Citation Nr: 22019063 Decision Date: 03/31/22 Archive Date: 03/31/22 DOCKET NO. 20-02 212 DATE: March 31, 2022 ORDER Service connection for a left thumb disability is granted. Service connection for a right thumb disability is granted. Service connection for a left eye disability is denied. Service connection for a stomach disability is denied. REMANDED Service connection for a left knee disability is remanded. Service connection for a back disability is remanded. Service connection for bilateral hearing loss is remanded. Service connection for migraine headaches is remanded. Service connection for a heart disability is remanded. FINDINGS OF FACT 1. The Veteran's left thumb disability was shown as chronic in service and is not attributable to intercurrent causes. 2. The Veteran's right thumb disability was shown as chronic in service and is not attributable to intercurrent causes 3. The Veteran does not have a left eye disability for which service connection may be granted. 4. The Veteran does not have a stomach disability for which service connection may be granted. CONCLUSIONS OF LAW 1. The criteria for service connection for a left thumb disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 2. The criteria for service connection for a right thumb disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 3. The criteria for service connection for a left eye disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.9. 4. The criteria for service connection for a stomach disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from March 1967 until his honorable retirement in May 1991. This appeal has been advanced on the Board of Veterans' Appeals' (Board) docket pursuant to 38 U.S.C. § 7107(b) and 38 C.F.R. § 20.902(c). This case comes before the Board on appeal from a November 2016 decision issued by a Regional Office of the United States Department of Veterans Affairs (VA). In June 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. Evidentiary Standards In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). "[E]vidence is not in 'approximate balance' or 'nearly equal,' and therefore the benefit-of-the-doubt rule does not apply, when the evidence persuasively favors one side or the other." Lynch v. McDonough, 21 F.4th 776, 2021 U.S. App. LEXIS 37307, at *11; 2021 WL 5983923 (Fed. Cir. Dec. 17, 2021) (en banc). The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 12829 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. Service Connection VA provides compensation for a disability resulting from disease or injury incurred in or aggravated by service. This is referred to as a "service connection." 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to be entitled to service connection there must be competent, credible evidence of (1) a current disability, (2) an in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). When these elements are satisfied, service connection may be granted on a direct basis. Analysis 1. Service connection for a left thumb disability 2. Service connection for a right thumb disability First element: A current disability The Veteran received a VA-contracted examination in October 2016 assessing his thumbs. The examiner diagnosed him with strain in each thumb, which resulted in functional loss. The Board finds the first element is satisfied for each claim. Second element: An in-service event, injury, or illness, or aggravation thereof The Veteran's April 1991 retirement examination documented degenerative joint disease in each thumb. For chronic diseases listed under 38 C.F.R. § 3.309(a), including degenerative joint disease, service connection may be presumed if the evidence is sufficient to identify the disease entity and to establish chronicity in service, or if the disease manifested to a compensable degree within the first post-service year, or if the evidence shows continuity of symptomatology since service, unless the chronic disease is "clearly attributable to intercurrent causes." See 38 C.F.R. §§ 3.303(b), 3.307(a); Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258, 26668 (2015); see also 38 C.F.R. § 3.307(d) (providing how the presumption of service connection may be rebutted). Here, the Veteran has credibly testified that he experienced bilateral thumb pain and functional limitation in-service. This pain was documented and diagnosed a degenerative joint disease. The same pain and functional limitations continued following his retirement from service. The Board finds the evidence of record sufficiently establishes chronicity of symptoms associated with the Veteran's left and right thumbs since service. Therefore, the Board finds the second element is satisfied. Third element: A causal link Presumptive service connection is warranted and there is no need for the Veteran to establish a direct link between his current thumb disabilities and his military service. 38 C.F.R. § 3.309(a). Accordingly, service connection for a left and right thumb disability is granted. 3. Service connection for a left eye disability At his June 2021 Board hearing, the Veteran testified that he had poor vision, characterized as farsightedness. He submitted correspondence in September 2021 in which he explained that an eye test, which was also submitted, demonstrated poor eye sight in his left eye. He has not identified any other left eye condition, nor do his VA and private medical records indicate any other current left eye condition. Farsightedness is a refractive error. Under VA regulation, farsightedness is not a disease or injury for which service connection may be granted. 38 C.F.R. § 3.303(c) (refractive error of eye is not disease or injury within meaning of applicable legislation). Although neither an examination nor medical opinion was obtained in relation to this claim, the Board finds that VA was not under an obligation to provide one. Section 5103A of Title 38 of the United States Code, captioned "DUTY TO ASSIST," mandates that a medical examination be provided in disability compensation claim cases only when: (1) There is competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability; (2) There is evidence establishing that an event, injury, or illness occurred in service or within an applicable presumptive period, or the Veteran has a service-connected disability; and (3) There is an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) There is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Waters v. Shinseki, 601 F.3d 1274, 1277 (Fed. Cir. 2010); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Each of the elements must be met. As the Veteran's farsightedness does not constitute a "disability" for purposes of service connection, a VA examination is not required. The Board acknowledges that during his Board hearing, the Veteran reported experiencing blurred vision, but that was only in relation to his migraine headaches. The Board finds his symptoms of blurred vision are not independent disabilities for which service connection might be warranted. Instead, they are related to his migraine headaches for which he has filed a separate claim for service connection, and which is addressed later in this decision. Accordingly, service connection for a left eye disability is not warranted. 4. Service connection for a stomach condition The Board first recognizes that the Veteran filed a separate appeal under the Appeals Modernization Act for which the Board issued a decision in January 2021 denying service connection for bowel incontinence, bladder incontinence, enlarged prostate, and kidney disease. As part of the present Legacy appeal, the Veteran seeks service connection for a stomach condition other than those identified in the January 2021 Board decision. The Veteran received two examinations assessing his claimed stomach disability, one in October 2016 and another in December 2019. The October 2016 examiner found the Veteran did not have an identifiable stomach disability. Although the Veteran reported a longstanding history of intermittent pyrosis and dyspepsia, which was worse with eating certain foods or beverages. Still, there was no identifiable pathology after reviewing the Veteran's medical records, including test results. The December 2019 examiner also did not diagnose the Veteran with a current stomach disability. She documented that the Veteran did not report receiving treatment for a current disability. Each examiner's opinion was based on consideration of the Veteran's relevant in-service medical records, private and VA medical records, lay statements, physical examination and test results, and overall medical history. The Board finds no credible evidence of record contradicting the examiners' respective opinions. Accordingly, the Board finds that the Veteran does not have a current stomach disability for which service connection may be granted. REASONS FOR REMAND 1. Service connection for a left knee disability is remanded. The Veteran received a VA-contracted examination assessing his left knee in October 2016. The examiner diagnosed him with left knee strain. The October 2016 examiner opined that the Veteran's left knee disability was less likely than not incurred in or caused by his active military service, the Board does not find the opinion probative. To support the opinion, the examiner reasoned that the Veteran's current left knee strain was not the same as the left knee disability he experienced in service. The examiner stated, "those strains would have resolved years ago. It is more likely as not that his current strain is of recent origin and incurred at home." The examiner offered no basis in fact to support this reasoning. Merely asserting one circumstance over another is not an adequate rationale unless it is supported by facts. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("It is the fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion."). Accordingly, remand is required for an addendum opinion. 2. Service connection for a back disability is remanded. The VA Regional Office obtained a VA examination and opinion in December 2019 addressing the Veteran's back disability. The examiner offered a negative nexus opinion addressing only direct service connection. The Board finds that the Veteran has reasonably raised a theory of secondary service connection. Based on his Board testimony, the Veteran claims his back disability was caused by or aggravated by his service-connected bilateral knee disabilities. No VA examiner, nor any other medical professional, as addressed the theory of secondary service connection. Accordingly, remanded is required to obtain an addendum opinion from a qualified clinician adequately addressing this theory of service connection. 3. Service connection for bilateral hearing loss is remanded. The Veteran received a VA-contracted examination in October 2016 assessing his bilateral hearing loss. At that time, he did not meet the requirements under 38 C.F.R. § 3.385 to have a current disability. For VA purposes, impaired hearing will be considered a disability when the auditory threshold for any of the frequencies of 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Following his June 2021 Board hearing, he submitted a private audiologic examination dated in September 2019. That examination showed that the Veteran's right ear and left ear did meet the auditory thresholds for VA disability purposes. Still, no medical opinion has been obtained addressing the etiology of bilateral hearing loss in light of this new evidence. Accordingly, remand is required to obtain a new examination and opinion addressing the etiology of the Veteran's bilateral hearing loss. 4. Service connection for migraine headaches is remanded. The Veteran received two examinations assessing his migraine headaches, one in October 2016 and another in December 2019. The October 2016 examiner found that the Veteran did not have a current disability. The Board finds that conclusion is inaccurate. The examiner recorded that the Veteran had migraines occasionally, just not at the time of the exam. The requirement for a veteran to have a "current disability" is satisfied when he or she has a disability (1) at the time a claim for VA disability compensation is filed or (2) has a disability during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Hence, the examiner had a misunderstanding of the applicable rules defining a "current" disability. The Veteran's occasional migraine headaches, even if not present at the time of the exam, still existed during the pendency of the claim, and the examiner did not adequately address that information. The December 2019 examiner did record a current disability of migraine headaches. The examiner opined that the Veteran's current migraine headaches were less likely than not related to his military service. The examiner reasoned "[t]he complaint of headaches documented in 1979 and 1990 on active duty [are] more likely an acute event without long term sequela, since there is no sign of continuation of symptomology or progressive symptoms during and/or after separation from active service." The Board finds this reasoning contradictory to the facts in evidence. The Veteran reported to the examiner that he experienced migraine headaches after service; he has reported the same in correspondence with VA and at his Board hearing. Reonal v. Brown, 5 Vet. App. 458, 461 (1993) ("An opinion based on an inaccurate factual premise has no probative value."). The examiner did not adequately explain why the Veteran's current headaches are independent of those he experienced in service, particularly in light of the Veteran's statements of continuity. Accordingly, remand is required to obtain an addendum opinion addressing the etiology of the Veteran's migraine headaches. 5. Service connection for a heart disability is remanded. In December 2016, a VA-contracted examiner did not diagnose the Veteran with a heart condition, other than hypertension for which he is currently service connected. But the examiner did state that he had "mild-moderate mitral valve regurgitation and bilateral atrial enlargement--noted on ECHO as an incidental finding not clinically symptomatic." In April 2017, the Veteran underwent mitral valve replacement. A new VA-contracted examination occurred in December 2019. The examiner identified the Veteran's mitral valve replacement and residuals as a current disability. The examiner opined that the Veteran's current heart disability was less likely than not related to his military service. The examiner reasoned "[t]he complaint of chest pain documented on active duty is more likely an acute event without long term sequela, since there is no sign of continuation of symptomology during and/or after separation from active service." The examiner offered no basis in fact to support this reasoning. There is evidence that the Veteran had repeated treatment for chest pains in service, and he reported additional chest pains after service, which led to heart surgery. The Board finds the examiner's opinion is not sufficiently supported by logical reasoning. Nieves-Rodriguez, 22 Vet. App. at 304 (2008). Accordingly, remanded is required to obtain an addendum opinion from a qualified clinician adequately addressing the etiology of the Veteran's heart disability in light of the medical and lay evidence of potential continuity of symptoms. Accordingly, the matters are REMANDED for the following actions: 1. Obtain any of the Veteran's outstanding VA medical records and associate them with the claims file. 2. After any additional records are associated with the claims file, obtain an addendum opinion from an appropriately qualified clinician to provide an opinion addressing the onset and etiology of the Veteran's left knee disability. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. If the examiner decides an examination is necessary, then one shall be provided. The examiner is asked to provide an opinion regarding whether it is at least as likely as not (50 percent probability or more) that the Veteran's left knee disability had its onset in or is otherwise etiologically related to an in-service event, injury, or disease. In rending his or her opinion, the examiner should consider and, if deemed relevant, address the following, in addition to any other relevant evidence: (a.) Statements made during the October 2016 examination that the Veteran first experienced left knee pain in 1970 during his active service, which continued since service. (b.) July 14, 1988; September 20, 1988; June 15, 1989, in-service medical records documenting treatment for bilateral knee pain. (c.) The Veteran's testimony before the Board in June 2021. The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his left knee disability, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of a left knee disability in service or the assertion that an in-service event, injury, or illness led to his current left knee disability. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion, including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, may be considered an insufficient rationale. The examiner is informed that the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, may be considered insufficient rationale. If the examiner determines a disability was acute rather than chronic, the examiner should explain how he or she arrived at that conclusion rather than providing a conclusory opinion. For example, what evidence led to that conclusion, what would the examiner expect to see if a condition was chronic, how do the Veteran's lay statements, if any, affect the conclusion? If the examiner relies on medical treatises, the examiner should identify the treatises. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 3. After any additional records are associated with the claims file, obtain an addendum opinion from an appropriately qualified clinician addressing the onset and etiology of the Veteran's back disability. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. If the examiner decides an examination is necessary, then one shall be provided. The examiner is asked to provide an opinion regarding: (a.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's back disability had its onset in or is otherwise etiologically related to an in-service event, injury, or disease. (b.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's currently diagnosed back disability was caused by (proximately due to or as the result of) his service-connected bilateral knee disabilities. (c.) Whether it is at least as likely as not (a 50 percent probability or more) that the Veteran's currently diagnosed back disability was aggravated by his service-connected bilateral knee disabilities. The examiner is advised "aggravation" means any increase in the severity of the underlying disability beyond its natural progression. In rending his or her opinion, the examiner should consider and, if deemed relevant, address the following, in addition to any other relevant evidence: (a.) The Veteran's June 2021 Board testimony. (b.) The correspondence received from the Veteran on September 16, 2021. (c.) July 4, 1980, in-service medical record documenting a back injury and treatment. The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his back disability, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of a back disability in service or the assertion that the Veteran's service-connected bilateral knee disabilities led to his currently diagnosed back disability. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinions, including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, may be considered an insufficient rationale. The examiner is informed that the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, may be considered insufficient rationale. If the examiner determines a disability was acute rather than chronic, the examiner should explain how he or she arrived at that conclusion rather than providing a conclusory opinion. For example, what evidence led to that conclusion, what would the examiner expect to see if a condition was chronic, how do the Veteran's lay statements, if any, affect the conclusion? If the examiner relies on medical treatises, the examiner should identify the treatises. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 4. After any additional records are associated with the claims file, obtain a new VA examination and opinion from an appropriately qualified clinician addressing the onset and etiology of the Veteran's bilateral hearing loss. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. The examiner is asked to provide an opinion regarding whether it is at least as likely as not (50 percent probability or more) that the Veteran's bilateral hearing loss had its onset in or is otherwise etiologically related to an in-service event, injury, or disease, to include as to due acoustic trauma as part of the Veteran's duties in the military. If the examiner relies on threshold shifts, the examiner MUST define how he/she measured a threshold shift. In rending his or her opinion, the examiner should consider and, if deemed relevant, address the following, in addition to any other relevant evidence: (a.) A private audiogram dated September 5, 2019 (received by VA on September 16, 2021). (b.) The correspondence received from the Veteran on September 16, 2021. (c.) The Veteran's Board testimony describing his acoustic trauma experienced in service. The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his hearing loss, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of hearing loss in service or the assertion that an in-service event, injury, or illness led to hearing loss. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, may be considered an insufficient rationale. The examiner is informed that the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, may be considered insufficient rationale. If the examiner relies on medical treatises, the examiner should identify the treatises. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 5. After any additional records are associated with the claims file, obtain an addendum opinion from an appropriately qualified clinician addressing the onset and etiology of the Veteran's heart disability. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. If the examiner decides an examination is necessary, then one shall be provided. The examiner is asked to provide an opinion regarding whether it is at least as likely as not (50 percent probability or more) that the Veteran's mitral valve replacement and associated residuals had their onset in or is otherwise etiologically related to an in-service event, injury, or disease, to include the numerous chest conditions the Veteran reported and was treated for in service. In rending his or her opinion, the examiner should consider and, if deemed relevant, address the following, in addition to any other relevant evidence: (a.) The in-service medical records documenting chest pains, dated June 5 and 7, 1989; April 2, 1985; May 11, 1984; May 8, 1983; February 8, 1974; October 14, 1979; November 11, 1969; and the April 29, 1991, Retirement Examination during which the Veteran reported chest pains. (b.) The correspondence received from the Veteran on September 16, 2021. (c.) The Veteran's June 2021 Board hearing testimony related to his heart disability. The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his heart disability, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of a heart disability in service or the assertion that an in-service event, injury, or illness led to his current heart disability. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, may be considered an insufficient rationale. The examiner is informed that the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, may be considered insufficient rationale. If the examiner determines a disability was acute rather than chronic, the examiner should explain how he or she arrived at that conclusion rather than providing a conclusory opinion. For example, what evidence led to that conclusion, what would the examiner expect to see if a condition was chronic, how do the Veteran's lay statements, if any, affect the conclusion? If the examiner relies on medical treatises, the examiner should identify the treatises. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 6. After any additional records are associated with the claims file, obtain an addendum opinion from an appropriately qualified clinician addressing the onset and etiology of the Veteran's migraine headaches. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. If the examiner decides an examination is necessary, then one shall be provided. The examiner is asked to provide an opinion regarding whether it is at least as likely as not (50 percent probability or more) that the Veteran's migraine headaches had their onset in or are otherwise etiologically related to an in-service event, injury, or disease. In rending his or her opinion, the examiner should consider and, if deemed relevant, address the following, in addition to any other relevant evidence: (a.) In-service medical records documenting headaches, dated February 7, 1991; June 28, 1989; March 12, 1988; December 12, 1987; November 12, 1987; October 8, 1987; October 31, 1986; September 16, 1985; March 4, 1985; October 23, 1981; October 8, 1984; March 1, 1985; February 5, 1990; and April 10, 1968. (b.) The correspondence received from the Veteran on September 16, 2021. (c.) The Veteran's Board testimony, during which he reported blurred vision associated with migraine headaches that occurred following active service. The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his migraine headaches, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of migraine headaches in service or the assertion that an in-service event, injury, or illness led to current migraine headaches. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, may be considered an insufficient rationale. The examiner is informed that the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, may be considered insufficient rationale. If the examiner determines a disability was acute rather than chronic, the examiner should explain how he or she arrived at that conclusion rather than providing a conclusory opinion. For example, what evidence led to that conclusion, what would the examiner expect to see if a condition was chronic, how do the Veteran's lay statements, if any, affect the conclusion? If the examiner relies on medical treatises, the examiner should identify the treatises. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. F. Sawka, 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.