Citation Nr: 25006751 Decision Date: 05/19/25 Archive Date: 05/19/25 DOCKET NO. 17-64 956 DATE: May 19, 2025 ORDER Entitlement to service connection for peripheral neuropathy, right upper extremity is denied. Entitlement to service connection for peripheral neuropathy, left upper extremity is denied. Entitlement to service connection for peripheral neuropathy, right lower extremity is denied. Entitlement to service connection for peripheral neuropathy, left lower extremity is denied. REMANDED Entitlement to service connection for gastrointestinal disorder (GI) is remanded. FINDINGS OF FACTS 1. The evidence does not show that the Veteran has been diagnosed with an upper extremity peripheral neuropathy, right or left. 2. There is no competent evidence showing the Veteran's claimed upper right or upper left peripheral neuropathy are etiologically related to service, were incurred in service, were otherwise related to service or were caused or aggravated by a service-connected disability. 3. The Veteran has been diagnosed with lumbar radiculopathy of the lower extremities. 4. There is no competent evidence showing the Veteran's lower right or left peripheral neuropathy are etiologically related to service, was incurred in service, was otherwise related to service or was caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for peripheral neuropathy, right upper extremity have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 2. The criteria for entitlement to service connection for peripheral neuropathy, left upper extremity have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 3. The criteria for entitlement to service connection for peripheral neuropathy, right lower extremity have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 4. The criteria for entitlement to service connection for peripheral neuropathy, left lower extremity have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from March 1968 to May 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2015 and March 2016 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO), which denied the claims on appeal. This appeal was developed in accordance with the VA Legacy appeals process. As such, the regulations specifically pertaining to VA's current appeals process under the Appeals Modernization Act (AMA) are not for application. The Board has previously remanded this appeal in July 2024 to assist in determining the likely nature and etiology of the Veteran's vertigo, gastrointestinal disorder and peripheral neuropathy. The case has since been returned to the Board for appellate review. By way of procedural background, the Veteran initially submitted a claim for service connection in July 2014, which included claims for bilateral upper and lower peripheral neuropathy. A rating decision was issued in March 2015, which denied the claims as there was no diagnosis nor were they incurred in or caused by service. The Veteran submitted a January 2016 statement regarding his claim for peripheral neuropathy. The Veteran submitted a claim for service connection in in January 2016, which included claims for vertigo and gastrointestinal disorder. A rating decision was issued in March 2016, which denied the claims as they neither incurred in nor were caused by service. The Veteran timely submitted separate notices of disagreement (NOD) in April 2016, seeking review of the claims. A statement of the case (SOC) was issued in November 2017, and the Veteran submitted substantive appeals (VA Form 9) in November 2017 and August 2019, each seeking a Board hearing. The Veteran appeared for a July 2021 Board hearing regarding his vertigo and gastrointestinal (GI) disorders, however, a complete transcript could not be produced due to an audio malfunction. The Veteran was afforded another Board hearing regarding his vertigo and GI disorder and the Veteran testified before a Veterans Law Judge (VLJ) in March 2023. A transcript is enclosed. In a May 2024 letter, the Veteran withdrew his request for a Board hearing regarding his remaining claims on appeal. In a July 2024 decision, the Board granted service connection for an acquired psychiatric disorder and remanded the remaining claims for examination and opinions. In an October 2024 letter, the Veteran withdrew his "herbicide claim." The Veteran stated, "I do not want to continue development for Exposure to Herbicides. Please continue the claimed conditions currently on appeal on a different basis. 'NOT due to herbicide exposures' to include under direct service connection and or secondary basis." A December 2024 rating decision granted service connection for vertigo as a part of hearing loss. As such, the claim for service connection for vertigo is no longer before the Board. Following submission of additional evidence, the claim was readjudicated in a March supplemental statement of the case (SSOC). The Board notes that the Veteran provided a March 2025 statement and an article entitled "The association between psychosocial factors and mental health symptoms in cervical spine pain with or without radiculopathy on health outcomes; a systematic review." While the Board recognizes this represents new evidence, it discusses cervical spine pain, which, as discussed below, is not applicable to the Veteran's claim. As such, the claims for service connection for gastrointestinal disorder and bilateral upper and bilateral lower peripheral neuropathy are properly before the Board for adjudication. ? Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Only chronic diseases listed under 38 C.F.R. § 3.309 (a) are entitled to the presumptive service connection provisions of 38 C.F.R. § 3.303 (b). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310 (a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382(1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in approximate balance, with the veteran prevailing in either event, or whether the weight of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Entitlement to service connection for peripheral neuropathy, right upper extremity. Entitlement to service connection for peripheral neuropathy, left upper extremity. The Veteran asserts that his bilateral upper extremity peripheral neuropathy is related to his military service. A review of the Veteran's service treatment records (STRs) are silent for any complaints, diagnosis or treatment for any neuropathy or similar symptoms. A review of the Veteran's post-service VA treatment is silent for any complaints, diagnosis or treatment for neuropathy, numbness or tingling of his right or left arm. See Costal Valley Bend VAMC. In a December 2015 statement, the Veteran reported: "I performed duties on the Korean DMZ and I was exposed to Herbicides. I have been suffering from Numbness and tingling on all my extremities ever since the early 70s." In an April 2016 statement with his NOD, the Veteran reported "Peripheral Neuropathy right upper extremity-I performed duties on the Korean DMZ and I was exposed to Herbicides. I have been suffering from Numbness and tingling on all my extremities ever since the early 70s." In December 2018, the Veteran provided a private medical opinion from Day & Night Clinic. The private provider noted that the Veteran had been a patient for many years and "in my opinion, the claimed conditions of ... peripheral neuropathy of right upper extremity, peripheral neuropathy of left upper extremity, peripheral neuropathy of right lower extremity, peripheral neuropathy of left lower extremity... are conditions that are at least likely as not (50 percent or greater probability) caused by or aggravated during his military service in the United States Army. I base my opinion pursuant to the review of his military medical records and the symptomology displayed since military service." The Board notes that the private provider only gives an overly broad identification of ailments and an overly broad opinion that such ailments were caused by or aggravated during the Veteran's military service. The private provider does not give a rationale, only a simple conclusion. Therefore, the Board finds this opinion to be inadequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008); see also Miller v. West, 11 Vet. App. 345, 348 (1998) (a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record). In an August 2019 statement, the Veteran reported that while he was in Korea during the latter part of December 1967, he "slipped on the icy sidewalk one morning as I stepped out of the building where I took showers. Due to icy conditions on the walkways, I fell on my back and I struck my lower back and the back of my head on the concrete sidewalk." In an August 2019 statement with his appeal to the Board, the Veteran reported: "I believe the neuropathy for my lower and upper extremities are related to the military due to a fall I suffer while in service. I did not report the incident because at the time I didn't think was a big deal. As time passed the pain continued and I was but since the pain would come and go I never thought it was just in my head. I tried contacting people who was with me and help me when I fell but I know one of them has passed away and I have no contact with the other." In a July 2021 statement, the Veteran reported that his bilateral upper extremities peripheral neuropathy, was "caused by an in-service event and or my deployment and exposure to Agent Orange on the DMZ. I performed top-secret special intelligence duties for two days in the Korean DMZ (20+ miles northwest of Camp Red Cloud, Uijeongbu Province). In the winter of 1968, I was near Panmunjom with M.I. I was the 201st M.I Detachment gathering information for incorporating it into intelligence for high official briefing reports to Army Generals and the U.S. Chief of Staff. This information was incorporated into daily briefings to Eighth Army Headquarters Top Officials in Seoul Korea. The area is known as Gyeonggi-do, Paju-is, South Korea, and as the result of deployment to that area, I was exposed to Agent Orange without my knowledge. I started to have these symptoms of Peripheral Neuropathy within 8 months of deployment to that area of service to my country. I have suffered from Peripheral Neuropathy while in military service; and, since then, I continue to deal with these symptoms. The symptoms include but are not limited to pain that affects my extremities such as pins-and-needles sensation, numbness, burning, stabbing. I get shooting pain that runs within my extremities and causes heaviness of limbs." The Veteran "also suffer from slow reflexes, tingling feet, arms, hands, and fingers, and muscle weakness which makes me incompetent to carry out normal activities. As a result, I lose my balance when I walk and even sometimes while a stand. I lose the coordination of my upper and lower extremities which occurs several times a month and lasts from 20 minutes to less than 1 hour." The Veteran was afforded a February 2025 VA peripheral nerve examination. The VA examiner noted a diagnosis of lumbar radiculopathy of the lower extremities. The Veteran reported he was unsure exactly what year the condition began. The Veteran reported having a back condition that contributed to the lower extremity pain and tingling. The VA examiner noted that for the Veteran's claimed condition of right and left upper extremity peripheral neuropathy, there was no diagnosis because there were no objective findings to support a diagnosis during examination and medical record only supported a diagnosis of lower extremity symptoms. The examiner noted that the physical examination on February 20, 2025 did not reveal upper extremity symptoms, diagnosis or findings and there were no objective findings to support a diagnosis at that time. The Veteran was afforded multiple VA medical opinions regarding direct service connection, secondary service connection, aggravation and a toxic exposure risk activities (TERA) examination with opinion. All such opinions were negative for association to service. As noted above, the U.S. Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Because the record does not show a diagnosis of bilateral upper extremity peripheral neuropathy, service connection is not warranted. (Emphasis added.) The Board has also considered the Veteran's statements regarding his belief that his bilateral upper extremity peripheral neuropathy is related to an in-service injury or event. However, as a lay person, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the etiology of the medically complex disorder of neuropathy. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). Bilateral upper extremity peripheral neuropathy is a medically complex processes because of its multiple possible etiologies and requires specialized testing to diagnose (e.g., x-rays and/or MRI). Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Board acknowledges that the Veteran is competent to describe his symptoms without any specialized knowledge or training. Layno v. Brown, 6 Vet. App. 465; Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011), Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Furthermore, the Board finds that the Veteran is competent to report symptoms and upper extremity pain that the Veteran experienced, as they would be readily apparent. See Horowitz v. Brown, 5 Vet. App. 217, 221-22 (1993) (lay statements are competent on in-service and post-service symptoms). However, the record does not reflect that the Veteran has been diagnosed with upper extremity peripheral neuropathy. For these reasons, and based on the evidence of record, the Board finds that the weight of the competent, credible, and probative evidence is against a finding of a relationship between the Veteran's claimed right and left upper extremity peripheral neuropathy and service. Therefore, the claims for service connection for right upper extremity peripheral neuropathy and left upper extremity peripheral neuropathy are denied. Entitlement to service connection for peripheral neuropathy, right lower extremity. Entitlement to service connection for peripheral neuropathy, left lower extremity. The Veteran asserts that his bilateral lower extremity peripheral neuropathy is related to his military service. A review of the Veteran's STRs are silent for any complaints, diagnosis or treatment for any neuropathy or similar symptoms. In a December 2015 statement, the Veteran reported: "I performed duties on the Korean DMZ and I was exposed to Herbicides. I have been suffering from Numbness and tingling on all my extremities ever since the early 70s. To date the condition continues to worsen and I am also suffering from Severe leg cramps almost daily." In an April 2016 statement with his NOD, the Veteran reported "Peripheral Neuropathy right upper extremity-I performed duties on the Korean DMZ and I was exposed to Herbicides. I have been suffering from Numbness and tingling on all my extremities ever since the early 70s. To date the condition continues to worsen and I am also suffering from Severe leg cramps almost daily." As noted above, in a December 2018 private medical opinion from Day & Night Clinic. The private provider noted that the Veteran had been a patient for many years and "in my opinion, the claimed conditions of ... peripheral neuropathy of right upper extremity, peripheral neuropathy of left upper extremity, peripheral neuropathy of right lower extremity, peripheral neuropathy of left lower extremity... are conditions that are at least likely as not (50 percent or greater probability) caused by or aggravated during his military service in the United States Army. I base my opinion pursuant to the review of his military medical records and the symptomology displayed since military service." The Board notes that the private provider only gives an overly broad identification of ailments and an overly broad opinion that such ailments were caused by or aggravated during the Veteran's military service. The private provider does not give a rationale, only a simple conclusion. Therefore, the Board finds this opinion to be inadequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008); see also Miller v. West, 11 Vet. App. 345, 348 (1998) (a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record). During the Veteran's post-service VA treatment in April 2019, the Veteran reported concern for numbness and tingling for his lower extremities that had been worsening since service. The Veteran reported low back pain all his life and reported tingling/numbness down both legs. The Veteran was assessed with numbness/fatigue likely secondary to decondition. A May 2019 MRI of the Veteran's lumbar spine showed "degenerative changes resulting in considerable spinal canal stenosis and intrathecal nerve root compression at L3-L4 and L4-L5, to a lesser degree L2-L3." The Veteran was advised that "Basically, your MRI of your back shows stenosis and nerve root compression. In lay man terms this is narrowing of your spinal cord pinching the roots this is likely the reason why you're having back pain which radiates to your legs." See Coastal Valley Bend VAMC. In an August 2019 statement, the Veteran reported that while he was in Korea during the latter part of December 1967, he "slipped on the icy sidewalk one morning as I stepped out of the building where I took showers. Due to icy conditions on the walkways, I fell on my back and I struck my lower back and the back of my head on the concrete sidewalk." The Veteran continued, "Everything was fine except for some pain in my lower spine, a headache, and a bump on the back of my head and; so I never went to see a doctor. I never imagined that I would have issues regarding pain on my lower spine, pain, and numbness in my legs in the future because of the fall on the icy concrete. One month later, I started experiencing symptoms of weakness and incoordination of my lower extremities with pain in my leg muscles and heaviness of the weight of my legs when I walked; and the pain in my lower spine and legs continues to this day. These issues have persisted ever since and sometimes has caused me losing my balance and fall to the ground on various occasions. Since then, I continue to experience these symptoms of pain on my lower spine and numbness, and heaviness in my lower extremities." As noted above, in an August 2019 statement with his appeal to the Board, the Veteran reported: "I believe the neuropathy for my lower and upper extremities are related to the military due to a fall I suffer while in service. I did not report the incident because at the time I didn't think was a big deal. As time passed the pain continued and I was but since the pain would come and go I never thought it was just in my head. I tried contacting people who was with me and help me when I fell but I know one of them has passed away and I have no contact with the other." Also as noted above, in a July 2021 statement, the Veteran reported that his bilateral upper extremities peripheral neuropathy, was "caused by an in-service event and or my deployment and exposure to Agent Orange on the DMZ. I performed top-secret special intelligence duties for two days in the Korean DMZ (20+ miles northwest of Camp Red Cloud, Uijeongbu Province). In the winter of 1968, I was near Panmunjom with M.I. I was the 201st M.I Detachment gathering information for incorporating it into intelligence for high official briefing reports to Army Generals and the U.S. Chief of Staff. This information was incorporated into daily briefings to Eighth Army Headquarters Top Officials in Seoul Korea. The area is known as Gyeonggi-do, Paju-is, South Korea, and as the result of deployment to that area, I was exposed to Agent Orange without my knowledge. I started to have these symptoms of Peripheral Neuropathy within 8 months of deployment to that area of service to my country. I have suffered from Peripheral Neuropathy while in military service; and, since then, I continue to deal with these symptoms. The symptoms include but are not limited to pain that affects my extremities such as pins-and-needles sensation, numbness, burning, stabbing. I get shooting pain that runs within my extremities and causes heaviness of limbs." The Veteran "also suffer from slow reflexes, tingling feet, arms, hands, and fingers, and muscle weakness which makes me incompetent to carry out normal activities. As a result, I lose my balance when I walk and even sometimes while a stand. I lose the coordination of my upper and lower extremities which occurs several times a month and lasts from 20 minutes to less than 1 hour." The Veteran was afforded a February 2025 VA peripheral nerve examination. The VA examiner noted a diagnosis of lumbar radiculopathy of the lower extremities. The Veteran reported he was unsure exactly what year the condition began. The Veteran reported having a back condition that contributed to the lower extremity pain and tingling. For the claimant's claimed condition of right and left lower extremity peripheral neuropathy, the VA examiner noted the medical record only supported a diagnosis of lower extremity symptoms. In a separate February 2025 medical opinion, the VA examiner opined that the claimed right and left lower extremity peripheral neuropathy condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner reasoned that "there is lack of medical evidence to support this lumbar radiculopathy lower extremity is related to a service injury, event, illness including TERA. There is lack of medical evidence to support a diagnosis of degenerative disc disease of the back or lumbar spine injury, complaints, diagnosis, treatment or pain radiating to the bilateral lower legs during service. There is no indication the spinal condition or lumbar radiculopathy stems from any in-service event. As per Medical record, in 2019 the veteran's MRI of the spine showed degenerative changes resulting in considerable spinal canal stenosis and intrathecal nerve root compression at L3-L4 and L4-L5, to a lesser degree L2-L3. On 5/15/19 the veteran's doctor left message for veteran stating, 'In lay man terms this is narrowing of your spinal cord pinching the roots which is likely the reason why you're having back pain which radiates to your legs.'" (Citations omitted.) Regarding secondary (causation) service connection, in a February 2025 medical opinion, the VA examiner opined that the claimed right and left lower extremity peripheral neuropathy condition was less likely than not due to or the result of the Veteran's service connected conditions, to include adjustment disorder with mixed anxiety and depressed mood; bilateral hearing loss with vertigo; and bilateral tinnitus with vertigo. The VA examiner reasoned that "there is no scientific research and medical evidence to support a connection between adjustment disorder with mixed anxiety and depressed mood, bilateral hearing loss with vertigo and bilateral tinnitus that causes lumbar radiculopathy lower extremity. As per NIH 2024, lumbosacral radiculopathy is characterized by pain resulting from compression or irritation of nerve roots in the lumbosacral region of the spine, along with numbness, weakness, and reflex changes. The veteran is diagnosed with lumbar radiculopathy impacting his sciatic nerve. As per Medical record, in 2019 the veteran's MRI of the spine showed degenerative changes resulting in considerable spinal canal stenosis and intrathecal nerve root compression at L3-L4 and L4-L5, to a lesser degree L2-L3. On 5/15/19 the veteran's doctor left message for veteran stating, 'In lay man terms this is narrowing of your spinal cord pinching the roots which is likely the reason why you're having back pain which radiates to your legs.'" (Citations omitted.) Likewise with aggravation by the Veteran's service connected conditions, the February 2025 VA examiner opined the claimed right and left lower extremity peripheral neuropathy condition was less likely than not aggravated by the veteran's service connected condition. The VA examiner reasoned that: There is no medical evidence or scientific research to support the veteran's lumbar radiculopathy was affected by o adjustment disorder with mixed anxiety and depressed mood o bilateral hearing loss with vertigo o bilateral tinnitus. As per NIH 2024, lumbosacral radiculopathy is characterized by pain resulting from compression or irritation of nerve roots in the lumbosacral region of the spine, along with numbness, weakness, and reflex changes. As per Medical record, in 2019 the veteran's MRI of the spine showed degenerative changes resulting in considerable spinal canal stenosis and intrathecal nerve root compression at L3-L4 and L4-L5, to a lesser degree L2-L3. On 5/15/19 the veteran's doctor left message for veteran stating, "In lay man terms this is narrowing of your spinal cord pinching the roots which is likely the reason why you're having back pain which radiates to your legs." There is absolutely no medical evidence in medical record to support bilateral tinnitus, bilateral hearing loss with vertigo and mixed anxiety further worsened or aggravated the lumbar radiculopathy. (Citations omitted.) Regarding aggravation by the Veteran's military occupational specialty (MOS), a February 2025 VA examiner opined that there "is no indication lumbar radiculopathy lower extremity existed prior to service. There is no indication a back or lumbar radiculopathy condition existed prior to service and worsened during service. STRs are silent for back/lumbar radiculopathy condition, complaints, diagnosis or treatments." In a February 2025 toxic exposure risk activities (TERA) examination, the VA examiner opined that the bilateral lower extremity peripheral neuropathy was less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The VA examiner reasoned "there is lack of medical evidence to support any exposures during service that led to the development of lumbar radiculopathy lower extremity. Records indicate risk factors outside of military service including degenerative changes to the spine. This risk factor outweighs any risk factors identified by the TERA (as no known risk factors were identified with TERA). As per Medical record, in 2019 the veteran's MRI of the spine showed degenerative changes resulting in considerable spinal canal stenosis and intrathecal nerve root compression at L3-L4 and L4-L5, to a lesser degree L2-L3. On 5/15/19 the veteran's doctor left message for veteran stating 'In lay man terms this is narrowing of your spinal cord pinching the roots which is likely the reason why you're having back pain which radiates to your legs.'" Regarding an "early-onset" of bilateral lower extremity peripheral neuropathy, in a February 2025 medical opinion, the VA examiner opined "there is lack of medical evidence to support this condition began within one year (i.e., "early-onset") after the last date of TERA. Medical records show MRI being conducted in 2019 support a source for the lower extremity pain/tingling. As per NIH 2024, lumbosacral radiculopathy is characterized by pain resulting from compression or irritation of nerve roots in the lumbosacral region of the spine, along with numbness, weakness, and reflex changes. As per Medical record, in 2019 the veteran's MRI of the spine showed degenerative changes resulting in considerable spinal canal stenosis and intrathecal nerve root compression at L3-L4 and L4-L5, to a lesser degree L2-L3. On 5/15/19 the veteran's doctor left message for veteran stating, 'In lay man terms this is narrowing of your spinal cord pinching the roots which is likely the reason why you're having back pain which radiates to your legs.'" The Board acknowledges that the Veteran is competent to describe his symptoms without any specialized knowledge or training. Layno v. Brown, 6 Vet. App. 465; Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011), Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Furthermore, the Board finds that the Veteran is competent to report symptoms and back pain that the Veteran experienced, as they would be readily apparent. See Horowitz v. Brown, 5 Vet. App. 217, 221-22 (1993) (lay statements are competent on in-service and post-service symptoms). The Board has also considered the Veteran's statements regarding his belief that his bilateral lower extremity peripheral neuropathy disorder is related to an in-service injury or event. However, as a lay person, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the etiology of the medically complex disorder of neuropathy. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). Neuropathy is a medically complex process because of its multiple possible etiologies and requires specialized testing to diagnose (e.g., x-rays and/or MRI). Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Board notes that the Veteran requested review without refence to "exposure to herbicide." See October 2024 statement. As noted above, VA opinions haven been rendered for all aspects and possible avenues of service connection. While the Veteran is competent to report his service experiences and his sincere belief his bilateral lower extremity peripheral neuropathy disorder is related to his military service, the Veteran's contentions are outweighed by the opinion of the VA examiners who reviewed his service records, reviewed his post-service medical treatment records, recognized his neuropathy disorder, considered multiple avenues of service connection but still concluded that the Veteran's bilateral lower extremity peripheral neuropathy was not related to his military service. As the only medical opinions of record addressing the etiology of the Veteran's current bilateral lower extremity peripheral neuropathy disorder are negative, there is no benefit of the doubt that could be resolved in the Veteran's favor. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. For these reasons, and based on the evidence of record, the Board finds that the weight of the competent, credible, and probative evidence is against a finding of a relationship between the Veteran's bilateral lower extremity peripheral neuropathy disorder and his military service. Therefore, the claims for service connection for right lower extremity peripheral neuropathy and left lower extremity peripheral neuropathy are denied. REASONS FOR REMAND Entitlement to service connection for gastrointestinal disorder (GI). The Veteran asserts that service connection for his gastrointestinal disorder (GI) is warranted. The Veteran's STRs note the Veteran reported frequent indigestion and stomach, liver or intestinal trouble at his February 1968 report of medical history at enlistment. The provider noted occasional indigestion for which the Veteran reported he took Pepto Bismol and had never sought medical treatment. Ina July 2021 statement, the Veteran reported he had cramping, abdominal pain, bloating, gas, persistent pain that was not relieved by passing gas for which he self-medicated since service. The Veteran provided several private medical opinions from Day & Night Clinic. In a May 2016 opinion, the provider stated that the Veteran was a patient and his gastrointestinal disorder was "least as likely as not caused by military services." In a December 2018 opinion, the provider opined that the Veteran's GI disorder was among "conditions that are at least likely as not (50 percent or greater probability) caused by or aggravated during his military service in the United States Army." The opinion was based on the examiner's "review of his military medical records and the symptomology displayed since military service." Although the opinions from the providers at Day & Night Clinic represent competent medical evidence, the Board finds that the opinions are inadequate. While the December 2018 opinion appears to cite the Veteran's "military records," there is no recitation of facts or evidence from such records to indicate such a review. As such, the Board finds the private provider did not review the Veteran's claims file, to include service records nor did the private providers provide any rationale to support the opinions that the Veteran's GI disorder was related to service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008); see also Miller v. West, 11 Vet. App. 345, 348 (1998) (a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record). The Veteran was afforded a September 2024 VA intestinal examination. The VA examiner noted a diagnosis of irritable bowel syndrome. The Veteran reported onset in 1968, that after receiving vaccines in 1968 prior to overseas deployment, the Veteran started with chronic diarrhea alternating with constipation. Then while being exposed to increased stress with deployment, the Veteran had symptoms of diarrhea and constipation continued along with a new symptom of nausea. In a separate September 2024 medical opinion, the VA examiner opined that the claimed GI condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The VA examiner reasoned that the "Veteran has claimed GI CONDITION as being directly related to military service. Based on review of the available evidence, it is less likely than not that the claimed condition is due to service as there is a lack of substantiating evidence supporting a nexus between the current diagnosis of GI INTESTINAL CONDITION and military service. Without chronicity during service or after service, a post-service event, illness, or injury is considered to be a more likely etiology." In a January 2025 VA intestinal addendum, the VA examiner opined that the claimed GI disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The January 2025 VA examiner reasoned that there was a lack of substantiating evidence supporting a nexus between the current gastrointestinal diagnoses of Irritable bowel syndrome, GERD, as well as Diverticulosis, and military service. The examiner noted the Veteran reported occasional indigestion at entry and reports of digestive problems at separation. The VA examiner provided a thorough medical description of indigestion and recitation of the Veteran's gastrointestinal history. The examiner concluded: "The most probative evidence of record are the service treatment records and post-service medical records which are negative for complaints, diagnosis, or treatment for the claimed disorder. These records are more probative than the lay claims to the contrary. Without chronicity during service or after service, a post-service event, illness, or injury is considered to be a more likely etiology. Therefore, the claimed condition 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." Likewise, the January 2025 VA examiner opined that the Veteran's claimed GI condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The VA examiner reasoned: "There is no objective evidence to establish that a chronic gastrointestinal condition clearly existed prior to service. The Veteran attested to occasional indigestion on the report of medical history from 2/6/68. He also reported occasional use of Pepto Bismol as a treatment modality, and never seeing a Doctor for the condition. There is not enough objective evidence to conclude that occasional indigestion with the use of over the counter medication is a symptom of a chronic gastrointestinal condition that existed prior to service with the limited evidence available. Indigestion is a common symptom with varying etiologies. It affects a significant portion of the general population and can fluctuate over short periods. The occurrence of occasional indigestion can be influenced by various factors, including dietary habits, stress, and lifestyle choices. For instance, high-fat and high-calorie meals have been associated with increased symptoms of indigestion. There is no objective evidence to substantiate the Veteran had a chronic preexisting condition, only acute episodes of indigestion. As such there is no evidence of a gastrointestinal condition, that existing prior to service and no aggravation nexus can be established." Regarding the occasional indigestion and treatment with Pepto-Bismol noted upon active service entry clearly and unmistakably constituted a pre-existing GI condition, the January 2024 VA examiner concluded: "The Veteran attested to occasional indigestion on the report of medical history from 2/6/68. He also reported occasional use of Pepto Bismol as a treatment modality, and never seeing a Doctor for the condition. There is not enough objective evidence to conclude that occasional indigestion with the use of over the counter medication is a symptom of a chronic gastrointestinal condition that existed prior to service with the limited evidence available. Indigestion is a common symptom with varying etiologies. It affects a significant portion of the general population and can fluctuate over short periods. The occurrence of occasional indigestion can be influenced by various factors, including dietary habits, stress, and lifestyle choices. For instance, high-fat and high-calorie meals have been associated with increased symptoms of indigestion. As such, occasional indigestion and treatment with Pepto-Bismol does NOT constitute a pre-existing GI condition, and is not objective evidence of preexisting GERD, Diverticulosis, or Irritable bowel syndrome." In March 2025, the Veteran provided a statement in which the Veteran argues that "People with depression may use food to cope with emotional pain, which can lead to overeating or poor food choices. Depression can cause hormonal imbalances, such as increased levels of cortisol, the stress hormone, which can lead to fat storage and therefore affecting the GI conditions." The Veteran generally contends that his GI condition was not considered as secondary to his service-connected psychiatric disability. The Board agrees. The Board regrets further delay in this case, but finds that a remand is once again required to comply with the Board's previous remand instructions. Stegall v. West, 11 Vet. App. 268, 270-71 (1998). The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate clinician in which the examiner is to address the nature and etiology of the Veteran's service-connected disability of adjustment disorder with mixed anxiety and depressed mood associated with bilateral tinnitus as it relates to the claimed gastrointestinal disease (GI). The examiner is to review the claims file, including all lay and medical evidence. The examiner is to specifically provide an opinion for the following: (a.) Whether any GI disorder is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) caused by (due to or the result of) the service-connected disability of adjustment disorder with mixed anxiety and depressed mood associated with bilateral tinnitus. (b.) Whether any GI disorder is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) aggravated by of the service-connected disability of adjustment disorder with mixed anxiety and depressed mood associated with bilateral tinnitus. **The examiner is advised that aggravation of the cervical spine disorder need NOT be permanent, and as such should consider any incremental increase in severity. See Ward v. Wilkie, 31 Vet. App. 233 (2019). 2. A complete and detailed rationale for all opinions must be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she must make clear that he or she has considered all procurable data, but any member of the medical community at large could not provide such an opinion without resorting to speculation. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (Continued on the next page) ? 3. After ensuring full compliance with this remand, readjudicate the claim on appeal. Danette Mincey Veterans Law Judge Board of Veterans' Appeals Attorney for the Board MELNYK, H. 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.