Citation Nr: 22015180 Decision Date: 03/16/22 Archive Date: 03/16/22 DOCKET NO. 18-39 410 DATE: March 16, 2022 ORDER Entitlement to service connection for brain tumor and residuals of partial left front resection is granted. FINDING OF FACT The evidence is at least in approximate balance as to whether the Veteran's brain tumor and residuals of partial left front resection disability is related to his active service. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for a brain tumor and residuals of partial left front resection disability have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2021). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 2003 to April 2008. This case comes before the Board of Veterans' Appeals (the Board) from a September 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The Veteran testified before the undersigned Veterans Law Judge (VLJ) in a May 2020 hearing. The transcript of the hearing is of record. The Board remanded the issue on appeal for additional development in August 2020. The directives having been substantially complied with, the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). The Veteran submitted additional evidence in support of his claim after the most recent supplementary statement of the case (SSOC) of October 2020, along with a waiver of review of such evidence by the agency of original jurisdiction. As such, the Board may properly consider such evidence at this time. See 38 C.F.R. §§ 19.37, 20.800, 20.1304(c); Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). On November 15, 2021, the United States Court of Appeals for Veterans Claims (Court or CAVC) issued a Joint Motion for Remand (JMR) that remanded the issue of service connection for brain tumor and residuals back to the Board for reconsideration consistent with the terms of the motion. See Forcier v. Nicholson, 19 Vet. App. 414, 425 (2006). Pursuant to the Court's remand and Kutscherousky v. West, the Board issued a 90-day letter to the Veteran and his representative dated November 23, 2021, notifying them of their ability to submit additional evidence or argument in support of their appeal within 90 days. 12 Vet. App. 369 (1999) (per curiam). The Veteran and his representative submitted no new additional evidence within the prescribed 90-day period. 38 C.F.R. § 20.1304(c). The Board will now consider the appeal. See Clark v. O'Rourke, 30 Vet. App. 92 (2018). The substance of the Court's JMR focused on the reasons and bases of the Board's January 2021 denial of the brain tumor claim, noting the Board was inconsistent in its findings, and that it did not consider the Veteran's lay statements without addressing credibility. Here, because this decision grants service connection for the issues on appeal that were addressed by the CAVC's JMR, the Board considers the Court's remand to be satisfied in full. The reasons and bases for the Board's grant of these issues will be discussed in further detail below. Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2021). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert. denied, U.S.C. Oct. 3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection for Brain Tumor and Residuals Legal Criteria for Service Connection Service connection may be granted for a disability resulting from a 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 entitlement to service-connected compensation benefits, 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. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases, to include malignant tumors, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). For malignant tumors, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). Service connection for a malignant tumor can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). For a chronic disease to be considered to have been "shown in service," there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. When the condition noted in service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id. A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Cotant v. Principi, 17 Vet. App. 116 (2003); VAOPGCPREC 3-2003 (2003). When no preexisting condition is noted upon entry into service, the burden falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the disability was both preexisting and not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any increase was due to the natural progress of the preexisting condition. Id. at 1096. A claimant is not required to show that the disease or injury increased in severity during service before VA meets both of these burdens. See VAOPGCPREC 3-2003. Clear and unmistakable evidence means that the evidence "cannot be misinterpreted and misunderstood, i.e., it is undebatable." Vanerson v. West, 12 Vet. App. 254, 258 (1999) (citing definition of "clear and unmistakable error" in Russell v. Principi, 3 Vet. App. 310, 31314 (1992)). The clear and unmistakable evidence standard is an "onerous" one. Laposky v. Brown, 4 Vet. App. 331, 334 (1993) (citing Akins v. Derwinski, 1 Vet. App. 228, 232 (1991)). Proof of a current disability is a threshold to establishing service-connection for any claimed disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). To be a present as a current disability, there must be evidence of the condition at some time during the appeals period. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. In making that decision, the Board must determine the probative weight to be ascribed as among multiple medical opinions, and state the reasons and bases for favoring one opinion over another. See Winsett v. West, 11 Vet. App. 420, 424-25 (1998); see also Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). This responsibility is particularly important where medical opinions diverge. The Board is also mindful that it cannot make its own independent medical determinations, and that there must be plausible reasons for favoring one medical opinion over another. See Evans at 31; see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). If the evidence for and against a claim is in approximate balance, the claim will be granted. 38 C.F.R. § 4.3. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. Id. A claim will be denied only if the approximate balance of the evidence is against the claim. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Evidence and Analysis Brain Tumor and Residuals The Veteran is asserting that his brain tumor, which manifested its presence in February 2015, is due to his service in Iraq while deployed to Balad Air Base, where he contends he was exposed to the smoke and airborne residue of the burn pits used there to destroy trash. The Veteran's service medical records for his entire period of active service from June 2003 to April 2008 are silent for any indications or symptoms of a possible brain tumor or any neurological symptoms. The Veteran received a comprehensive VA Gulf War examination in June 2013, and the results were silent for any possible indications or symptoms for a brain tumor or possibly related neurological symptoms. In February 2015, the Veteran received emergency medical treatment after experiencing a grand mal seizure in the presence of his then-fiancé, now his spouse. As part of the initial evaluation, an MRI revealed a brain tumor, and the Veteran was recommended for immediate surgery to resect the tumor. That surgery occurred in March 2015 approximately one month after the initial onset of symptoms. In the aftermath of this treatment, the Veteran filed a claim for service connection of his brain tumor in June 2015, asserting that his exposure to the burn pits at his deployed base of Balad, Iraq, was the cause of his brain cancer. The Veteran was provided a VA examination to assess his brain tumor and central nervous system in July 2015. This examiner noted the symptomatic onset of the brain tumor in February 2015, initially diagnosed as an oligoastrocytoma, and the attempts to immediately address it via surgery. The examiner noted the immediate residuals for the Veteran, to include an inability to walk or talk coherently. Subsequent therapy and rehabilitation have enabled the ability to walk, but there are continuing headaches, stuttering, and other facial tics. At the time of the July 2015 VA examination, the Veteran was attempting to return to his job, but with functional limitations based on the residual symptoms experience by the Veteran related to his brain tumor and subsequent surgery. This July 2015 VA examiner provided a negative opinion for direct service connection, saying it was less likely than not that the claimed condition was incurred in or caused by the claimed inservice injury, event, or illness. The examiner's rationale was that there has been no link from any medical research about the burn pits used in Iraq and any kind of link to cancers, to include a brain tumor. The examiner also pointed out that there were no symptoms of any brain or central nervous system problems during service or after service ended in 2008 until the precipitating grand mal seizure event in February 2015. In May 2019, one of the Veteran's treating physicians, the local VAMC chief of neurology, Dr. E.J.D., provided a written statement where he noted the Veteran's tumor as a low-grade glioma. This neurologist noted the type of tumor of the Veteran generally grows slowly, sometimes very slowly, and can be present and asymptomatic for years. Dr. E.J.D. finished his opinion by saying that "[he] believed, more likely than not, that the Veteran's tumor was already present during the time of his military service." In May 2020, the Veteran testified before the undersigned VLJ regarding his brain tumor claim and his theory that the burn pits in Iraq and another deployed location had triggered his brain cancer. The Veteran testified as to his Iraq service, to include as near burn pits which he believed to the source of his brain tumor. Also in May 2020, the Veteran's treating neurosurgeon, Dr. J.M., provided an opinion with the Veteran's care regarding his low grade glioma, stating in a letter where he noted the Veteran's tumor to be slow growing and can be present and asymptomatic for years. This physician noted the Veteran presented with a seizure in February 2015 and that he performed a tumor resection in March 2015. Dr. J.M. concluded by saying that in his opinion, "that more than likely, that the Veteran's tumor was present during the time of his military service." No further rationale was provided. After an August 2020 Board remand to investigate the possibility of a pre-existing condition, deriving from the opinions of Drs. E.J.D. and J.M., that the brain tumor could have preexisted service, the Veteran received a VA addendum opinion that same month to address that theory of service connection. This VA physician examiner first noted the diagnosis of the original brain tumor had been redefined to be a low-grade glioma (LGG), or a glial tumor, based on genetic analysis and studies that indicate the mutation of a particular gene. The examiner noted that glial tumors in general account for nearly half of all central nervous system cancers, and in adults, most commonly arise in the frontal lobe. The MRI done in February 2015 following the grand mal seizure and subsequent diagnosis revealed a mass in the left superior and middle frontal gyri. The examiner noted that LGG tumors are indolent in nature and survival is measured in years to decades as opposed to more aggressive central nervous system tumors. The LGG tumors, like that of the Veteran, are by nature slow growing and annual growth rates range from an average of 16 percent in those that did not undergo malignant transformation to 26 percent for those that did. The examiner explained that this means a doubling time of 3 to 5 years assuming a constant growth rate. The examiner then explained that in the Veteran's case where the LGG tumor had been present for years and that it is not infrequent that they do undergo malignant transformation to a more aggressive tumor, as is likely in the Veteran's case. The examiner noted there had not been serial MRIs to note the growth rate of the tumor, indicating that there was not great concern about tumor growth. This VA examiner then noted and commented on the two physician examiners, previously discussed above, who postulated that the Veteran's tumor was already present during his time of military service. This examiner first noted that no tests were done would have revealed the presence of a mass prior to 2015. The examiner speculated that if Dr. E.J.D.'s and Dr. J.M.'s medical opinions were correct, then the Veteran's tumor clearly and unmistakably preexisted service, though without any medical evidence to support that proposition. If one were to accept that as a given, went the examiner, then the Veteran's LGG tumor was already present prior to the onset of active service in June 2003, and then the examiner opined that it was his medical opinion that it was not symptomatically manifest prior to 2015, but was likely present but quiet, and therefore that it was not caused by, secondary to, or aggravated by, any in-service event condition or exposure to include exposure to burn pits, other toxins or chemicals used in Iraq, or any predeployment vaccines. The examiner further noted that assuming the LGG tumor existed before or during service, as was inferred by this examiner from the two other physicians noted, then the fact that the Veteran's LGG tumor remained quiet after the end of active service in April 2008 until it manifested in February 2015 indicates that the LGG tumor was not permanently aggravated by any service event or incident. The examiner added further rationale that there are no known chemical exposures that cause gliomas in current medical literature. The Board notes a mix of opinions but finds the July 2015 and August 2020 VA opinions to be of low probative value. While the Board has previously noted the incomplete opinion of the July 2015 examiner, making that opinion only of limited value, the August 2020 addendum opinion for service connection, to include an opinion for aggravation of a pre-existing condition, is based on unsupported assumptions and conclusions drawn from a lack of evidence. As such, that August 2020 VA addendum opinion is also of limited probative value because of the conclusory nature with unsupported assumptions and inferences as to the reasoning of these negative opinions. This August 2020 examiner makes improper inferences based on what the May 2019 and May 2020 examiners did not say, with no supporting reasoning as to why any negative inference or conclusion should be drawn from their statements. To be adequate, a medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). On the other hand, the positive opinions offered by the VA neurologist Dr. E.J.D. in May 2019 and the Veteran's treating neurosurgeon Dr. J. M. in May 2020 are specifically aware of the Veteran's service and medical history, in their roles as treating physicians for the Veteran's diagnosed brain tumor. Furthermore, treatment notes from these two physicians indicate they noted the lay statements of the Veteran. The Board thus considers these two opinions of May 2019 and May 202 to be of strong probative value. Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). The Board also notes the Veteran's consistent statements over time. Importantly, there is no reason to doubt the credibility of the Veteran's self-reported history of his brain tumor and its residuals, which has been documented in multiple VA treatment notes over time. See 38 C.F.R. § 3.159(a)(2) (lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person); see Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Smith v. Derwinski, 1 Vet. App. 235, 237-38 (1991) (credibility determinations are within the purview of the Board). See also 38 U.S.C. § 1154(a) (reflecting that due consideration is to be given to the places, types, and circumstances of a claimant's service). A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App. 370, 374 (2002). Pre-existing Condition Analysis Pursuant to 38 C.F.R. § 3.304 The Veteran served on active duty June 2003 to April 2008, and no service treatment record or examination notes any pre-existing brain tumor or central nervous system disorder. Pursuant to 38 U.S.C. § 1111 and 38 C.F.R. § 3.304, if a pre-existing condition is not noted at service entrance, then the initial evidentiary burden is upon VA, using a clear and unmistakable evidence standard, to show 1) the asserted condition pre-existed service, and 2) the pre-existing condition was not aggravated during service. See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004) (emphasis added). The Secretary (of VA) may rebut the second prong of the presumption of soundness through demonstrating, by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or (2) any increase in disability was due to the natural progression of the condition. Quirin v. Shinseki, 22 Vet. App. 390, 397 (2009) (citing Wagner, 370 F.3d at 1096) (emphasis added); see also Horn v. Shinseki, 25 Vet. App. 231 (2012). Clear and unmistakable evidence means that the evidence "cannot be misinterpreted and misunderstood, i.e., it is undebatable." Vanerson v. West, 12 Vet. App. 254, 258 (1999) (citing definition of "clear and unmistakable error" in Russell v. Principi, 3 Vet. App. 310, 31314 (1992)). The clear and unmistakable evidence standard is an "onerous" one. Laposky v. Brown, 4 Vet. App. 331, 334 (1993) (citing Akins v. Derwinski, 1 Vet. App. 228, 232 (1991)). As previously discussed, the Veteran had no conditions noted in his medical or personnel records at service entrance. In consequence, the initial evidentiary burden is upon VA, using a clear and unmistakable evidence standard, to show 1) the asserted condition pre-existed service, and 2) the pre-existing condition was not aggravated during service. See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004) (emphasis added). Here, based on the medical evidence, the Board finds that the Veteran had a pre-existing condition that was not noted at service entrance. The statements of the VA physician examiners of July 2015 and August 2020 note the likelihood that the Veteran's LLG tumor preceded service based on nature of the Veteran's particular diagnosis and a review of medical literature regarding the nature of LLG tumors. There is no statement or inference by any medical professional from any source that disagrees with the assessment that the LLG tumor likely preceded service, thus satisfying the first Wagner condition. A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). The presumption of aggravation applies only when pre-service disability increases in severity during service. Beverly v. Brown, 9 Vet. App. 402, 405 (1996). The occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002). Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition itself, as contrasted with mere symptoms, has worsened. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The Veteran's service treatment records are silent for any pre-existing condition or disorder. Two different VA physicians have opined the Veteran's LGG tumor likely pre-existed active service, and there is no record of any LGG tumor or related central nervous system symptomatology until the February 2015 grand mal seizure that led to the formal diagnosis and subsequent treatment by Doctors E.J.D. and J.M., neither of whom made a direct statement as to the possibility or likelihood of a preexisting condition related to the brain tumor. The Veteran himself has never suggested that he had any LGG tumor or central nervous system symptomatology prior to February 2015. There is no probative record of permanent aggravation of such a pre-existing condition beyond its normal course. The second Wagner condition is thus satisfied, and the Veteran is thus presumed sound at service entrance, and the analysis for aggravation for a pre-existing condition not documented at service entrance fails. 38 U.S.C. § 1111; 38 C.F.R. § 3.304; Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); see also Quirin v. Shinseki, 22 Vet. App. 390, 397 (2009); Horn v. Shinseki, 25 Vet. App. 231 (2012). In addition, the CAVC noted in its November 2021 JMR on this issue that it considered the Board's previous finding that the Veteran was considered to be sound at service entrance to be a favorable finding. While this is a legacy appeal under VA law and regulation, and not an appeal under the modernized system post-February 2019 where that statement would have legal import, the Board will accept the CAVC's non-precedential statement on the matter, which reinforces its findings from earlier Board decisions. Direct Service Connection Evidence and Analysis Even though analysis pursuant 38 U.S.C. § 1111 and 38 C.F.R. § 3.304 for the Veteran's claim for service connection for a brain tumor disability fails, the Veteran can still establish such entitlement via direct service connection analysis. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). With reference to the earlier discussion, above, regarding the relative probative value of the four opinions in this appeal, the Board notes a mix of opinions but finds the July 2015 and August 2020 VA opinions to be of low probative value. While the Board has previously noted the incomplete opinion of the July 2015 examiner, making that opinion only of limited value, the August 2020 addendum opinion for service connection, to include an opinion for aggravation of a pre-existing condition, is based on unsupported assumptions and conclusions drawn from a lack of evidence. As such, that August 2020 VA addendum opinion is also of limited probative value because of the conclusory nature with unsupported assumptions and inferences as to the reasoning of these negative opinions. To be adequate, a medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). On the other hand, the positive service connection opinions offered by the VA neurologist Dr. E.J.D. in May 2019 and the Veteran's treating neurosurgeon Dr. J. M. in May 2020 are specifically aware of the Veteran's service and medical history, in their roles as treating physicians for the Veteran's diagnosed brain tumor. Furthermore, treatment notes from these two physicians indicate they noted the lay statements of the Veteran. The Board thus considers these two opinions of May 2019 and May 202 to be of strong probative value. Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). As noted previously, the Veteran has a diagnosis of an oligoastrocytoma, a form of brain tumor, thus satisfying the first requirement of service connection. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). The second requirement is to establish in-service incurrence or aggravation of a disease or injury. The Board notes the Veteran has claimed that his brain tumor disability is due to his exposure to burn pits while in Iraq. Here, the Board notes that there is no diagnosis or treatment of symptoms for any brain or central nervous system condition until his February 2015 grand mal seizure. However, the two most probative medical opinions from May 2019 and May 2020 on this matter both indicate that the Veteran's brain tumor disorder was likely present during active service. The Board thus finds that the second prong of service connection, an in-service incurrence or aggravation of a disease or injury, to be satisfied. Id. The third requirement of direct service connection is a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement." Here, again, the Board notes a mix of opinions, as discussed earlier. As noted earlier, if the evidence for and against a claim is in approximate balance, the claim will be granted. 38 C.F.R. § 4.3. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. Id. Here, the Board notes the two stronger positive service connection opinions are entitled to greater weight than the two Jul 2015 and August 2020 negative VA opinions, both of which opine that the Veteran's current brain tumor disorder existed back during active service. As such, the Board the third element of service connection, that of a nexus requirement between the current disability that ties back to service, to be satisfied. Holton at 1366. Here, upon review of the record, the Board concludes that entitlement to direct service connection for a brain tumor disability, diagnosed as a low-grade glioma, is warranted. The Board notes a current diagnosis of the glioma, and thus the requirement for a current disability is shown. The Board finds there is credible evidence of a brain tumor disorder in service that manifested as a current disability in February 2015. The Board notes the highly probative May 2019 and May 2020 examinations and opinions which indicate the Veteran's brain tumor disability is likely related to active military service. The Board finds that these conclusions are not contradicted by any comparably probative or persuasive competent evidence of record. Therefore, the Board finds that the opinion and evidence of the Veteran's brain tumor and residuals is, at a minimum, in approximate balance, and as such, must find in favor of the Veteran's claim. Even if, arguendo, the Veteran was not found to be sound at service entrance, pursuant to 38 C.F.R. § 3.304 as previously discussed, the Board notes that an asymptomatic brain tumor condition became malignant as discovered in February 2015, leading to the surgical resection in March 2015 as previously discussed. As such, the Board finds that if it was a preexisting condition, then the previously asymptomatic condition was aggravated during service such that it manifested as the glioma as diagnosed in February 2015, based on the highly probative May 2019 and May 2020 medical opinions. As such, then, the Veteran would qualify for service connection under this analysis as well. 38 U.S.C. § 1111; 38 C.F.R. § 3.304; Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); see also Quirin v. Shinseki, 22 Vet. App. 390, 397 (2009); Horn v. Shinseki, 25 Vet. App. 231 (2012). Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed brain tumor disability was incurred due to service, or was permanently aggravated during active service. For these reasons, the Board finds that an approximate balance of the evidence is in favor of the claim of service connection for a brain tumor disability, and the claim must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Setter, 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.