Citation Nr: A25035757 Decision Date: 04/17/25 Archive Date: 04/17/25 DOCKET NO. 231002-381235 DATE: April 17, 2025 ORDER Service connection for genitourinary condition, claimed as a kidney disability, is denied. Service connection for left upper extremity radiculopathy is denied. Service connection for right upper extremity radiculopathy is denied. Service connection for a bilateral hearing loss disability is denied. Service connection for a right shoulder disability is denied. REMANDED Service connection for a left shoulder disability is remanded. Service connection for athlete's foot, to include as due to service-connected disease or injury, is remanded. Service connection for a for skin disability, claimed as dermatitis, is remanded. FINDINGS OF FACT 1. The evidence of record persuasively weighs against finding that the Veteran has had a kidney disability at any time during or approximate to the pendency of the claim. 2. The evidence of record persuasively weighs against finding that the Veteran has had left upper extremity radiculopathy at any time during or approximate to the pendency of the claim. 3. The evidence of record persuasively weighs against finding that the Veteran has had right upper extremity radiculopathy at any time during or approximate to the pendency of the claim. 4. The evidence of record persuasively weighs against finding that the Veteran has had a kidney disability at any time during or approximate to the pendency of the claim. 5. The evidence of record persuasively weighs against finding that the Veteran has had bilateral hearing loss for VA purposes at any time during or approximate to the pendency of this claim. CONCLUSIONS OF LAW 1. The criteria for service connection for a kidney disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for left upper extremity radiculopathy are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for right upper extremity radiculopathy are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for a right shoulder disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303 5. The criteria for service connection for a bilateral hearing loss disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1978 to September 1992, with subsequent service in the Reserve. VA has conceded the Veteran's participation in a toxic exposure risk activity (TERA) during active duty with exposures to soldering fumes, industrial solvents, fuels-petroleum fuels, hydraulic fluids, paint thinners, lacquers, paint strippers, cleaning supplies, glues and adhesives synthetic oils, esters, ototoxic chemicals, vehicle/aircraft exhaust, excessive vibrations, and other explosive chemicals and compounds. See other (July 2024). In May 2023, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of a March 31, 2023, rating decision. On September 2, 2023, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal, which considered the evidence of record at the time of the prior March 2023 decision. On the October 2, 2023, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the March 2023 AOJ decision, which was subsequently subject to HLR. 38 C.F.R. § 20.301. If evidence was submitted during the period after the AOJ issued the March 2023 decision, which was subsequently subject to HLR the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. The Veteran's claim for entitlement to service connection for dermatitis has been more generally characterized as a claim for service connection for a skin disability, to include dermatitis, in consideration of Clemons v. Shinseki, 23 Vet. App. 1 (2009). Additionally, the Board notes that the Veteran's claim for service connection for his shoulders were characterized in the September 2023 rating decision as service connection for bilateral shoulder pain. However, given the facts of this case, the Board finds it necessary to recharacterize the claim into two separate issues, service connection for a right shoulder disability, and service connection for a left shoulder disability. The March 2023 rating decision found that new and relevant evidence had been received to readjudicate the claim of service connection for a bilateral hearing loss disability. This is a favorable finding by the AOJ and the Board will proceed to the address the claim on the merits. See 38?U.S.C. § 5104A; 38?C.F.R. § 3.104(c). Service Connection Service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a), (d). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). 1. Service connection for a kidney disability. 2. Service connection for left upper extremity radiculopathy. 3. Service connection for right upper extremity radiculopathy. 4. Service connection for a right shoulder disability. The Veteran contends that he is entitled to service connection for a kidney disability, right and left upper extremity radiculopathy, and a right shoulder disability. He has not detailed his contentions. The Board concludes that the evidence of record persuasively weighs against finding the Veteran has had a kidney disability, right or left upper extremity radiculopathy, or a right shoulder disability at any time during the pendency of the claims or recent to the filing of the claims. See 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303. In regard to upper extremity radiculopathy, VA treatment records during the period on appeal do not reflect any complaints of or treatment for an upper extremity nerve disorder, to include radiculopathy. See CAPRI (March 2023). There are no reports of tingling, weakness, spasm, or numbness for either upper extremity. Further, during a March 2023 VA physical, the Veteran's extremities did not reveal cyanosis, clubbing, or edema. See Id. at 16. His pedal pulses and light sensation were intact. Of relevance, the records do reveal regular treatment for lower extremity neuropathy. Additionally, a January 2023 VA peripheral nerves disability benefits questionnaire (DBQ) examination report specifically found no objective evidence of left or right upper extremity radiculopathy. See C&P Exam (January 2023). There was no evidence of left or right upper extremity pain, numbness, or paresthesias and/or dysesthesias. The Veteran exhibited normal strength bilaterally in his elbows, wrists, grip, and pinch. The sensory examination was normal for both left and right upper extremities. Ultimately, the examination report reflects that the Veteran's upper extremity nerves and radicular groups were normal. VA treatment records during the period on appeal also do not reflect any complaints of or treatment for a kidney disability. See CAPRI (March 2023). Here, the Veteran denied genitourinary symptoms during August 2021, February 2022, August 2022, and March 2023 VA treatment. Id. at 15, 143, 309, 473. When asked if he had any kidney or liver disease during April 2022 treatment, the Veteran reported cirrhosis, but no kidney disorders. Id. at 224. The Board notes that the Veteran is currently service-connected for diabetes mellitus, type II, and receives regular endocrinology treatment. There is no indication that the Veteran has had any diabetic nephropathy during the period on appeal, and during March 2023 VA treatment his diabetes was noted to be well-controlled with oral medication and diet. Id. at 16. Similarly, VA treatment records during the period on appeal also do not reflect any complaints of or treatment for the right shoulder. See Id. There is no probative evidence that the Veteran has any right shoulder pain or impairment. The Veteran denied joint pain during October 2021 VA treatment. Id. at 365. He also denied arthralgia during February 2022, August 2022, and March 2023 VA treatment. Id. at 15, 145, 312. The Board finds that competent, credible evidence has not been submitted showing that the Veteran has or has had recent to the filing of his claim, a left or right upper extremity radiculopathy disability, a kidney disability, or a right shoulder disability. Further, the Veteran has not provided evidence of such. Neither the lay nor the available medical evidence shows any functional loss or impairment in earning capacity, especially in the absence of any functional impairment. See Saunders v. Wilkie, 886 F.3d 1356, 1367-69 (Fed. Cir. 2018), ("pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of a functional impairment of earning capacity."). The Veteran has not provided information describing how any symptomatology associated with his claimed left or right upper extremity radiculopathy disabilities, kidney disability, or right shoulder disability causes him functional impairment. On balance, the weight of the evidence is against the claim. It is noted that the existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. §§ 1110, 1131; Degmetich v. Brown, 104 F. 3d 1328 (1997). In the absence of proof of a present disability due to disease or injury, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, the claims for service connection for left and right upper extremity radiculopathy disabilities, a kidney disability, and a right shoulder disability are denied. As the evidence of record persuasively weighs against the claims, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). As to the above matters, the Board acknowledges that the AOJ did not obtain examinations or medical opinions. However, the Board finds that the AOJ had no duty to obtain an examination in these matters prior to the decision on appeal because there was not competent, credible evidence of disability. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (a VA examination and/or opinion is warranted when there is an indication in the record that a current disability is related to military service; the threshold for an indication is low). 5. Service connection for a bilateral hearing loss disability. The Veteran contends that he has hearing loss disability due to noise exposure in service. See C&P Exam (December 2021). VA has conceded the Veteran's in-service noise exposure. See Rating Decision (March 2023). The Board concludes that the evidence of record persuasively weighs against finding that the Veteran has had a bilateral hearing loss disability for VA purposes at any time during or approximate to the pendency of the claim. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). Sensorineural hearing loss shall be considered to have been incurred in or aggravated by service although not otherwise established during the period of service if manifested to a compensable degree within one year following service in a period of war or following peacetime service on or after January 1, 1947. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). For the purpose of applying the laws administered by the VA, impaired hearing is considered to be a disability when the auditory threshold at any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater, or when speech recognition scores utilizing the Maryland CNC Tests are less than 94 percent. 38 C.F.R. § 3.385. As an initial matter, the Board notes that the March 2023 rating decision made a favorable finding that the Veteran had a disability because he was diagnosed with hearing loss in December 2005. See Rating Decision - Narrative (March 2023). This finding was overturned in the September 2023 HLR decision, which noted that the Veteran did have hearing loss, but his audiometry results did not reflect hearing loss for VA purposes. Here, the RO rebutted the favorable finding by showing that the disability determination was clearly and unmistakably erroneous, as is required by 38 C.F.R. § 3.104(c), because the there was no medical evidence reflecting hearing loss as defined by VA regulations. 38 C.F.R. § 3.385. As this prior favorable finding has been appropriately overturned by the AOJ, the Board is not bound by it. Turning to the facts, service treatment records (STRs) reflect no complaints or findings for bilateral hearing loss. Audiological examinations performed in August 1978, August 1982, and August 1991 do not reflect any hearing loss. See STR at 1, 4 (January 1994). An audiometric test performed at the Veteran's May 1992 separation examination reflects the following: HERTZ 500 1000 2000 3000 4000 RIGHT 0 5 0 0 0 LEFT 5 10 0 0 10 Additionally, the Veteran specifically denied currently having or ever having had any history of hearing loss, or ear, nose, or throat trouble, or running ears in the corresponding, self-completed, May 1992 report of medical history. See Id. at 13. The Veteran was afforded a VA audiological evaluation in March 2017, and pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 Average CNC RIGHT 15 15 25 20 20 20 100% LEFT 10 20 25 25 20 23 98% Another VA examination was obtained in December 2021. See C&P Exam (December 2021). The Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 Average CNC RIGHT 15 15 25 25 30 24 98% LEFT 15 15 20 30 35 25 96% Based on these results, the Veteran does not have a current hearing loss disability as defined by VA regulations. See 38 C.F.R. § 3.385. These findings are supported by the Veteran's VA treatment record, which reflect that the Veteran had normal hearing at 250Hx - 800Hx at an April 2022 VA audiology appointment. See CAPRI at 19 (December 2022). While the Veteran is competent to report hearing loss, the presence of a hearing loss disability for VA purposes is not susceptible to lay observation because the presence of a hearing loss disability is made through an audiological examination conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. 38 C.F.R. § 4.85. While the Board recognizes the Veteran's reports of hearing loss, to include reports to medical providers, the Veteran's medical opinion is not predicated on any testing that meets the VA requirements and the presence of disability for VA purposes is not susceptible to lay observation. Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007). Therefore, the Veteran's medical opinion has no probative value. Consequently, the Board assigns greater probative weight to the VA audiological examinations showing that the Veteran did not meet the criteria for a hearing loss disability for VA purposes. This is more probative than the Veteran's uncorroborated opinion as they were obtained by state-licensed audiologists and included controlled speech discrimination tests (Maryland CNC) and pure tone audiometry tests. In the absence of proof of a present disability due to disease or injury, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, the Veteran does not meet the criteria for a hearing loss disability as defined by VA regulations at 38 C.F.R. § 3.385. Accordingly, the claim of service connection for bilateral hearing loss is denied. As the evidence of record persuasively weighs against the claim, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Notwithstanding, the Veteran may file a supplemental claim with new and relevant evidence to have the matter readjudicated. Instructions are included with this decision. REASONS FOR REMAND 6. Service connection for a skin disability, to include dermatitis, is remanded. 7. Service connection for athlete's foot, to include as due to service-connected disease or injury, is remanded. The Veteran contends that he is entitled to service connection for dermatitis and athlete's foot. He has not detailed his contentions. The issues of service connection for a skin disability and athlete's foot are remanded to correct duty to assist errors that occurred prior to the March 2023 rating decision on appeal. First, VA's duty to assist claimants in the development of their claim includes obtaining an examination and/or opinion when necessary to decide a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. §3.159(c)(4). Further, once an examination or opinion is obtained, VA must ensure that it is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that it is adequate). In regard to the Veteran's athlete's foot claim, the AOJ obtained a VA examination and opinion in January 2023, requesting an opinion, in part, on whether the Veteran's athlete's foot was related to his service-connected pes planus. See Medical Opinion (January 2023). Although a January 2023 VA examination was obtained, it provides insufficient findings. See C&P Exam (January 2023). The VA examination report determined that the Veteran did not have an athlete's foot diagnosis, and therefore provided no etiological opinion. December 2022 VA treatment records, however, reflect that the Veteran has been "applying his antifungal cream," "and continues to experience some itching on the soles of the feet. This has been a longstanding chronic recalcitrant problem." See CAPRI at 52 (March 2023). Tinea pedis, also known as athlete's foot, is also listed as a current medical problem for the Veteran. Id. at 1. Given that the Veteran has been diagnosed with athlete's foot during the appeal period, remand is necessary to obtain an opinion on etiology. See Colvin v. Derwinski, 1 Vet. App. 171 (1991); see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence... is essential for a proper appellate decision"). For the Veteran's entitlement to service connection for a skin disability, the Board finds that the AOJ erred by not obtaining an opinion regarding the etiology of the claimed conditions prior to the decision on appeal. Here, the record reflects that during December 2022 VA dermatology treatment, the Veteran was treated for eczema with Lichen simplex chronicus (LSC). See CAPRI at 55, 2136 (March 2023). Further, the September 2023 HLR decision included a favorable finding that there was an in-service event, injury, or disease, which was identified as March 1979 in-service treatment for body rash of questionable etiology, a November 1982 in-service medical history report reflecting skin diseases, and November 1983 in-service treatment for nonspecific granulomatous dermatitis. The Board is bound by this favorable finding. See 38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c). Thus, given the available evidence at the time of the rating decision on appeal, VA's duty to obtain a medical opinion was triggered. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). See also, McLendon v. Nicholson, 20 Vet. App. 79 (2006) (a VA examination and/or opinion is warranted when there is an indication in the record that a current disability is related to military service; the threshold for an indication is low). Second, a remand is warranted under 38 C.F.R. § 20.802 to satisfy a regulatory or statutory duty, specifically, the duty to obtain a medical examination and opinion under the standard for TERA in 38 U.S.C. § 1168. Given the record, there is a reasonable possibility that a remand could assist in substantiating the Veteran's athlete's foot and skin condition claims. Recently passed legislation provides that where a veteran submits a service connection claim with evidence of a disability and evidence of participation in a TERA during active military service and such evidence is not sufficient to establish service connection for the disability, the Secretary shall provide the veteran with a medical examination and secure a nexus opinion unless VA determines that there is no assertion that the claimed disorder is related to the toxic exposure risk activity. See 38 U.S.C. § 1116; Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), 38 U.S.C. § 1168. Here, although not explicitly asserted by the Veteran, the record reflects that the Veteran participated in TERA during his service, with conceded exposures to soldering fumes, industrial solvents, fuels-petroleum fuels, hydraulic fluids, paint thinners, lacquers, paint strippers, cleaning supplies, glues and adhesives synthetic oils, esters, ototoxic chemicals, vehicle/aircraft exhaust, excessive vibrations, and other explosive chemicals and compounds while performing duties in instrument repair, as a cannon crew member, and as a nuclear, biological, and chemical non-commissioned officer. See DPRIS at 12, 42 (March 2023); other (July 2024). Further, as noted above, VA treatment records show current diagnoses of athlete's foot and eczema with LSC, but there is insufficient evidence to establish service connection for the disability. Consequently, his claims for service connection as result of participation in a TERA has been raised by the record. Because the Board is unable to grant this claim at this time, and because the requirements to obtain a medical opinion compliant with 38 U.S.C. § 1168 are met, but such opinion has not yet been obtained, a remand is needed for VA to obtain one. Therefore, remand is necessary to correct the duty to assist errors on the part of the AOJ in satisfying its duties under 38 U.S.C. § 5103A, which occurred prior to the rating decision on appeal. See 38 C.F.R. § 20.802. 8. Service connection for a left shoulder disability is remanded. The Veteran contends that he is entitled to service connection for a bilateral shoulder disability. He has not detailed his contentions. The issue of service connection for a left shoulder disability is remanded to correct a duty to assist error that occurred prior to the March 2023 rating decision on appeal. VA's duty to assist claimants in the development of their claim includes obtaining an examination and/or opinion when necessary to decide a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. §3.159(c)(4). The Board finds that the AOJ erred by not obtaining an opinion regarding the etiology of the left shoulder condition prior to the decision on appeal. Here, VA treatment records reflect reports of left shoulder pain during April 2022 treatment. See CAPRI at 223 (March 2023). The Board notes that pain alone is sufficient to demonstrate functional impairment for a current disability for VA purposes. See Saunders v. Wilkie, 886 F.3d 1356 (2018). Further, the September 2023 HLR decision included a favorable finding that there was an in-service event, injury, or disease, which was identified as a March 1979 in-service softball injury causing left shoulder pain. The Board is bound by this favorable finding. See 38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c). Thus, given the available evidence at the time of the rating decision on appeal, VA's duty to obtain a medical opinion was triggered. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). See also, McLendon, 20 Vet. App. 79. Therefore, remand is necessary to correct this duty to assist error on the part of the originating agency in satisfying its duties under 38 U.S.C. § 5103A, which occurred prior to the March 2023 rating decision on appeal. See 38 C.F.R. § 20.802. Lastly, although VA has an obligation to provide VA examinations for any service connection claim which cannot be presumptively granted where there is evidence of a TERA, VA has identified several exceptions to this general obligation. Specifically, a TERA examination is not required for disabilities resulting from physical trauma; mental disorders; disabilities that have not been shown to have any positive association with herbicide exposure; and disabilities that manifested during service or with a clear etiology that is not associated with toxic exposure. See VBA Letter 20-22-10 at 10-13, Processing Claims Involving the PACT Act, 87 Fed. Reg. 78,543 (Dec. 22, 2022). In this case, the left shoulder claim is based on an in-service physical trauma. Thus, the Board finds that an exception to the TERA examination requirements applies, and an additional examination is not warranted on this basis. See 38 U.S.C. § 1168(b). In remanding these matters, 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. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician addressing whether the Veteran's athlete's foot is secondary to his service-connected pes planus. The phrase "at least as likely as not" means the likelihood is at least approximately balanced or nearly equal. The clinician should address the following: (a.) Whether athlete's foot is at least as likely as not caused by service-connected pes planus. Explain. (b.) Alternatively, whether athlete's foot is at least as likely as not aggravated by service-connected pes planus. Explain. NOTE (1): The examiner is advised all that is needed is a "but for" causation or aggravation. Spicer v. McDonough, 61 F. 4th 1360, 1366 (Fed. Cir. 2023) NOTE (2): Aggravation exists even if there is only an incremental increase in disability or where there is any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected disabilities above the degree of disability existing before the increase regardless of its permanence. See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019). Provide separate rationales addressing causation and aggravation as independent concepts. (c.) Whether the Veteran's athlete's foot is at least as likely as not, due to or the result of the Veteran's in-service TERA's described as exposure to soldering fumes, industrial solvents, fuels-petroleum fuels, hydraulic fluids, paint thinners, lacquers, paint strippers, cleaning supplies, glues and adhesives synthetic oils, esters, ototoxic chemicals, vehicle/aircraft exhaust, excessive vibrations, and other explosive chemicals and compounds. Consider: (1) the total potential exposure through all applicable deployments; and (2) the synergistic, combined effect of all toxic exposure risk activities of the veteran 2. Schedule the Veteran for a VA examination for the claimed skin disabilities. The examiner must review the claims file and provide the requested opinions regarding etiology. The phrase "at least as likely as not" means the likelihood is at least approximately balanced or nearly equal. The clinician should opine as to: (a.) Whether it is at least as likely as not that the Veteran's skin disabilities first manifested during service. Explain. Consider the Veteran's STRs reflecting March 1979 in-service treatment for body rash of questionable etiology, a November 1982 in-service medical history report reflecting skin diseases, and November 1983 in-service treatment for nonspecific granulomatous dermatitis. (b.) Whether it is at least as likely as not that the Veteran's skin disabilities are etiologically related to his TERA described exposure to soldering fumes, industrial solvents, fuels-petroleum fuels, hydraulic fluids, paint thinners, lacquers, paint strippers, cleaning supplies, glues and adhesives synthetic oils, esters, ototoxic chemicals, vehicle/aircraft exhaust, excessive vibrations, and other explosive chemicals and compounds. performing his duties in instrument repair, as a cannon crew member, and as a nuclear, biological, and chemical non-commissioned officer. Consider: (1) the total potential exposure through all applicable deployments; and (2) the synergistic, combined effect of all toxic exposure risk activities of the veteran. 3. Schedule the Veteran for a VA examination for the claimed left shoulder disability. The examiner must review the claims file. The phrase "at least as likely as not" means the likelihood is at least approximately balanced or nearly equal. The clinician should address whether it is at least as likely as not that any identified left shoulder disability is related to the Veteran's May 1979 in-service softball injury. Explain. Optional: The clinician may consider the Veteran's history as to onset and progression; and any documented history in formulating an opinion. AMANDA G. ALDERMAN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T.F., 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.