Citation Nr: A26009586 Decision Date: 02/02/26 Archive Date: 02/02/26 DOCKET NO. 250605-551855 DATE: February 2, 2026 ORDER Entitlement to a 20 percent initial rating, but no higher, for a neck/cervical strain is granted. Entitlement to a 30 percent initial rating, but no higher, for bilateral plantar fasciitis is granted. Entitlement to a 10 percent initial rating, but no higher, for scars related to bilateral plantar fasciitis release surgery is granted. Entitlement to service connection for lumbosacral strain with degenerative arthritis is granted. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for hypertension is granted. Entitlement to service connection for asthma is granted. Entitlement to service connection for hemorrhoids is granted. Entitlement to service connection for the residuals of basal cell carcinoma is granted. REMANDED Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. FINDINGS OF FACT 1. The Veteran has at least as likely as not experienced functional impairment approximating cervical spine forward flexion greater than 15 degrees but not more than 30 degrees since the effective date of service connection for his neck/cervical spine disability, but the evidence is persuasively against findings of limitation of forward flexion to 15 degrees or less; ankylosis, or the functional equivalent thereof; and/or intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during a 12-month period at any point during the applicable rating period. 2. The Veteran has at least as likely as not experienced functional impairment approximating bilateral plantar fasciitis with no relief from both non-surgical and surgical treatment since the effective date of service connection for the disability, but the evidence is persuasively against a finding of a loss of use of the feet due to bilateral plantar fasciitis at any point during the applicable rating period. 3. The scars related to the Veteran's bilateral plantar fasciitis release surgery have at least as likely as not been painful since the effective date of service connection, but the evidence is persuasively against findings that any of the scars are unstable or cover an area of 39 square centimeters or more, when considered either individually or collectively. 4. The Veteran's current back/thoracolumbar spine disability is at least as likely as not the result of an in-service injury. 5. The Veteran at least as likely as not experienced tinnitus during active service with recurrent symptoms thereafter. 6. A continuity of symptomatology links the Veteran's current hypertension to a condition noted during active service. 7. Although there is evidence that suggests the Veteran's asthma may have pre-existed his active service, the evidence fails to establish the condition was clearly and unmistakably not aggravated therein with competent evidence linking the current disability to in-service environmental exposures. 8. The Veteran's hemorrhoids are at least as likely as not the result of an in-service disease or injury. 9. The Veteran's residuals of basal cell carcinoma are at least as likely as not the result of an in-service disease or injury. CONCLUSIONS OF LAW 1. The criteria for service connection for a 20 percent initial rating, but no higher, for a neck/cervical strain have been met. 38?U.S.C. §§?1155, 5107; 38?C.F.R. §§?4.3, 4.71a. 2. The criteria for a 30 percent initial rating, but no higher, for bilateral plantar fasciitis have been met. 38?U.S.C. §§?1155, 5107; 38?C.F.R. §§?4.3, 4.71a. 3. The criteria for a 10 percent initial rating, but no higher, for scars related to bilateral plantar fasciitis release surgery have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.118. 4. The criteria for service connection lumbosacral strain with degenerative arthritis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 5. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 6. The criteria for service connection for hypertension have been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 7. The criteria for service connection for asthma have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 8. The criteria for service connection for hemorrhoids have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 9. The criteria for service connection the residuals of basal cell carcinoma have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 2001 to March 2002, from October 2004 to September 2005, and from January 2006 to March 2008. These matters come before the Board of Veterans' Appeals (Board) from March 2025 and April 2025 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In June 2025, the Veteran filed a timely notice of disagreement (VA Form 10182) and requested appellate review of claims adjudicated by the March 2025 and April 2025 rating decisions via the Board's evidence-submission docket. Applicable Evidentiary Windows Under the evidence-submission docket, the Board's review is limited to evidence considered by the Agency of Original Jurisdiction (AOJ) in the respective decision on appeal, as well as evidence submitted by the Veteran, or his authorized representative, with his June 2025 notice of disagreement or within 90 days following receipt of the notice of disagreement. See 38 C.F.R. §?20.303. If evidence was associated with the claims file outside these evidentiary windows, the Board has not considered it at this time. The Veteran is advised of the supplemental claim option if he desires consideration of any additional evidence not encompassed by the record for the present appeal. See 38 C.F.R. § 3.2501. 1. Entitlement to a 20 percent initial rating, but no higher, for a neck/cervical strain is granted. The April 2025 rating decision on appeal awarded the Veteran service connection for a neck/cervical strain with a 10 percent initial rating, effective January 4, 2024. The Veteran has appealed the initial rating assigned for the disability, asserting his service-connected neck/cervical strain should be rated as 20 percent disabling. The Board notes disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disabilities must be viewed in relation to their entire history. 38 C.F.R. § 4.1. VA is required to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. VA is also required to evaluate functional impairment on the basis of lack of usefulness and the effects of the disabilities upon the claimant's ordinary activity. 38 C.F.R. §?4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation of parts of the system, to perform the normal working movements of the body with normal excursion, strength, coordination, and endurance. 38 C.F.R. § 4.40. The functional loss may be due to the loss of part or all of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology, and evidenced by visible behavior of the claimant undertaking the motion. Id. Weakness is as important as limitation of motion, and a body part which becomes painful on use must be regarded as seriously disabled. See DeLuca v. Brown, 8?Vet. App.?202 (1995); see also 38 C.F.R. §§ 4.40, 4.45. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40 and 4.45, pertaining to functional impairment. DeLuca, 8 Vet. App. at 207-08. In applying these regulations, VA should obtain examinations in which the examiner determines whether the disability was manifested by pain, weakened movement, excess fatigability, incoordination, and flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations, if feasible, should be expressed in terms of the degree of additional range-of-motion loss due to those factors. DeLuca, supra; see also Mitchell v. Shinseki, 25?Vet. App.?32 (2011); 38 C.F.R. § 4.59. Where service connection has been granted and the assignment of an initial evaluation is disputed, separate evaluations may be assigned for different periods of time based on the facts found. Fenderson v. West, 12?Vet. App.?119, 125-26 (1999). When there is a question as to which of two ratings apply, VA will assign the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. §?4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. VA shall give the benefit of the doubt to the claimant when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3; see also Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (holding evidence is not in approximate balance, or nearly equal, when the evidence "persuasively favors one side or the other"). Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is assigned for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; the combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating requires forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is reserved for unfavorable ankylosis of the entire cervical spine. Higher rating require ankylosis of the entire spine. Initially, the Board finds the Veteran has at least as likely as not experienced functional impairment approximating cervical spine forward flexion greater than 15 degrees but not more than 30 degrees since the effective date of service connection for his neck/cervical spine disability. His January 2025 VA examination report reflects forward flexion limited to 30 degrees without no additional range-of-motion loss with repeated use over time and/or during flare-ups. In contrast, a May 2025 private evaluation the Veteran submitted in the evidence-submission window after his June 2025 notice of disagreement reflects forward flexion limited to 20 degrees. The Board finds the reports are generally consistent with each other with neither report being inherently more persuasive than the other. Resolving reasonable doubt in favor of the Veteran, the Board finds a 20 percent initial rating is warranted for his service-connected neck/cervical strain as asserted on appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Although not explicitly claimed by the Veteran, the Board finds a rating in excess of 20 percent is not warranted for his service-connected neck/cervical strain. Neither of his examination reports - either VA and private - reflect limitation of forward flexion to 15 degrees or less, even with consideration of additional functional impairment due to pain, weakened movement, excess fatigability, incoordination, and flare-ups. There are no treatment records that show limitation of flexion beyond those shown in these reports, and the Veteran has not asserted a rating in excess of 20 percent is warranted based on limitation of flexion to 15 degrees or less. Further, the evidence of record, to include the Veteran's lay reports, does not suggest ankylosis of any degree, or the functional equivalent thereof. There is also no evidence that indicates the Veteran has intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during a 12-month period at any point during the applicable rating period. In sum, the Board finds an initial 20 percent rating is warranted for the Veteran's service-connected neck/cervical strain, as asserted on appeal, but no further increase is warranted based on the evidence of record. To this extent, the Veteran's appeal is granted. 2. Entitlement to a 30 percent initial rating, but no higher, for bilateral plantar fasciitis is granted. The general rating principles outlined in the context of the Veteran's neck/cervical spine rating appeal, to include those related to musculoskeletal disabilities, are applicable in the context of the Veteran's appeal of the 10 percent initial rating assigned for his service-connected bilateral plantar fasciitis. In his June 2025 notice of disagreement, the Veteran asserts a 40 percent initial rating is warranted for the disability. The Veteran's service-connected bilateral plantar fasciitis is rated under the criteria outlined in 38 C.F.R. § 4.71a, Diagnostic 5269. Under Diagnostic Code 5269, a 10 percent rating is assigned for unilateral or bilateral plantar fasciitis. A 20 percent rating is warranted for unilateral plantar fasciitis with no relief from both non-surgical and surgical treatment. A 30 percent rating is granted for bilateral plantar fasciitis with no relief from both non-surgical and surgical treatment. A note to Diagnostic Code 5269 provides that a 40 percent disability rating will be assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5269, Note (1). A second note indicates that if a veteran has been recommended for surgical intervention, but is not a surgical candidate, the plantar fasciitis is to be rated under the 20 percent or 30 percent criteria, whichever is applicable. 38 C.F.R. § 4.71a, Diagnostic Code 5269, Note (2). Here, the record establishes the Veteran underwent bilateral plantar fasciitis release surgery; therefore, the material issue in his rating appeal is whether he experienced relief from such treatment. The AOJ based the assignment of a 10 percent rating based on a January 2025 VA examiner's report that indicates the Veteran has experienced relief due to surgical treatment. In contrast, the May 2025 private evaluation report submitted by the Veteran in July 2025 indicates his bilateral plantar fasciitis has continued to progress after his surgical treatment. The Board again finds the two competing reports are essentially of equal persuasive value. Resolving reasonable doubt in the Veteran's favor, a 30 percent initial rating is warranted for his service-connected bilateral plantar fasciitis based on a finding of impairment approximating no relief from both non-surgical and surgical treatment. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The Board acknowledges the Veteran has asserted a 40 percent rating is warranted for his service-connected bilateral plantar fasciitis; however, this requires a finding of loss of use of the feet. The Board finds the evidence is persuasively against a finding of loss of use of the feet. In this regard, the Board notes the January 2025 VA examiner reported the Veteran experiences limited symptomatology due to plantar fasciitis after surgical treatment. While the May 2025 private evaluation suggests the Veteran's condition has continued to progress, it does not suggest loss of use of the feet. Loss of use is typically found when there is no effective function remains other than that which would be equally well served by an amputation stump with the use of a suitable prosthetic appliance. Although the May 2025 private evaluation indicates the Veteran now experiences daily pain, the private examiner reported this typically occurs with first weight bearing in the morning and at other times after rest but typically resolves within an hour with the Veteran thereafter being able to resume normal ambulation. The Board finds this pain on initial use is not consistent with a finding of no effective function remains other than that which would be equally well served by an amputation stump with the use of a suitable prosthetic appliance. There is no other evidence that is suggestive of this level of impairment. As a result, the evidence is persuasively against a finding of loss of use of the feet due to bilateral plantar fasciitis, prohibiting the assignment of a 40 percent rating in the Veteran's case. Nevertheless, a higher 30 percent initial rating is warranted for the disability. To this extent, the Veteran's appeal is granted. 3. Entitlement to a 10 percent initial rating, but no higher, for scars related to bilateral plantar fasciitis release surgery is granted. The general rating principles - other than those specific to musculoskeletal disabilities - apply in the context of the Veteran's appeal of the noncompensable rating assigned for scars related to bilateral plantar fasciitis release surgery. The rating criteria for scars are outlined in Diagnostic Codes 7800 through 7805 in the VA Rating Schedule. 38 C.F.R. § 4.118. Diagnostic Code 7800 relates to scars of the head, face, or neck and is therefore not applicable in the Veteran's case. Diagnostic Code 7801 provides ratings for scars, other than the head, face, or neck, that "are associated with underlying soft tissue damage." Yet, the scar, or scars, must cover an area exceeding 6 square inches (39 sq. cm.) to be compensable under Diagnostic Code 7801. VA examination reports reflect the Veteran's scars do not cover an area exceeding 6 square inches, when considered individually or collectively; therefore, a compensable rating is not warranted under Diagnostic Code 7801 at any point. Similarly, Diagnostic Code 7802 provides ratings for scars, other than the head, face, or neck, that "are not associated with underlying soft tissue damage." Yet, the scar, or scars, must cover an area exceeding 144 square inches (929 sq. cm.) to be compensable under Diagnostic Code 7802. As noted above, the Veteran's scars do not cover an area exceeding 6 square inches when considered individually or collectively, which also prohibits a rating under Diagnostic Code 7802. October 2008 changes to the VA Rating Schedule eliminated Diagnostic Code 7803 with some of its provisions being subsumed into the amended Diagnostic Code 7804, as noted below; therefore, discussion of Diagnostic Code 7803 is not necessary. See 73 Fed. Reg. 54710 (Oct. 23, 2008). Diagnostic Code 7804 provides progressively higher ratings based on the number of unstable and/or painful scars. Diagnostic Code 7804 provides a 10 percent rating for one or two scars that are unstable or painful. A 20 percent rating is assigned for three or four scars that are unstable or painful. A 30 percent rating is authorized when there are five or more scars that are unstable or painful. Note 1 to Diagnostic Code 7804 explains an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 indicates that, if one or more scars are both unstable and painful, a 10 percent rating should be added to the evaluation that is based on the total number of unstable or painful scars. 38 C.F.R. § 4.118. The Board notes Diagnostic Code 7804 appears to be the most applicable diagnostic code in the Veteran's case. The AOJ denied a compensable rating based on a January 2025 VA examiner's report that the Veteran's scars are neither unstable nor painful; however, his lay reports and the May 2025 private evaluation submitted to support his appeal support a finding that his scars are painful. Resolving reasonable doubt in the Veteran's favor, the Board finds a 10 percent rating is warranted in accordance with Diagnostic Code 7804, which provides such rating for one or two scars that are either unstable or painful. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The evidence is persuasively against any further increase in rating for the Veteran's service-connected scars related to bilateral plantar fasciitis release surgery. In this regard, the most persuasive evidence establishes the scars are not "unstable" as contemplated by Diagnostic Code 7804 because there is no indication of frequent loss of covering of skin over any the scars. The VA examination report of record explicitly states this type of impairment is not present in the Veteran's case, and this type of impairment is not otherwise noted in treatment records, the May 2025 private evaluation submitted by the Veteran, or his lay reports. Diagnostic Code 7805 is also of limited consideration in the Veteran's case because he is already compensated for loss of function associated with bilateral plantar fasciitis under Diagnostic Code 5269, as previously discussed; therefore, any compensation for the scars beyond the effects on the skin would constitute impermissible pyramiding under VA regulation. See 38 C.F.R. § 4.14. In sum, the Board finds an initial 10 percent rating, but no higher, is warranted for the Veteran's scars related to bilateral plantar fasciitis release surgery, but the evidence is persuasively against any further increase at this time. The Board notes it is granting service connection for the residuals of basal cell carcinoma, as discussed in a subsequent subsection of this decision. The AOJ will assign an initial rating for this disability and potentially revisit the rating assigned under Diagnostic Code 7804 for totals scars, providing the Veteran an opportunity for administrative/appellate review of that decision at a future date; however, based on the two service-connected bilateral plantar fasciitis release surgery scars, a 10 percent initial rating is warranted under Diagnostic Code 7804. To this extent, the Veteran's appeal of the scar ratings assigned by the April 2025 rating decision is granted. 4. Entitlement to service connection for lumbosacral strain with degenerative arthritis is granted. The Veteran seeks service connection for a lumbosacral strain, which he asserts is due to the physical nature of his duties in the Coast Guard, to include, but not limited to, physical trauma incurred a result of strong waves crashing into his assigned vessel. Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) 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). When there is an approximate balance of positive and negative evidence regarding any material issue, reasonable doubt will be resolved in favor of the claimant. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (holding evidence is not in approximate balance, or nearly equal, when the evidence "persuasively favors one side or the other"). The record establishes a current disability as the record has been diagnosed with lumbosacral strain, which has progressed to include degenerative arthritis. The AOJ denied the Veteran's claim based on a March 2025 VA examiner's negative nexus conclusion; however, when viewed in the light most favorable to the Veteran, the March 2025 VA examiner's report actually supports a grant of service connection. The March 2025 VA examiner attributed the claimed disability to an injury incurred when the Veteran was performing Coast Guard duties outside of his periods of verified active service. The Board notes the Veteran's specific duty status is essentially irrelevant so long as the disability incurred was the result of an injury resulting from military service because a physical injury, as opposed to disease, incurred during either active duty for training (ACDUTRA) or inactive duty for training (INACDUTRA) can support a service connection award. See 38 U.S.C. §§ 101(24), 106, 1110. The evidence establishes that the Veteran was at least as likely as not performing military service when he incurred the injury to which his current disability has been attributed. This is consistent with the totality of the record, to include his lay statements, treatment records, and service records. Resolving reasonable doubt in the Veteran's favor, the Board finds lumbosacral strain with degenerative arthritis is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 5. Entitlement to service connection for tinnitus is granted. Certain chronic diseases listed in 38 C.F.R. § 3.309(a) will be service connected on a presumptive basis if they manifest to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Tinnitus is an organic disease of the nervous system and is therefore a chronic disease under 38 C.F.R. § 3.309(a). See Fountain v. McDonald, 27 Vet. App. 258 (2015). The Veteran's lay reports are sufficient to establish manifestation of tinnitus. See Charles v. Principi, 16 Vet. App. 370, 374 (2002). Although the Veteran's January 2025 VA examiner noted the Veteran reported "noticing" tinnitus symptoms approximately three to four years prior to the date of that examination, there is favorable evidence that suggests the Veteran experienced such symptoms during active service. The Board finds it necessary to resolve reasonable doubt in the Veteran's favor given the approximate balance of positive and negative evidence regarding the date of onset. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Board notes recurrent tinnitus is a compensable disability. See 38 C.F.R. § 4.87, Diagnostic Code 6260. Accordingly, the Board finds service connection for tinnitus is warranted pursuant to the chronic disease presumption of 38 U.S.C. § 1112(a)(1). 6. Entitlement to service connection for hypertension is granted. Similar to the service connection claim for tinnitus, the Board also finds service connection for hypertension is warranted pursuant to the presumptive provisions for chronic diseases, although on a slightly different basis. The Boad notes, if a chronic disease enumerated in 38 C.F.R. § 3.309(a) is diagnosed after separation from service, the nexus requirement of a claim for service connection can be proven by evidence of a continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-99 (1997) (overruled on other grounds Walker, supra). Hypertension is a chronic disease enumerated in 38 C.F.R. § 3.309(a). Although the Veteran was noted to have elevated blood pressure at various times during service, a November 2007 service treatment record reflects a "provisional diagnosis" of hypertension. The Board finds the November 2007 service treatment record during the Veteran's final period of verified active service from January 2006 to March 2008 is sufficient to establish a condition "noted" during active service as contemplated by Walker. As noted in the opinions obtained regarding the Veteran's claim, he has continuously been found to have elevated blood pressure thereafter throughout his remaining career in the Coast Guard Reserve. This evidence is sufficient to establish a continuity of symptomatology following the provisional diagnosis during active service. Hypertension was confirmed on examination in January 2025. The May 2025 private medical evaluation submitted by the Veteran also links his current hypertension to the condition noted in service. Resolving reasonable doubt in the Veteran's favor, the Board finds service connection is warranted in accordance with the presumptive provisions for chronic diseases when considering a continuity of symptomatology as explained in Walker. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 7. Entitlement to service connection for asthma is granted. The precise basis of the AOJ's denial of service connection for asthma is not entirely clear from the record. An initial January 2025 VA examiner provided a negative nexus opinion regarding asthma, noting treatment records that suggest the condition may have pre-existed the Veteran's active service. Thereafter, the AOJ correctly requested a new opinion addressing the presumption of soundness because asthma was not noted on the Veteran's initial service entry examination or during several service examinations thereafter. The Board parenthetically notes a veteran is considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). The presumption of soundness may be rebutted by clear and unmistakable evidence showing that a disability pre-existed service and that the disability was not aggravated by service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Thus, when the presumption of soundness applies, the Veteran is not required to show that a pre-existing injury or disease increased in severity during service. Id. Rather, the burden remains with VA to show by clear and unmistakable evidence that the pre-existing disease or injury was not aggravated by service. Id. VA may show a lack of aggravation if clear and unmistakable evidence establishes that there was no increase in disability during service, or that any increase in disability was due to the natural progress of the pre-existing condition. Id. If this burden is met, then the claimant is not entitled to service connection benefits. Id. On the other hand, if VA fails to show a lack of aggravation by clear and unmistakable evidence, then the presumption has not been rebutted. Id. at 1094 (holding that Congress intended to "convert aggravation claims to ones for service connection when the government fails to overcome the presumption of soundness"). In that case, the claim will be considered as a normal claim for service connection and, if granted, no deduction for the degree of disability existing at the time of entrance will be made. Id. at 1096 (citing 38 C.F.R. § 3.322). In other words, the claim may not be denied, nor benefits deducted, on the basis of a finding that the disability in question pre-existed active service, if VA does not also meet its evidentiary burden of showing that the disability was not aggravated during service. The clear-and-unmistakable-evidence standard is a much more formidable evidentiary burden to meet than the preponderance-of-the-evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that the clear-and-unmistakable-evidence standard is more demanding than the clear-and-convincing-evidence standard, which in turn is higher than the preponderance-of-the-evidence standard). It is an "onerous" and "very demanding" evidentiary standard, requiring that the evidence be "undebatable." See Cotant v. West, 17 Vet. App. 116, 131 (2003) (citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993)). Here, a subsequent March 2025 VA examiner reported it is at least as likely as not the Veteran's asthma was aggravated beyond its natural progression during active service due to in-service environmental exposures. The March 2025 VA examiner agreed with the previous assessment that asthma pre-existed service; however, the unequivocal statement regarding in-service aggravation establishes that is not "undebatable" there was no in-service aggravation as suggested by the previous January 2025 opinion. As a result, the presumption of soundness has not been rebutted in the Veteran's case. The evidence otherwise establishes a nexus to service for the Veteran's current disability. Again, resolving reasonable doubt in the Veteran's favor, the Board finds service connection for asthma is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 8. Entitlement to service connection for hemorrhoids is granted. The record establishes the Veteran has a current disability to support his service connection claim for hemorrhoids. This was confirmed on examination in January 2025 and is shown in treatment records. The Veteran asserts he was diagnosed with hemorrhoids during his second verified period of active service from October 2004 to September 2005 and has experienced continuous hemorrhoidal symptoms thereafter. Indeed, service treatment records include a September 2005 separation examination report that corroborates the Veteran's reports regarding the onset of hemorrhoids during active service. A January 2025 VA examiner who provided a toxic exposure risk activity (TERA) regarding the Veteran's claim did not address the Veteran's lay reports or corroborating evidence in service treatment records. The May 2025 private opinion submitted by the Veteran includes a favorable nexus conclusion regarding hemorrhoids that is consistent with his lay reports and corroborating evidence in service treatment records. Resolving reasonable doubt in the Veteran's favor, the Board finds service connection for hemorrhoids is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 9. Entitlement to service connection for the residuals of basal cell carcinoma is granted. The record establishes the Veteran was diagnosed as having basal cell carcinoma, which was treated surgically, resulting in symptomatic scarring, and continues to be monitored by dermatology. The May 2025 private opinion submitted by the Veteran attributes his skin cancer to excessive sun exposure during active service, which is consistent with the rationale provided by VA examiners who provided opinions noting his military service was primarily in tropical locations working on boats with little to no sun protection. The statements regarding excessive sun exposure include in the expert opinions of record are generally consistent with the circumstances of the Veteran's service as documented in personnel records. There has been some confusion as to the nature of the Veteran's specific skin cancer diagnosis; however, as clarified by a March 2025 VA examiner, treatment records clearly show a diagnosis of basal cell carcinoma despite a past family history of melanoma. Resolving reasonable doubt in the Veteran's favor, the Board finds service connection for the residuals of basal cell carcinoma is also warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND Under the provisions of the Appeals Modernization Act, the Board must remand any appeal that cannot be granted in full for correction of a pre-decisional duty-to-assist error. 38 C.F.R. § 20.802(a). The Board may also remand to ensure compliance with a regulatory or statutory duty if such compliance would have a reasonable possibility of aiding in substantiating the claim. Id. The Board finds VA did not fulfill its duty to assist regarding the issues of service connection left and right shoulder disabilities to the extent it failed to obtain an adequate opinion regarding the claims. A March 2025 VA examiner provided a negative nexus conclusion regarding the claims, noting, in pertinent part, the "Veteran's claims file is silent for shoulder condition, injury, or pain during military service or in the immediate year following military service." The Board notes this opinion appears to be based on an inaccurate factual history of the claimed disabilities. The Veteran's service treatment records reflect several instances of treatment for shoulder pain, often associated with neck and/or upper back pain, but, at times, limited specifically to the shoulder. The March 2025 VA examiner failed to consider this documented treatment; therefore, a new opinion is necessary regarding the Veteran's shoulder claims to ensure compliance with VA's duty to assist. The matters are REMANDED for the following action: Schedule the Veteran for a new examination to obtain an opinion addressing whether he has a left and/or right shoulder disability that is at least as likely as not the result of an in-service disease or injury, to include, but not limited to, his documented treatment for pain during active service. For the purposes of the opinion, the examiner should assume the Veteran's statements about his symptoms and history are credible, unless they are inconsistent with the evidence of record or with medical principles concerning his condition. The Board emphasizes that this does not constitute a positive credibility determination, as the Board will weigh the evidence, if necessary, should the claim return on appeal. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. In doing so, the examiner may identify any discrepancies, inconsistencies, or contradictions contained in the evidence of record, and may state whether or not the Veteran's lay statements are supported by medical or other evidence. The examiner may not dismiss the Veteran's statements about his symptoms and history solely because they are not documented in contemporaneous treatment records. The examiner's report must include a complete rationale to support all conclusions contained therein. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. S. Kyle, 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.