referred treatment with intraarticular injection of Hyalgan during service. The August 2021 VA medical opinion is inadequate because the opinion is inconsistent with the other evidence of record. Specifically, the service treatment records do not show complaints or treatment for knee pain, left knee contusion, or a degenerative knee condition. Moreover, VA examinations conducted in September 1997 and November 1998 showed normal musculoskeletal examinations. Accordingly, a remand is required to address the conflicting medical opinions. 6. The claim of entitlement to service connection for a memory disorder is remanded. The Veteran was not afforded a VA Persian Gulf examination to address the nature and etiology of his claimed memory loss. The August 2021 VA medical opinion addressed whether the cervical spine disorder, low back disorder, and bilateral knee disorders were undiagnosed illnesses, medically unexplained chronic multisymptom illnesses, or otherwise related to Persian Gulf environmental exposures. Unfortunately, the examiner did not address the claimed memory loss. Accordingly, a remand is required to obtain a VA examination. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 7. The claim of entitlement to a TDIU is remanded. The issue of entitlement to a TDIU is intertwined with the issues remanded herein. Harris v. Derwinski, 1 Vet. App. 180 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together). Therefore, further consideration of the claim of entitlement to a TDIU must be deferred. The matters are REMANDED for the following action: 1. The AOJ should undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claims. If any requested records are not available, the record should be annotated to reflect such, and the Veteran notified in accordance with 38 C.F.R. § § 3.159 (e). 2. The AOJ should afford the Veteran a VA examination by an examiner with sufficient expertise to fully assess the severity of his angioedema. All pertinent evidence of record should be made available to and reviewed by the examiner. All necessary studies should be performed. The AOJ should ensure that the examiner provides all information required for rating the Veteran's angioedema under Diagnostic Codes 7825 and 7118. The examiner should specifically address whether the Veteran's disorder involves hives under the skin, on the skin, or both. The examiner should also address whether the Veteran's scalp psoriasis, hemangioma, neurofibroma, and subcutaneous cysts are associated with his service-connected angioedema. 3. The AOJ should afford the Veteran a VA examination by a physician with sufficient expertise, to determine the nature and etiology of his psychiatric disorder. All pertinent evidence of record must be made available to and reviewed by the examiner. Any necessary tests and studies should be accomplished. The examiner must identify all psychiatric disorders present during the period of the claim. The examiner should confirm or rule out a diagnosis of PTSD. Following the examination and a review of the relevant records and lay statements, the examiner should state an opinion as to whether it is at least as likely as not that the disorder is etiologically related to the Veteran's active duty service. In so opining, the VA examiner must consider and discuss the VA treatment records and lay statements showing that the Veteran experienced war-related flashbacks and nightmares, that his depression symptoms were triggered by young servicemembers returning home from war, and that his psychiatric symptoms are related to altercations he was involved in during service. The examiner must provide a complete rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. Then, the AOJ should obtain an addendum medical opinion from an examiner, other than the examiner who provided the April 2021 opinion. Another examination of the Veteran should only be performed if deemed necessary by the person providing the opinion. All pertinent evidence of record must be made available to and reviewed by the examiner. Following a review of the relevant records and lay statements, the examiner must state an opinion as to the following: (a) Whether it is at least as likely as not (50 percent probability or greater) that the erectile dysfunction is etiologically related to the Veteran's active service. (b) Whether it is at least as likely as not (a 50 percent probability or greater) that the erectile dysfunction was caused or aggravated by his service-connected angioedema. In so opining, the examiner must consider and discuss the January 1999 VA examination report showing that the Veterans experienced angioedema attacks in which he suffered severe body edema, including the testicles and penis with pain and burning with urination. The examiner must provide a complete rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 5. Then, the AOJ should obtain an addendum medical opinion from an examiner, other than the examiner who provided the April 2021 opinion. Another examination of the Veteran should only be performed if deemed necessary by the person providing the opinion. All pertinent evidence of record must be made available to and reviewed by the examiner. Following a review of the relevant records and lay statements, the examiner must state an opinion as to the following: (a) Whether it is at least as likely as not (50 percent probability or greater) that the low back disorder is etiologically related to the Veteran's active service, to include any symptomatology therein. (b) Whether it is at least as likely as not (a 50 percent probability or greater) that the low back disorder was caused or aggravated by his service-connected angioedema. The examiner must provide a complete rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 6. Then, the AOJ should obtain an addendum medical opinion from an examiner, other than the examiner who provided the August 2021 opinion. Another examination of the Veteran should only be performed if deemed necessary by the person providing the opinion. All pertinent evidence of record must be made available to and reviewed by the examiner. Following a review of the relevant records and lay statements, the examiner must state an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the bilateral knee disorder is etiologically related to the Veteran's active service. The examiner must provide a complete rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 7. Thereafter, the AOJ should afford the Veteran a VA examination by a physician with sufficient expertise, to determine the nature and etiology of the Veteran's memory loss, to include abdominal pain. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be accomplished. Following an examination of the Veteran, and a thorough review of the record, the appropriate examiner is requested to: (a) Identify all memory disorders that have been present during the period of the claim. (b) With respect to each such disorder the examiner should state an opinion as to whether there is a 50 percent probability that the disorder began in or is otherwise related to the Veteran's active duty service, to include as due to environmental hazards in the Persian Gulf. (c) If there are objective manifestations of a disorder manifested by memory loss that are not due to a known clinical diagnosis, the examiner should identify those manifestations and state an opinion as to whether there is a 50 percent probability or higher that the manifestations are due to an undiagnosed illness or chronic multisymptom disability of unknown etiology. The rationale for all opinions expressed must also be provided. If the examiner is unable to provide any required opinion, he or she should explain why. If an opinion cannot be provided without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, examiner should identify the additional information that is needed. 8. Then, the AOJ should readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran's satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. N. McKinley, 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.