Citation Nr: 22014589 Decision Date: 03/14/22 Archive Date: 03/14/22 DOCKET NO. 16-06 970 DATE: March 14, 2022 ORDER From January 1, 2021, to March 5, 2021, a rating of 20 percent for left lower extremity neuropathy is granted. Entitlement to a compensable rating for left ear hearing loss is denied. Entitlement to service connection for right ear hearing loss is denied. Entitlement to service connection for a right hand disability other than radiculopathy is denied. Entitlement to service connection for a left hand disability other than radiculopathy is denied. Entitlement to service connection for a right elbow disability other than radiculopathy is denied. Entitlement to service connection for a left elbow disability other than radiculopathy is denied. Entitlement to service connection for a bilateral eye disability is denied. REMANDED Entitlement to an increased rating for a left ankle disability is remanded. Entitlement to an initial compensable rating for herpes simplex is remanded. Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for a gastrointestinal disorder, to include irritable bowel syndrome (IBS), an ulcer, and/or diverticulosis / diverticulitis, is remanded. Entitlement to service connection for a respiratory disability, to include sinusitis and/or rhinitis, is remanded. FINDINGS OF FACT 1. The Veteran's moderate incomplete paralysis of the left lower extremity common peroneal, superficial peroneal, and deep peroneal nerves, manifested following her on November 6, 2020 surgery, for which she received a temporary total rating until December 31, 2020. 2. Throughout the appeal, the Veteran's hearing loss was manifested by Level I hearing acuity in the left ear and level I hearing acuity in the nonservice-connected right ear. 3. The Veteran's current right ear hearing loss does not constitute a disability due to impaired hearing for VA purposes. 4. The Veteran does not have a current right hand disability other than service-connected radiculopathy. 5. The Veteran does not have a current left hand disability other than service-connected radiculopathy. 6. The Veteran does not have a current right elbow disability other than service-connected radiculopathy. 7. The Veteran does not have a current left elbow disability other than service-connected radiculopathy. 8. The Veteran does not have a current disability of the eyes for VA compensation purposes. CONCLUSIONS OF LAW 1. From January 1, 2021, to March 5, 2021, the criteria for entitlement to a rating of 20 percent for left lower extremity neuropathy are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.30, 4.123, 4.124a, Diagnostic Codes 8520-23. 2. Throughout the appeal, the criteria for entitlement to a compensable rating for left ear hearing loss are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.85, 4.86, Diagnostic Code 6100. 3. The criteria for entitlement to service connection for right ear hearing loss are not met. 38 U.S.C. §§ 1110, 1131, 5017; 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.385. 4. The criteria for entitlement to service connection for a right hand disability other than radiculopathy are not met. 38 U.S.C. §§ 1110, 1131, 5017; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for entitlement to service connection for a left hand disability other than radiculopathy are not met. 38 U.S.C. §§ 1110, 1131, 5017; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for entitlement to service connection for a right elbow disability other than radiculopathy are not met. 38 U.S.C. §§ 1110, 1131, 5017; 38 C.F.R. §§ 3.102, 3.303, 3.310. 7. The criteria for entitlement to service connection for a left elbow disability other than radiculopathy are not met. 38 U.S.C. §§ 1110, 1131, 5017; 38 C.F.R. §§ 3.102, 3.303, 3.310. 8. The criteria for entitlement to service connection for a disability of the eyes are not met. 38 U.S.C. §§ 1110, 1131, 5017; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from October 1989 to April 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision by an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). In August 2018, the Veteran testified before the undersigned. In March 2019 and November 2020, the Board remanded this appeal for additional development. Except as set forth below, there has been substantial compliance with the Board's remand directives. In this regard, the AOJ secured updated VA treatment records, and the Veteran submitted outstanding relevant private treatment records. Moreover, the AOJ secured adequate medical opinions and examination reports sufficient to address some, but not all, of the issues on appeal; in the remand section below the Board will address necessary remedial action on those issues where it is required. After the November 2020 Board remand, the AOJ granted a temporary total rating related to left lower extremity surgery, as well as a separate 20 percent rating for left lower extremity radiculopathy and a separate 10 percent rating for a painful left foot scar. See February 2021 Rating Decision; March 2021 Rating Decision; April 2021 Rating Decision. Thus, the appeal seeking an increased rating for a left ankle disability has been recharacterized. Moreover, the Board has bifurcated this increased rating claim so as to award compensation over a portion of the appeal without delay. See Locklear v. Shinseki, 24 Vet. App. 311 (2011) (bifurcation of an appeal is generally within the Board's discretion). In June 2021, the AOJ granted entitlement to service connection for a (1) cervical spine disability with radiculopathy, (2) a right shoulder disability; and (3) a benign cyst of the breast. Thus, these issues are no longer on appeal, as the Veteran's appeal has been granted in full. If the Veteran disagrees with the initial ratings or effective dates of service connection assigned by the AOJ, she should seek review of the June 2021 rating decision by filing the appropriate VA form. Additional VA treatment records were associated with the claims file after the issuance of the September 2021 Supplemental Statement of the Case (SSOC). However, these records are duplicative of records that were previously obtained or otherwise not relevant with respect to the issues adjudicated in this decision. 1. From January 1, 2021, to March 5, 2021, a rating of 20 percent for left lower extremity neuropathy is granted. On November 6, 2020, during the pendency of the appeal, the Veteran underwent left lower extremity surgery. The AOJ granted a temporary total rating following her surgery through December 31, 2020, as well as entitlement to service connection for left lower extremity neuropathy effective March 5, 2021, the date of a relevant VA examination. Initially, the Board notes that the AOJ determined that the Veteran had moderate incomplete paralysis and assigned a 20 percent rating under 38 C.F.R. § 4.124a, Diagnostic Code 8520. The Board will not disturb the AOJ's finding that the Veteran's neuropathy was equivalent to moderate incomplete paralysis, as it is not clearly erroneous. The AOJ assigned a rating using Diagnostic Code 8520, which applies to paralysis of the sciatic nerve. The Board notes that the examiner did not note the presence of paralysis of the sciatic nerve. However, the examiner did note the presence of paralysis of the common peroneal nerve, superficial peroneal nerve, and deep peroneal nerve. Paralysis of the common peroneal (external popliteal) nerve is rated under Diagnostic Code 8521. Moderate incomplete paralysis of the common peroneal nerve warrants a 20 percent rating, the same rating that is warranted for moderate incomplete paralysis of the sciatic nerve under Diagnostic Code 8520. Here, the evidence shows that the Veteran's neuropathy initially manifested after her November 6, 2020 left lower extremity surgery. Accordingly, the 20 percent rating assigned by the AOJ is warranted from the date of expiration of her temporary total rating, or January 1, 2021. The Board emphasizes that this rating is being awarded as a partial grant of the appeal, without prejudice to the potential award of a higher rating. Thus, the Board will not disturb the more favorable rating put in place by the AOJ. When this matter returns from remand, the Board will fully adjudicate the Veteran's appeal seeking an increased rating for her left ankle disability. 2. Entitlement to a compensable rating for left ear hearing loss is denied. The Veteran asserts that she was told that her hearing loss had worsened. See, e.g., Board Hearing Transcript at 14. The Veteran is currently in receipt of a noncompensable (zero percent) rating for left ear hearing loss throughout the appeal. The period on appeal is from September 15, 2011, the date of claim, plus the one-year lookback period. There has been substantial compliance with the Board's remand directives, as the Veteran was afforded an adequate examination and the June 2017 and November 2020 audiograms were secured. Initially, the Board acknowledges the Veteran's attempt to secure complete VA audiology records and her report that she was told that the "Maryland CNC-25" test used for her November 2020 examination was not adequate for rating purposes. See October 2021 Correspondence. The Board observes that the relevant VA regulation only requires the use of the Maryland CNC testing and does not state that the "Maryland CNC-50" test must be used. See 38 C.F.R. § 4.85. Thus, the Board will consider the November 2020 audiological testing results. However, as the "W-22" speech test was used for the June 2017 audiological examination, that test is not adequate for rating purposes. See March 2021 VA Medical Opinion (explaining which tests were used during the appeal). Additionally, records secured on remand show that the Veteran presented for an audiology examination in February 2013, but as the "W-22" speech recognition test was also used this examination, the examination report is not adequate for rating purposes. See July 2021 CAPRI (Audiological Records). In addition to the adequate November 2020 audiological examination, the Veteran presented for examinations in June 2012 and February 2020. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85, DC 6100. To evaluate the degree of disability from bilateral service-connected hearing loss, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII. Here, the Veteran is only service-connected for left ear hearing loss. Thus, the Board will use "Level I" acuity for her nonservice-connected right ear. 38 C.F.R. § 4.85(f). However, the Board observes that even if her right ear was service-connected, the level of hearing loss would be "Level I" hearing acuity. An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). The Veteran presented for a VA audiology examination in June 2012. The examination report reveals that the Veteran reported understanding speech with background noise present and a hard time hearing at work on the telephone. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: June 2012 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 5 10 5 20 10 100% LEFT 5 15 45 15 20 100% Applying the results to Table VI, the findings yield a numeric designation of Level I in the service-connected left ear and Level I in the nonservice-connected right ear. An exceptional pattern of hearing impairment is not shown. Entering the resulting bilateral numeric designation of Level I for the right ear and Level I for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a noncompensable (zero percent) disability rating under Diagnostic Code 6100. The Veteran presented for an audiology examination with a VA-contracted examiner in February 2020. The examination report reveals that the Veteran reported difficulty understanding speech. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: Feb 2020 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 5 10 5 30 13 100% LEFT 5 25 45 20 24 100% Applying the results to Table VI, the findings yield a numeric designation of Level I in the service-connected left ear and Level I in the nonservice-connected right ear. An exceptional pattern of hearing impairment is not shown. Entering the resulting bilateral numeric designation of Level I for the right ear and Level I for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a noncompensable (zero percent) disability rating under Diagnostic Code 6100. The Veteran underwent VA audiology testing on November 2, 2020. See November 2020 Audiology Report. The VA treatment records associated with that examination show the Veteran's report of difficulty understanding speech, especially in the presence of background noise. See November 2, 2020 VA Audiology Note; see also 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: Nov 2020 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 10 15 10 25 15 96% LEFT 10 25 45 20 25 96% Applying the results to Table VI, the findings yield a numeric designation of Level I in the service-connected left ear and Level I in the nonservice-connected right ear. An exceptional pattern of hearing impairment is not shown. Entering the resulting bilateral numeric designation of Level I for the right ear and Level I for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a noncompensable (zero percent) disability rating under Diagnostic Code 6100. Here, no examination report of record shows audiometric findings that could support entitlement to a higher rating. While the Veteran competently and credibly reported difficulty understanding speech and has been prescribed a hearing aid, this type of functional loss is contemplated by the VA schedular rating criteria for hearing loss. Thus, as there are no examination findings that warrant a rating in excess of zero percent, the competing evidence is not in approximate balance, or nearly equal, the benefit-of-the-doubt rule is not applicable and the appeal must be denied. See Lynch v. McDonough, 999 F.3d 1391, 1395 (Fed. Cir. 2021). Law and Regulations Governing Service Connection Service connection may be established for a disability resulting from injury or disease incurred during or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be established for a disability that is proximately due to or aggravated by a service connected disability. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310. Service connection may not be established for disability due to impaired hearing unless the auditory threshold in any of the frequencies 500, 1000, 2000, 3000 or 4000 hertz is 40 decibels or greater; or the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000 or 4000 hertz 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. Congenital or developmental defects, refractive error of the eye, personality disorders and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation and thus service connection may not be granted for disability due to these conditions. 38 C.F.R. §§ 3.303(c), 4.9. 3. Entitlement to service connection for right ear hearing loss is denied. The Veteran attributes her hearing loss to service and argues that direct or secondary service connection should be granted. As discussed above, the Veteran presented for audiological examinations in June 2012, February 2020, and November 2020. However, there are no current audiological findings of record showing the presence of right ear hearing loss for VA purposes pursuant to 38 C.F.R. § 3.385. Thus, the evidence does not show a current right ear hearing loss disability, and in the absence of a current right ear hearing loss disability, service connection for right ear hearing loss cannot be established. Brammer v. Derwinski, 3 Vet. App. 223 (Fed. Cir. 1992). The Board acknowledges that the February 2020 VA-contracted examiner opined that it is at least as likely as not that the Veteran's right ear hearing loss was incurred in service, as her service audiograms show a significant threshold shift. While the evidence shows that the Veteran has abnormal hearing for clinical purposes and that this abnormal hearing is related to her service, the current level of impairment does not constitute a disability for VA compensation purposes. Thus, the appeal must be denied. However, if the Veteran obtains new and relevant evidence as to the presence of a right ear hearing loss disability for VA purposes, she may submit this evidence along with the appropriate VA form. 4. Entitlement to service connection for a right hand disability other than radiculopathy is denied. 5. Entitlement to service connection for a left hand disability other than radiculopathy is denied. 6. Entitlement to service connection for a right elbow disability other than radiculopathy is denied. 7. Entitlement to service connection for a left elbow disability other than radiculopathy is denied. The Veteran reported pain and numbness in the hands and elbows that she attributed to her in-service duties including dead lifting pilots. In the alternative, she attributes these symptoms to her cervical spine disability. She reported that her provider told her that her upper extremity pain was related to her cervical spine disability. See, e.g., Board Hearing Transcript at 18-19. The April 2021 examiner diagnosed the Veteran with degenerative disc disease of the cervical spine and intervertebral disc syndrome with bilateral upper extremity radiculopathy. See May 2021 Neck Conditions Disability Benefits Questionnaire (DBQ). The examiner opined that these conditions are related to the Veteran's service and in June 2021 the Veteran was awarded service connection for a neck disability with radiculopathy. The examiner opined that the Veteran did not have a disability of the hands or elbows. The examiner noted that the "objective examination" was normal and that symptoms were "subjective only." Critically, the examiner explained that the Veteran's hand symptoms radiate from the neck and referred to the examination report for radiculopathy, and further stated that "objective exam[ination] support[s] a diagnosis of radiculopathy but no diagnosis is warranted for [the] elbow joint[s]." See May 2021 Hand and Fingers DBQ; Elbow and Forearm DBQ. The examiner's opinion linking the Veteran's upper extremity radiculopathy to her neck disability explains that her symptoms of bilateral upper extremity pain radiate to her shoulders, elbow, and hands. Here, the Veteran has competently and credibly reported her upper extremity symptoms. However, the most probative evidence of record demonstrates that the Veteran's bilateral hand and elbow symptoms are due to her bilateral upper extremity radiculopathy, for which she is service connected. In this regard, while the Veteran is of the opinion that her symptoms constitute a separate disability that is subject to service connection, the question of whether her symptoms are of neurological or musculoskeletal origin is a complex medical question that is beyond the knowledge of a layperson. As the Veteran is not shown to have the necessary expertise or knowledge to provide a medical opinion, the Board does not afford her opinion probative weight. As the evidence does not show a separate or concurrent disability of the hand and/or elbow joints, there is no current disability for which the Veteran is not already in receipt of service connection. Thus, entitlement to service connection for bilateral hand and bilateral elbow disabilities other than radiculopathy must be denied due to absence of a current disability. See Brammer, supra. 8. Entitlement to service connection for a bilateral eye disability is denied. The Veteran asserts that she has raised yellow dots on the white of her eye that do not hurt but need to be watched. See, e.g., Board Hearing Transcript at 16-18. The Veteran's service treatment records (STRs) show complaints of a small growth on the white part of the eye with a diagnosis of "early pinguecula." See, e.g., March 1995 STR. Her separation examination report shows normal eyes. See March 1996 Separation Examination Report. The June 2012 VA examination report shows that the Veteran does not have a current eye condition other than congenital or developmental errors of refraction. The examiner noted no current eye disease and that the Veteran only required eyeglasses. See June 2012 VA Eye Conditions DBQ. The Veteran's VA treatment records show good ocular health bilaterally, with refractive error including myopia (nearsightedness) and presbyopia (age-related farsightedness). See, e.g., November 26, 2019 VA Optometry Report. The Veteran's private treatment records show clear conjunctiva with no visual changes or eye pain. See, e.g., November 22, 2013 Dr. S.T. Treatment Note. Here, the evidence does not show the presence of a current eye disability for VA compensation purposes. Although the Veteran's STRs show complaints of eye symptoms and include a reference to early pinguecula, the evidence does not show a current diagnosis of pinguecula or any other compensable eye disability; the only currently-diagnosed eye conditions are myopia and presbyopia, which are types of refractive error that are not subject to service connection. 38 C.F.R. §§ 3.303(c), 4.9. In the absence of a current disability, service connection cannot be established. The Board acknowledges the Veteran's competent and credible testimony that her symptoms first manifested on active duty, have persisted to the present, and that she has been told to continue to monitor her condition. While the Veteran is competent to report her symptoms, the diagnosis of a disease based on these symptoms is a medical question beyond the scope of a layperson and the Veteran is not shown to have the necessary expertise to provide such a diagnosis. Moreover, VA regulations permit an award of presumptive service connection for certain chronic conditions when continuity of symptomatology is established; however, these regulations do not, at present, permit an award of service connection as no there is no current diagnosis of any chronic eye disease, or any other disease subject to service connection. In the event that the Veteran is diagnosed with a compensable eye condition, she may submit new and relevant evidence as to the presence of any related disability along with the appropriate VA form. REASONS FOR REMAND 9. Entitlement to a rating in excess of 10 percent for a left ankle disability is remanded. The Board sincerely regrets the delay, but remand is necessary to secure an adequate addendum opinion. In this regard, the May 2021 Ankle Conditions DBQ indicates that the Veteran did not report flare-ups, yet an accompanying medical opinion explained that the Veteran had "objective limitation of function" during flare-ups with inability to bear weight without pain, inability to run, and walking with a limp. See May 2021 Ankle Flare-ups Opinion. On remand, this discrepancy should be reconciled and an adequate estimate of functional loss during flare-ups should be obtained. Updated VA and relevant private treatment records, if any, should be secured. 10. Entitlement to an initial compensable rating for herpes simplex is remanded. Remand is necessary to obtain an addendum opinion. In this regard, an August 2021 examiner stated that it was not possible to describe the estimate the body surface area affected during a flare-up without speculation because the Veteran was not examined during a flare-up. This is rationale is inadequate, as the Veteran could competently describe the area affected by lesions during a flare of her condition, requiring remand. 11. Entitlement to service connection for a left shoulder disorder is remanded. Remand is necessary for an addendum opinion. In this regard, the examiner noted that "objective findings" were negative with "subjective symptoms" only. Moreover, the examiner noted that the Veteran's neck pain that radiated into her shoulders but did not explicitly attribute left shoulder pain to radiculopathy. On remand, the examiner should clarify whether the Veteran's left shoulder symptoms are due to radiculopathy, and if not, should address whether her subjective symptoms are due to a disability or productive of functional impairment that is etiologically related to service. 12. Entitlement to service connection for a gastrointestinal disorder, to include IBS, an ulcer, and/or diverticulosis / diverticulitis, is remanded. Remand is necessary to secure an addendum opinion, as the opinion secured does not address all the gastrointestinal diagnoses of record. Additionally, the provided opinion does not include an adequate rationale. 13. Entitlement to service connection for a respiratory disability, to include sinusitis and/or rhinitis, is remanded. Remand is necessary to secure an addendum opinion, as the opinion of record incorrectly states that there is no evidence that the Veteran underwent sinus surgery shortly after service but that "a review would be in order" should record of the surgeries be secured. See April 2021 Sinus Opinion. Here, the record includes evidence of the Veteran's sinus surgery and septoplasty, and thus this medical opinion is based on an inaccurate factual basis and is inadequate. See November 2020 Email Correspondence (noting that the Veteran underwent functional nasal septal reconstruction for acquired deviated nasal septum on January 6, 1998); Medical Treatment Records Received October 6, 2011 (noting January 1998 septal reconstruction and August 2002 functional endoscopic sinus surgery). On remand, an opinion should be secured premised on an accurate factual basis. The matters are REMANDED for the following action: 1. Secure updated VA treatment records. 2. With any necessary assistance from the Veteran, secure relevant outstanding private treatment records. Please advise the Veteran that the Board is only requesting new records, if any. 3. After completing #1 and #2, secure an addendum opinion as to the nature and severity of the Veteran's left ankle disability during a flare-up. The claims file should be available to the examiner. No additional examination of the Veteran is necessary unless the examiner determines otherwise. The examiner should opine as to the degree of functional impairment of the Veteran's left ankle disability due to flare-ups and after repetitive use over time, accounting for pain, incoordination, weakened movement, and excess fatigability on use, and, to the extent possible, report such impairment in terms of additional degrees of limitation of motion. If the examiner is unable to provide such an opinion without resort to speculation, the examiner must provide a rationale for this conclusion, with specific consideration of the instructions in the VA Clinician's Guide to estimate, "per [the] veteran," what extent, if any, flare-ups affect functional impairment. In addressing this question, the examiner should reconcile the Ankle Conditions DBQ received May 7, 2021 indicating "no flare-ups" with the medical opinion indicating additional functional loss during flare-ups due to inability to bear weight without pain, inability to run, and walking with a limp. A complete rationale for the examiner's opinion should be provided, citing to specific evidence of record, as necessary. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. 4. After completing #1 and #2, secure an addendum opinion as to the nature and severity of the herpes simplex during a flare-up. The claims file should be available to the examiner. No additional examination of the Veteran is necessary unless the examiner determines otherwise. The examiner should address the following: (a) Estimate describe the area affected by lesions during a flare-up. If the examiner is unable to provide such an opinion without resort to speculation, the examiner must provide a rationale and reconcile this statement with the Veteran's description of the areas affected during a flare-up. The examiner is advised that the absence of a flare-up at the time of examination is not a sufficient reason to decline to estimate the area affected during a flare-up. (b) State whether Valtrex or other medications taken by the Veteran for herpes outbreaks constitutes "intermittent systemic therapy." (c) State whether the Veteran has taken Valtrex for a total of at least six-weeks over any one-year period since September 2011. An accompanying rationale could include the number of outbreaks per year and the normal medication course per outbreak. A complete rationale for the examiner's opinion should be provided, citing to specific evidence of record, as necessary. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. 5. After completing #1 and #2, secure an addendum opinion as to the nature and etiology of the Veteran's left shoulder disability. The claims file should be made available to and should be reviewed by the examiner. No additional examination of the Veteran is necessary unless the examiner determines otherwise. The examiner should address the following: (a) Diagnose all current left shoulder disabilities and/or functional impairments. If the only left shoulder disability and/or functional impairment is encompassed by or an aspect of the Veteran's service-connected left upper extremity radiculopathy, please so state. The examiner is advised that a functional impairment due to pain or other etiology constitutes a disability for VA compensation purposes, even in the absence of diagnosed pathology. For the purposes of this question, a current disability or functional impairment includes any disability or impairment present since September 2011, even if subsequently resolved. (b) If any only if a left shoulder disability or functional impairment other than left upper extremity radiculopathy is diagnosed, opine whether it is at least as likely as not (50 percent or greater probability) that such disability or impairment had its onset during or is otherwise etiologically related to the Veteran's active duty service, to include as a result of the cumulative impact of dead lifting pilots for training, pulling hoses, bending and pushing as related to her MOS as an aviation boatswain's mate. In addressing this question, please assume as true her reports of continuous shoulder pain since service and determine whether a nexus to service is "medically plausible" based on the same.. (c) If any only if a left shoulder disability or functional impairment other than left upper extremity radiculopathy is diagnosed, opine whether it is at least as likely as not (50 percent or greater probability) that such disability or impairment is proximately due to the Veteran's cervical spine disability. (d) If any only if a left shoulder disability or functional impairment other than left upper extremity radiculopathy is diagnosed, opine whether it is at least as likely as not (50 percent or greater probability) that such disability or impairment has been aggravated (worsened beyond natural progression) by the Veteran's cervical spine disability. A complete rationale for the examiner's opinion should be provided, citing to specific evidence of record, as necessary. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. 6. After completing #1 and #2, secure an addendum opinion as to the nature and etiology of the Veteran's gastrointestinal disability. The claims file should be made available to and should be reviewed by the examiner. No additional examination of the Veteran is necessary unless the examiner determines otherwise. The examiner should address the following: (a) Diagnose all current gastrointestinal disorder(s) present at any time since September 2011. For the purposes of this question, a current disability or functional impairment includes any disability or impairment present since September 2011, even if subsequently resolved. (b) For each disorder diagnosed in subpart (a), opine whether it is at least as likely as not (50 percent or greater probability) that such disorder had its onset during or is otherwise etiologically related to the Veteran's active duty service, to include in-service abdominal pain and cramping, as well as "stomach, liver, or intestinal trouble" (lower abdominal pain) therein. The examiner should provide s separate opinion for each condition diagnosed in subpart (a). In addressing this question, the examiner is advised that the Board has accepted the Veteran's competent and credible reports of continuity of symptomatology (diarrhea, abdominal pain and bloating since basic training in 1989) since service as true and determine whether a nexus to service is "medically plausible" based on the same. See also Medical Treatment Record Received October 6, 2011 (historical treatment). A complete rationale for the examiner's opinion should be provided, citing to specific evidence of record, as necessary. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. 7. After completing #1 and #2, secure an addendum opinion as to the nature and etiology of the Veteran's respiratory disability, to include sinusitis and/or rhinitis. The claims file should be made available to and should be reviewed by the examiner. No additional examination of the Veteran is necessary unless the examiner determines otherwise. The examiner should address the following: (a) Diagnose all current respiratory disorder(s) present since September 2011, to include sinusitis and/or rhinitis. (b) For each disorder diagnosed in subpart (a), opine whether it is at least as likely as not (50 percent or greater probability) that such disorder had its onset during or is otherwise etiologically related to the Veteran's active duty service, considering her in-service reports of nasal congestion, sore throat, URIs, headaches, and post nasal drip. In addressing this question, the examiner's attention is invited to records of the Veteran's post-service treatment for respiratory complaints, to include a septal reconstruction in January 1998 and sinus surgery in August 2002. See, e.g., Medical Treatment Records Received October 6, 2011. The examiner should also accept as true the Veteran's statements regarding a continuity of symptomatology and determine whether a nexus to service is "medically plausible" based on the same. The examiner should provide s separate opinion for each condition diagnosed in subpart (a). A complete rationale for the examiner's opinion should be provided, citing to specific evidence of record, as necessary. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.M. Badaczewski, Associate 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.