Citation Nr: 22016015 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 15-37 169 DATE: March 21, 2022 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include depression and anxiety, for substitution purposes, is granted. Entitlement to service connection for residuals of an appendectomy, for substitution purposes, is denied. Entitlement to service connection for right foot fracture, for substitution purposes, is denied. Entitlement to service connection for pyoderma, claimed as scabies, for substitution purposes, is denied. Entitlement to service connection for headaches, for substitution purposes, is denied. Entitlement to service connection for face lacerations, for substitution purposes, is denied. Entitlement to service connection for a dental condition is denied. Entitlement to an initial 10 percent rating, but no higher, for residuals of rib fracture, for substitution purposes, is granted, subject to the laws and regulations governing the award of monetary benefits. REMANDED Entitlement to service connection for skin cancer, to include as due to radiation exposure and sun exposure, for substitution purposes, is remanded. Entitlement to service connection for prostate cancer, to include as due to radiation exposure, for substitution purposes, is remanded. Entitlement to service connection for Parkinson's disease, to include as due to radiation exposure, for substitution purposes, is remanded. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as due to radiation exposure, for substitution purposes, is remanded. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as due to radiation exposure, for substitution purposes, is remanded. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as due to radiation exposure, for substitution purposes, is remanded. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as due to radiation exposure, for substitution purposes, is remanded. Entitlement to service connection for chronic obstructive pulmonary disease (COPD), claimed as punctured lung, for substitution purposes, is remanded. Entitlement to service connection for obstructive sleep apnea, for substitution purposes, is remanded. Entitlement to service connection for a right knee condition, for substitution purposes, is remanded. Entitlement to service connection for a left knee condition, for substitution purposes, is remanded. Entitlement to service connection for a gastroesophageal condition, claimed as esophagitis, for substitution purposes, is remanded. Entitlement to an initial rating in excess of 10 percent for bilateral hearing loss, for substitution purposes, is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt, the Veteran's psychiatric disorder had its onset during his active service. 2. The weight of the evidence is against the establishment of an in-service injury or event related to the residuals of appendectomy, right foot fracture, and headaches. 3. The weight of the evidence does not establish current diagnoses of pyoderma and facial lacerations. 4. The Veteran did not have a current diagnosis of a dental condition that is compensable according to VA standards. 5. For the entire initial rating period, the Veteran's residuals of rib fracture were manifested by pain, painful motion, tenderness, and shortness of breath. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for an acquired psychiatric disorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for residuals of appendectomy have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for right foot fracture have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for entitlement to service connection for pyoderma have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for entitlement to service connection for headaches have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for entitlement to service connection for face lacerations have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for entitlement to service connection for a dental condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.381, 4.150. 8. The criteria for entitlement to an initial 10 percent rating, but no higher, for residuals of rib fracture have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5299-5297. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from February 1946 to December 1947, and in the United States Army from November 1951 to November 1952. The Veteran died in January 2018, during the pendency of his appeal. The Appellant is his surviving spouse and properly substituted claimant. This appeal to the Board of Veteran's Appeals (Board) arose from multiple rating decisions by the Department of Veteran Affairs (VA) Regional Office (RO). A hearing was scheduled before the Board to be conducted in January 2022. However, the Appellant was deemed a no-show. As good cause has not been proffered, nor has the Appellant requested another hearing, the Board will continue with the adjudication of the appeal. 1. Entitlement to service connection for an acquired psychiatric disorder, to include depression and anxiety. The evidence of the record establishes that the Veteran had a current diagnosis of depression and anxiety disorder. Service connection is granted where evidence shows that an injury or disease that results in a current disability was incurred during service or was aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To be entitled to service connection, the evidence must support (1) a current disability; (2) an in-service injury or event; and (3) a nexus between the current disability and the in-service injury or event. 38 C.F.R. § 3.303(a). Regarding an in-service injury or event, on the November 1952 Report of Medical History for Separation, the Veteran reported that he experienced depression and excessive worry. See March 2014 Service Treatment Records (STR Medical). The physician remarked that the Veteran was "nervous". See id. Regarding whether there is a nexus, the VA examiner in May 2012 opined that it was less likely than not that the Veteran's depression and anxiety disorder was related to his service. The examiner explained that the primary stressor was long-term medical problems and poor coping. The examiner opined that the Veteran did not seem distraught over reported military stressors. On that examination report, it was noted that the Veteran had a long-term history of anxiety and depression "since the 1960's". The examiner also reported that nervousness was associated with the Veteran's anxiety. The Board acknowledges the examiner's conclusion. However, the examiner does not explain the notation regarding experiencing depression, excessive worry, and nervousness on his November 1952 separation examination. The entrance and reenlistments examinations on file are absent of any reports of depression. Therefore, the Veteran entered service in sound condition pertaining to any psychiatric disorder. The examiner also noted that medical problems was a factor in his psychiatric disorder without further explanation, such as if any medical issues related to his service contributed to his psychiatric disorder. After a thorough consideration of the evidence of the record, including the Veteran's assertions and medical records, the Board finds that the evidence is at least in approximate balance as to whether the Veteran's psychiatric disorder had its initial onset during military service. In this regard, the Board observes that the Veteran's accounts of his symptoms during and after service, when considered in tandem with the symptoms and diagnosis identified in the treatment records and VA examination, nonetheless, puts the evidence in at least relative equipoise. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021), affirmed en banc 2021 U.S. App. LEXIS 37307 (Dec. 17, 2021). Resolving reasonable doubt, the Board finds that the Veteran's psychiatric condition had its onset during service. Accordingly, entitlement to service connection for an acquired psychiatric disorder, for substitution purposes, is granted. 2. Entitlement to service connection for residuals of appendectomy. The Veteran sought entitlement to compensation for residuals of appendectomy. While the evidence shows that the Veteran had a post-service medical history of undergoing an appendectomy, the evidence is absent any complaints, diagnosis or treatment of any appendix condition during his service. The Veteran denied any conditions or symptoms related to his appendix during service. See March 2014 STR Medical. The Veteran or Appellant have not provided a specific assertion as to the onset of such condition. Accordingly, the weight of the evidence does not support an occurrence of an in-service injury or event as it pertains to the Veteran's appendix. The Board does not determine that the Veteran's assertions, or absence of, lack credibility merely because those assertions are unaccompanied by contemporaneous medical evidence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). However, the Board finds that the Veteran's assertions are contradicted by the medical reports of symptoms during his service. As mentioned previously, the Veteran denied any issues regarding his appendix. Since there is no probative evidence establishing an in-service event or injury, the Board finds that service connection is not warranted for residuals of appendectomy. 3. Entitlement to service connection for right foot fracture. Regarding whether the Veteran had a current diagnosis of a right foot fracture, on the May 2012 examination report, the Veteran reported that while returning from Guam, he was driving out in a rural area, when the truck dropped off a cliff and he fractured his foot. The examiner noted that in the service treatment records, the Veteran reported breaking his right foot in 1943, as a result of it being ran over in Danville, Illinois. The examiner opined that it was less likely than not that he had a right foot fracture during service. The examiner noted that the 1943 alleged incident happened prior to service. Regarding the right ankle condition diagnosed at the May 2012 examination, based on the review of the medical records, the examiner stated that the Veteran reported injuring his ankle as a teenager. A review of the service treatment records do document the 1947 accident. It was reported that the Veteran sustained chest and back injuries as a result. There were no notations regarding injuring his right foot. As stated by the examiner, the Veteran did report injuring his right foot in 1942 or 1943 while in Danville. See March 2014 STR Medical (November 1952 Report of Medical History); November 1953 VA Examination (November 1953 Report of Medical History). Accordingly, the weight of the evidence does not support an occurrence of an in-service injury or event as it pertains to the Veteran's right foot. Again, the Board does not determine that the Veteran's assertions lack credibility merely because those assertions are unaccompanied by contemporaneous medical evidence. See Davidson, supra; Buchanan, supra. Rather, the Board finds that the Veteran's assertions are contradicted by the medical reports of symptoms. Since there is no probative evidence establishing an in-service event or injury, the Board finds that service connection is not warranted for right foot fracture. 4. Entitlement to service connection for pyoderma and face lacerations. Regarding current diagnoses of the above conditions, the May 2012 examiner noted that while the Veteran did have pyoderma during his service, he denied any recurrences of the condition. On the examination, there were no skin conditions causing scarring or disfigurement of the head, face, or neck. Based on the evidence of the record, the Board finds that the Veteran did not have current disabilities involving pyoderma or facial lacerations. Service connection requires a showing of a current disability. In the absence of proof of a present disability (and, if so, of a nexus between that disability and service), there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board has considered that the current disability requirement is satisfied when the claimant has a disability at the time the claim is filed or during the pendency of the appeal even though the disability may resolve prior to adjudication. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Also, "when the record contains a recent diagnosis of a disability prior to a Veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency." Romanowsky v. Shinseki, 26 Vet. App. 289, 293-94 (2013). However, based on review of the claims file, the evidence does not support that the Veteran had an occurrence of pyoderma or face lacerations during the appeal period. Accordingly, the criteria for service connection have not been met and entitlement is not warranted for these matters. 5. Entitlement to service connection for headaches. Although the post-service medical records show that the Veteran was being treated for migraine headaches, there is no in-service complaints of headaches, nor are there any assertions from the Veteran or Appellant regarding the onset of such headaches. On the November 1952 Report of Medical History, the Veteran denied experiencing frequent or severe headaches. Regarding any head trauma caused by the 1947 accident, it was noted that there was no evidence of trauma to his head or neck. Accordingly, the weight of the evidence does not support an occurrence of an in-service injury or event as it pertains to the Veteran's headaches. Again, the Board does not determine that the Veteran's assertions, or absence of, lack credibility merely because those assertions are unaccompanied by contemporaneous medical evidence. The Board finds that the Veteran's assertions are contradicted by the medical reports of symptoms relating to his head. Since there is no probative evidence establishing an in-service event or injury, the Board finds that service connection is not warranted. 6. Entitlement to service connection for a dental condition. Dental disorders are treated differently than other medical disorders in the VA benefits system. See 38 C.F.R. § 3.381. Under current VA regulations, compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150. These conditions include various conditions of the maxilla, mandible, or temporomandibular articulation, loss of whole or part of the ramus, loss of the condyloid process or coronoid process, loss of the hard palate, or loss of teeth due to loss of substance of the body of the maxilla or mandible due to trauma or disease such as osteomyelitis rather than as a result of periodontal disease. See 38 C.F.R. § 4.150. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not considered disabling conditions, and may be considered service connected solely for establishing eligibility for VA outpatient dental treatment. See 38 C.F.R. § 3.381(a). The evidence does show that the Veteran incurred cavities during service. As stated previously, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not considered disabling conditions. Therefore, entitlement to service connection for a dental condition for compensation purposes must be denied. 7. Entitlement to an initial compensable rating for residuals of rib fracture. The Veteran's service-connected fractured rib disability was rated under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5297. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Here, the use of Diagnostic Code 5321-5297 reflects that there is no diagnostic code specifically applicable to the Veteran's service-connected fractured rib disability, and that the disability has been rated by analogy to removal of ribs, under Diagnostic Code 5297. 38 C.F.R. § 4.20. Under Diagnostic Code 5297, a 10 percent rating is warranted for removal of one rib or resection of two or more ribs without regeneration. A 20 percent rating is warranted for removal of two ribs. A 30 percent rating is warranted where three or four ribs have been removed. A 40 percent rating is warranted where five or six ribs have been removed. A maximum 50 percent rating is warranted for the removal of six or more ribs. 38 C.F.R. § 4.71a. On the November 2010 VA examination, the Veteran reported having continued problems with his ribs since the in-service fracture. He endorsed recurrent pain and episodic shortness of breath. The Veteran experienced flare-ups, every one to two months, lasting one to two weeks. The severity was moderate. The Veteran shared that during the flare-ups, he had to significantly restrict activities. Precipitating factors included prolonged physical activities, coughing or sneezing. The Board notes that the Veteran's residuals of pain, painful breathing, shortness of breath, and resulting functional impairments on movement are not specifically addressed in Diagnostic Code 5297. However, Diagnostic Code 5297 is used to evaluate what is considered a musculoskeletal disability. 38 C.F.R. § 4.40 states that a disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance, and in evaluating such a disability these defects must be taken into consideration. Further, painful motion is entitled to at least the minimum compensable rating for a joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 3-5 (2011). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). The competent medical evidence of record shows that the Veteran consistently reported rib pain, shortness of breath, and limited movement. In this regard, it is recognized that that there is no diagnostic code specifically applicable to the Veteran's service-connected fractured rib disability, and that the service-connected disability is currently rated only by analogy under Diagnostic Code 5297 for removal of rib(s). In view of the foregoing, the Board finds the Veteran's symptoms and resulting limitations are comparable to the minimum, and no higher, 10 percent rating afforded under Diagnostic Code 5297. A higher 20 percent rating is available for removal of two ribs; however, removal of two ribs, or even more ribs, was not demonstrated or approximated at any point during the appeal period. Thus, a 20 percent evaluation, or even higher evaluations for removal of more than two ribs, is not warranted. Additionally, there are no other identified residuals to warrant consideration of other diagnostic codes, as the injury is specific to the Veteran's ribs and does not involve any potentially related muscles. Therefore, for the entire initial rating period, the Board finds that entitlement to a 10 percent rating, but no higher, for the Veteran's rib disability is warranted. REASONS FOR REMAND 1. Entitlement to service connection for skin cancer, to include as due to radiation exposure and sun exposure, is remanded. 2. Entitlement to service connection for prostate cancer, to include as due to radiation exposure, is remanded. 3. Entitlement to service connection for Parkinson's disease, to include as due to radiation exposure, is remanded. The Veteran asserted that the above conditions were due to radiation exposure during his service. The Veteran stated that he participated in Operation Crossroads. In a November 2013 Memorandum from the Defense Threat Reduction Agency, it was determined that the Veteran was assigned to the U.S. Naval Air Base, Kwajalein Atoll, Marshall Islands, as of July 1, 1946. He departed Kwajalein on September 17 and arrived at the U.S. Naval Receiving Station, Guam, Mariana Islands, on September 28, remaining there until departing on October 5, and arriving two days later for duty at the U.S. Naval Base, Manus Island, Admiralty Islands. He remained assigned to duty at the U.S. Naval Base, Manus Island through the end of the six-month post-operational periods for Operation Crossroads. The memorandum continued that personnel assigned to Kwajalein during Operation Crossroads are considered participants only when there is documentation indicating they were present on Kwajalein specifically in support of the operation, or if they were issued a film badge. There was no documentation in the service records indicating that the Veteran served at Kwajalein in support of Operation Crossroads. Additionally, after a search of available dosimetry data, no records of radiation exposure were found. When a Veteran claims service connection for a radiogenic disease and alleges exposure to ionizing radiation during military service, applicable regulations require that a radiation dose assessment be procured from the Under Secretary for Health. 38 C.F.R. § 3.311(a)(2)(iii). A "radiogenic disease" means a disease that may be induced by ionizing radiation. 38 C.F.R. § 3.311(b)(2). For veterans who participated in defined "radiation risk activities" and develop one of the listed diseases, service connection is presumed. 38 C.F.R. § 3.309(d). In all other cases, service connection is determined on a "facts-found" basis. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The Board notes that a radiation risk activity is defined as onsite participation during an official operational period [or the six-month period following the official operational period] of an atmospheric nuclear test, presence at the test site, or performance of duties in connection with equipment used in direct support of nuclear test. 38 C.F.R. § 3.309(d). The November 2013 Memorandum determined that the Veteran served in support of Operation Crossroads according to the regulations. However, the Veteran did not have the diseases listed under 38 C.F.R. § 3.309(d), so entitlement to service connection based on presumption is not warranted here. However, as skin cancer and prostate cancer are radiogenic diseases, entitlement to service connection can be warranted under 38 C.F.R. § 3.311. Regarding requesting dose information, a request should be made for any available records concerning the Veteran's exposure to radiation. These records normally include but may not be limited to the Veteran's Record of Occupational Exposure to Ionizing Radiation (DD Form 1141), if maintained, service medical records, and other records which may contain information pertaining to the veteran's radiation dose in service. All such records will be forwarded to the Under Secretary for Health, who will be responsible for preparation of a dose estimate, to the extent feasible, based on available methodologies. See 38 C.F.R. § 3.311(a)(2)(iii) These claims were not referred for a dosage estimate pursuant to the requirements of 38 C.F.R. § 3.311. See Hilkert v. West, 12 Vet. App. 145, 148 (1999) (holding that "[o]nce a claimant has established a diagnosis of a radiogenic disease within the specified period and claims that the disease is related to his radiation exposure while in service, VA must then obtain a dose assessment"). The Board acknowledges that Parkinson's disease is not listed as a radiogenic disease. However, as service connection can be determined on facts-found basis, any information obtained during the development of the radiation claim will be relevant to the service connection claim for Parkinson's disease. Lastly, pertaining to the skin cancer claim, the Veteran also alleged that his skin cancer developed as a result of sun exposure due to his military duties. Therefore, during remand, the RO should complete the required development outlined in 38 C.F.R. § 3.311. After that development is completed, medical opinions should be obtained to address the nature and etiologies of all three conditions. 4. Entitlement to service connection for peripheral neuropathy of right upper extremity, to include as due to radiation exposure, is remanded. 5. Entitlement to service connection for peripheral neuropathy of left upper extremity, to include as due to radiation exposure, is remanded. 6. Entitlement to service connection for peripheral neuropathy of right lower extremity, to include as due to radiation exposure, is remanded 7. Entitlement to service connection for peripheral neuropathy of left lower extremity, to include as due to radiation exposure, is remanded. Pertaining to the Veteran's peripheral neuropathy, VA treatment records note that the Veteran had a known history of severe peripheral neuropathy "presumably from diabetes and noted previous radiation exposure". See August 2018 VA Medical Treatment Records (CAPRI). Based on this notation, the Board finds that these claims should be remanded while the development of the Veteran's alleged radiation exposure is being completed by the RO. An opinion should be obtained addressing the nature and etiology of the Veteran's neuropathy. 8. Entitlement to service connection for COPD, claimed as punctured lung, is remanded. 9. Entitlement to service connection for OSA is remanded. Regarding the Veteran's lung condition and sleep apnea, in May 2012, a VA examiner opined that while the Veteran did suffer a punctured lung during his active service, his COPD and OSA were less likely than not related to that injury. The examiner stated that the Veteran's shortness of breath did not start till 2011, nearly 50 years after the service incident. The examiner stated that the Veteran's punctured lung would have caused restrictive lung disease much earlier in a way of respiratory compromise. The examiner concluded that the Veteran's claimed punctured lung condition had not caused any residual disability. The Board notes that the Veteran originally filed his claim for service connection for "punctured lung". See November 2010 VA Form 21-4138 (Statement in Support of Claim). The examiner indicated that the Veteran did sustain a punctured lung. The opinion is unclear whether the Veteran currently suffers from a punctured lung. Furthermore, while the examiner provided an explanation regarding whether the punctured lung would cause COPD or OSA, the examiner did not explain why the punctured lung would not have aggravated, i.e., worsen beyond its natural progression, the COPD or OSA. In summation, it is unclear whether the Veteran had a separate condition of a punctured lung related to his service, and if that punctured lung aggravated his COPD or OSA. During the remand, an addendum opinion should be obtained that fully answers the remaining questions of the record regarding the Veteran's lung conditions. 10. Entitlement to service connection for right and left knee conditions. In October 1947, the Veteran complained of pain in his right knee. This was during his treatment for injuries sustained during the 1947 motor vehicle accident. There has been no opinion to address the nature and etiology of the Veteran's knee conditions. Although the service treatment records do not show complaints regarding the Veteran's left knee, based on the complaint of right knee pain, and having current bilateral knee conditions, affording every possible consideration of the claims, an opinion should be obtained to address whether any knee condition was related to the in-service accident. 11. Entitlement to service connection for a gastroesophageal condition, claimed as esophagitis. The post-service medical evidence shows that the Veteran was being treated for gastroesophageal reflux disease (GERD). On the November 1952 Report of Medical History, the Veteran reported that he experienced frequent indigestion. It was explained that he experienced it after meals. There has been no opinion to address whether the Veteran's gastroesophageal condition had its onset during service. Therefore, on remand, an opinion should be obtained. 12. Entitlement to an initial rating in excess of 10 percent for bilateral hearing loss is remanded. The last examination conducted before the Veteran's death was in March 2012. Subsequent VA medical records document the Veteran's complaints and treatment of hearing loss. It was noted that his hearing loss was severe in July 2017. The Veteran shared still having great difficulty hearing even with his hearing aids. See August 2018 CAPRI. There is evidence to indicate a worsening in the Veteran's hearing loss. Unfortunately, an examination to obtain puretone thresholds and speech discrimination scores cannot be conducted. Therefore, in order for the Board to adequately assess the severity of the Veteran's hearing loss during the entire initial rating period, during the remand, the RO should obtain a retrospective opinion that addresses the severity of the Veteran's hearing loss. Accordingly, the matters are REMANDED for the following action: 1. Provide the Appellant an opportunity to identify any pertinent treatment records. The RO should secure any necessary authorizations. Copies of all available private and VA documents should be associated with the Veteran's claims folder. If the records are unavailable, inform the Appellant of such and of the efforts made to obtain them. The Appellant should also be notified that she may submit any such records himself. All efforts should be recorded in the claims folder. 2. Once all medical records have been associated with the file, ensure that all pertinent service records are associated with the file and forward the claims folder and any other available pertinent documents, to include DD Form 1141 (if maintained), service treatment records, and service personnel records, to the VA Under Secretary for Health for a radiation dose estimate, to the extent feasible, in accordance with 38 C.F.R. § 3.311(a)(2)(iii). 3. If it is determined the Veteran was exposed to ionizing radiation, forward the Veteran's claim to the VA Under Secretary for Benefits for consideration in accordance with 38 C.F.R. § 3.311(c). Further consideration by the VA Under Secretary for Benefits includes determining whether sound scientific and medical evidence supports a conclusion that it is at least as likely as not that radiation exposure resulted in the Veteran's skin and prostate cancer, or whether there is no reasonable possibility that the Veteran's cancers resulted from radiation exposure. Either determination should be in writing with supporting rationale. 4. Once all available, relevant medical records have been received and associated with the claims file, the RO should refer the Veteran's entire claims file to a medical professional of appropriate expertise to provide an addendum opinion to address the nature and etiology of the Veteran's conditions. The claims file and a copy of this REMAND should be made available to the examiner for review. After record review, the VA examiner should offer his or her opinion with supporting rationale as to the following inquiries, as clearly and precisely as possible: Prostate Cancer (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's prostate cancer was incurred in, caused by, or etiologically related to the Veteran's service, including exposure to radiation? Skin Cancer (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's skin cancer was incurred in, caused by, or etiologically related to the Veteran's service, including exposure to radiation and the sun? Parkinson's Disease (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's Parkinson's disease was incurred in, caused by, or etiologically related to the Veteran's service, including exposure to radiation? The Board acknowledges that Parkinson's disease is not a radiogenic disease or disease entitled to presumptive service connection based on radiation exposure. The examiner cannot base the opinion solely on that fact. The examiner is asked to consider and discuss the likelihood that the Veteran's Parkinson's disease was related to any exposure to radiation, given the particulars of this Veteran's medical history, family history, and the absence or presence of other risk factors, etc. Peripheral Neuropathy of the Bilateral Upper and Lower Extremities (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's peripheral neuropathy was incurred in, caused by, or etiologically related to the Veteran's service, including exposure to radiation? The Board acknowledges that peripheral neuropathy is not a radiogenic disease or disease entitled to presumptive service connection based on radiation exposure. The examiner cannot base the opinion solely on those facts. The examiner is asked to consider and discuss the likelihood that the Veteran's peripheral neuropathy was related to any exposure to radiation, given the particulars of this Veteran's medical history, family history, and the absence or presence of other risk factors, etc. Lung Conditions (punctured lung, COPD, OSA) (a) Did the Veteran have a current diagnosis of a punctured lung during the pendency of the appeal? (b) If so, was it at least as likely as not (50 percent or greater probability) related to the in-service notation of a punctured lung? (c) It is at least as likely as not that the Veteran's COPD was aggravated (i.e., worsened beyond the natural progress) by a punctured lung? (d) It is at least as likely as not (50 percent or greater probability) that the Veteran's OSA was aggravated (i.e., worsened beyond the natural progress) by a punctured lung? Right and Left Knee Conditions (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's knee conditions were incurred in, caused by, or etiologically related to the Veteran's service, specifically the 1947 motor vehicle accident. Gastroesophageal Condition (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's gastroesophageal condition was incurred in, caused by, or etiologically related to his service. The examiner must address whether the November 1952 notation reporting frequent indigestion was at all related to the onset of the Veteran's condition. 5. Obtain a retroactive medical opinion to determine the severity of the Veteran's bilateral hearing loss disability. The examiner must review the entire claims file and the examination report should note that review. The examiner is asked to address the following: (a) State whether it is at least as likely as not (50 percent or greater probability) that the Veteran's observable hearing loss symptoms were consistent with the numeric designation listing in the diagnostic code for a rating higher the 10 percent. The opinion should include an estimate of audiometric testing results, an estimate of Maryland CNC speech discrimination scores, and a description of the functional effects of the Veteran's hearing loss, after reviewing and considering all the pertinent lay and medical evidence of record. In rendering these opinions, the examiner is advised that the Veteran was competent to report his symptoms and medical history and that such reports must be acknowledged and considered in formulating any opinion. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. A fully-articulated medical rationale for each opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of this Veteran's medical history, pertinent lay evidence, and the relevant medical literature or studies as applicable to this case, which may reasonably explain the medical analysis in the study of this case. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 6. Then, review the record, conduct any additional development deemed necessary, and readjudicate the appeal. If any benefit sought remains denied, furnish to the Appellant (and, if appropriate, her representative) a supplemental statement of the case (SSOC). The Appellant should be afforded the appropriate time period to respond. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. Melissa Barbee Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Middleton, Syesa T. 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.