Citation Nr: 25003303 Decision Date: 03/07/25 Archive Date: 03/07/25 DOCKET NO. 20-24 983 DATE: March 7, 2025 ORDER New and material evidence having been received, the petition to reopen the previously denied claim of entitlement to service connection for eosinophilic esophagitis with dysphagia is granted. Entitlement to service connection for eosinophilic esophagitis with dysphagia is granted. Entitlement to service connection for a right shoulder disorder is denied. REMANDED Entitlement to service connection for a left shoulder disorder is remanded. FINDINGS OF FACT 1. In an October 2011 rating decision, the Agency of Original Jurisdiction (AOJ) denied the Veteran's claim of entitlement to service connection for eosinophilic esophagitis with dysphagia; the Veteran did not appeal that decision within one year of notice of the decision. 2. Evidence added to the record since the October 2011 rating decision relates to an unestablished fact necessary to substantiate the claim for service connection for eosinophilic esophagitis with dysphagia. 3. The Veteran's eosinophilic esophagitis with dysphagia is etiologically related to his service. 4. At no time during the pendency of the claim does the Veteran have a diagnosis for a right shoulder disorder, and the record does not contain a recent diagnosis of such disability prior to the Veteran's filing of a claim. CONCLUSIONS OF LAW 1. The criteria for reopening the claim of entitlement to service connection for eosinophilic esophagitis with dysphagia have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. The criteria for service connection for eosinophilic esophagitis with dysphagia are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a right shoulder disorder are not met. 38 U.S.C. §§ 1110, 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 Army from August 2004 to January 2006 and from May 2009 to January 2010. These matters come to the Board of Veterans' Appeals (Board) on appeal from a March 2018 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in September 2022. A transcript of the hearing has been associated with the claims file. The record was held open for 90 days following the Board hearing for submission of additional evidence. In December 2022, the Veteran's representative requested an additional 30 day extension of time to submit evidence and argument. The Board granted this Motion for Extension of Time in December 2022. This requested extension of time has expired. In February 2024, the Board remanded this matter to the AOJ for further development. More specifically, the Board directed the AOJ to schedule the Veteran for new examinations to determine the etiology of his disabilities and to evaluate all possible theories of entitlement and to obtain outstanding treatment records. Updated VA treatment records have been associated with the claims file and a February 2024 letter requested that the Veteran complete an appropriate authorization form to allow VA to obtain treatment records on his behalf. A VA examination was conducted in September 2024 to determine the nature and etiology of the Veteran's claimed shoulder disorders. In October 2024, the AOJ issued a Supplemental Statement of the Case again denying service connection for the Veteran's claimed bilateral shoulder conditions. The Board finds that there has been substantial compliance with its previous remand with regards to the claim for service connection for a right shoulder disorder. However, the Board also finds that there has not been substantial compliance with the Board's previous remand directives regarding the issue of entitlement to service connection for a left shoulder disorder and another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). In the February 2024 decision, the Board also denied the petition to reopen the previously denied claim of entitlement to service connection for eosinophilic esophagitis with dysphagia, stating that new and material evidence has not been received. Subsequently, the Veteran appealed the Board's February 2024 decision to the United States Court of Appeals for Veterans' Claims (Court). The parties to an October 2024 Joint Motion for Partial Remand agreed to vacate the Board's October 2024 decision to the extent the Veteran's claim was denied and remanded the matter for further consideration. An October 2024 rating decision granted the Veteran's claims for service connection for a right and left knee condition and assigned an initial rating for each disability. As this decision represents a full grant of the benefits sought with respect to these claims for service connection, such issues are no longer before the Board for consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). The Board notes that the Veteran submitted additional evidence in support of his appeal in January 2025. In a January 2025 submission, the Veteran requested that the Board adjudicate his case without remand to the AOJ for review of the additional evidence submitted in his appeal. the Veteran also waived any remaining time to submit additional evidence or argument. The Board will therefore proceed with its adjudication. New and Material Evidence Criteria As a threshold matter, the Board must determine whether new and material evidence has been submitted to reopen a previously denied claim. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (reopening after a prior unappealed AOJ denial). A rating decision becomes final when it has not been appealed within the prescribed time period and when no additional material evidence was received within a year of the decision; the decision is not subject to revision on the same factual basis. 38 U.S.C. § 7105(b); 38 C.F.R. §§ 3.104, 20.302, 20.1103. In order to reopen a claim, there must be added to the record "new and material evidence." 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can neither be cumulative or redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. 38 C.F.R. § 3.156(a), which defines new and material evidence, requires that evidence raise a reasonable possibility of substantiating the claim in order to be considered "new and material," and defines material evidence as evidence, that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. The Court has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). 1. New and material evidence having been received, the petition to reopen the previously denied claim of entitlement to service connection for eosinophilic esophagitis with dysphagia is granted. The parties to the October 2024 Joint Motion for Partial Remand agreed that the February 2024 Board decision erred in providing adequate reasons and bases for the issue. Specifically, the parties agreed that the Board did not fully address how the evidence was duplicative nor did the Board discuss whether the evidence shows the Veteran's esophagus condition was incurred in or aggravated by service. By way of background, the Veteran's claim for service connection for eosinophilic esophagitis with dysphagia was originally denied by an October 2011 rating decision. The evidence considered at the time of the October 2011 rating decision included the Veteran's service treatment records, post-service VA and private treatment records, and September 2011 VA examination reports. Service treatment records showed complaints of sore throat, swelling of throat, vomiting, and difficulty swallowing in June 2003 with a diagnosis of eosinophilic esophagitis and dysphagia in November 2009. A September 2011 VA examination report diagnosed eosinophilic esophagitis that was less likely than not related to military service. The October 2011 rating decision denied the claim of service connection for an esophagus condition as the evidence does not show that the Veteran's condition resulted from, or was aggravated, by a service-connected disability and that the evidence does not show that an esophagus condition was incurred in or aggravated by service. In October 2011, the Veteran was advised of the decision and his appellate rights. However, no further communication regarding his claim of entitlement to service connection was received until November 2017, when VA received a petition to reopen his claim for entitlement to service connection for eosinophilic esophagitis with dysphagia. Therefore, the October 2011 rating decision is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. In this regard, the Board has considered the applicability of 38 C.F.R. § 3.156(b). However, in the instant case, such regulation is inapplicable as no relevant evidence pertaining to the Veteran's claim for service connection was received or was in the constructive possession of VA prior to the expiration of the appeal period stemming from the October 2011 rating decision. See also Lang v. Wilkie, 971 F.3d 1348 (2020); Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011); Roebuck v. Nicholson, 20 Vet. App. 307, 316 (2006); Muehl v. West, 13 Vet. App. 159, 161-62 (1999). Moreover, no additional relevant service records (warranting reconsideration of the claim) have been received at any time. See 38 C.F.R. § 3.156(c). The Veteran sought to reopen his claim of entitlement to service connection for eosinophilic esophagitis with dysphagia in November 2017. Evidence received since the October 2011 rating decision includes additional updated VA treatment records, a February 2018 VA examination report and a January 2025 private medical opinion. Although the VA treatment records and the February 2018 VA examination are new, they are redundant as it either just provides evidence of a diagnosis or continues to indicate that the Veteran has an esophagus condition that was less likely than not related to his active service. Evidence that was before the AOJ at the time of the October 2011 rating decision. However, the January 2025 private medical opinion presents positive evidence that there is a nexus between the Veteran's claimed disability and service. This evidence is new and material as it is not redundant of evidence already of record in the October 2011 rating decision and it relates to whether the Veteran's esophagus condition stems from service. See 38 C.F.R. § 3.156(a). As such, the issue of entitlement to service connection for eosinophilic esophagitis with dysphagia is reopened. To that extent, the appeal is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, supra. Service Connection Criteria Generally, service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Every veteran is presumed to be in sound condition upon entry except as to any injury or disease noted at the time of enlistment. 38 U.S.C. § 1111; Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). In determining whether a specific condition is "noted" on entry, the Board's analysis is limited to whether the condition was recorded in the enlistment examination report. 38 C.F.R. § 3.304(b). The burden then falls on the Government to rebut the presumption of soundness by clear and unmistakable evidence that the disability was both preexisting and not aggravated by service. Wagner, 370 F.3d at 1096. Under 38 U.S.C. § 1153 and 38 C.F.R. § 3.306, a preexisting disability will be considered to have been aggravated by active military service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. Aggravation will be rebuttably presumed where there is affirmative evidence of in-service worsening. Conversely, aggravation will not be conceded where the preexisting disability underwent no discernible increase in severity in service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b); see also Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Mere "temporary or intermittent flare-ups" of a preexisting condition are generally insufficient to show that in-service worsening has occurred. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993). However, the degree of in-service worsening need not be so great as to warrant compensation for the presumption of aggravation to attach. Browder v. Derwinski, 1 Vet. App. 204, 207 (1991). Notably, once the presumption of aggravation does attach, the government bears the burden of showing, by clear and unmistakable evidence, "that the increase in disability is due to the natural progress of the disease." 38 U.S.C. § 1153; 38 C.F.R. § 3.306; Wagner v. Principi, supra. Pertinent to a claim for service connection, such a determination requires a finding of a current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; see also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (the term "disability" as used in 38 U.S.C. § 1110" refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability"). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that the requirement of the existence of a current disability is satisfied when a claimant has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a claimant filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999). 2. Entitlement to service connection for eosinophilic esophagitis with dysphagia is granted. The Veteran contends this his eosinophilic esophagitis with dysphagia stems from service. Specifically, the Veteran contends that it stems from environmental hazards and allergens while in service, to include burn pits and smokestacks. See September 2022 Board Hearing (pg. 3-4). The AOJ concedes that the Veteran was exposed to toxins as a Gulf War Veteran. See December 2022 Toxic Exposure Memorandum. The Veteran's service treatment records reveal a diagnosis of gastritis in June 2003 and a diagnosis of eosinophilic esophagitis in November 2009. The Board notes that the record contains three separate opinions which must be considered and weighed. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 193 (1991)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (stating that the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). A September 2011 VA examiner opined that the Veteran's eosinophilic esophagitis is less likely than not the result of or related to military service or Guld War exposure. The examiner explained that the Veteran was hospitalized at age three for four days for dysphagia and asthma and was diagnosed with a food allergy to beans. The examiner stated that the Veteran had a positive skin prick test to beans, coconut, corn, peanuts, peas and soybeans. The examiner concluded that the Veteran's eosinophilic esophagitis is more likely than not caused by and related to his food allergy since he was the age of three, his history of allergic rhinitis since adolescence and his childhood asthma. The Board finds this opinion to be inadequate for adjudicative purposes. While the examiner focuses on the Veteran's food allergies as a child, the examiner does not address any of the Veteran's contentions about his exposure to environmental hazards like burn pits and smokestacks while in service. Further, the Veteran does not contend that his condition is a pre-existing condition aggravated by service as he was first diagnosis while on deployment. See September 2022 Board Hearing (pg. 6). The examiner does not explain the relevance of the Veteran's childhood food allergy on his claimed eosinophilic esophagitis. It is a medical examiner's responsibility to provide a well-supported opinion so that the Board may carry out its duty to weigh the evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (concluding that medical opinion is not entitled to any weight "if it contains only data and conclusions"). This opinion is therefore afforded little, if any, probative weight. A March 2018 VA examiner opined that the Veteran's disability was less likely than not (less than 50 percent probability) caused by or related to Gulf War environmental exposure. The examiner states that the Veteran's eosinophilic esophagitis is due to food or pollen allergies and his history of gastroesophageal reflux disease. The Board finds this opinion inadequate for adjudicative purposes. The examiner does not provide a sufficient reasoning and bases for his conclusion and does not address the Veteran's contentions. See Nieves-Rodriguez v. Peake, supra. This opinion is therefore afforded little, if any, probative weight. In January 2025, the Veteran provided a private opinion by Dr. V.C. The physician opined that the Veteran's eosinophilic esophagitis was at least as likely as not caused by his military service. The physician stated that prior to enlistment, the Veteran had an allergy to beans which caused laryngeal edema with difficulty breathing and swallowing which is not indicative of eosinophilic esophagitis. The physician also stated that the Veteran's episodes of gastritis and pharyngitis before and during service is not indicative of eosinophilic esophagitis as the symptoms were in the larynx and pharynx not the mid-esophagus. The physician noted that air pollution is a factor for developing eosinophilic esophagitis and that the aeroallergens and irritants in burn pits are well documented. The physician emphasized that the Veteran had already completed two back-to-back deployments in the span of three years before he was diagnosed with dysphagia. The physician concluded that it is highly probable that the aeroallergens and irritants the Veteran encountered during his first deployment triggered a severe response to the same allergens three years later. The Board finds that the examiner considered all evidence of record after thorough review of the claims file, including lay statements properly weighed. See Nieves-Rodriguez v. Peake, supra. Furthermore, the medical examination report contained clear conclusions with supporting data and a thorough rationale. Therefore, this etiology opinion is afforded probative weight. In sum, the Veteran has a diagnosis of eosinophilic esophagitis and was exposed to toxins during service. The Board finds that the only probative opinion of record is in support of the Veteran's claim for entitlement to service connection eosinophilic esophagitis with dysphagia. Moreover, there is no sufficient basis for the Board to reject this supportive opinion and to further develop the claim. Cf. Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (holding that, because it is not permissible for VA to undertake additional development to obtain evidence against an appellant's case, VA must provide an adequate statement of reasons or bases for its decision to pursue such development where such development could be reasonably construed as obtaining additional evidence for that purpose). Accordingly, the Board finds that service connection for eosinophilic esophagitis with dysphagia is warranted. The appeal is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, supra. 3. Entitlement to service connection for a right shoulder disorder is denied. The Veteran contends this his right shoulder disorder stems from service. Specifically, he contends that it stems from injuring his right shoulder during his military service as a result of his work as a combat infantryman, and during the same vehicle rollover incident when trying to help rescue the other servicemembers. See September 2022 Board Hearing (pg. 12). The Veteran testified he dislocated his right shoulder and was treated in the field by a medic (pg. 12). The Veteran denied post-service injuries to his right shoulders at any time. Service treatment records are negative for any complaints, treatments or diagnosis of a right shoulder disorder. Post-service treatment records are negative for any complaints, treatments or diagnosis related to a right shoulder disorder. A February 2018 examiner did not provide a diagnosis or etiology opinion as to the Veteran's claimed right shoulder disorder; the Board deemed the opinion inadequate for adjudicative purposes its February 2024 decision. An August 2024 examiner opined that the claimed right shoulder disorder was less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that there is no diagnosis rendered for the Veteran's right shoulder disability. The examiner noted that the Veteran's report of right shoulder pain or pathology is primarily due to a neck condition. The Board therefore concludes that the Veteran does not have a current diagnosis of a right shoulder disorder and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, supra; McClain v. Nicholson, supra. As the record does not reflect a current diagnosis related to a right shoulder disorder, the cornerstone element of service connection has not been met, and service connection is not warranted. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, supra. No further discussion of the remaining elements is necessary. The Board acknowledges the Court's holding in Saunders but does not find a basis for determining that there is functional impairment related to a diagnosis of a right shoulder disorder. See Saunders v. Wilkie, supra. Moreover, the Veteran has not alleged manifestations of similar severity, frequency and duration as those VA has determined by regulation would cause impaired earning capacity in an average person. Wait v. Wilkie, 33 Vet. App. 8 (2020). The Board acknowledges the Veteran's assertions and sincere belief that he has a diagnosis of a right shoulder condition that is related to service. In this regard, the Veteran is competent to report the type of symptoms he experienced in and after service, as this is observable through the five senses. See Layno v. Brown, 6 Vet. App. 465 (1994). However, a determination as to the appropriate diagnosis, and the etiology thereof, is a complex medical determination which goes beyond lay observation of symptoms. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this regard, the question of causation involves a medical subject concerning an internal process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of diagnostic testing such as X-rays. In the instant case, there is no suggestion that the Veteran has had any medical training. As such, the question of etiology in this case may not be competently addressed by lay evidence and the opinions of the Veteran are nonprobative evidence. In the absence of the claimed disability, service connection may not be granted. See Brammer, supra; see also Degmetich v. Brown, 104 F.3d 1328 (1997); Gilpin v. Brown, 155 F.3d. 1353 (Fed. Cir. 1998) (service connection cannot be granted if the claimed disability does not exist). Accordingly, the Board finds that service connection for a right shoulder disorder is not warranted. The appeal is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, supra. REASONS FOR REMAND 4. Entitlement to service connection for a left shoulder disorder is remanded. The Veteran contends this his left shoulder disorder stems from service. Specifically, the Veteran contends that his left shoulder disorder is caused by overuse and the physical rigor of military service. See September 2022 Board Hearing (pg. 15). The Veteran was diagnosed with status post left clavicle resection in February 2018 and left shoulder strain in August 2024. The Veteran was afforded a VA examination in February 2018. At that time, the VA examiner opined that the Veteran's left shoulder disorder was less likely than not related to his environmental exposures in Southwest Asia and was more likely than related ot his recent esophagus surgery. The Board found the February 2018 VA etiology opinion to be inadequate to decide the claim as the examiner relied solely on the lack of diagnoses during active service when rendering the opinions. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). In addition, the Board noted that the VA examiner did not render an opinion as to direct service connection as to the left shoulder and did not adequately address the Veteran's contention of in-service injury. See Nieves-Rodriguez v. Peake, supra. An August 2024 VA examiner opined that the claimed left shoulder disorder was less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that there is evidence of left shoulder pain that manifested in 2018 since his left clavicle resection in December 2017 and the Veteran's left shoulder X-ray of 2018 was unremarkable. The examiner stated that there is insufficient evidence in the claims file for a direct link to military service without mere speculation at this time, that there was no evidence of chronicity of the condition beginning in service or immediately after service until the and that a nexus cannot be established with currently available evidence. The Board finds this opinion to be inadequate for adjudicative purposes. The examiner speculates on the etiology of the Veteran's left shoulder disorder. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a causal relationship). See also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (a doctor's statement framed in terms such as "could have been" is not probative); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) ("may or may not" language by a physician is too speculative). Further, the examiner does not address the Veteran's contentions of wear and tear of his left shoulder from carrying heavy weapons and equipment while in service. See Nieves-Rodriguez v. Peake, supra. This opinion is therefore insufficient to decide the appeal. Therefore, an addendum opinion to determine the etiology of the Veteran's left shoulder disorder should be obtained. See Barr v. Nicholson, 21 Vet. App. 303 (2007). On remand, an addendum opinion should be obtained. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. §5103A (b)(2) and 38 C.F.R. §3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for a VA examination with an appropriate medical examiner and obtain an etiology opinion from an appropriate medical examiner to determine the nature and etiology of the Veteran's claimed left shoulder disorder. The need for physical examination or telehealth evaluation is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. All indicated tests and studies should be accomplished and the findings then reported in detail. The examiner should respond to the following question: Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any currently present left shoulder disorder had its onset during the Veteran's active service, or is otherwise etiologically related to such service, to include to include his in-service exposure to the environmental hazards in Southwest Asia (notwithstanding the fact that there may not be a presumed association)? The examiner must specifically address the Veteran's contentions that he left shoulder disorder is caused by overuse and the physical rigor of military service. (Continued on the next page) ? A rationale should be provided for all opinions offered. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resorting to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Adeyemi, 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.