Citation Nr: 22018135 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 17-23 379 DATE: March 28, 2022 ORDER New and material evidence having been received, the appeal to reopen the claim of entitlement to service connection for a right shoulder disability is granted. Service connection for insomnia is granted. Service connection for a vascular condition is denied. Service connection for sleep apnea is denied. REMANDED Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for migraine headaches is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a neurological disorder of the bilateral lower extremities is remanded. Entitlement to service connection for a neurological disorder of the bilateral upper extremities is remanded. Entitlement to service connection for tinnitus is remanded. FINDINGS OF FACT 1. Rating decisions issued in November 2008, February 2013, and April 2014 denied the claim of entitlement to service connection for a right shoulder disability; the Veteran did not file a timely notice of disagreement, and no evidence was received within one year of the rating decisions, nor were new, relevant service records received any time thereafter. 2. The evidence associated with the claims file subsequent to the April 2014 rating decision denying service connection for a right shoulder disability is not cumulative, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim. 3. The Veteran has a diagnosis of insomnia that was caused and/or aggravated by his service-connected psychiatric disability. 4. The Veteran does not have a currently diagnosed vascular condition. 5. Symptoms of sleep apnea were not continuous or recurrent in service and have not been continuous or recurrent after service separation; and there is no medical nexus between the Veteran's sleep apnea and active service. CONCLUSIONS OF LAW 1. The November 2008, February 2013, and April 2014 rating decisions, which denied service connection for a right shoulder disability, became final. 38 U.S.C. § 7105(a); 38 C.F.R. §§ 20.302, 20.1103. 2. The evidence received subsequent to the April 2014 rating decision denying service connection for a right shoulder disability is new and material, and the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for insomnia have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310. 4. The criteria for service connection for a vascular condition have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 5. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant in this case, had active service from August 1989 to August 1992, followed by Reserve service until 1996. This matter comes before the Board of Veterans' Appeals (BVA or Board) from July 2008, October 2015, September 2016, and August 2017 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). On his VA Form 9, the Veteran requested a Board hearing. A virtual hearing was scheduled for April 29, 2021. However, prior to the hearing, the Veteran cancelled the hearing, and no request has been received asking that the hearing be rescheduled. Under 38 C.F.R. § 20.704(e), a request for hearing may be withdrawn by an appellant at any time before the hearing. Thus, the Board will proceed with appellate review. At the outset, the Board observes that the Veteran filed an initial service connection claim for a back disability in May 2008. The claim was denied in a July 2008 rating decision. He filed a timely notice of disagreement in September 2008; however, a statement of the case was not issued. Therefore, while the AOJ subsequently characterized the back disability claim as one requiring new and material evidence, the Board finds that new and material evidence is not required as the Veteran preserved his claim by filing the timely notice of disagreement to the July 2008 rating decision. With regard to the migraine headaches issue, the Veteran filed an initial claim for service connection in June 2015, and the October 2015 rating decision denied the claim. The Veteran did not include migraine headaches in his notice of disagreement to that rating decision, and instead filed a request to reopen the claim in June 2016, which was denied in the September 2016 rating decision. However, he presented new and material evidence within one year of the October 2015 rating decision; as such, this appeal stems from the initial claim filed in June 2015 and new and material evidence is not required to reopen it. 38 C.F.R. § 3.156(b). New and Material Evidence 1. New and material evidence having been received, the appeal to reopen the claim of entitlement to service connection for a right shoulder disability is granted. In September 2008, the Veteran filed an initial claim for service connection for a right shoulder disability. The claim was denied in a November 2008 rating decision, in which the RO found no evidence of a medical nexus between the right shoulder disability and active service. The Veteran did not file a timely NOD, and no evidence was received within one year of the November 2008 rating decision, nor were new, relevant service records received at any time thereafter. 38 C.F.R. § 3.156(b) and 3.156(c). Consequently, the November 2008 rating decision became final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. In January 2012 and April 2013, the Veteran filed requests to reopen his claim of entitlement to service connection for a right shoulder disability. In February 2013 and April 2014 rating decisions, the RO denied reopening of the claim, finding that no new and material evidence had been received. The Veteran did not file timely NODs, and no evidence was received within one year of the February 2013 or April 2014 rating decisions, nor were new, relevant service records received at any time thereafter. 38 C.F.R. § 3.156(b) and 3.156(c). Consequently, the February 2013 and April 2014 rating decisions became final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. In June 2015, the Veteran filed another request to reopen his claim of entitlement to service connection for a right shoulder disability. In the October 2015 rating decision on appeal, the RO denied reopening of the claim. Based on the procedural history outlined above, the issue for consideration with respect to the Veteran's claim is whether new and material evidence has been received to reopen the claim of entitlement to service connection for a right shoulder disability. Evidence added to the record since the time of the last final denial of the right shoulder disability claim in April 2014 includes a July 2014 VA treatment record showing a diagnosis of and treatment for long-standing right shoulder pain with an MRI revealing partial thickness rotator cuff tears and tendinosis; the Veteran reported that he believed his right shoulder pain was related to an accident on a bus while abroad (during active service) more than 10 years ago. The Board finds that this evidence constitutes new and material evidence as it tends to support the existence of a nexus between the claimed right shoulder disability and active service, which was the basis for the previous denial of the claim. In this regard, the Board notes that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Therefore, the Board finds that the evidence added to the record since the last final April 2014 denial of the right shoulder disability claim constitutes new and material evidence, and that the criteria under 38 C.F.R. § 3.156(a) have been satisfied; therefore, the claim of entitlement to service connection for a right shoulder disability is reopened. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. The claimed conditions are not among the "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) (requiring continuity of a condition after service if chronicity is not found in service) does not apply to this case. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The United States Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a 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); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Further, service connection may be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). 2. Service connection for insomnia is granted. The Veteran contends and the evidence demonstrates that his insomnia is caused and/or aggravated by his service-connected psychiatric disability. He has a 70 percent disability rating for major depressive disorder, effective from June 15, 2015. VA treatment records from August 2008 forward show that the Veteran consistently reported trouble sleeping in the context of receiving mental health treatment, with nightmares occurring frequently. In April 2015, he reported getting 2 hours of sleep "here and there," tossing and turning through the night, and ruminating before falling asleep. VA treatment records from that time forward indicate that he was prescribed a separate medication for insomnia. At an August 2016 sleep disorder consultation, the Veteran reported an onset of insomnia 10 to 15 years prior. He was referred to VA's sleep clinic for treatment of insomnia, separately from treatment for his psychiatric disability. The Board acknowledges that sleep disturbance is a symptom of the Veteran's service-connected psychiatric disability. However, in this case, the Veteran has been separately diagnosed with and treated for insomnia. Therefore, the Board finds that service connection for insomnia is warranted as secondary to his service-connected psychiatric disability. 3. Service connection for a vascular condition is denied. The Veteran contends, without specificity, that he has a vascular condition other than hypertension that is related to active service. However, the Board finds that the evidence does not demonstrate a current diagnosis of any vascular condition other than hypertension, which is addressed in the remand portion of this decision. Service and post-service treatment records are entirely negative for any signs, symptoms, findings, treatment, or diagnosis of a vascular condition. In July 2016, the Veteran submitted an Artery and Vein Conditions DBQ completed by VA clinician, who indicated that he was diagnosed with hypertension in March 2012 and did not diagnose any other vascular conditions. Regarding the Veteran's statements that he has a vascular condition that is related to his active service, the Board recognizes that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. Sept. 14, 2009) (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007)). However, while the Veteran is competent to provide his lay description of symptoms, he is not competent to diagnose or opine on medical etiology for complex medical questions requiring specific medical knowledge and training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). This case involves complex medical matters and requires specific findings and testing to confirm a diagnosis. The question of whether the Veteran has a current vascular condition requires objective medical evidence, which, in this case, is absent. Without a showing of a current disability, the claim for service connection for a vascular condition must be denied. "Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability... in the absence of a proof of present disability there can be no claim." Brammer, 3 Vet. App. at 225. The Board recognizes that the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, where the overall record fails to support a current disability, as is the case here, that holding would not apply. For the foregoing reasons, the Board finds that there is no current vascular condition. As such, the Board does not reach the additional question of the relationship between the claimed disability and active service, and the claim is denied. Because the evidence weighs persuasively against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Service connection for sleep apnea is denied. The Veteran contends that his current sleep apnea is related to his active service. For the reasons discussed below, the Board finds that the weight of the evidence is against a finding of a medical nexus between the claimed sleep apnea and active service. Reviewing the most relevant evidence of record, service treatment records are negative for any signs, symptoms, reports, findings, treatment, or diagnosis of sleep apnea. At the July 1992 separation examination, the Veteran denied frequent trouble sleeping on his Report of Medical History. Following separation from service in 1992, the Veteran's Reserve treatment records are also negative for sleep apnea. At October 1993 and October 1994 physical examinations, the Veteran again denied frequent trouble sleeping. In August 2008, the Veteran reported difficulty sleeping in the context of receiving mental health treatment. In June 2010, he underwent a sleep disorder consultation at which he reported that he snored whenever sleeping and had excessive daytime sleepiness with multiple awakenings at night. He stated that his fiancé noticed occasional breathing pauses at night. The clinician assessed possible sleep apnea and scheduled the Veteran for a sleep study; however, the Veteran did not attend the scheduled study. In June 2013, the Veteran presented for an initial evaluation at the sleep disorders clinic with chief complaint of snoring and difficulty breathing in his sleep. The clinician assessed probable obstructive sleep apnea and scheduled a sleep study, which diagnosed primary snoring and was negative for sleep apnea. The Veteran underwent a sleep disorders consultation in August 2016 at which he reported snoring and gasping at night and daytime sleepiness. A second sleep study revealed mild sleep apnea. The Veteran submitted an August 2017 Sleep Apnea DBQ completed by D.L., whose credentials are not listed. D.L. assessed mild positional sleep apnea with a history of snoring and insomnia. D.L. indicated that the June 2013 sleep study had shown no sleep apnea, but that a later August 2016 sleep study confirmed the diagnosis. She stated that this is extremely mild OSA that was not present on sleep study in 2013 but positional in nature in 2016. She stated his daytime sleepiness may be due to insomnia. She did not provide a nexus opinion. After a review of all of the evidence, lay and medical, the Board finds that the evidence weighs persuasively against a finding that the Veteran's sleep apnea is etiologically related to his active service. Symptoms of sleep apnea were not continuous or recurrent during active service. As noted above, service treatment records are silent as to any symptoms of sleep apnea, and the Veteran denied frequent trouble sleeping during active service, providing highly probative evidence against such a finding. Next, the Board finds that symptoms of sleep apnea were not continuous or recurrent since service separation in 1992. Following service separation, the evidence of record shows no mention of trouble sleeping until 2008, as described above. The absence of post-service complaints, findings, diagnosis, or treatment for 16 years after service separation is one factor that tends to weigh against a finding of continuous symptoms of the claimed disability after service separation. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Other evidence of record showing that symptoms of sleep apnea were not continuous or recurrent since service includes the Veteran's denial of trouble sleeping during his Reserve service, as described above. To the extent that the Veteran's current statements can be interpreted as a claim of continuous or recurrent symptoms of sleep apnea since service, the Board finds that, while the Veteran is competent to report the onset of his observable symptoms, his more recent assertions made in the context of the current disability claim of continuous or recurrent symptoms since service are outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and are not reliable. See Charles v. Principi, 16 Vet. App. 370 (2002). The Board finds that the Veteran's assertion of continuous or recurrent symptoms after service is not accurate because it is outweighed by other evidence of record that includes the more contemporaneous service treatment records, which are negative for sleep apnea and show normal clinical evaluations at the time of separation; the negative Reserve physical examination reports; and the lack of any report of symptoms of trouble sleeping for 16 years after service separation. As such, the Board finds that the evidence does not sufficiently support continuous or recurrent symptomatology since service so as to warrant a grant of service connection. Moreover, the medical evidence of record does not suggest an etiological relationship between the claimed sleep apnea and active service. The Board acknowledges the Veteran's belief that his sleep apnea is related to active service. However, his statements alone do not establish a medical nexus. Indeed, while the Veteran is competent to provide evidence regarding matters that can be perceived by the senses, he is not shown to be competent to render medical opinions on questions of etiology. See Jandreau, 492 F.3d 1372; see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology). As such, as a lay person, he is without the appropriate medical training and expertise to offer an opinion on a medical matter, including the diagnosis, etiology, or causation of a specific disability. The question of diagnosis and causation, in this case, involves complex medical issues that the Veteran is not competent to address. Jandreau, supra. For these reasons, the claim must be denied. Because the evidence weighs persuasively against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a right shoulder disability is remanded. The Veteran suffered an injury to his right shoulder during annual Reserve training in June 1996. Service treatment records show he was diagnosed with right shoulder impingement syndrome, a sprain/stretch injury to the right glenohumeral joint capsule, and bursitis. An x-ray was normal, and an MRI study revealed no evidence of a rotator cuff tear. A March 2013 MRI study revealed low grade partial thickness undersurface tears of the insertional fibers of both the infraspinatus and supraspinatus tendons, which demonstrate moderate underlying tendinosis. The Veteran was afforded a VA examination in October 2008. The examiner opined that the current right shoulder condition was not related to military service, reasoning that physical examination of the right shoulder on June 14, 1996 was normal, an x-ray on July 24, 1996 was normal, and he was diagnosed with a right shoulder strain on July 26, 1996. The examiner stated that, generally, a right shoulder strain can occur without residual effects. Therefore, his right shoulder strain was not due to military service. The Board finds that the October 2008 VA examiner's opinion is inadequate in that the examiner relied on a hypothetical premise that a shoulder strain can, in theory, resolve without residuals, and did not address this particular Veteran's case. A new VA examination and opinion is necessary prior to appellate review. 2. Entitlement to service connection for migraine headaches is remanded. The Veteran contends that his migraine headaches, which are documented in his post-service treatment records since 2008, were caused and/or aggravated by his service-connected psychiatric disability. No VA opinion has been obtained with regard to the claimed migraine headaches. As such, a remand is necessary to obtain a VA examination and opinion regarding the nature and etiology of the migraine headaches. 3. Entitlement to service connection for hypertension is remanded. The Veteran contends that his hypertension, which is documented in his post-service treatment records since 2011, was caused and/or aggravated by his service-connected psychiatric disability. No VA opinion has been obtained with regard to the claimed hypertension. As such, a remand is necessary to obtain a VA examination and opinion regarding the nature and etiology of the hypertension. 4. Entitlement to service connection for a back disability is remanded. The Veteran contends that his back disability is related to injuries that occurred during active service. First, he contends that he suffered a fall from a ladder in 1992 while on board the USS Estocin and has had continuous back pain since that time. The claims file includes several buddy statements which corroborate that the Veteran had back pain after a fall in 1992. He also reported occasional lower back pain with heavy lifting at his July 1992 separation examination and clinical evaluation revealed decreased range of motion of the spine. Second, he states his back disorder was aggravated in June 1996 when he was involved in a bus accident and was diagnosed with a lumbosacral strain. He has also averred that his back disability was caused or aggravated by an altered gait due to his service-connected plantar fasciitis and bilateral ankle disabilities. A March 2013 Aid and Attendance examination report indicates that the Veteran had an antalgic gait and used a cane due to his ankle disabilities. The Veteran was afforded a VA examination in September 2015. The examiner diagnosed a lumbosacral strain and opined that the current back condition was less likely than not due to his military service. Although the July 1992 separation examination reported decreased range of motion for "spine, other musculoskeletal," another report of medical exam dated in October 1994 reflected a normal "spine, other musculoskeletal." Further, the examiner stated that although in 1996, while the Veteran was in the Reserves, he was treated for a lumbosacral strain, it was less likely than not that his current back condition is related to a strain which occurred almost 20 years ago. The September 2015 examiner did not address the Veteran's competent statements regarding continuous back pain since 1992, nor did the examiner address whether the back condition was caused or aggravated by an altered gait due to service-connected ankle disabilities. A remand is necessary to obtain a VA examination and opinion which addresses the nature and etiology of the Veteran's back disability. 5. Entitlement to service connection for a neurological disorder of the bilateral lower extremities is remanded. The Veteran contends that he has a neurological disorder of the bilateral lower extremities (radiculopathy) related to his claimed back disability. A July 2008 VA treatment note indicates he reported a fall in 1989 (presumably mis-recorded and should be 1992) involving a low back injury, leg numbness, and leg weakness. He reported current pain in his left foot. Subsequent VA treatment records document reports of lower extremity weakness, and the Veteran has reported numbness and tingling in his legs during the course of this appeal. At the September 2015 VA back examination, the examiner indicated that the Veteran did not have any radicular pain or any other signs or symptoms of radiculopathy, despite the Veteran's reports otherwise. A remand is necessary to fully assess the nature and etiology of the Veteran's bilateral lower extremity disorder, to include whether or not it is etiologically related to the claimed back disability. 6. Entitlement to service connection for a neurological disorder of the bilateral upper extremities is remanded. The Veteran contends that he has a bilateral upper extremity neurological disorder (claimed as numbness and tingling) related to active service or to a service-connected disability. As noted above, his Reserve service treatment records show a diagnosis of right shoulder impingement in June 1996. VA treatment records from 2008 list a diagnosis of cervical radiculopathy; however, an EMG/NCV study of the right upper extremity conducted many years later in September 2017 was normal with no electrophysiologic evidence of a right upper extremity neuropathy, brachial plexopathy, or a right cervical radiculopathy. In April 2013, he reported intermittent right hand paresthesias with prolonged sitting and overhead activity in conjunction with a physical therapy evaluation for his right shoulder. Based on the foregoing, the Board finds that a VA examination is necessary to provide clarification on the nature and etiology of the bilateral upper extremity neurological symptoms, to include an opinion as to whether the right upper extremity symptoms could be related to the claimed right shoulder disorder or to the in-service shoulder injury in 1996. 7. Entitlement to service connection for tinnitus is remanded. The Veteran has not been afforded a VA examination to determine the etiology of his claimed tinnitus; therefore, a remand is necessary to obtain a VA examination and opinion regarding the etiology of his tinnitus. The matters are REMANDED for the following action: 1. Obtain a VA examination and opinion from an appropriate specialist to address the nature and etiology of the Veteran's right shoulder disability. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. (a.) The examiner should first identify any and all right shoulder disorders. (b.) The examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's right shoulder disability was incurred during or caused by active service, to include as due to the documented right shoulder injury in June 1996? Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any 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. 2. Obtain a VA examination and opinion from an appropriate specialist to address the nature and etiology of the Veteran's migraine headaches. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. (a.) The examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's migraine headaches were incurred during or caused by active service? (b.) Next, the examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's current migraine headaches were caused or aggravated by the service-connected psychiatric disability? Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. Note: The term "aggravated" in the above context refers to a worsening of the pre-existing or underlying condition, as contrasted to temporary or intermittent flare-ups of symptoms which resolve with return to the previous baseline level of disability. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any 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. 3. Obtain a VA examination and opinion from an appropriate specialist to address the nature and etiology of the Veteran's hypertension. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. (a.) The examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's hypertension was incurred during or caused by active service? (b.) Next, the examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's current hypertension was caused or aggravated by the service-connected psychiatric disability? Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. Note: The term "aggravated" in the above context refers to a worsening of the pre-existing or underlying condition, as contrasted to temporary or intermittent flare-ups of symptoms which resolve with return to the previous baseline level of disability. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any 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. 4. Obtain a VA examination and opinion from an appropriate specialist(s) to address the nature and etiology of the Veteran's back disability and bilateral lower extremity neurological disorder. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner(s) should be accomplished, and a rationale for any opinion expressed should be provided. The claims file must be made available to the examiner(s) for review of the history in conjunction with the examination, and the examination report(s) should reflect that such review was accomplished. (a.) The examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's back disability was incurred during or caused by active service? The examiner should discuss the July 1992 separation examination report showing decreased range of motion of the spine and reports of occasional lower back pain, as well as the June 1996 treatment records documenting a lumbosacral strain. The examiner must also discuss the Veteran's statements that he has had continuous back pain since his fall in 1992 and is advised that the Veteran is competent to describe symptoms that are observable by a lay person, such as back pain. If the examiner rejects the Veteran's reports regarding his symptoms, the examiner must provide a reason for doing so. (b.) Next, the examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's current back disability was caused or aggravated by an altered gait due to the service-connected bilateral ankle disabilities? The examiner should specifically discuss the March 2013 Aid and Attendance examination report indicating that the Veteran had an antalgic gait and used a cane due to his ankle disabilities. (c.) The examiner should record all bilateral lower extremity symptoms reported by the Veteran and is advised that he is competent to report symptoms observable by a lay person, such as pain, numbness, and tingling. Based on the Veteran's reported symptoms and physical examination, the examiner should identify all current bilateral lower extremity neurological disorders. (d.) The examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's bilateral lower extremity neurological disorder was incurred during or caused by active service? The examiner should discuss the July 2008 VA treatment record reflecting that the Veteran reported leg weakness and numbness in the context of his 1992 fall, as well as his current reports of numbness and tingling. (e.) Next, the examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's bilateral lower extremity neurological disorder was caused or aggravated by his back disability? Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. Note: The term "aggravated" in the above context refers to a worsening of the pre-existing or underlying condition, as contrasted to temporary or intermittent flare-ups of symptoms which resolve with return to the previous baseline level of disability. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any 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. 5. Obtain a VA examination and opinion from an appropriate specialist to address the nature and etiology of the Veteran's bilateral upper extremity neurological disorder. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. (a.) The examiner should first record all upper extremity neurological symptoms reported by the Veteran, and then identify all upper extremity neurological disorders based on his reports as well as physical examination. (b.) The examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's bilateral upper extremity neurological disorder was incurred during or caused by active service, to include as a result of the 1996 injury to the right shoulder as well as any other in-service injuries reported by the Veteran? (c.) Next, the examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's current right upper extremity neurological disorder was caused or aggravated by his right shoulder disability? Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. Note: The term "aggravated" in the above context refers to a worsening of the pre-existing or underlying condition, as contrasted to temporary or intermittent flare-ups of symptoms which resolve with return to the previous baseline level of disability. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any 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. Obtain a VA examination and opinion from an appropriate specialist to address the nature and etiology of the Veteran's tinnitus. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. (a.) The examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's tinnitus was incurred during or caused by active service? Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any 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. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Sherrard, 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.