Citation Nr: 22018871 Decision Date: 03/30/22 Archive Date: 03/30/22 DOCKET NO. 16-05 857 DATE: March 30, 2022 ORDER Service connection for degenerative disc disease of the lumbar spine and thoracolumbar strain (hereinafter low back disability) is granted. Service connection for degenerative disc disease of the cervical spine (hereinafter neck disability) is granted. Service connection for cervical radiculopathy is denied. An initial disability rating in excess of 30 percent for service-connected migraine headaches is denied. REMANDED Entitlement to service connection for right lower extremity radiculopathy, to include as secondary to service-connected low back disability, is remanded. Entitlement to service connection for left lower extremity radiculopathy, to include as secondary to service-connected low back disability, is remanded. Entitlement to service connection for a gynecological disability is remanded. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran's low back disability is related to service. 2. The evidence is at least evenly balanced as to whether the Veteran's neck disability is related to service. 3. The evidence of record persuasively weighs against finding that the Veteran has had cervical radiculopathy at any time during or approximate to the pendency of the claim. She has been diagnosed with bilateral carpal tunnel syndrome and has been awarded service connection for that disability. 4. The Veteran's service-connected migraine headaches have not been manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). 2. The criteria for service connection for a neck disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). 3. The criteria for service connection for cervical radiculopathy are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for an initial rating in excess of 30 percent for service-connected migraine headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.124a, Diagnostic Code 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 2005 to December 2006, August 2009 to August 2010, September 2010 to August 2011, and from August 2015 to November 2017. She had additional periods of active duty for training from July 1988 to December 1988 and from September 2004 to February 2005. This appeal comes before the Board of Veterans' Appeals (Board) from March 2013 and May 2013 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In the March 2013 rating decision, the RO, in pertinent part, granted service connection for migraine headaches and assigned a 30 percent rating, effective from September 1, 2011; and denied service connection for cervical fibroids. The Veteran's notice of disagreement (NOD) was received in April 2013. In the May 2013 rating decision, the RO, in pertinent part, denied service connection for low back disability, cervical spine disability, and cervical radiculopathy. The RO also continued to deny an initial increased rating in excess of 30 percent for migraine headaches. The Veteran's notice of disagreement (NOD) was received in June 2013. The RO issued the statement of the case (SOC) addressing all the above issues in January 2016, and the Veteran's VA Form 9, substantive appeal was received in February 2016. In September 2019 and September 2021, the Board remanded the case to the RO for further development and adjudicative action. SERVICE CONNECTION Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 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. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases may also be established based upon a legal "presumption" by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected condition. 38 C.F.R. § 3.310. 1. Entitlement to service connection for degenerative disc disease of the lumbar spine and thoracolumbar strain. The Veteran contends that she has experienced low back pain since her period of active service in 2005. See e.g. August 2020 VA examination. At the outset, the Veteran has current diagnoses of degenerative disc disease of the lumbar spine and thoracolumbar strain. See VA MRI report dated in October 2019 and November 2021 VA examination. Service treatment records (STRs) reflect that the Veteran's November 2005 pre-deployment health assessment conducted prior to her 2005 to 2006 period of active duty does not note a lumbar spine disability. However, a December 2006 post-deployment health assessment reflects complaints of back aches for approximately four months during active-duty deployment. The post-service medical evidence of record shows continued complaints of, and treatment for, low back pain following the 2005 to 2006 period of active service. Reserve STRs in August 2007 and September 2007 reflect that the Veteran continued to report back pain. In November 2008, the Veteran reported experiencing low back pain for the last year. An August 2009 Reserve STR indicates ongoing low back pain. Subsequent medical records indicate continued complaints of low back pain. See e.g. Reserve STRs dated in January 2010, October 2010, June 2011, August 2012. First, there is no reason to doubt the Veteran's statements regarding occurrence of low back symptoms during and after service. See Caluza v. Brown, 7 Vet. App. 498 (1995). In this regard, the Veteran's statements are consistent with STRs and post-service treatment records. Furthermore, she is competent to report observable symptoms such as pain. See Barr v. Nicholson, 21 Vet. App. 303 (2007). VA opinions were obtained in April 2013, May 2013, and August 2020. The April 2013 VA examiner opined that the Veteran's thoracolumbar strain with recurrent muscle spasms was related to complaints during active duty based on a review of her claims file. The May 2013 VA addendum opinion states that the Veteran's current complaints were not aggravated beyond normal progression if the assumed original injury/incident occurred other than active duty or during reserve duty. The May 2013 examiner noted no line of duty letter was found in the claims file. The August 2020 VA examiner opined that the Veteran's low back condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The August 2020 VA examiner indicated there was no low back trauma or low back condition that would have aggravated the Veteran's low back beyond natural progression on her reserve time or when activated to active duty. The examiner noted there was not a line of duty injury form. Finally, the examiner noted that the Veteran admitted to participating in marathons on her own time which is not a military requirement of duty and she complained of cervical neck pain after a 72-hour marathon. The April 2013 VA examiner provided no rationale in support of the proffered nexus opinion. Regarding the May 2013 and August 2020 VA opinions, the Board reiterates that the Veteran has had multiple periods of active service. Neither opinion indicates whether the Veteran's lumbar spine disability preexisted each period of active duty service, including her active duty service from November 2005 to December 2006, nor do they provide a rationale for the findings that the condition preexisted each period of active duty service. As noted above, the Veteran's November 2005 pre-deployment health assessment did not include a finding of a lumbar spine disability. For the foregoing reasons, the April 2013, May 2013, and August 2020 VA medical opinions are of diminished probative value. An addendum VA medical opinion was obtained in November 2021. The VA physician concluded that the Veteran's claimed condition was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The physician explained that the Veteran had no issues related to the claimed back condition prior to military service and that the current diagnosis of thoracolumbar strain is related to the deployment. The physician stated that there is evidence of chronicity in available treatment notes and C&P exams and that, given the available evidence and erring in veteran's favor, a nexus can be established. The November 2021 VA opinion clearly articulates a nexus between the Veteran's in-service symptoms and her current low back disability. The opinion is based on knowledge of the Veteran's medical history, is consistent with the medical and lay evidence of record, and contains an adequate supporting rationale. Accordingly, the November 2021 VA medical opinion is afforded significant probative value. Given the above, the Board finds that the evidence is at least evenly balanced as to whether the Veteran's degenerative disc disease of the lumbar spine and thoracolumbar strain is related to service. In such cases the doubt is resolved in the Veteran's favor and therefore service connection is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 2021 U.S. App. LEXIS 37307, No. 2020-2067 (Fed. Cir. Dec. 17, 2021). 2. Entitlement to service connection for degenerative disc disease of the cervical spine. 3. Entitlement to service connection for cervical radiculopathy. The Veteran contends that she has experienced continuous neck and upper back pain following a long distance race. See April 2013 VA examination. The Veteran has also reported being struck in the face with a basketball while on active duty in Kuwait in 2010. At the outset, the Veteran has current diagnoses of degenerative disc disease of the cervical spine and cervical strain. See VA MRI report dated in January 2013 and August 2012 service treatment note. Every veteran is presumed to be in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities or disorders noted at the time of the examination, acceptance and enrollment or where clear and unmistakable evidence demonstrates the injury or disease existed prior to service and was not aggravated by service. See 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Only such conditions as are recorded in examination reports are to be considered as "noted" for the purpose of this analysis. 38 C.F.R. § 3.304(b). If a condition is not "noted" upon entrance into service, VA must rebut the presumption of soundness by showing clear and unmistakable evidence that (1) there was a pre-existing condition and (2) that the pre-existing condition was not aggravated during or by the Veteran's service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); VAOPGCPREC 3-2003 (July 16, 2003). To satisfy this second-prong requirement for rebutting the presumption of soundness, the government must show by clear and unmistakable evidence either that there was no increase in disability during service or that any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845, 847 (Fed. Cir. 2006). Here, STRs reflect that the Veteran's November 2005 pre-deployment health assessment conducted prior to her 2005 to 2006 period of active duty does not note a cervical spine disability. Thus, the Veteran is presumed sound on entry to the 2005 to 2006 period of active service. The post-service medical evidence of record shows continued complaints of, and treatment for, neck and upper back pain following the 2005 to 2006 period of active service. A November 2008 Reserve STR indicates that the Veteran reported upper back pain which began during her most recent deployment in 2005 and 2006. She specifically reported that pain started during her deployment but was unable to have an evaluation until she returned to the United States for the pain, which increased with physical activities. A Reserve STR dated in August 2009 similarly notes that the Veteran complained of upper back and neck pain. Notably, during her next period of active service in 2010, the Veteran was diagnosed with neck strain and cervicalgia after running a marathon. She reported that she was in a motor vehicle accident (MVA) 10 years earlier but that she had complete resolution of symptoms related to that accident. A February 2010 STR indicates that the Veteran was struck in the face with a basketball, and she reported that her neck has been stiffer since the incident. Subsequent medical records indicate continued complaints of neck and upper back pain and diagnoses of cervical strain and degenerative disc disease of the cervical spine. See e.g. STRs dated in July 2010, October 2010, December 2010, March 2011, May 2011, August 2012, October 2013. First, there is no reason to doubt the Veteran's statements regarding occurrence of neck and upper back symptoms during and after service. See Caluza, 7 Vet. App. at 498. In this regard, the Veteran's statements are consistent with STRs and post-service treatment records. Furthermore, she is competent to report observable symptoms such as pain. See Barr, 21 Vet. App. at 303. VA opinions were obtained in April 2013, May 2013, and August 2020. The April 2013 VA examiner provided a positive direct service connection opinion after finding that the Veteran's whiplash in 2000 following a motor vehicle accident was the initial injury to the Veteran's neck. The May 2013 addendum opinion indicated that the examiner found that the Veteran's current complaints were not aggravated beyond normal progression if the assumed original injury/incident occurred during a time other than on active duty or during reserve duty. The May 2013 examiner noted no line of duty letter was found in the claims file. In providing a negative nexus opinion, the August 2020 examiner indicated the Veteran has historically provided a contradictory history of how her cervical neck pain began, including onset in January 2010 after running a 72-hour marathon, an injury in 2000 related to a motor vehicle accident and whiplash, and an August 2020 report of neck pain from being hit in the head with a ball in Kuwait. The examiner found the Veteran's neck condition was not aggravated beyond its natural progression during her military service because no excess trauma was noted after exhaustive review of the Veteran's claims file. As discussed above, the May 2013 and August 2020 VA examiners failed to indicate whether the finding that the Veteran's cervical spine disability preexisted service applies to each period of active duty service. The Board notes the Veteran's August 2009 pre-deployment health assessment does not list a cervical spine disability at the time of entrance to active duty. While the April 2013 examiner found the Veteran's cervical spine disability is related to her 2000 whiplash and the May 2013 and August 2020 examiner found the Veteran's cervical spine disability clearly and unmistakably preexisted service, the opinions do not address the February 2003 and October 2004 Reserve reports of medical examination and history, which reflect normal clinical evaluations of the spine and no history of cervical spine symptoms; the November 2005 pre-deployment health assessment, which does not reflect referral for an orthopedic problem; her January 2010 report that her symptoms completely resolved after the motor vehicle accident; or the general lack of cervical spine complaints following the reported motor vehicle accident until November 2008. Moreover, while the August 2020 opinion indicates the Veteran has provided a contradictory history of the onset of her neck pain, review of the April 2013 VA examination indicates the Veteran reported onset of her cervical spine condition in 2010, but the April 2013 examiner opined that the Veteran's 2000 whiplash was the onset of the Veteran's cervical spine condition without providing a rationale to support this finding. Furthermore, the August 2020 VA examiner found that the Veteran's STRs do not show documentation that support the Veteran's report that she had cervical spine pain after being hit in the head with a ball in Kuwait. However, a February 2010 service treatment record reflects neck stiffness after being hit in the face with a basketball and her October 2010 post-deployment health reassessment reflects 'basketball struck head' and 'cervical strain.' Finally, a June 2010 statement of medical examination and duty status note neck pain associated with running two weeks prior to visit while the Veteran was on active duty. For the foregoing reasons, the April 2013, May 2013, and August 2020 VA medical opinions are of diminished probative value. An addendum VA medical opinion was obtained in November 2021. The VA physician concluded that the Veteran's neck disability was aggravated beyond its natural progression by an in-service injury event or illness. The physician stated that current history and exam along with the STRs identify permanent aggravation of the neck condition by military service to be plausible. The physician noted that the Veteran's STRs support aggravation while in-service and post-service records show chronicity of care for a neck condition beginning soon after 2005/2006 period of active service and continuing thereafter. The physician stated that a nexus has been established. While the November 2021 VA opinion is incorrectly framed as an opinion regarding aggravation of a pre-existing condition, the opinion nevertheless clearly articulates a nexus between the Veteran's in-service symptoms and her current neck disability. The opinion is based on knowledge of the Veteran's medical history, is consistent with the medical and lay evidence of record, and contains an adequate supporting rationale. Accordingly, the November 2021 VA medical opinion is afforded significant probative value. Given the above, the Board finds that the evidence is at least evenly balanced as to whether the Veteran's degenerative disc disease of the cervical spine and cervical strain are related to service. In such cases the doubt is resolved in the Veteran's favor and therefore service connection is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch, supra. Finally, while STRs dated in 2011 indicate that the Veteran had cervical radiculopathy affecting her hands, subsequent medical evidence clarifies that the Veteran has carpal tunnel syndrome which is responsible for her reported symptoms of tingling, numbness and pain affecting her upper extremities and for which she is already service-connected. See e.g. April 2013 VA Neck examination and June 2018 VA Peripheral Nerves examination. Moreover, even assuming that the Veteran has cervical radiculopathy affecting her upper extremities, as she has already been awarded service connection for bilateral carpal tunnel syndrome which encompasses her reported symptoms and so another award due to neuropathy for the same symptoms would constitute impermissible pyramiding. Therefore, the evidence weighs persuasively against a finding that the Veteran has cervical radiculopathy related to her now service-connected neck disability or has symptoms of such radiculopathy separate from her already service-connected bilateral carpal tunnel syndrome. The claim is denied. INCREASED DISABILITY RATINGS Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). 4. Entitlement to an initial disability rating in excess of 30 percent for service-connected migraine headaches. The Veteran contends that the symptoms of her migraines warrant a higher initial disability rating. Her migraine headaches are rated as 30 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8100 for migraines. Under DC 8100, migraine headaches with characteristic prostrating attacks occurring on an average once a month over the last several months warrant a 30 percent rating. Migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability warrant the maximum 50 percent rating. The regulations do not define "prostrating." The term has been defined as "lacking in vitality or will: powerless to rise: laid low." See Johnson v. Wilkie, 30 Vet. App. 245, 252 (2018) (citing to Webster's Third New International Dictionary of The English Language Unabridged 1822 (1966)). The term "characteristic" refers to "a trait, quality, or property or a group of them distinguishing an individual, group, or type." Johnson, 30 Vet. App. at 252 (citing to Webster's Third New International Dictionary of The English Language Unabridged 376 (1966)). The Johnson Court found that "the phrase 'characteristic prostrating attacks' plainly describes migraine attacks that typically produce powerlessness or a lack of vitality." Id. The rating criteria for a 50 percent rating contains several undefined phrases. The descriptive phrase "very frequent" connotes a frequency at least greater than once a month, as is required by the rating criteria corresponding to a lesser 30 percent rating. Id. at 253. The phrase "completely prostrating" generally means that the migraines attack must render the veteran entirely powerless. Id. The completely prostrating attacks must also be "prolonged," which is defined as "to lengthen in time: extend duration: draw out: continue, protract." Id. VA regulations also do not define "severe economic inadaptability." In Pierce v. Principi, 18 Vet. App. 440, 445 (2004), the Court examined the term "productive of severe economic inadaptability" in the criteria for a 50 percent rating under DC 8100, and noted that "[n]owhere in the DC is 'inadaptability' defined, nor can a definition be found elsewhere in title 38 of the [C.F.R.]." Id. at 446. The Court explained that, "nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating" because "[i]f 'economic inadaptability' were read to import unemployability," a claimant who "met the economic-inadaptability criterion, would then be eligible for a rating of total disability based on individual unemployability [(TDIU)]...rather than just a 50 percent rating." Id. The Court therefore rejected the notion that "severe economic inadaptability" was equivalent to an inability to secure or follow a substantially gainful occupation, the unemployability standard for TDIU. Id. In addition, the Court acknowledged VA's concession that the phrase "productive of severe economic inadaptability" in DC 8100 should be construed as either "producing" or "capable of producing" severe economic inadaptability. Id. at 445. The Veteran underwent a VA examination in November 2012. The VA examiner noted that the Veteran's treatment plan included taking medication such as Toradol and ibuprofen for headaches. The Veteran reported that she experienced pulsating or throbbing headache pain localized to one side of the head which worsens with physical activity. She reported experiencing sensitivity to light associated with her headaches. The Veteran stated that her typical headache pain lasts less than one day. The examiner noted that the Veteran has characteristic prostrating attacks of migraine headache pain more frequently than once per month but noted that the Veteran does not have very frequent prostrating and prolonged attacks of migraine headache pain. The examiner indicated that the Veteran does not have prostrating attacks of non-migraine headache pain. The Veteran reported that she worked full time as a postal clerk and missed five days in the past year related to her migraine headaches. She stated that she had to lie down once per week for one to two hours due to her migraine headaches. The Veteran underwent a VA examination in October 2021. The Veteran reported that her headaches have worsened since onset in 2006 and that she was recently started on prescription for sumatriptan. She stated that her headaches occured three to four times per month and lasted six to eight hours without sumatriptan and four to six hours with sumatriptan. She reported non-headache symptoms of sensitivity to light and sound, dizziness, and fatigue. The VA examiner noted that the Veteran's treatment plan included taking sumatriptan for her headaches. The Veteran reported that she experienced headache pain localized to one side of the head which worsened with physical activity. The Veteran stated that her typical headache pain lasted less than one day. The examiner noted that the Veteran had characteristic prostrating attacks of migraine/non-migraine headache pain occurring once per month but noted that the Veteran did not have very prostrating and prolonged attacks of migraine headache pain productive of severe economic inadaptability. The examiner found that the Veteran's headaches did not impact her ability to work. The examiner provided several remarks in response to the September 2021 Board remand. The examiner stated that they repeated the Veteran's symptoms back to her and asked whether she had anything to add and if the examiner documented all of her symptoms and the Veteran confirmed that the examiner's documentation of her headache symptoms was correct. The examiner noted that the Veteran reported experiencing the same type of symptoms as when her headaches began as she does now. The examiner stated that, while the Veteran reports that her headaches were more frequent, neither the objective medical record or the examination supported this. The examiner noted that the Veteran had not picked up her prescription for sumatriptan since November 2020 and that this behavior was inconsistent with her complaints of worsening headaches. Based on the foregoing, the evidence persuasively shows that the Veteran's service-connected migraine headaches do not result in very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability at any point during the appeal period. The Veteran is competent to describe the frequency, severity, and duration of her headaches. However, the lay and medical evidence reflect that the Veteran did not experience very frequent prostrating and prolonged attacks of migraine or non-migraine headache pain. As noted above, the Veteran reported headaches occurring three to four times a month which lasted, at most, eight hours. Thus, the Veteran's headaches were not prolonged as the duration was reportedly always less than one day. Regarding the prong on severe economic inadaptability, while the Veteran reported during the November 2012 VA examination that she had missed five days of work in the past 12 months due to her headaches, she did not report that she had any special accommodations at work, such as laying down, to assist with her headache symptoms. Additionally, while a July 2020 VA treatment note indicates that the Veteran was unemployed, there is no indication anywhere in the record that this was due to or related to the Veteran's migraine headache symptoms. Moreover, the Veteran reported working as a loan technician during the August 2020 VA Back examination. While she reported two to four weeks of lost work time in the past 12 months, she did not attribute this lost time to her migraine headache symptoms. Finally, while the Veteran reported during the July 2014 DRO hearing that she had to take off work frequently, around 12 hours a week, for her migraine headaches, her statements during the hearing are inconsistent and contradictory. Notably, she later stated that she has not used any sick leave recently due to her headaches. See July 2014 DRO hearing transcript at p. 6. B The Veteran also reported that she hadn't taken any time off work due to her headaches because she recently started a new job. These answers suggest that while the Veteran's migraine headaches clearly result in functional impairment, as reflected by the currently assigned 30 percent disability rating, her headaches are not productive of severe economic inadaptability given that the Veteran was able to continue working through her headache attacks. The Board finds that the nature and frequency of the Veteran's migraine headaches are not capable of producing severe economic inadaptability. Accordingly, the Veteran's migraine headaches did not manifest as symptoms more closely aligned with the 50 percent criteria. Thus, an initial rating in excess of 30 percent is not warranted. REASONS FOR REMAND 1. Service connection for right lower extremity radiculopathy, as secondary to service-connected low back disability, is remanded. 2. Service connection for left lower extremity radiculopathy, as secondary to service-connected low back disability, is remanded. Based on June 2018 and August 2020 VA examination findings, the question of potential secondary service connection for bilateral lower extremity, due to service-connected low back disability, has been raised by the record. In June 2018, the Veteran was afforded a peripheral neuropathy VA examination where bilateral sciatic was an incidental finding. The examiner found it was not related to the Veteran's carpal tunnel syndrome. During the Veteran's August 2020 VA examination for her lumbar spine disability, the examiner noted findings of mild bilateral lower extremity radiculopathy. However, the examiner did not provide an opinion regarding whether the current bilateral lower extremity radiculopathy was caused or aggravated by lumbar spine disability. The Board notes that this decision has granted service connection for lumbar spine disability. On remand, obtain an addendum medical opinion as to whether the Veteran's bilateral lower extremity radiculopathy is related to her active duty periods or whether it was caused or aggravated by the Veteran's service-connected low back disability. The opinion regarding secondary service connection should address the August 2020 VA examiner's findings of mild bilateral lower extremity radiculopathy during an examination for her low back disability. 3. Entitlement to service connection for a gynecological disability is remanded. The Veteran seeks service connection for a gynecological disability. During the appeal period, the Veteran has been provided diagnoses of uterine fibroids and myomectomy, left ovarian cysts with cystectomy, abdominal hysterectomy without oophorectomy, pelvic adhesions and female sexual arousal disorder (FSAD). The Veteran most recently underwent a VA examination in October 2021. The examiner found that the Veteran's uterine fibroids, left ovarian cysts with cystectomy, abdominal hysterectomy without oophorectomy and pelvic adhesions were less likely than not related to service and were not caused or aggravated by active service. However, the opinions are not supported by adequate rationale. First, the examiner failed to indicate whether the finding that the Veteran's gynecological disabilities preexisted service as applied to each period of active duty service. The examiner's opinion appears to only address potential aggravation during the Veteran's August 2015 to November 2017 period of active service despite noting complaints and treatment for several of the diagnosed gynecological disabilities during prior periods of active service. In this regard, while the examiner found that there was no documentation to support the Veteran's statements that she underwent myomectomy in 2009 to remove uterine fibroids, a photograph submitted by the Veteran appears to show several fibroids and contains a stamp from Summerville Medical Center dated January 12, 2009. Moreover, the November 2011 VA examination indicates that the Veteran reported undergoing a surgery to remove uterine fibroids in January 2009. Additionally, the examiner noted that the Veteran underwent surgery for her left ovarian cyst in March 2016 during active service but concluded that the Veteran's left ovarian cyst with cystoscopy was nether caused by, resulted from, or caused aggravation of any other gynecological conditions without providing any other rationale for this finding. The opinion also appears internally inconsistent. The examiner stated that military service neither caused nor aggravated pre-existing fibroids and that the Veteran was predisposed to develop uterine fibroids whether or not she served in the military. With the exception of adhesions caused by pelvic surgery, the examiner also stated that an opinion could not be proffered on the cause of the Veteran's gynecological disorders without mere speculation as the medical community did not know the cause of uterine fibroids. The examiner then opines that research and clinical experience pointed to etiological factors such as genetic changes, hormonal changes, and other growth factors. Additionally, while the examiner found that the Veteran did not have FSAD, the examiner did not indicate whether this finding was because the prior diagnosis was in error or because the FSAD had resolved since the prior diagnosis. Finally, during the examination, the Veteran reported undergoing a surgery to have her uterine fibroids removed in 2009. She reported that VA consulted her out to Summerville Medical Center for the surgery and stated that she does not have a copy of this surgery in her medical record. Those records are not associated with the claims file and an attempt has not been made to obtain them. Accordingly, a remand is necessary to make such an attempt. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion to determine the etiology of radiculopathy of the left or right lower extremity. The examiner should review the file and provide a complete rationale for all opinions expressed. The examiner should provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or higher) that radiculopathy of the left and right lower extremities is related to the Veteran's active duty periods or whether either was caused or aggravated by the Veteran's service-connected low back disability. The opinion regarding secondary service connection should address the August 2020 VA examiner's findings of mild bilateral lower extremity radiculopathy during an examination for her low back disability. 2. Ask the Veteran to complete a VA Form 21-4142 for any outstanding private treatment records, to include from the Summerville Medical Center. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 3. After the requested development is completed, obtain a medical opinion for the service connection claim for a gynecological disability from an appropriate medical specialist, preferably, a gynecologist, if possible. Only arrange for the Veteran to undergo an examination if deemed necessary in the judgment of the medical specialist designated to provide the medical opinion. The entire, electronic claims file to include a complete copy of this REMAND must be made available to the designated individual, and the medical opinion report should include discussion of the Veteran's documented history and assertions. If the Veteran is examined, all indicated tests and studies should be accomplished (with all results made available to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. For uterine fibroids status post myomectomy, left ovarian cysts with cystectomy, abdominal hysterectomy without oophorectomy, pelvic adhesions and female sexual arousal disorder (FSAD) and any other gynecological disabilities documented in the medical records during the appeal period, the medical specialist is requested to address or provide a response to the following: Did the gynecological disability clearly and unmistakably preexist the Veteran's service? The Board reiterates that the Veteran served on active duty from November 2005 to December 2006, August 2009 to August 2010, September 2010 to August 2011, and August 2015 to November 2017. Each constitutes a separate period of service. If the examiner finds the gynecological disability did clearly and unmistakably preexist a period of active duty service, was it clearly and unmistakably not aggravated by service? If the examiner finds that the gynecological disability did not clearly and unmistakably preexist service, the examiner must opine whether it is at least as likely as not that it onset in or is causally related to a period of active service. In rendering each requested opinion, the medical specialist must consider and discuss all service treatment records and post-service medical and other objective evidence of record. The medical specialist also must consider and discuss all lay assertions, to include any assertions as to in-service events, and as to the nature, onset, and continuity of symptoms. Notably, the absence of documented evidence of a specific disability or associated symptoms during and shortly after service should not, alone, serve as the sole basis for a negative opinion. In this regard, the medical specialist is advised that the Veteran is competent to report her observable symptoms and history, and such reports must be specifically acknowledged and considered in formulating opinions. If lay assertions in any regard are discounted, the medical specialist should clearly so state, and explain why. In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. J. LEE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Modesto, Victor 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.