INTERVERTEBRAL DISC SYNDROME

WILLIAM H. DONNELLY · 2026 · Case ID: 26004886

MIXED

Summary

The veteran, who served in the U.S. Army from June 1982 to May 1996, appeals the denial of service connection for fatigue (including chronic fatigue syndrome) and a seizure disability, and the remand of claims for a back disability, heart condition, joint pain, hand numbness (carpal tunnel syndrome), and Total Disability based on Individual Unemployability (TDIU). The Board granted service connection for a back disability, finding the veteran's lay testimony credible and sufficient to establish onset in service and continuity of symptoms, despite inadequate VA medical opinions. The Board denied service connection for fatigue, noting that the veteran's symptoms were attributed to other diagnosed conditions like acquired psychiatric disorder, chronic pain, and low testosterone, and that no diagnosis of chronic fatigue syndrome was established. Service connection for a seizure disorder was also denied due to a lack of diagnosis and inconsistent symptom reporting, despite the Veteran's belief and prescription of gabapentin. The case was remanded for further development on the heart condition, joint pain, hand numbness, and TDIU claims. For the heart condition, a remand was ordered for a VA opinion on secondary service connection to the acquired psychiatric disorder. For joint pain, the remand was for substantial compliance with prior directives, requiring consideration of the veteran's contentions and lack of post-service treatment due to no health insurance. Hand numbness claims were remanded for a VA opinion on secondary service connection to MGUS. The TDIU claim was remanded due to the need to first adjudicate the back disability and obtain a VA Form 21-8940, as well as the intertwined nature of the remanded heart and joint pain claims.

Rationale

Lay testimony found credible and sufficient for onset and continuity; VA medical opinions found inadequate; Benefit of the doubt resolved in veteran's favor

Service Branch

ARMY

Special Benefit

TDIU

Docket No.

17-04 990A

Full Decision Text

Citation Nr: 26004886
Decision Date: 04/23/26 Archive Date: 04/23/26

DOCKET NO. 17-04 990A
DATE: April 23, 2026

ORDER

Service connection for a back disability is granted.

Service connection for fatigue, to include chronic fatigue syndrome, is denied.

Service connection for a seizure disability is denied.

REMANDED

Service connection for a heart condition is remanded.

Service connection for joint pain is remanded.

Service connection for right hand numbness, also claimed as carpal tunnel syndrome (CTS), is remanded.

Service connection for left hand numbness, claimed as CTS, is remanded.

Entitlement to a finding of total disability based on individual unemployability (TDIU) is remanded.

FINDINGS OF FACT

1. The Veteran's back condition began in service and has continued since service.

2. The Veteran does not have a diagnosis of chronic fatigue syndrome, and his fatigue and tiredness are symptoms of other conditions, including service-connected posttraumatic stress disorder (PTSD) with depression and insomnia.

3. The Veteran does not have a seizure disability.

CONCLUSIONS OF LAW

1. The criteria for service connection for a back disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for fatigue, to include chronic fatigue syndrome, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

3. The criteria for service connection for a seizure condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from June 1982 to May 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision by an agency of original jurisdiction (AOJ) of the U.S. Department of Veterans Affairs (VA).

Initially, the Veteran testified in a September 2019 Board hearing. However, the recording of the hearing was found to be inaudible. Subsequently, in February 2021, the Veteran testified before a Veterans Law Judge (VLJ) by virtual hearing. A transcript of the February 2021 Board hearing has been associated with the claims file and reviewed. In March 2022 the Veteran was informed that the VLJ that had conducted the February 2021 hearing was no longer employed at the Board, and he was offered another opportunity to have a hearing. The letter further stated that if no response was received, it would be assumed that the Veteran did not want another hearing. No response has been received, and, thus, the Board will continue adjudication of the claim.

This matter was most recently before the Board in June 2023 where these claims were remanded for further development. This appeal has returned to the Board for further appellate consideration.

Service Connection

Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994).

To establish an entitlement to service connection, the Veteran must establish (1) the existence of a present disability, (2) an in-service occurrence or aggravation of a disease or injury, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 38 C.F.R. § 3.303(a). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

Service connection may also be granted as secondary to a currently service-connected disability. To meet the criteria for secondary service connection, the Veteran must prove that there is (1) a current disability that is not already
entitlement to service connection, the Veteran must establish (1) the existence of a present disability, (2) an in-service occurrence or aggravation of a disease or injury, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 38 C.F.R. § 3.303(a). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

Service connection may also be granted as secondary to a currently service-connected disability. To meet the criteria for secondary service connection, the Veteran must prove that there is (1) a current disability that is not already service-connected; and (2) at least one service-connected disability; and (3) evidence that the non-service connected disability is either proximately due to or the result of a service-connected disability, or aggravated (increased in severity) beyond its natural progress by a service connected disability. 38 C.F.R. § 3.310.

Some chronic diseases may be presumed to have been incurred in service, if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Organic diseases of the nervous system are listed, with a presumptive period of one year following separation from service.

Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability that are subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006).

To the extent the evidence is found in "approximate balance," the Board will afford the benefit of the doubt in favor of the Veteran. Lynch v. McDonough, 21 F. 4th 776 (Fed. Cir. 2021).

Back Disability

The Veteran claims his back condition warrants service connection. He asserts that he began experiencing back pain in service, and continued to experience back pain since service.

Service treatment records (STRs) from February 1992 include complaints and treatment for low back pain where the provider instructed bedrest for 72 hours. The Veteran's STRs do not include a separation examination.

Private and VA treatment records show ongoing care for the Veteran's back condition since 2007. The Board notes that the Veteran claims he sought post-service treatment for his back condition in 1999, however, the claims file indicates that those records are not available.

In an October 2012 VA examination, the Veteran was diagnosed with spondylosis of the lumbar spine based on an MRI of the lumbar spine. The examiner attributed the back condition to age related degenerative changes. The examiner provided a negative nexus opinion, acknowledging the treatment for back conditions in service, but relied on the lack of evidence of treatment after service until 2008 as negative evidence of continuity of symptoms. A medical opinion based solely on the absence of documentation in the record is inadequate and the medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). The examiner based their opinion on lack of medical treatment records establishing continuity of symptomatology and failed to consider the Veteran's competent and credible account of symptoms in and since service. Id.; Jandreau supra. As such, the October 2012 medical opinion offers no probative value.

In the September 2014 VA examination for back conditions, the Veteran was diagnosed with lumbosacral strain, and lumbar spondylosis. The Veteran reported pain in the left lower back that radiates through the buttocks down to the knee. The examiner opined that the Veteran's back condition was not caused by or the result of his exposures in Southwest Asia, and that his lumbar condition was due to degenerative arthritis of the cervical spine. The September 2014 medical opinion offers no probative value as it is conclusory and failed to address the Veteran's claim of chronic
in and since service. Id.; Jandreau supra. As such, the October 2012 medical opinion offers no probative value.

At the February 2021 Board hearing, the Veteran testified that his back started to give him problems while in service, claiming it could get bad enough that he could hardly walk and required bedrest. He reported that after service he did not seek regular medical treatment for his back condition until 1999, as he did not have health insurance after service until 1999. He testified that he would occasionally go to the emergency room, would lay around, and/or treat his back with over the counter medications, but he dealt with the condition until he was able to get insurance.

In December 2023, a VA medical opinion was rendered based on records reviewed for the claimed back condition. The examiner was directed to review the prior VA examinations and February 2021 hearing transcripts. The examiner rendered a negative nexus opinion for direct service connection, stating that while the Veteran's statements are credible, it is unlikely that he developed the current lumbar spine spondylosis while in service and it was unlikely that he was able to treat such with over the counter medication and occasional emergency room trips. The examiner acknowledged that the Veteran did not have health insurance after service, but opined, that given the general severity of the condition, it is "uncommon for patients to not have to seek clinical treatment at least within the first couple of years of onset" even without health insurance. The examiner's assessment that the Veteran did not have a continuing condition since service because it is "uncommon" for patients not to seek clinical care is not persuasive and offers little probative value, particularly in light of their assessment that the Veteran's statements about his back condition are credible as well as the Veteran's statements about his particular circumstances.

Although the record does not have an adequate medical opinion as to the etiology of the Veteran's back condition, the Board resolves reasonable doubt in the Veteran's favor; thus, the Board finds the lay statements of the Veteran to be credible and sufficient to establish that the Veteran's back condition began during service and that his symptoms have continued since that time. The Veteran credibly testified that the in service occurrence of back pain in service, requiring bedrest, was the "start" of his back conditions, and that he continued to experience back pain since. The Veteran's symptoms of back pain and limitations due to back pain are observable symptoms which are capable of being identified by the Veteran as a lay witness. See Jandreau, 492 F.3d at 1377; Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011).

Due to the foregoing, the weight of the evidence supports the claim and shows onset of a back condition while on active duty, which has continued since then. Accordingly, service connection for a back disability is warranted.

Fatigue, including Chronic Fatigue Syndrome

The Veteran claims he has a fatigue condition that warrants service connection, including as part of an undiagnosed illness or chronic fatigue syndrome.

For VA purposes, chronic fatigue syndrome requires a new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months, the exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms, and six or more of the following: acute onset of the condition, low grade fever, nonexudative pharyngitis, palpable or tender cervical or axillary lymph nodes, generalized muscle aches or weakness, fatigue lasting 24 hours or longer after exercise, headaches (of a type, severity, or pattern that is different from headaches in the pre-morbid state), migratory joint pains, neuropsychologic symptoms, and/or sleep disturbance. 38 C.F.R. § 4.88a.

The Veteran's STRs are silent as to chronic fatigue syndrome or related symptoms.

VA treatment records show reports of fatigue in November 2010, when being evaluated for thyroid and pituitary conditions. VA treatment records from November 2011 show that the Veteran was diagnosed with a sleep disorder, not otherwise specified, and a mood disorder due to general medical
able or tender cervical or axillary lymph nodes, generalized muscle aches or weakness, fatigue lasting 24 hours or longer after exercise, headaches (of a type, severity, or pattern that is different from headaches in the pre-morbid state), migratory joint pains, neuropsychologic symptoms, and/or sleep disturbance. 38 C.F.R. § 4.88a.

The Veteran's STRs are silent as to chronic fatigue syndrome or related symptoms.

In a September 2014 VA examination for mental disorders, the Veteran was diagnosed with major depressive disorder. Chronic sleep impairment was identified as a symptom of his major depressive disorder. The Veteran described his sleep pattern as waking up after 10 minutes, then being awake all night, and napping during the day. The examiner noted that the Veteran also has pituitary, thyroid and low testosterone conditions, in addition to his major depression, which contribute to some of his symptoms.

In the September 2014 VA examination, the Veteran claimed chronic fatigue as part of Gulf War Syndrome. The Veteran reported onset of chronic fatigue around 2005, and the examiner noted that around the same time he was diagnosed with depression, with symptoms of feeling tired and sleeping poorly. The examiner also noted reports of trouble sleeping due to chronic pain in the lower back, as well as the Veteran's medical history of low testosterone. The examiner acknowledged the Veteran's reports of chronic fatigue but determined that the Veteran does not have chronic fatigue syndrome. The examiner opined that the Veteran's chronic pain, insomnia, and use of Metoprol, Gabapentin, and/or Hydrocodone as contributing to his fatigue.

At the February 2021 Board hearing, the Veteran testified that he had depression, and that he always felt tired. He did not report or indicate that he has a diagnosis of chronic fatigue syndrome or other similar disorder.

In April 2024, the Veteran underwent a VA examination for chronic fatigue syndrome, but was not diagnosed with chronic fatigue syndrome or other diagnoses related to chronic fatigue syndrome. The Veteran reported onset about 15 years prior, and symptoms of feeling tired all of the time and joint pain. The examiner noted the Veteran's acquired psychiatric disorder, low testosterone, and degenerative arthritis as clinical conditions that produce similar symptoms. The examiner provided a negative nexus opinion, stating that the Veteran does not have a diagnosis of chronic fatigue syndrome, that his condition is not related to toxic exposures, and that his fatigue is likely related to the previously noted comorbidities, as well as migraines, hypertension, and vitamin D deficiency.

The Board notes that the Veteran is service-connected for an acquired psychiatric disorder, which includes chronic sleep impairment as a symptom. Treatment records and VA medical opinions attribute the Veteran's feelings of tiredness and fatigue as a symptom of other diagnosed conditions, including an acquired psychiatric disorder, a heart disability, chronic pain, and low testosterone. No medical evidence indicates or suggests that the Veteran's symptoms are a condition or disorder separate and distinct from other comorbid conditions. Moreover, the Veteran has submitted no medical evidence or information to demonstrate a diagnosis of chronic fatigue syndrome or similar disability. While he may believe that his symptoms of fatigue and tiredness are a disability resulting from service, to include service in Southwest Asia, he is not competent to render an opinion on such a complex medical question. See Kahana, 24 Vet. App. at 435. In the absence of proof of a present disability there can be no valid claim. Brammer supra.

Due to the foregoing, the evidence is not at least in approximate balance to support finding a diagnosed fatigue disability at any time during the appeal. The Board has considered the benefit of the doubt doctrine but finds that it does not apply. As such, service connection for a fatigue disability, including chronic fatigue syndrome, is not warranted.

Seizure Disability

The Veteran claims he has a seizure disorder that warrants service connection.

STRs are silent as to any seizure or epilepsy symptoms.

Seizure Disability

The Veteran claims he has a seizure disorder that warrants service connection.

STRs are silent as to any seizure or epilepsy symptoms.

A review of VA treatment records from 2008 to 2023 shows no diagnosis of seizure or epilepsy disorder. In an October 2010 VA treatment record, the Veteran reported periods of upset stomach, feeling hot, and falling down on the ground, which lasts seconds, but no confusion with awakening; the clinician noted that there was no seizure activity. In October 2010, the Veteran underwent a routine EEG, including photic stimulation and hyperventilation which did not produce changes, and the results were a normal EEG in awake and drowsy states, with no epileptiform activity seen. In September 2013, the Veteran requested paperwork regarding medical disability for his back and the "mini-seizures" he's been having. In a later September 2013 VA treatment record, the Veteran told a nurse he had a seizure, describing symptoms of pain on the left side of his neck, to his jaw, and down to his chest, hands trembling, and passing out; a clinician explained to the Veteran that his description does not sound like a seizure, additionally noting that the Veteran was able to talk during the episode and did not lose urinary control. Subsequent VA treatment records include reports of no seizures in the review of system notations. In July 2017, the Veteran was referred for evaluation for a TENS unit for his back where he denied having a pacemaker or seizures. In a February 2018 mental health consultation, the Veteran reported having seizures for 20 years or more. In March 2018, the Veteran underwent a sleep deprived EEG to evaluate seizure activity, where photic stimulation and hyperventilation were done but did not show any electrographic changes and no epileptiform activity was seen; the results of the EEG were normal in the awake, drowsy, and sleep states, however, the clinician noted the absence of epileptiform abnormalities does not preclude a clinical diagnosis of seizures.

In September 2014, the Veteran underwent a VA examination for seizure disorders. The examiner indicated that the Veteran did not have or has ever been diagnosed with a seizure disorder. The Veteran stated that he feels that since he is on medication used to treat seizures, he has a seizure disorder. The examiner noted that the Veteran has been prescribed Gabapentin and Lyrica for chronic pain, but that the Veteran is not on and has never taken medication to treat a seizure disorder. The Veteran described his symptoms as nausea, sweating, "seeing dots," "waking up 'somewhere,'" and experiencing shaking hands afterwards. No loss of bladder or bowel control was noted, he does not always pass out during an episode, and he has never injured himself during an episode. The examiner's concluding remarks stated that the Veteran does not have a diagnosed seizure disorder condition.

In the February 2021 Board hearing, the Veteran testified that he experienced feeling sick in his stomach, getting shaky, hot, and sweaty. He testified that when he described these symptoms to his doctor, she said he was having miniature seizures, but then, later, another doctor said the symptoms were related to anxiety attacks. The Veteran testified to being prescribed gabapentin, saying that "they say it had something to do with the brain that helps out on seizures. And plus the gabapentin is supposed to be for nerves. So, I don't know which one it's for." When the VLJ appeared to inquire if gabapentin was for seizures, the Veteran replied "Yes, I don't know."

In a December 2023 VA medical opinion based on records reviewed, the examiner reiterates that there is no diagnosis or evidence of seizures, even after extensive testing by medical professionals. The examiner addressed the Board's prior remand directive regarding the Veteran's reports of loss of consciousness, conscious control, and episodes of tremors, stating that many medical conditions can cause these symptoms, and the etiology of the symptoms are likely a combination of the Veteran's heart condition, hypotensive episodes, and panic attacks.

The Board has reviewed the evidence of record, and finds that there is no diagnosis of a seizure disorder. Treatment record show that the Veteran believes he has experienced seizures, however no medical practitioner has affirmed the Veteran's belief or diagnosed him with a seizure condition. While the Veteran has been prescribed medications such as gabapentin and Lyrica, which can be used to treat "mini" or partial seizures, VA treatment records indicate that these medications were prescribed for nerve pain.

The Veteran has submitted no medical evidence or information to demonstrate a diagnosis of a seizure condition. While he may believe a seizure disorder exists, as a layperson, the Veteran lacks the competence to render an opinion on such a complex medical question. See Kahana, 24 Vet. App. at 435. Moreover, although the Veteran was prescribed medications for nerve pain which can also treat seizures, there is no medical evidence that the Veteran was prescribed and taking such medications for seizures. His testimony from the February 2021 Board hearing demonstrated that he was unclear as to what condition his medication was treating, but VA treatment records are clear.

The Board concludes that the evidence is not at least in approximate balance to support finding that the Veteran has a current diagnosis of a seizure disability. Accordingly, the Board finds there is no basis upon which to award service connection for a seizure disability. Brammer supra. The Board has considered the benefit of the doubt doctrine but finds that it does not apply. As such, service connection for a seizure condition is not warranted.

REASONS FOR REMAND

Remand is required for further development with regard to the remaining claims.

Heart Condition

In the April 2024 VA examination for heart conditions, the VA examiner provided a negative nexus opinion as to whether the Veteran's heart condition is related to service including his exposure to burning oil wells. In the rationale, the examiner cited other risk or contributing factors related to the Veteran's diagnosed condition, including anxiety. The Veteran is service-connected for an acquired psychiatric disorder, which includes symptoms of anxiety. Thus, a secondary theory of entitlement has been raised by the record. When determining service connection, all theories of entitlement, direct and secondary, must be considered if raised by the evidence of record, applying all relevant laws and regulations. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). The claims file does not contain a medical opinion addressing the secondary theory of entitlement, and the Board is unable to adjudicate the claim on the evidence of record. Accordingly, a remand is required to obtain a medical opinion as to whether the Veteran's heart condition is proximately due to or aggravated by a service-connected disability.

Generalized Joint Pain

In the June 2023 remand, the Board directed development for the Veteran's claim of joint pain, specifically to obtain an opinion regarding the etiology of the Veteran's joint pain that includes consideration of the Veteran's remarks of onset and use of over the counter treatments.

In a January 2024 VA medical opinion, the examiner provided a negative nexus opinion for direct service connection. The examiner based their opinion on the lack of substantiating evidence to support a nexus between the joint pain condition and military service, and lack of evidence of chronicity of care during or after service. The examiner did not address the Veteran's testimony that he took over the counter medication for his joint pain, nor did the examiner acknowledge that the Veteran may not have sought medical treatment following service due to his lack of health insurance.

In the May 2024 VA medical opinion, the examiner stated that the Veteran's joint pain is a disease with a clear and specific etiology and diagnosis, then generally discussed osteoarthritis. However, the examiner failed to discuss the Veteran's contentions or his VA treatment records that include a diagnosis of arthralgia or polyarthralgia, that is, joint pain without inflammation.

The Board finds that the June 2023 remand directives were not substantially complied with. A remand by the Board confers upon the claimant, as a matter of law, the right to substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, a remand is required for substantial compliance with the June 2023 remand.

Left and Right Hand Numbness

Since the June 2023 Board remand, the Veteran has been service-connected for monoclonal gammopathy of undetermined significance (MGUS), which is noted to have been present since at least 2014. One possible symptom of this disability is peripheral neuropathy of the hands and/or feet. Accordingly, a theory of secondary service-connection must be developed and considered.

TDIU

The Board, above, has granted service connection for a back disability. This
substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, a remand is required for substantial compliance with the June 2023 remand.

Left and Right Hand Numbness

TDIU

The Board, above, has granted service connection for a back disability. This grant must be implemented prior to adjudicating whether TDIU is warranted due to the Veteran's service-connected disabilities. In implementing the above, the AOJ must make a determination as to the functional and occupational impairment due to the Veteran's back condition and a rating must be assigned in the first instance by the

AOJ. The implementation of service connection for the back disability is inextricably intertwined with the claim for TDIU. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (stating that two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered).

Also, the claims file shows that the AOJ has not undertaken appropriate development for the Veteran's claim for TDIU, including requesting VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability.

Moreover, the issues of service connection for a heart condition and joint pain are being remanded. The claim for TDIU is inextricably intertwined with the claim for service connection of a heart condition and joint pain, being remanded herein. Thus, the issue of entitlement to TDIU is inextricably intertwined with the claim being remanded to the AOJ. See Harris supra.

For the foregoing reasons, the issue of entitlement to TDIU must be remanded.

The matters are REMANDED for the following action:

1. Provide the Veteran with notice of the requirements to substantiate a claim for TDIU. The Veteran should be sent VA Form 21-8940 with a request that he provide details regarding his employment history and education. An appropriate period of time should be allowed for response.

2. Schedule the Veteran for a VA examination for heart conditions to determine the nature and etiology of his claimed heart disability; the claims file must be reviewed in conjunction with the examination.

The examiner must identify all heart disabilities for the period on appeal. For each diagnosed disability, the examiner must opine as to whether any such is at least as likely as not (1) was caused OR (2) or aggravated by the Veteran's service-connected disabilities, to include his service-connected acquired psychiatric disorder. The opinion must address causation and aggravation, which are two separate inquiries.

The examiner must address the April 2024 VA examiner's discussion about the relationship between the heart condition and anxiety, and if there is conflicting opinions, such must be clearly stated with supporting rationale.

A complete rationale must be provided for all opinions presented.

3. Schedule the Veteran for a VA arthritis examination to assess the nature and etiology of the complaints of generalized joint pain; the claims file must be reviewed in conjunction with the examination.

The examiner must identify all disabilities which may account for the complaints of generalized joint pain, and opine whether any such is at least as likely as not caused or aggravated by service.

The examiner must also provide an opinion with consideration of 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.

In rendering the above medical opinions, consideration of the Veteran's remarks of onset and over the counter treatments, as well as his lack of health insurance until 1999, is required.

A complete rationale must be provided for all opinions presented.

4. Schedule the Veteran for a VA peripheral nerves examination; the claims file must be reviewed in conjunction with the examination.

The examiner must identify any current disability of the left and/or right upper extremities, to include CTS; the examiner must opine as to whether any such are at least as likely as not caused or aggravated by service or a service-connected disability, to include MGUS.

4. After completing the above, the Veteran's claims should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, furnish the Veteran and his representative with a supplemental statement of the case (SSOC) and return the case to the Board.

WILLIAM H. DONNELLY

Veterans Law Judge

Analyze in VA Law Explorer