Citation Nr: 22018522 Decision Date: 03/29/22 Archive Date: 03/29/22 DOCKET NO. 18-22 109 DATE: March 29, 2022 ORDER Entitlement to service connection for a cervical spine disorder is denied. Entitlement to service connection for a low back disorder is denied. Entitlement to service connection for a heart disorder is denied. Entitlement to service connection for benign prostate hypertrophy (BPH) is denied. Entitlement to service connection for a right knee disorder, to include arthritis, is denied. Entitlement to service connection for a left knee disorder, to include arthritis, is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to an initial rating in excess of 10 percent for gastroesophageal reflux disease (GERD) is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is denied. REMANDED Entitlement to service connection for right index trigger finger is remanded. Entitlement to service connection for anemia, to include as secondary to service-connected GERD, is remanded. FINDINGS OF FACT 1. The evidence persuasively weighs against finding that a cervical spine disorder, to include arthritis, began during active service or within one year of service, or is otherwise related to an in-service injury, event, or disease. 2. The evidence persuasively weighs against finding that a low back disorder, to include arthritis, began during active service or within one year of service, or is otherwise related to an in-service injury, event, or disease. 3. The evidence persuasively weighs against finding that a heart disorder began during active service or within one year of service, or is otherwise related to an in-service injury, event, or disease. 4. The evidence persuasively weighs against finding that benign prostate hypertrophy began during active service or within one year of service, or is otherwise related to an in-service injury, event, or disease. 5. The evidence persuasively weighs against finding that a bilateral knee disorder began during active service or within one year of service, or is otherwise related to an in-service injury, event, or disease. 6. The evidence persuasively weighs against finding that sleep apnea began during active service or within one year of service, or is otherwise related to an in-service injury, event, or disease. 7. Throughout the period on appeal, the Veteran's GERD has been manifested by pyrosis, reflux, regurgitation, and sleep disturbance, but has not resulted in persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 8. The Veteran does not meet the minimum threshold requirements for a TDIU on a schedular basis; his service-connected disabilities are not sufficient to preclude all forms of substantially gainful employment consistent with his education and occupational background at any time during the pendency of this claim. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical spine disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a low back disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a heart disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a benign prostate hypertrophy are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for a right knee disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for a left knee disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for sleep apnea are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for an initial rating in excess of 10 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.114, Diagnostic Code 7346. 9. The criteria for establishing entitlement to TDIU have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1964 to May 1967. The Veteran testified before the undersigned Veterans Law Judge at a March 2021 hearing. A transcript of the hearing has been associated with the claims file. These issues, along with entitlement to service connection for bilateral hand and bilateral foot frostbite residuals, were remanded by the Board in a June 2021 decision for further development. As a result, the issues of entitlement to service connection for bilateral hand and bilateral foot frostbite residuals were granted service connection. As this is the benefit sought on appeal, the issues of entitlement to service connection for bilateral hand and bilateral foot frostbite residuals are no longer on appeal to the Board. The remaining issues have since returned to the Board for appellate review. Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, 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. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection for certain chronic diseases, including arthritis, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(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. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309 (2017); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Federal Circuit has held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic. See Walker, supra; 38 C.F.R. § 3.309(a). Secondary service connection is warranted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Briefly, the threshold legal requirements for a successful secondary service connection claim are: (1) Evidence of a current disability for which secondary service connection is sought; (2) a disability for which service connection has been established; and (3) competent evidence of a nexus between the two. In relevant part, 38 U.S.C. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit has held that "[l]ay 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). Once evidence is determined to be competent, the Board must then determine whether such evidence is also credible. See Layno, 6 Vet. App. at 469. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Cervical and Thoracolumbar Spine Disorders The Veteran asserts that he is entitled to service connection for a cervical spine disorder on a direct basis. However, as outlined below, the evidence persuasively weighs against finding that the Veteran's cervical spine disorder manifested during, within the year following, or as a result of active service. As such, service connection cannot be established on a direct basis. On the February 1967 service treatment record (STR) separation examination, the medical provider indicated the Veteran's neck and spine are normal. In a December 2011 VA treatment record, the Veteran stated he has experienced pain in the neck and low back since a 1986 motor vehicle accident. He stated he has a diagnosis of spondylitis since 2007. An October 2014 private medical provider stated Veteran has been under his care since July 2007 for neck and low back disorders. On the April 2018 substantive appeal, the Veteran stated that his cervical and thoracolumbar spine disorders are manifested by inflammation and stiffness since service and has persisted since separation from service. He stated the range of motion is limited due to pain. At the March 2021 Board hearing, the Veteran testified that there was no injury that caused the neck or thoracolumbar spine disorders. Board Hearing Transcript (T.) at 11. The Veteran stated that crawling under and over heavy equipment caused his neck problems. Id. He stated that in service, he was required to repair and operate heavy equipment, to include tractors, dozers, and fire engines. Id. The Veteran stated he has experienced neck pain since separation from service. T. at 12. In a May 2021 private treatment letter, the treatment provider stated that the Veteran has multiple areas of osteoarthritis and degenerative disc disease. The treatment provider stated these disorders may be related to the Veteran's military service. On the August 2021 VA neck examination, the examiner indicated the Veteran has a diagnosis of ankylosing spondylitis. The Veteran stated he noted neck pain in 1972. He stated it worsened through the years. He stated he was diagnosed with ankylosing spondylitis in 2005 and has injection every two months. He stated he experiences radiation of pain down the arms. On the August 2021 VA back examination, the examiner indicated the Veteran has a diagnosis of ankylosing spondylitis, degenerative arthritis, degenerative disc disease (DDD), lumbar strain, and a compression fracture. The Veteran stated he began to have back pain in 1979. He stated the pain became worse through the years. He stated he had an industrial accident in 1986 when a stacker crane fell, and he was strapped in the seated position. He stated this accident resulted in the compression fracture. He stated he was diagnosed with ankylosing spondylitis in 2005. VA sought clarifying opinions for the cervical and thoracolumbar spine opinions in November 2021. The November 2021 VA examiner opined that the Veteran's cervical spine disorder is less likely than not caused by service. The examiner reasoned that the Veteran's repeated use of tools and bending and lifting during service could have caused neck pain, however there is no documentation of this occurring or even treatment right after service. The examiner stated that the Veteran's ankylosing spondylitis was diagnosed in 2005, over 30 years after separation from service. Therefore, the examiner stated that it is reasonable to state the Veteran's cervical spine disorder did not occur in service. The November 2021 VA examiner opined that the Veteran's low back disorder is less likely than not caused by service. The examiner reasoned that the Veteran's claim file shows no treatment in service or on the February 1967 separation examination. The examiner stated the Veteran's repeated use of tools and bending and lifting during service could have caused pain while in service, however there is no documentation of this occurring or even treatment right after service. The examiner stated that the Veteran's back pain more likely was the result of the compression fracture in 1986. Furthermore, the examiner stated that the Veteran's back pain became worse after the diagnosis of ankylosing spondylitis in 2005. The examiner stated that the degenerative arthritis and DDD was not seen on imaging until 2014, over 30 years after separation from service. The examiner concluded that it is reasonable to state that the Veteran's low back disorder did not occur in service. Based on the foregoing, the Board finds that there is evidence of a current disability for both the cervical and thoracolumbar spines. Likewise, the Board notes that the in-service element has been met in this case, as previously noted by the Board's acceptance of the Veteran's lay statement that he had neck and low back pain in service as a result of his duties as a mechanic. The first two elements of service connection are therefore met, and the Board will focus solely on the nexus element. Initially, the Board acknowledges the Veteran's statements throughout the record that he has had neck and low back pain since military service. The Board, however, finds those statements to be not credible. As noted above, the Veteran did not report any neck or low back pain during military service, at separation from military service, or within the first year after military service. Indeed, the first evidence of any neck or low back pain in the record is the Veteran's statements in December 2011 that he had neck and low back pain since a 1986 motor vehicle accident. Notably, these statements are internally inconsistent with the Veteran's other statements of record that he had neck and low back pain since military service. The Board finds these statements in December 2011 to be inherently more credible and probative. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care); Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the Veteran). Consequently, the Board finds that there is no competent and credible evidence that the Veteran's initial manifestations of his neck and low back disorders have been chronic and continuous from military service. Rather, the evidence of record does not disclose any evidence of neck or low back pain until many years after military service. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim, which weighs against the claim). Moreover, the evidence of record demonstrates that the onset of neck and low back pain after military service coincides with evidence of an intervening injury to the Veteran's neck and back post-service. Finally, the Board notes that the Veteran has not demonstrated he has the requisite medical knowledge and expertise to provide a nexus opinion in this case. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). Thus, although the Board acknowledges the Veteran's statements and sincere beliefs that his neck/cervical spine and low back/thoracolumbar spine disorders are related to military service, such statements are not credible nexus opinions. Regarding competent nexus evidence, the Board acknowledges the May 2021 private treatment letter stating that the Veteran's arthritis and DDD may be caused by service. The Board finds that this statement is not probative because of the speculative nature of the opinion. See Tirpak v. Derwinski, 2 Vet. App. 609, 610 (1992) (doctor's letter stating probability in terms of "may or may not" was speculative). Likewise, the May 2021 private treatment provide does not reference any evidence of record from the Veteran's service treatment records or medical history to inform his medical opinion. Instead, his statement that it "may be related" to military service is conclusory in nature without any explanation for that conclusion. See Guerrieri v. Brown, 4 Vet. App. 467 (1993) (the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches.); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (the failure of the physician to provide a basis for his/her opinion affects the weight or credibility of the evidence). Instead, the Board finds the November 2021 examiner's opinions to be the most probative evidence of record in this case. That examiner reviewed the entire record and provided well-reasoned medical opinion based on the evidence of record. The other evidence of record does not refute November 2021 examiner's findings. As such, the Board finds that the evidence of record does not demonstrate that the Veteran's cervical spine and thoracolumbar spine disorders were incurred in or otherwise the result of military service, to include duties as a mechanic of large and heavy equipment. Accordingly, service connection for a cervical spine and thoracolumbar spine disorders are not warranted based on the evidence of record at this time. See 38 C.F.R. §§ 3.303, 3.307, 3.309. Heart Disorder The Veteran asserts that he is entitled to service connection for a heart disorder on a direct basis. However, as outlined below, the evidence persuasively weighs against finding that the Veteran's heart disorder manifested during, within the year following, or as a result of active service. As such, service connection cannot be established on a direct basis. On a February 1967 STR separation examination, the medical provider indicated the Veteran's heart is normal. In a September 2010 private treatment record, the Veteran complained of chest discomfort for the last few months. He stated the pain lasts about an hour at a time. He stated he also noticed pain when he is walking. The medical provider assessed the Veteran to have nonspecific chest pain syndrome. The provider stated this could be a variant of angina. In August 2014 private treatment record, the Veteran complained of shortness of breath. He stated he has shortness of breath with exertion and gets tired and short of breath with normal daily activities. The medical provider indicated the Veteran was being assessed for congestive heart failure (CHF). In a December 2014 private treatment record progress note, the medical provider stated the Veteran's CHF is due to diastolic dysfunction from hypertension. In a June 2015 private treatment record, the medical provider stated the Veteran has diastolic heart failure secondary to hypertension. At the March 2021 Board hearing, the Veteran testified that he was diagnosed with fluid around the heart and a disorder with a valve. T. at 23. The Veteran stated the valve is prevent the blood from flowing back to the feet. Id. He stated that during service he experienced pain in the legs to the ankles. Id. The Veteran stated his foot pain was caused by prolonged standing and tightness. Id. On the August 2021 heart examination, the examiner indicated the Veteran has a diagnosis of CHF. The Veteran stated he experiences shortness of breath. He stated when he was admitted to the hospital, he was observed to have fluid around his heart. He stated he has follow-up treatment with a cardiologist every three to five years. He stated he was told he has a leaky valve. The October 2021 VA medical opinion stated that the Veteran's CHF and hypertensive heart disease is less likely than not caused by service. The examiner reasoned that the Veteran's claim file shows no documentation of a heart disability during service or on the February 1967 separation examination, which showed a normal heart condition. The examiner stated that the Veteran's blood pressure on the separation examination was 118/80, which is normal. The examiner stated that the Veteran's heart disorder did not present itself until 2014, over 40 years after separation from service. Therefore, the examiner found that it is reasonable to state that the Veteran's heart disorder did not occur in service. Initially, the Board acknowledges that the Veteran has diagnoses of hypertension and CHF related to his hypertension; therefore, the first element of service connection has been met in this case. The Board will address both of those. The Board further acknowledges that hypertension is known to have some association with tactical herbicide exposure. However, such is not relevant in this case, as the Veteran has not alleged any exposure to herbicides as a result of his military service. Moreover, the Veteran's Form DD-214 shows that although he had foreign service during the Vietnam era, such service was in Europe and not in the Republic of Vietnam or the territorial waters thereof. Furthermore, there is no evidence that the Veteran's heart disorder was manifested in service or to a compensable degree in the first year following his separation from service. Consequently, service connection for a heart disorder on the basis that such became manifest in service and persisted, or on a presumptive basis (as a chronic disease under 38 U.S.C. § 1112), is not warranted. Notably, the Veteran has not submitted competent evidence to show that he has suffered from the heart disorder continuously since service. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). Turning to other nexus evidence, the Board notes that the Veteran has not demonstrated he has the requisite medical knowledge and expertise to provide a nexus opinion in this case. See Jandreau, supra; see also Jones, supra. Thus, although the Board acknowledges the Veteran's statements and sincere beliefs that his heart disorders are related to military service, such statements are not credible nexus opinions. The sole competent evidence of record regarding a nexus to military service is the October 2021 VA examiner's medical opinion. That examiner found that the Veteran's heart disorders were not the result of military service. That examiner reviewed the entire record and provided well-reasoned medical opinions based on the evidence of record. The other evidence of record does not refute October 2021 examiner's findings. As such, the Board finds that the evidence of record does not demonstrate that the Veteran's heart disorders, to include hypertension and CHF, were incurred in or otherwise the result of military service. Accordingly, service connection for heart disorders is not warranted based on the evidence of record at this time. See 38 C.F.R. §§ 3.303, 3.307, 3.309. Benign Prostate Hypertrophy (BPH) The Veteran asserts that he is entitled to service connection for BPH on a direct basis. However, as outlined below, the evidence persuasively weighs against finding that the Veteran's benign prostate hypertrophy manifested during, within the year following, or as a result of active service. As such, service connection cannot be established on a direct basis. On the February 1967 STR separation examination, the medical provider indicated the Veteran's genitourinary system is normal. In a June 2010 private treatment record the Veteran complained of nocturia every two hours. The medical provider assessed the Veteran to have benign prostatic hypertrophy. In an October 2013 private treatment record, the Veteran complained of recent worsening urinary symptoms of weak stream and nocturia. In a December 2014 private treatment record, the Veteran reported urinary hesitancy, lower abdomen pain, and nausea that started that day. The medical provider diagnosed the Veteran with nausea and abdominal pain. In an October 2015 private treatment record, the medical provider assessed the Veteran's benign prostatic hypertrophy is age related. On the April 2018 substantive appeal, the Veteran stated his benign prostate disorder was undiagnosed until the pain and ability to relieve began to be uncontrollable. The Veteran asserts this disorder is a secondary disability. At the March 2021 Board hearing, the Veteran testified that that he has to urinate frequently, approximately every hour. T. at 15. The Veteran stated he urinates three or four times a night. Id. The Veteran stated he also has urinary infections once every six or eight months. T. at 16. The Veteran stated that in service he increased urinary frequency. T. at 17. He stated that during service he awakened to urinate one to two times a night. Id. He testified that his disorder has worsened. Id. On the August 2021 VA male reproductive organ examination, the examiner indicated the Veteran has a diagnosis of erectile dysfunction (ED) and BPH. The Veteran stated the BPH had its onset in the 1990s. The Veteran noted urinary frequency for many years. He stated he is not being treated for the disorder. He stated his symptoms are worsening. He stated ED had its onset about six years prior. He stated he has been told he is prediabetic, but he is not taking any medications. The October 2021 VA examiner opined that the Veteran's BPH is less likely than not caused by service. The examiner reasoned that the claims file does not show any prostate condition during service or on the February 1967 separation examination. The examiner noted that the Veteran's prostate issues did not start until 1990, over 20 years after separation from service. Therefore, the examiner stated that the Veteran's prostate disorder did not occur in service. Initially, the Board reflects that the Veteran has BPH and therefore the first element of service connection has been met. However, there is no evidence that the Veteran's BPH was manifested in service or to a compensable degree in the first year following his separation from service. Consequently, service connection for a BPH on the basis that such became manifest in service and persisted, or on a presumptive basis (as a chronic disease under 38 U.S.C. § 1112), is not warranted. See 38 C.F.R. § 3.303(b); Savage, supra. The Board notes that insofar as the Veteran's hearing testimony seems to indicate that the Veteran testified that his BPH began in service although it was not diagnosed until many years later when his symptoms became uncontrollable, the Board finds those statements to be not credible with the other evidence of record, including the lack of in-service treatment or complaints, as well as the normal prostate on separation from service. The Board further notes that the Veteran's testimony is internally inconsistent with the medical history provided to the October 2021 examiner, noting onset of symptoms many years after military service. Turning to other nexus evidence, the Board notes that the Veteran has not demonstrated he has the requisite medical knowledge and expertise to provide a nexus opinion in this case. See Jandreau, supra; see also Jones, supra. Thus, although the Board acknowledges the Veteran's statements and sincere beliefs that his BPH is related to military service, such statements are not credible nexus opinions. The sole competent evidence of record regarding a nexus to military service is the October 2021 VA examiner's medical opinion. That examiner found that the Veteran's BPH was not the result of military service. That examiner reviewed the entire record and provided well-reasoned medial opinions based on the evidence of record. The other evidence of record does not refute October 2021 examiner's findings. As such, the Board finds that the evidence of record does not demonstrate that the Veteran's BPH was incurred in or otherwise the result of military service. Accordingly, service connection for BPH is not warranted based on the evidence of record at this time. See 38 C.F.R. §§ 3.303, 3.307, 3.309. Bilateral Knee Disorders The Veteran asserts that he is entitled to service connection for a bilateral knee disorder on a direct basis. However, as outlined below, the evidence persuasively weighs against finding that the Veteran's bilateral knee disorder manifested during, within the year following, or as a result of active service. As such, service connection cannot be established on a direct basis. In a June 1966 STR, the Veteran was treated for a left knee abrasion. The February 1967 STR separation examination noted the Veteran's lower extremities are normal. In a September 2014 private treatment record the Veteran complained of right knee pain compatible with an acute gouty episode. In a November 2014 private treatment record, imaging showed the Veteran to have degenerative change in the left knee. In a December 2014 private physical therapy reassessment, the Veteran complained of joint pain, joint stiffness, and muscle weakness. In a May 2015 private treatment record the Veteran complained of increased generalized pain in the bilateral knees for the past week and a half. In a June 2015 private treatment record, the medical provider stated the Veteran has arthritis in the bilateral knee. On the April 2018 substantive appeal, the Veteran stated he experienced bilateral knee symptoms since service. He stated the bilateral knees have pain. At the March 2021 Board hearing, the Veteran testified he was a mechanic during service. T. at 18. The Veteran stated he had to crawl on his knees to go under or over the dozers and tractors. Id. The Veteran stated he is now unable to work on his knees. T. at 19. In a May 2021 private treatment letter, the treatment provider stated that the Veteran has multiple areas of osteoarthritis and degenerative disc disease. The treatment provider stated these disorders may be related to the Veteran's military service. On the August 2021 VA knee examination, the examiner indicated the Veteran has a diagnosis of bilateral knee strain and left knee arthritis. The Veteran stated that he noted knee pain during service in 1965 as a heavy equipment mechanic. He stated he did not seek care or receive care. He stated that he has worked as a repairman, crane operator, and a forklift operator. He stated he treated his knees with cream and an ace wrap. In the October 2021 VA medical opinion, the examiner opined that the Veteran's left knee arthritis and bilateral knee strain are less likely than not caused by service. The examiner reasoned that the Veteran worked as a heavy equipment operator during service and after separation from service he worked as a general electrician, repairman, crane operator, and a forklift operator for 41 years. The examiner stated there is no documentation showing any knee condition in service that may lead to a condition now. The examiner stated that the left knee arthritis was noted in 2014, over 45 years after separation from service. The examiner concluded that it is more likely that the bilateral knee disorders were caused by his work after separation from service because he worked manual labor for 41 years. Initially, the Board reflects that the Veteran has bilateral knee disorders and therefore the first element of service connection has been met. Likewise, the Board notes that the in-service element has been met in this case, as the service evidence demonstrates a left knee abrasion, as well as the Board's acceptance of the Veteran's lay statement that he had knee in service as a result of his duties as a mechanic. The first two elements of service connection are therefore met, and the Board will focus solely on the nexus element. As previously discussed with regards to the Veteran's cervical and thoracolumbar spine disorders, the Board finds that the Veteran's own statements regarding a nexus to service are not competent. See Jandreau, supra; see also Jones, supra. Furthermore, as also previously discussed, the Board finds the May 2021 private treatment provider's statement to be not credible or probative. See Tirpak, supra; Guerrieri, supra; Curry, supra. Turning to the other nexus evidence, the Board notes that the evidence does not demonstrate any chronic or continuous problems with the left knee after the abrasion in service, nor any problems with the right knee during military service. The Veteran's separation examination is normal as to his bilateral knees. Further, it does not appear that the Veteran has indicated that he had continued pain and knee issues since discharge from service, but rather he did not report any problems with his knees until many years after discharge from service. See Maxson, supra. Consequently, service connection for a bilateral knee disorder on the basis that such became manifest in service and persisted, or on a presumptive basis (as a chronic disease under 38 U.S.C. § 1112), is not warranted. Notably, the Veteran has not submitted competent evidence to show that he has suffered from the bilateral knee disorder continuously since service. See 38 C.F.R. § 3.303(b); Savage, supra. The sole competent evidence of record regarding a nexus to military service is the October 2021 VA examiner's medical opinion. That examiner found that the Veteran's bilateral knee disorders were not the result of military service, but rather a lifetime of post-service occupational stress. That examiner reviewed the entire record and provided well-reasoned medical opinions based on the evidence of record. The other evidence of record does not refute October 2021 examiner's findings. As such, the Board finds that the evidence of record does not demonstrate that the Veteran's bilateral knee disorders were incurred in or otherwise the result of military service. Accordingly, service connection for bilateral knee disorders is not warranted based on the evidence of record at this time. See 38 C.F.R. §§ 3.303, 3.307, 3.309. Sleep Apnea The Veteran asserts that he is entitled to service connection for sleep apnea on a direct basis. However, as outlined below, the evidence persuasively weighs against finding that the Veteran's sleep apnea manifested during, within the year following, or as a result of active service. As such, service connection cannot be established on a direct basis. On the February 1967 STR separation report of medical history, the Veteran reported he did not experience frequent trouble sleeping. In a December 2010 private treatment record the Veteran complained of difficulty sleeping in the last month. The Veteran stated that he experienced choking that wakes him up at night. The Veteran stated he does snore. The Veteran stated he felt short of breath at the time of choking, which resolved after a few days. The medical provider assessed the Veteran to have possible sleep apnea. On the April 2018 substantive appeal, the Veteran stated the sleep apnea persisted and is manifested with changes in sleep patterns during active duty. He stated during service he had restless nights that required the use of sleep aids. At the March 2021 Board hearing, the Veteran testified he was diagnosed with sleep apnea in 2005. T. at 20. The Veteran stated that in service he snored and would have a sore throat and nose. Id. He stated that after separation from service he was experiencing a sore throat and he was then diagnosed with sleep apnea. Id. In a May 2021 lay statement, L.B. stated that the Veteran experiences loud snoring, grunting, and gasping for air several times a night. She stated these symptoms caused the Veteran to wake. She also stated that the Veteran will stop breathing and requires someone to wake and reposition him. She stated the Veteran wakes complaining of headaches and feeling fatigued during the day. In a May 2021 lay statement, the Veteran's wife stated that the Veteran snored badly after separation from service. She stated she would have to wake the Veteran and turn him from his back. She stated that some nights they had to sleep apart. The August 2021 VA sleep apnea examiner indicated the Veteran has a diagnosis of obstructive sleep apnea. The Veteran stated that experienced fatigue and at age 60 he obtained a sleep study diagnosing him with sleep apnea. He stated that he was a smoker and quit in 1988. The October 2021 VA examiner opined that the Veteran's sleep apnea is less likely than not caused by service. The examiner reasoned there is no documentation in the Veteran's claims file showing any sleep conditions that was treated in service or on the February 1967 separation examination. The examiner noted that the Veteran noted fatigue at the age 60 and had a sleep study showing sleep apnea. The examiner noted the Veteran was a smoker and quit smoking in 1988.The examiner stated that risk factors for sleep apnea include obesity, being male, and smoking. The examiner concluded that the Veteran's sleep apnea is more likely the result of his age, being male, using sleeping medication, and excess weight rather than any event or results of being in service. Based on the foregoing, there is no evidence that the Veteran's sleep apnea was manifested in service or to a compensable degree in the first year following his separation from service. Consequently, service connection for sleep apnea on the basis that such became manifest in service and persisted, or on a presumptive basis (as a chronic disease under 38 U.S.C. § 1112), is not warranted. Notably, the Veteran has not submitted competent evidence to show that he has suffered from sleep apnea continuously since service. See 38 C.F.R. § 3.303(b); Savage, supra. The Board acknowledges the Veteran's, his wife's and L.B.'s statements noting the Veteran's snoring and other observed symptomatology during and after service. The Veteran, his spouse and L.B. have not demonstrated they have the medical experience or expertise to render a diagnosis or medical opinion in this case. See Jandreau, supra; see also Jones, supra. Rather, the sole competent evidence in this case of a nexus is the October 2021 examiner's opinion. That examiner reviewed the entire claims file, including the Veteran's, his spouse's and L.B.'s statements, and found that the Veteran's sleep apnea was more likely related to his excessive weight, smoking history and being male. The opinion is well-reasoned and based on a thorough review of the record. There is no competent and probative evidence to refute the October 2021 examiner's findings and conclusions. As such, the Board finds that the evidence of record does not demonstrate that the Veteran's sleep apnea incurred in or otherwise the result of military service. Accordingly, service connection for sleep apnea is not warranted based on the evidence of record at this time. See 38 C.F.R. §§ 3.303, 3.307, 3.309. Increased Rating for GERD The Veteran asserts that his GERD is more severe than the rating currently assigned. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity in civil occupations. Separate diagnostic codes identify the various disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § Part 4. Where a veteran appeals the initial rating assigned for a disability at the time that service connection for that disability is granted, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous . . .." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Under Diagnostic Code 7346 for hernia hiatal, a 10 percent rating is warranted for two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Id. A 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. Id. On the January 2016 VA esophageal examination, the examiner indicated the Veteran has a diagnosis of GERD. The Veteran reported that he experienced recurrent epigastric pain and burning. The Veteran also stated his food tries to come up. On examination, the examiner indicated the Veteran experiences pyrosis (heartburn) four or more times a year; reflux four or more times a year; and regurgitation four or more times a year. The examiner found the Veteran does not have any epigastric distress, dysphagia, substernal arm or shoulder pain, sleep disturbance caused by reflux, anemia, weight loss, nausea, vomiting, hematemesis, melena, esophageal stricture, spasm of esophagus, or an acquired diverticulum of the esophagus. On the April 2018 substantive appeal, the Veteran stated that his GERD medication causes constipation, diarrhea, and heartburn, which has produced permanent internal stomach symptoms that are chronic. At the March 2021 Board hearing, the Veteran testified the symptoms of GERD have worsened. Board Hearing Transcript (T.) at 3. The Veteran stated the symptoms occur at night and the medication causes him to be nauseated and his stomach to hurt. Id. The Veteran stated he also has an ulcer. Id. The Veteran stated he has trouble swallowing, burning in the chest, reflux or regurgitation of food, and arm and shoulder pain. T. at 4. The Veteran stated he also has blood in his stool and hemorrhoids. T. at 5. The Veteran stated that these symptoms cause a considerable impairment of health. Id. On the August 2021 VA esophageal conditions examination, the examiner indicated the Veteran has a diagnosis of GERD. The Veteran stated his GERD has improved since onset. The examiner indicated the Veteran's treatment plan includes taking continuous medication. The examiner indicated the Veteran experiences symptoms of pyrosis, reflux, regurgitation, and sleep disturbance four or more times a year. The examiner did not find the Veteran to experience symptoms productive of considerable impairment of health, symptoms combination productive of severe impairment of health, any epigastric distress, dysphagia, pain (substernal, arm or shoulder), material weight loss, nausea, vomiting, hematemesis, or melena with moderate anemia. The examiner also did not find the Veteran to have an esophageal stricture, spasm of esophagus, or an acquired diverticulum of the esophagus. While the evidence of record documents that the Veteran has pyrosis, reflux, regurgitation, and sleep disturbance, the evidence does not show that these symptoms are accompanied persistently recurrent epigastric distress with dysphagia, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The evidence also does not demonstrate that the Veteran experiences pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. Thus, the Board finds that the Veteran's GERD symptoms are best characterized by two or more of the symptoms for the 30 percent rating of less severity, which warrants his current 10 percent disability rating. 38 C.F.R. § 4.114, Diagnostic Code 7346. The Board has considered the application of the remaining diagnostic codes under the current version of the regulation in an effort to determine whether a higher rating may be warranted for the Veteran's GERD but finds none are raised by the medical evidence. Furthermore, the Veteran's symptoms do not appear to have changed significantly during this initial rating period so as to warrant a staged rating. Fenderson, 12 Vet. App. at 126. The Board notes that in adjudicating a claim, the competence and credibility of the Veteran must be considered. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. For example, he is competent to report that he experiences certain symptoms, such as nausea, and he is credible in this regard. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Board acknowledges that at the March 2021 Board hearing the Veteran testified that he experienced nausea, an ulcer, trouble swallowing, burning in the chest, reflux or regurgitation of food, and arm and shoulder pain, all of which results in considerable impairment of health. However, the Board finds that the Veteran's belief that his disability is worse than the assigned rating is outweighed by the competent and credible medical examination that evaluated the true extent of impairment based on objective data coupled with the lay complaints. Although the Veteran is competent to state that he believes that his symptoms are worse, the Veteran is not competent to provide a medical opinion that his symptoms are actually worse such that they rise to the level of considerable or severe impairment of health. See Jandreau, supra; Jones, supra. Rather, the VA examiner has the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings. Also, as stated above, the rating criteria are specific in indicating that some of the criteria must be objectively demonstrated. The Board also notes that at the March 2021 Board hearing he stated his symptoms have worsened and are productive of a considerable impairment of health and then the Veteran reported to the August 2021 VA examiner that his symptoms have improved since onset. The Board finds that these statements are internally inconsistent. The Board finds the statements in August 2021 VA examination to be inherently more credible and probative. See Rucker, 10 Vet. App. at 67, 73. In sum, the evidence persuasively weighs against the assignment of an initial disability rating in excess of 10 percent for the service-connected GERD at any time during the appeal period. The claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. TDIU The issue of TDIU is before the Board as a part of the increased rating claim for GERD. See Rice v. Shinseki, 22 Vet. App. 447 (2009). TDIU may be assigned when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that: if the veteran has only one such disability, the disability must be rated at 60 percent or more, or, if the veteran has two or more disabilities, at least one disability is rated at 40 percent or more and additional disabilities bring the veteran's combined disability rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For a veteran to prevail on a claim for a total compensation rating based on individual unemployability, the record must reflect some factor which takes his or her case outside of the norm. The sole fact that he or she is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). A veteran who fails to meet these percentage standards may still qualify for an extraschedular TDIU rating under 38 C.F.R. § 4.16(b). Under that provision, VA will grant a TDIU when the evidence shows that the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, when the Board conducts a TDIU analysis, it must take into account the individual veteran's education, training, and work history. See Hatlestad v. Derwinski, 1 Vet. App. 164, 168 (1991). It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 U.S.C. § 4.16. Therefore, at the regional office (RO) level, rating boards are to submit to the Director of Compensation Service (Director) for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). The Board itself cannot assign an extraschedular rating in the first instance. Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996). However, the Board can adjudicate whether to refer a case to the Director for an extraschedular evaluation when the issue is either raised by the claimant or is reasonably raised by the evidence of record. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If, and only if, the Director determines that an extraschedular evaluation is not warranted, does the Board then have jurisdiction to decide the extraschedular claim on the merits. Anderson v. Shinseki, 22 Vet. App. 423, 427-8 (2009). In this case, the Veteran is service connected for GERD, rated as 10 percent; right hand frostbite, rated as 10 percent; left hand frostbite, rated as 10 percent; right foot frostbite, rated as 10 percent; left foot frostbite, rated as 10 percent; and a fracture of the right little finger as noncompensable. The Veteran's combined rating is 40 percent. See 38 C.F.R. § 4.25. Therefore, the Veteran does not meet the schedular requirements for TDIU under 38 C.F.R. § 4.16(a). Accordingly, the only remaining question is whether referral for extraschedular TDIU is warranted under 38 C.F.R. § 4.16(b). On the January 2016 VA hand examination, the examiner found that the Veteran's right little finger fracture impacts his ability to work. The examiner explained that the Veteran's fingers lock up and it is difficult for him to hold his tools. On the January 2016 VA esophageal examination, the examiner found that the Veteran's GERD does not impact the Veteran's ability to work. On the August 2021 VA peripheral nerves examination, the examiner found that the Veteran's bilateral hand and bilateral foot frostbite impact the Veteran's ability to work by limiting the Veteran's walking to one half mile, limiting standing to 15 minutes, limiting lifting to 15 pounds, and limiting the Veteran to constant gripping or torquing. The examiner stated the Veteran's sitting is not affected. At the March 2021 Board hearing, the Veteran testified that his GERD is severe enough to prevent him from obtaining any kind of gainful employment. T. at 7. The Veteran explained that that he would "stay off of work" with pain in the stomach and has to seek treatment from a doctor. Id. The Veteran stated that he completed one year of college. Id. He stated his other training was from the Army as a heavy equipment mechanic. T. at 8. After separation from service, the Veteran testified that he worked in assembling air conditioning (heating, ventilation, and air conditions (HVAC)). T. at 8-9. The Veteran stated that he retired in 2007 due to ankylosing spondylitis in the neck and back and fractured pinky finger. T. at 9-10. The Veteran asserted that his fractured pinky finger prevents him from working because he is unable to grip and hold items in his dominant right hand. T. at 10. The Veteran stated that he is prevented from turning wrenches and holding and assembling parts as a result. Id. Upon review of the record, the Veteran's service-connected disabilities do not present a disability picture indicating that TDIU is warranted. The record reflects that the Veteran's service-connected bilateral hand frostbite and right-hand fifth finger fracture affects his ability grip and torque items and limit lifting to 15 pounds. The record also shows the Veteran, as a result of bilateral foot frostbite, is unable to walk more than one half mile or stand more than 15 minutes. However, the August 2021 VA examiner stated that sitting is not affected. The VA treatment records are silent related to any limitations to the Veteran's activities of daily living or any impact on the Veteran's ability to obtain or maintain employment. Further, at the March 2021 Board hearing, the Veteran did state he attended one year of college, and obtained mechanic training in the Army, and has professional training and experience in assembling air conditioning units. Although the record demonstrates that the Veteran is limited in his ability to grip and torque tools and is limited in his ability to walk and stand, thereby precluding him from his previous work as a mechanic or with air conditioning systems, the record does not indicate that his right little fifth finger fracture, bilateral hand disorder, bilateral foot disorder, or GERD affect his ability to obtain or maintain non-physical employment. Therefore, there is insufficient evidence to conclude that the Veteran's education, training, and experience preclude him from securing and maintaining all forms of substantially gainful employment due to service-connected disabilities. Thus, referral to the Director of Compensation Service is not warranted, and entitlement to TDIU must be denied. See 38 C.F.R. § 4.16(b). The Board has considered the Veteran's lay statements and testimony explaining the impact of his service-connected disabilities on his ability for occupational function. Initially, the Board notes that the Veteran testified that he retired as a result of his cervical and thoracolumbar spine disorders in 2007. As noted above, those disorders are nonservice-connected disabilities. The Board therefore cannot consider their effects on his employability. The Board acknowledges that the Veteran has difficulty with gripping and torquing tools, lifting items, prolonged standing, and prolonged walking, which may have caused him to not obtain certain positions that he desired. However, such does not demonstrate that he is precluded from substantially gainful employment, and the additional disability compensation he receives with regard to his service-connected disabilities is intended to compensate the Veteran, in part, for these lost opportunities resultant from his service-connected disabilities. In sum, as the Veteran does meet the schedular criteria for a TDIU and does not warrant referral for extra-schedular consideration, the evidence persuasively weighs against a finding that he is unemployable due to his service-connected disabilities. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, because the evidence persuasively weighs against the Veteran's claim for a TDIU, that doctrine is not helpful to the Veteran. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND Right Index Finger On the January 2016 VA hand examination, the examiner indicated the Veteran has a diagnosis of right trigger finger and right fifth finger fracture. The Veteran stated that his index and middle fingers are painful and lock up periodically since around 2010. The January 2016 VA examiner remarked that the little finger fracture and trigger fingers condition are not related because the fracture was in the right fifth finger and the trigger fingers are in the second and third fingers of the right hand. On the April 2018 substantive appeal, the Veteran stated the symptoms of the right index finger have worsened over time and have limited his ability to perform basic task. The Veteran stated there is arthritis in the joint that requires him to manually raise the finger. At the March 2021 Board hearing, the Veteran testified that the right index finger locks up and requires the Veteran to manually unlock the finger. T. at 25. The Veteran stated the finger eventually required surgery. T. at 25-26. The Veteran stated the finger started to lock in the 1970s or 1980s. T. at 26. The Veteran stated the finger started to pop during service. Id. The Veteran stated the popping occurred with repeated motion, to including grabbing and holding wrenches. Id. The Veteran stated the symptoms have worsened over time. Id. On the August 2021 VA hand and finger examination, the examiner indicated the Veteran diagnoses for the right hand and fingers that do not include the index finger. The August 2021 VA examiner opined that the Veteran's right index finger disorder is less likely than not caused by service. The examiner reasoned that although the STRs show the Veteran experienced right index finger trigger finger in February 1967, there is no current disorder based on examination. The examiner stated that even if there was a disorder, frostbites do not result in trigger finger. The examiner stated that while the causes of trigger finger are not well known, several factors may increase the risk for developing the disorder, which include diabetes and rheumatoid arthritis. The August 2021 VA hand and finger examiner also opined that the Veteran does not have a right index finger disorder and therefore opined that there is no right index finger disorder to be caused or aggravated by the service-connected right fifth finger disorder. On a September 2021 private treatment record, the imaging revealed the Veteran's right hand metacarpophalangeal (MCP) joints and interphalangeal joints to demonstrate no significant arthritic changes. In an October 2021 VA addendum medical opinion, the examiner opined that the Veteran's right index finger disorder is less likely than not caused by service. The examiner reasoned that the Veteran worked as a heavy equipment operator in service and worked manual labor after separation from service for 41 years. The examiner stated there is no documentation showing any finger disorder in service that may lead to the current disorder. The examiner stated that it is more likely caused by his manual labor after separation from service. Respecting the symptoms of the right index finger, the Board reflects that the August 2021 VA examiner found the Veteran to not have a diagnosis of the right index finger, however, the VA examiner did not address the etiology of the reported symptoms. As the VA examiner failed to provide an adequate rationale for the conclusions, the Board finds the August 2021 examination and opinion to be inadequate. Additionally, the Board further notes that in Saunders v. Wilkie, 886 F.3d 1356 (2018), the Court held that pain can be a disability if such results in a functional impairment in earning capacity. The Board notes that the August 2021 examiner did not address this aspect of the case. Accordingly, a remand is necessary in order for the Agency of Original Jurisdiction (AOJ) to obtain another examination that adequately addresses whether the Veteran has a current right index finger disability, including trigger finger, and if so, whether such is related to military service or is caused or aggravated by service-connected right fifth finger fracture. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005) (a VA examination must be based on an accurate factual premise). Anemia In a January 2014 private treatment record, the medical provider assessed the Veteran to have mild and intermittent anemia. On the April 2018 substantive appeal, the Veteran stated that his anemia is an underlying condition of GERD and has persisted since onset in service and after separation from service. He stated that he is prescribed daily medication. At the March 2021 Board hearing, the Veteran testified that he experiences tiredness, short windedness, and weakness. T. at 13. The August 2021 VA hematological examiner indicated the Veteran has a diagnosis of anemia with iron deficiency. The Veteran stated he was diagnosed with ankylosing spondylitis about 20 years ago and gets a monthly infusion. He stated he was diagnosed with anemia after this diagnosis. The October 2021 VA examiner opined that the Veteran's anemia is less likely than not caused by service. The examiner reasoned that the Veteran's claims file does not show documentation of anemia in service or on the February 1967 separation examination. The examiner noted the Veteran was diagnosed with ankylosing spondylitis in 2006 and has been getting infusion of medication. The examiner stated that long term use of this medication may lower the number of blood cells in the blood. The examiner stated that fewer white blood cells lower the body's ability to fight infections and fewer red blood cells can lead to anemia. The examiner stated that GERD is not a known disease process to cause anemia. The examiner noted that peptic ulcers are known to cause anemia, but that is not the case in this Veteran. The examiner stated that the Veteran's chronic use of the infusion medication for the ankylosing spondylitis is the cause of the Veteran's anemia, and not his GERD. The June 2021 Board decision requested the AOJ to obtain a medical opinion addressing whether anemia was either (a) caused by or (b) aggravated by a service-connected disability. Here, the August 2021 VA examiner addressed the issue of whether the Veteran's anemia was caused by the Veteran's service-connected GERD, however, the examiner did not address whether the Veteran's anemia is aggravated by the service-connected GERD. Accordingly, the Board finds that the August 2021 VA examination and the October 2021 medical opinion do not substantially comply with the Board's June 2021 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). As such, the Board finds that remand is required in order to obtain a new VA medical addendum opinion, or a new VA examination if found necessary, that complies with the June 2021 Board remand. The matter is REMANDED for the following action: 1. Schedule the Veteran for an examination in order to determine the precise nature and etiology of his asserted right index finger disability. If the examiner finds that the Veteran does not have a diagnosis of right index trigger finger, the examiner should specifically explain the basis of that conclusion, including indicating why the Veteran does not meet the criteria for such diagnosis. Additionally, the examiner should indicate whether any right index finger symptoms, to include pain and locking, claimed or present throughout the appeal period is otherwise a functional impairment of earning capacity such that the Veteran has a current disability under Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The examiner is required to opine as to whether it at least as likely as not that the Veteran has a right index finger disability had onset in service, was manifested by arthritis within one year of separation from service or is otherwise the result of a disease or injury in service, to include reported service as a heavy equipment operator. The examiner should specifically address the Veteran's contentions regarding repeated use of tools and bending/lifting during service. The examiner must also opine whether any such disability is at least as likely as not (a) caused by (in whole or in part); or (b) aggravated by (i.e., worsened) by his service connected right fifth finger fracture. The examiner is reminded that both prongs (a) and (b) should be addressed and rationales provided for both prongs. Additionally, if the Veteran's current right index finger disability is aggravated by a service-connected disability, the examiner should, to the extent possible, also indicate the level of such aggravation by identifying a baseline of level of disability. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, the examiner must provide a reason for doing so. The absence of evidence of treatment for a particular right index finger disability in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, the examiner should explain why this is so, and what if any additional evidence would be necessary before an opinion could be rendered. 2. Obtain an addendum medical opinion, or a new VA examination if found necessary, in order to determine the precise nature and etiology of his asserted disability manifested by anemia. After review of the claims file, and examination of the Veteran if such is deemed necessary, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's asserted disability manifested by anemia is (a) caused by; or (b) aggravated (i.e., worsened) by service-connected disability, to specifically include service-connected GERD? The examiner is reminded that he or she should address both prongs (a) and (b). With respect to causation, the examiner should specifically discuss the previous examiner's findings that the infusion and not a peptic ulcer or GERD in this Veteran is the cause of his anemia. The examiner is reminded that anemia is noted as one of the symptoms of a hiatal hernia in Diagnostic Code 7913, under which the Veteran's GERD is rated. If the examiner finds that the Veteran's anemia is not caused by a service-connected disability, the examiner still must provide an opinion as to whether the Veteran's anemia is aggravated by a service-connected disability. If the Veteran's asserted disability manifested by anemia is aggravated by service-connected disability, the examiner should, to the extent possible, also indicate the level of such aggravation by identifying a baseline level of disability. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, the examiner must provide a reason for doing so. If the examiner is unable to provide an opinion without resort to speculation, the examiner should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Thompson, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.