PROSTATE MALIGNANT NEOPLASM

S. HENEKS · 2026 · Case ID: 26005096

MIXED

Summary

The Veteran served in the Marine Corps Reserve from October 1953 to September 1957 and on active duty from September 1957 to August 1959. The Veteran appeals the denial of service connection for prostate cancer, bladder disorder, and hypertension, all claimed to be due to exposure to contaminated water at Camp Lejeune and/or ionizing radiation. The Veteran also appeals the denial of service connection for lumbar spine, bilateral shoulder, and right hip disabilities, claimed as secondary to other service-connected conditions. The Board notes that service connection for chronic kidney disease was granted based on Camp Lejeune exposure. However, for the appealed conditions of prostate cancer, bladder disorder, and hypertension, the Board found no evidence of in-service incurrence or aggravation, nor a nexus to service or claimed exposures, leading to denial. The Board also notes that the claims for lumbar spine, bilateral shoulder, and right hip disabilities were remanded in a prior decision for additional medical opinions, but these opinions were not obtained as the Veteran missed scheduled VA examinations. The Board found no indication that the VA attempted to contact the Veteran to reschedule or inform him of the consequences of missing the examinations. The Veteran's son reported the Veteran had significant dementia after his wife's passing. The case is remanded for further development regarding the lumbar spine, bilateral shoulder, and right hip claims.

Rationale

No evidence of in-service incurrence or aggravation; No nexus to service or claimed exposures; Prostate cancer did not originate in service, within a year of service, or is not otherwise etiologically related to active service

Service Branch

MARINE CORPS

Special Benefit

NO SPECIAL BENEFIT

Docket No.

15-05 807

Full Decision Text

Citation Nr: 26005096
Decision Date: 04/30/26 Archive Date: 04/30/26

DOCKET NO. 15-05 807
DATE: April 30, 2026

ORDER

Entitlement to service connection for prostate cancer, to include as due to exposure to ionizing radiation and/or to contaminated water at Camp Lejeune, is denied.

Entitlement to service connection for a bladder disorder, to include as due to exposure to ionizing radiation and/or to contaminated water at Camp Lejeune, is denied.

Entitlement to service connection for hypertension, to include as due to exposure to ionizing radiation and/or to contaminated water at Camp Lejeune, or in the alternative, on a secondary basis, is denied.

REMANDED

Entitlement to service connection for a lumbar spine disability, to include on a secondary basis, is remanded.

Entitlement to service connection for a bilateral shoulder disability, to include on a secondary basis, is remanded.

Entitlement to service connection for a right hip disability, to include on a secondary basis, is remanded.

FINDINGS OF FACT

1. The Veteran has not been shown to have exposure to ionizing radiation in service.

2. The Veteran's service at Camp Lejeune has been conceded.

3. The Veteran's diagnosed prostate cancer did not originate in service, within a year of service, and is not otherwise etiologically related to his active service.

4. The Veteran's diagnosed bladder disorder did not originate in service, within a year of service, and is not otherwise etiologically related to his active service.

5. The Veteran's diagnosed hypertension did not originate in service, within a year of service, and is not otherwise etiologically related to his active service.

CONCLUSIONS OF LAW

1. The criteria for service connection for prostate cancer have not been met. 38 U.S.C. §§ 1112, 1113, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.311.

2. The criteria for service connection for a bladder disorder have not been met. 38 U.S.C. §§ 1112, 1113, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.311.

3. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1112, 1113, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310, 3.311.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from September 1957 to August 1959, with additional service in the Marine Corps Reserve from October 1953 to September 1957.

A July 2024 rating decision granted service connection for chronic kidney disease stage three based on the Veteran's exposure to contaminated water at Camp Lejeune during periods of active duty for training (ACDUTRA) and/or inactive duty for training (INACDUTRA) service. See July 2024 Rating Decision - Narrative.

These matters come before the Board of Veterans' Appeals (Board) on appeal from October 2012 and September 2014 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO).

By way of background, these matters were previously before the Board in April 2017, January 2022, February 2023, and July 2025, when they were remanded for further development.

The Board notes that the July 2025 Board remand also included the issue of entitlement to service connection for a right knee disorder, to include as secondary to service-connected left knee disability and left hip disabilities. See July 2025 BVA Decision. However, during the pendency of the appeal, a September 2025 rating decision granted service connection for right knee strain. See September 2025 Rating Decision - Narrative. Accordingly, as the Veteran's service connection claim has been granted, the issue of entitlement to service connection for a right knee disorder is no longer in appellate status as there is no case or controversy presently before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed
Board remand also included the issue of entitlement to service connection for a right knee disorder, to include as secondary to service-connected left knee disability and left hip disabilities. See July 2025 BVA Decision. However, during the pendency of the appeal, a September 2025 rating decision granted service connection for right knee strain. See September 2025 Rating Decision - Narrative. Accordingly, as the Veteran's service connection claim has been granted, the issue of entitlement to service connection for a right knee disorder is no longer in appellate status as there is no case or controversy presently before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997).]

Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); 38 C.F.R. § 3.303.

Camp Lejeune

The Veteran reported that his prostate cancer, bladder disorder, and hypertension may have been caused by exposure to contaminated water at Camp Lejeune while he was serving in the Marine Corps Reserve.

The Board notes that service connection may be granted on a presumptive basis for certain diseases associated with exposure to contaminants (defined as the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE or PERC), benzene, and vinyl chloride) in the on-base water supply located at Camp Lejeune, even though there is no record of such disease during service, if they manifest to a compensable degree at any time after service, in a veteran, former reservist, or a member of the National Guard, who had no less than 30 days (consecutive or nonconsecutive) of service at the United States Marine Corps Base Camp Lejeune and or Marine Corps Air Station New River in North Carolina, during the period beginning on August 1, 1953, and ending on December 31, 1987. 38 C.F.R. § 3.307(a)(7).

In addition, a review of his service personnel records (SPRs) shows that the Veteran attended annual training at Camp Lejeune while he was serving in the Marine Corps Reserve from July 17 to July 31, 1954, and a certificate "given" at Camp Lejeune in October 1954 indicates that the Veteran met all necessary requirements, to include completion of a 10 week course, to qualify as a Marine Scout Sniper. See November 2018 Military Personnel Record; December 2022 Military Personnel Record.

A May 2024 toxic exposure risk activity memorandum shows that the Veteran qualified for a presumption of exposure to Camp Lejeune water contamination. Therefore, exposure to contaminated water at Camp Lejeune has been conceded.

Radiation Exposure

The Veteran states that his diagnosed prostate cancer residuals, bladder disorder, and hypertension were caused by exposure to ionizing radiation during an accident involving an "Honest John Rocket" while he was stationed in Kitzingen, Germany in or around June or July 1958. He further stated that a fellow service member was medically discharged and died as a result of such exposure.

In support of his claim, the Veteran submitted photographs showing him standing adjacent to a missile, described as an "atomic war head" and as an "Honest John rocket" and of him standing next to a vehicle during service. See, e.g., December 2010 Photographs.

A "radiation-exposed veteran" is defined by 38 C.F.R. § 3.309(d)(3) as a veteran who while serving on active duty or on active duty for training or inactive duty training, participated in a radiation-risk activity. "Radiation-risk activity" is defined to mean onsite participation in a test involving the atmospheric detonation of a nuclear device; the occupation of Hiroshima, Japan or Nagasaki, Japan by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946; or internment as a prisoner of war (or service on active duty in Japan immediately following such internment) during World War II which resulted in an opportunity for exposure to ionizing radiation comparable to that of the United States occupational forces in Hiroshima or Nagasaki during the period
3) as a veteran who while serving on active duty or on active duty for training or inactive duty training, participated in a radiation-risk activity. "Radiation-risk activity" is defined to mean onsite participation in a test involving the atmospheric detonation of a nuclear device; the occupation of Hiroshima, Japan or Nagasaki, Japan by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946; or internment as a prisoner of war (or service on active duty in Japan immediately following such internment) during World War II which resulted in an opportunity for exposure to ionizing radiation comparable to that of the United States occupational forces in Hiroshima or Nagasaki during the period from August 6, 1945 through July 1, 1946. 38 C.F.R. § 3.309(d)(3)(i). Here, the Board finds that the evidence is persuasively against finding that Veteran is a "radiation-exposed veteran" because he did not participate in a "radiation risk activity." See 38 C.F.R. § 3.309(d)(3)(ii)(A). Accordingly, service connection under 38 C.F.R. § 3.309(d) is not warranted.

Under the special development procedures in 38 C.F.R. § 3.311(a), dose data will be requested from the Department of Defense (DoD) in claims based upon participation in atmospheric nuclear testing, and claims based upon participation in the American occupation of Hiroshima or Nagasaki, Japan, prior to July 1, 1946. 38 C.F.R. § 3.311(a)(2). In all other claims, 38 C.F.R. § 3.311(a) indicates that a request be made for any available records concerning the Veteran's exposure to radiation. These records normally include but may not be limited to the Veteran's Record of Occupational Exposure to Ionizing Radiation (DD Form 1141), if maintained, service treatment records, and other records which may contain information pertaining to the Veteran's radiation dose in service. All such records will be forwarded to the Under Secretary for Health, who will be responsible for preparation of a dose estimate, to the extent feasible, based on available methodologies. 38 C.F.R. § 3.311(a)(2)(iii).

The Veteran's DD-214 shows that his military occupational specialty (MOS) was field artillery rocket crewman. See January 2015 Certificate of Release or Discharge from Active Duty (e.g., DD 214, NOAA 56-16, PHS 1867).

In a January 2012 letter, the Army Dosimetry Center indicated that they were unable to locate any records of exposure to ionizing radiation for the Veteran. See January 2012 Third Party Correspondence. In November 2020, VA sent a letter to the United States Army Dosimetry Center for radiation exposure verification. Specifically, the letter asked whether the Veteran's unit was tasked with guarding "Honest John Rocket[s]" and whether there were any reported incidents that would have exposed persons serving in the area of Kitzingen, Germany to radiation between 1957 and 1958. However, a December 2020 response from the Army Dosimetry Center shows that they were unable to locate any records of exposure to ionizing radiation for the Veteran. See February 2021 Correspondence.

In addition, a May 2024 toxic exposure risk activity memorandum shows that the Veteran, in pertinent part, qualified for a presumption of exposure to Camp Lejeune water contamination. However, the memorandum also indicates that the Veteran did not qualify for a presumption of exposure to ionizing radiation in service. See May 2024 Other; see also July 2024 Rating Decision - Narrative.

In support of his claim, the Veteran completed and submitted a radiation risk activity worksheet in February 2011. However, the Veteran's STRs and SPRs do not contain a DD Form 1141 or any other evidence indicating that he was exposed to radiation during service. Moreover, January 2012 and December 2020 letters show that the Army Dosimetry Center was unable to obtain any records to corroborate the Veteran's reports that he was exposed to radiation during service, to include records of any reported incidents that would have exposed persons in the area of Kitzingen, Germany to radiation between 1957 and 1958.

Upon review of the record, the Board concludes that the evidence is persuasively against finding that the Veteran was exposed to ionizing radiation during service. Thus, while the Board acknowledges the Veteran's assertions that he was exposed to ionizing radiation while stationed in Germany, the Board finds that he is not
any other evidence indicating that he was exposed to radiation during service. Moreover, January 2012 and December 2020 letters show that the Army Dosimetry Center was unable to obtain any records to corroborate the Veteran's reports that he was exposed to radiation during service, to include records of any reported incidents that would have exposed persons in the area of Kitzingen, Germany to radiation between 1957 and 1958.

Upon review of the record, the Board concludes that the evidence is persuasively against finding that the Veteran was exposed to ionizing radiation during service. Thus, while the Board acknowledges the Veteran's assertions that he was exposed to ionizing radiation while stationed in Germany, the Board finds that he is not competent to state that he was exposed to such and that the assertions by the Veteran are less persuasive and probative than the Veteran's STRs and SPRs and the responses from the Army Dosimetry Center. As such, the Board finds that the most probative evidence is against a finding that the Veteran was exposed to ionizing radiation in service, to include during an accident involving an "Honest John Rocket" while he was stationed in Kitzingen, Germany in or around June or July 1958. Accordingly, service connection is not available under 38 C.F.R. § 3.309(d). Further, as exposure to ionizing radiation is not shown in this case, presumptive service connection for prostate cancer under 38 C.F.R. § 3.111(b)(2) is not for application in this case.

1. Entitlement to service connection for prostate cancer, to include as due to exposure to ionizing radiation and/or to contaminated water at Camp Lejeune, is denied.

2. Entitlement to service connection for a bladder disorder, to include as due to exposure to ionizing radiation and/or to contaminated water at Camp Lejeune, is denied.

The Board notes that exposure to contaminated water at Camp Lejeune has been conceded, but exposure to ionizing radiation has not.

The Veteran's service treatment records (STRs) are silent for any findings or diagnoses of prostate cancer and/or bladder disorders. See September 2014 STR - Medical; January 2019 STR - Medical.

A review of the post-service treatment records shows that the Veteran was diagnosed with prostate cancer in 2009. In addition, a March 2009 spiral CT of the Veteran's pelvis revealed nonspecific moderate distension of the urinary bladder. Thereafter, an August 2009 private treatment record shows that the Veteran sought treatment for a sluggish bladder and was subsequently diagnosed with a neurogenic bladder. See June 2011 Medical Treatment Record - Non-Government Facility; October 2011 Medical Treatment Record - Non-Government Facility; November 2011 Medical Treatment Record - Non-Government Facility; February 2015 Medical Treatment Record - Non-Government Facility.

In support of his claim, the Veteran submitted a private medical opinion from Dr. A. Hsu dated in September 2014. Dr. Hsu opined that the Veteran's in-service radiation exposure may have been the main catalyst leading to his diagnosed prostate cancer. In support of his opinion, Dr. Hsu stated that the Veteran was a member of a top-secret atomic rocket unit in service and indicated that he was exposed to ionizing radiation after a technician exposed atomic fission material while the Veteran was guarding him in service. See September 2014 Medical Treatment Record - Non-Government Facility.

In addition, the Veteran submitted an undated private medical opinion from Dr. Hsu in May 2018. Dr. Hsu noted that the Veteran was under his constant care and opined that it was more likely than not that the contaminated water the Veteran drank at Camp Lejeune contributed to his prostate cancer, had some effect on his health, and could have created his inability to urinate without the use of medication. In support of his opinion, Dr. Hsu stated that the Veteran trained at Camp Lejeune in the summers of 1954 and 1955 and reported that he consumed large amounts of contaminated water during those periods. See March 2018 Correspondence.

VA initially obtained a medical opinion to determine the nature and etiology of the Veteran's diagnosed prostate cancer and bladder disorder in April 2019. After reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed prostate cancer and bladder disorder were caused by or the result of his exposure to contaminated water at Camp Lejeune. In support of his opinion, the examiner noted that the most important risk factors for prostate cancer were age, race, and genetic factors. In addition, the examiner opined that it was more likely than not that the Veteran's bladder obstructive complaints were caused by his diagnosed prostate cancer
contaminated water during those periods. See March 2018 Correspondence.

VA initially obtained a medical opinion to determine the nature and etiology of the Veteran's diagnosed prostate cancer and bladder disorder in April 2019. After reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed prostate cancer and bladder disorder were caused by or the result of his exposure to contaminated water at Camp Lejeune. In support of his opinion, the examiner noted that the most important risk factors for prostate cancer were age, race, and genetic factors. In addition, the examiner opined that it was more likely than not that the Veteran's bladder obstructive complaints were caused by his diagnosed prostate cancer. In this regard, he explained that the Veteran was diagnosed with prostate cancer in 2009, underwent cryotherapy treatment, and subsequently reported complaints of difficulty urinating. See April 2019 C&P examination.

VA next obtained an addendum medical opinion in April 2022. After reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed prostate cancer was caused by or the result of exposure to contaminated water at Camp Lejeune. In support of his opinion, the examiner stated that there was no logical clinical foundation to support the assertion that weeks of exposure to contaminated water at Camp Lejeune led to the Veteran's adverse health effects, which initially manifested 55 years after such exposure. He further emphasized that data from the Agency for Toxic Substances and Disease Registry failed to show an association between exposure to contaminated water at Camp Lejeune and prostate cancer. However, he noted that prostate cancer was very common, affecting approximately one in seven men, and although there was often no specific reason or cause as to why the condition developed, advanced age was seen as a major risk factor. The examiner further stated that the Veteran had multiple additional risk factors for developing prostate cancer, to include a history of tobacco and alcohol use and prior malignancy. See April 2022 C&P examination.

The Veteran was afforded a VA examination for urinary tract conditions in May 2024. The examiner noted that the Veteran had been diagnosed with neurogenic bladder and bladder outlet obstruction. After performing an examination, reviewing the evidence of record, and considering the Veteran's total potential exposure through all of his applicable military deployments and the synergistic, combined effect of all of his toxic exposure risk activities, the examiner opined that it was less likely than not that the Veteran's diagnosed bladder disorders were caused by his indicated toxic exposure risk activities. In support of his opinion, the examiner acknowledged the Veteran's reports that his bladder disorder was caused by exposure to contaminated water at Camp Lejeune but explained that the medical literature did not support a nexus between exposure to contaminated water at Camp Lejeune, to include exposure to perchloroethylene, trichloroethylene, vinyl chloride, and benzene, and the Veteran's diagnosed bladder disorders, to include neurogenic bladder and bladder outlet obstruction. See June 2024 C&P examination.

VA obtained an addendum medical opinion to determine the nature and etiology of the Veteran's diagnosed prostate cancer in August 2024. After reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed prostate cancer was caused by exposure to contaminated water at Camp Lejeune, led, or fuels in service. In support of his opinion, the examiner found that there was no medical or scientific evidence of a relationship between the Veteran's claimed prostate cancer and his in-service toxic exposure risk activities. In this regard, he explained that the exact etiology of prostate cancer was not known; however, he stated that various modifiable and unmodifiable risk factors had been suggested as contributing factors, to include age, ethnicity, family history, genetics, obesity, diet, hormones, smoking, alcohol, and certain medications, though none had been conclusively proven to be a definite etiological factor for prostate cancer, with the possible exceptions of ethnicity and age. See August 2024 C&P examination.

In March 2025, a VA examiner completed an examination report for urinary tract conditions by a review of the available records, rather than by an in-person examination. In this regard, the examiner explained that the evidence of record sufficiently reflected the Veteran's current condition and that a telephone interview and/or in-person examination would likely provide no additional relevant evidence. The examiner noted that the Veteran had been diagnosed with neurogenic bladder and bladder outlet obstruction.

After reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed bladder disorders were incurred in or caused by the claimed in-service injury, event, or illness. In support of his opinion, the examiner explained that there was no evidence of the Veteran's diagnosed
2025, a VA examiner completed an examination report for urinary tract conditions by a review of the available records, rather than by an in-person examination. In this regard, the examiner explained that the evidence of record sufficiently reflected the Veteran's current condition and that a telephone interview and/or in-person examination would likely provide no additional relevant evidence. The examiner noted that the Veteran had been diagnosed with neurogenic bladder and bladder outlet obstruction.

The examiner further opined that it was less likely than not that the Veteran's diagnosed bladder disorders were proximately due to or the result of exposure to contaminated water at Camp Lejeune. In support of his opinion, the examiner stated that the Veteran's neurogenic bladder was diagnosed in 2012, more than 53 years after he was discharged from active duty. He further emphasized that there were external factors that may have contributed to the development of neurogenic bladder in addition to the natural progression of aging and other health conditions which impacted him after he was discharged from active duty in 1959. See March 2025 C&P examination.

Within records provided by the Veteran and associated with the claims file in July 2025, a statement titled "A note to the VA" reflected that the contaminated water the Veteran ingested at Camp Lejeune had a profound effect on his entire urinary tract system and life. The statement indicated that VA should read Dr. Hsu's report for additional details on how the biochemically noxious water effected the Veteran's existence. However, the statement is undated, unsigned, was not written on professional letterhead, and does not otherwise identify the author thereof. Further, "REDICULOUS and Un-American" was typed at the conclusion of the statement. The Board affords this document no probative value. See July 2025 CAPRI.

VA last obtained an addendum medical opinion in August 2025. After reviewing the evidence of record and considering the Veteran's total potential exposure through all of his applicable military deployments and the synergistic, combined effects of all of his in-service toxic exposure risk activities, the examiner opined that it was less likely than not that the Veteran's diagnosed prostate cancer was caused by his indicated toxic exposure risk activities. In support of his opinion, the examiner explained that there was a lack of clear medical evidence to support a relationship between the Veteran's in-service toxic exposure risk activities and prostate cancer.

In this regard, he acknowledged that the Veteran was exposed to contaminated water while he was serving at Camp Lejeune but emphasized that the medical literature did not support a relationship between such exposure and the development of prostate cancer. However, the examiner noted that other risk factors outside of the Veteran's in-service toxic exposure risk activities likely contributed to the development of the claimed condition. In this regard, he noted that age, race, and family history were the principal risk factors for developing prostate cancer, and although he acknowledged that the Veteran did not have a family history of prostate cancer, he found that aging was likely a significant factor as such was common in older men with the risk increasing significantly after age 50. The examiner further stated that hormonal factors, to include high levels of testosterone or insulin-like growth factor-1 (IGF-1), may also play a role in the development of prostate cancer.

In addition, after reviewing the evidence of record and considering the Veteran's total potential exposure through all of his applicable military deployments and the synergistic, combined effects of all of his in-service toxic exposure risk activities, the examiner opined that it was less likely than not that the Veteran's diagnosed bladder disorders were caused by his indicated toxic exposure risk activities. In support of his opinion, the examiner explained that there was a lack of clear medical evidence indicating a relationship between the development of the Veteran's diagnosed bladder disorders, to include neurogenic bladder and bladder outlet obstruction, and his in-service toxic exposure risk activities. However, he emphasized that other risk factors, separate from the Veteran's in-service toxic exposure risk activities likely contributed to the development of the claimed conditions, to include age-related alterations in the brain-bladder axis including decreased tissue responsiveness, impaired signaling, and reduced control over the voiding reflex, which collectively contributed to the pathogenesis and worsening of the claimed conditions. See September 2025 C&P examination.

Following a review of the evidence of record, the Board finds that service connection for the Veteran's
his opinion, the examiner explained that there was a lack of clear medical evidence indicating a relationship between the development of the Veteran's diagnosed bladder disorders, to include neurogenic bladder and bladder outlet obstruction, and his in-service toxic exposure risk activities. However, he emphasized that other risk factors, separate from the Veteran's in-service toxic exposure risk activities likely contributed to the development of the claimed conditions, to include age-related alterations in the brain-bladder axis including decreased tissue responsiveness, impaired signaling, and reduced control over the voiding reflex, which collectively contributed to the pathogenesis and worsening of the claimed conditions. See September 2025 C&P examination.

Following a review of the evidence of record, the Board finds that service connection for the Veteran's diagnosed prostate cancer and bladder disorders is not warranted.

Initially, the Board notes that the Veteran has not argued, and the evidence does not show, that his diagnosed prostate cancer or bladder disorder began in service or within one year thereafter. Rather, the service treatment records are absent for findings or diagnoses of prostate cancer and bladder disorders, and the post-service treatment records show that the Veteran was initially diagnosed with prostate cancer and a neurogenic bladder in 2009, approximately 50 years after he was discharged from active duty service. Thus, the Board finds that presumptive service connection is not warranted for the Veteran's prostate cancer or bladder disorder because the disorders were not diagnosed in service or within one year thereafter.

Moreover, the medical evidence of record shows that the Veteran developed prostate cancer and a bladder disorder approximately five decades following his separation from service. In this regard, the Board notes that the September 2014 private medical opinion from Dr. Hsu stated as fact that the Veteran had been exposed to ionizing radiation in service. However, the Board finds that Dr. Hsu's assertions were not supported by any evidence and that the private physician did not provide rationale to support his conclusions, therefore, such statements would necessarily be based on second-hand knowledge provided by the Veteran. As reflected above, VA has not conceded exposure to ionizing radiation. Thus, the Board provides no more weight to these letters than if the Veteran had made those statements himself. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); see also Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that "an opinion based upon an inaccurate factual premise has no probative value").

The following diseases are deemed associated with exposure to contaminated water at Camp Lejeune: kidney cancer, liver cancer, Non-Hodgkin's lymphoma, adult leukemia, multiple myeloma, Parkinson's disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer. 38 C.F.R. § 3.309(f). Therefore, the Veteran's diagnosed prostate cancer and bladder disorder, to include neurogenic bladder and bladder outlet obstruction, are not listed in 38 C.F.R. § 3.309(f) as diseases recognized by exposure to contaminated drinking water at Camp Lejeune.

Notwithstanding the presumption, service connection for a disability claimed as due to exposure to contaminated drinking water at Camp Lejeune may be established by showing that a disorder resulting in disability was in fact causally linked to such exposure. See Brock v. Brown, 10 Vet. App. 155, 162-64 (1997); Combee v. Brown, 34 F. 3d 1039.

However, with regard to whether the Veteran's diagnosed prostate cancer and bladder disorder were caused by exposure to contaminated water at Camp Lejeune, the Board finds the August 2025 VA examiner's opinion to be the most probative evidence of record.

In this regard, the Board affords the undated medical opinion, received in May 2018, from Dr. Hsu low probative weight. Specifically, although he concluded that the Veteran consumed large amounts of water while training at Camp Lejeune in the summers of 1954 and 1955, Dr. Hsu did not provide any rationale to support his opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).

In contrast, the Board finds the August 2025 VA examiner's opinions to be the most probative evidence of record. In this regard, the Board finds that the August 2025 VA examiner considered all pertinent evidence of record, to include the Veteran's statements and his relevant medical history, and provided complete rationales, relying on and citing to the records reviewed. Moreover, the opinions include clear conclusions with supporting
concluded that the Veteran consumed large amounts of water while training at Camp Lejeune in the summers of 1954 and 1955, Dr. Hsu did not provide any rationale to support his opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).

In contrast, the Board finds the August 2025 VA examiner's opinions to be the most probative evidence of record. In this regard, the Board finds that the August 2025 VA examiner considered all pertinent evidence of record, to include the Veteran's statements and his relevant medical history, and provided complete rationales, relying on and citing to the records reviewed. Moreover, the opinions include clear conclusions with supporting data, as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions").

In reaching the above conclusions, the Board has considered the Veteran's statements that his diagnosed prostate cancer and bladder disorder were caused by exposure to contaminated water at Camp Lejeune. However, the question of whether such a relationship exists is a complex medical issue that is far beyond the purview of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007) (providing that the question of whether lay evidence is competent and sufficient is an issue of fact that is to be addressed by the Board); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting that personal knowledge is "that which comes to the witness through the use of his senses-that which is heard, felt, seen, smelled, or tasted").

Therefore, the Board concludes that any lay assertions by the Veteran in the present case are outweighed by the medical evidence of record, including the August 2025 VA medical opinions. As stated above, the examiner has the training, knowledge, and expertise on which he relied to form his opinions, and he provided persuasive rationales.

Based on the foregoing, the Board finds that the weight of the evidence is persuasively against the Veteran's claims for entitlement to service connection for prostate cancer and a bladder disorder. Therefore, the claims are denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F.3d 1391, 1394 (Fed. Cir. 2021).

3. Entitlement to service connection for hypertension, to include as due to exposure to ionizing radiation and/or to contaminated water at Camp Lejeune, or in the alternative, on a secondary basis, is denied.

The Veteran's STRs are silent for any findings or diagnoses of hypertension. See September 2014 STR - Medical. However, as noted above, the Veteran's exposure to contaminated water at Camp Lejeune has been conceded. See, e.g., July 2024 Rating Decision - Narrative. He has also asserted that it might be related to his service-connected acquired psychiatric disability.

A review of the post-service treatment records shows that the Veteran was diagnosed with hypertension in or around 2000. See February 2015 Medical Treatment Record - Non-Government Facility.

In December 2010, the Veteran submitted an undated letter from Dr. Hsu. Dr. Hsu reported that he had been treating the Veteran's hypertension for the preceding eight years and indicated that there were times when the Veteran was so agitated that his blood pressure was out of control. See December 2010 Medical Treatment Record - Non-Government Facility; see also May 2011 Medical Treatment Record - Non-Government Facility.

VA obtained a medical opinion in June 2019. After reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed hypertension was proximately due to or the result of his service-connected unspecified anxiety disorder. In support of his opinion, the examiner noted that the Veteran was diagnosed with hypertension in 2000. He further noted that the medical literature showed that older age, smoking, and being overweight/obese were risk factors for hypertension, and emphasized that the Veteran had a body mass index (BMI) of 29 in the early 2000s, was a former smoker, and was 65 years old at the time of his diagnosis in 2000.
overnment Facility.

The examiner further opined that it was less likely than not that the Veteran's hypertension was aggravated beyond its natural progression by his service-connected unspecified anxiety disorder. In support of his opinion, the examiner noted that anxiety could cause temporary elevations in blood pressure during anxious periods, but emphasized that there was no evidence to support a permanent aggravation. In this regard, he explained that permanent aggravation by any cause would include left ventricular hypertrophy and that no diagnosis of such had been rendered to date. See June 2019 C&P examination.

A May 2019 private medical record states that the Veteran's renal dysfunction may be the basis of his chronic hypertension. See July 2019 Medical Treatment Record - Non-Government Facility. The Veteran is service connected for a kidney condition.

VA obtained an addendum medical opinion in February 2020. The examiner noted that the Veteran had not undergone a VA examination since 2014 and as such, indicated that her opinions were based on the available, outdated information. After reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's hypertension was caused or aggravated by his service-connected anxiety. In support of her opinion, the examiner explained that the Veteran's diagnosed hypertension was not aggravated by any cause, to include his service-connected anxiety, and emphasized that the Veteran had not been diagnosed with left ventricular hypertrophy. In addition, the examiner explained that the medical literature did not support a causal relationship between stress and hypertension and found that no permanent aggravation was plausible, given the Veteran's medical treatment records. In this regard, the examiner found that, if present, any elevations and/or temporary aggravations in the Veteran's blood pressure were due to many factors including diet, weight, exercise, and other medical conditions. See February 2020 C&P examination.

The Veteran underwent a VA examination for hypertension in June 2022. The examiner noted that the Veteran had been diagnosed with hypertension. During the examination, the Veteran reported that he was exposed to contaminated water at Camp Lejeune and noted that his high blood pressure condition manifested in the 1960s, immediately after he was discharged from active duty. He further explained that he was advised to reduce his sodium intake and discussed lifestyle modifications with his physician but noted that no other treatment had been warranted at that time.

After performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's hypertension was aggravated beyond its natural progression by his service-connected unspecified anxiety disorder. In support of her opinion, the examiner stated that there was no evidence in the Veteran's STRs or post-service treatment records to indicate that the Veteran required or sought medical evaluation or treatment for high blood pressure in service or shortly after he was discharged from active duty. Rather, she found that the first medical evidence of record noting a diagnosis of hypertension was dated in 2004.

The examiner further acknowledged that the exact etiology of primary hypertension remained unclear but found that a number of risk factors were strongly and independently associated with its development, including age, obesity, family history, race, reduced nephron number, high sodium diet, excessive alcohol consumption, and physical inactivity. However, although she acknowledged that episodes of anxiety could cause dramatic, temporary spikes in blood pressure and that some medications, including serotonin and norepinephrine reuptake inhibitors, could increase blood pressure, the examiner found that anxiety did not cause hypertension. In this regard, she noted that a review of recent literature on the association between comorbid anxiety disorders and hypertension revealed increasing evidence of a positive association between comorbid anxiety and hypertension but emphasized that evidence of an association was not the same as causation. As such, she found that the medical literature did not support or indicate that anxiety was a cause or risk factor for the development of hypertension. Rather, she found that the Veteran's medical records, recent lab work, and findings noted during the physical examination showed that
anxiety could cause dramatic, temporary spikes in blood pressure and that some medications, including serotonin and norepinephrine reuptake inhibitors, could increase blood pressure, the examiner found that anxiety did not cause hypertension. In this regard, she noted that a review of recent literature on the association between comorbid anxiety disorders and hypertension revealed increasing evidence of a positive association between comorbid anxiety and hypertension but emphasized that evidence of an association was not the same as causation. As such, she found that the medical literature did not support or indicate that anxiety was a cause or risk factor for the development of hypertension. Rather, she found that the Veteran's medical records, recent lab work, and findings noted during the physical examination showed that his average blood pressure had improved with his current treatment. See July 2022 C&P examination.

VA obtained an addendum medical opinion in August 2022. After reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's hypertension was aggravated beyond its natural progression by his service-connected disabilities. In support of his opinion, the examiner noted that blood pressure rises and falls throughout the day depending on stress level and activity. He further emphasized that the Veteran's blood pressure had not changed and that there was not much documented in the evidence of record to constitute aggravation. See August 2022 C&P examination.

VA also obtained an addendum medical opinion in January 2024. After reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed hypertension was caused by the claimed in-service injury, event, or illness. In support of his opinion, the examiner noted that the Veteran had been diagnosed with hypertension but found no evidence to indicate that such had its onset in service.

In addition, the examiner opined that it was less likely than not that the Veteran's diagnosed hypertension was aggravated beyond its natural progression by his service-connected unspecified anxiety disorder. In support of his opinion, the examiner acknowledged that unspecified anxiety disorder could result in transient elevation of blood pressure situationally but found no evidence that the Veteran's diagnosed hypertension had been aggravated beyond its natural course by his service-connected unspecified anxiety disorder. See March 2024 C&P examination.

VA obtained an addendum medical opinion in February 2025. After reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed hypertension was aggravated beyond its natural progression by his service-connected unspecified anxiety disorder. In support of his opinion, the examiner noted that the Veteran had been diagnosed with hypertension and unspecified anxiety disorder but found no evidence that the hypertension was aggravated beyond its natural progression by his unspecified anxiety disorder. He further explained that elevated blood pressure from anxiety was unrelated to the mechanism from primary hypertension, which caused derangement of the renal-angiotensin aldosterone system, rather than transient elevation in catecholamines from stress-related anxiety. See February 2025 C&P examination.

VA next obtained an addendum medical opinion in August 2025. After reviewing the evidence of record and considering the total potential exposure through all of the Veteran's applicable military deployments and the synergistic, combined effects of all of his in-service toxic exposure risk activities, the examiner opined that it was less likely than not that the Veteran's hypertension was caused by his indicated toxic exposure risk activities. In support of his opinion, the examiner acknowledged that the Veteran was exposed to contaminated water at Camp Lejeune but found that there was a lack of clear medical evidence indicating a relationship between the development of hypertension and the Veteran's toxic exposure risk activity.

However, the examiner noted that risk factors outside of the Veteran's toxic exposure risk activities, to include obesity, likely contributed to the development of hypertension. In this regard, he explained that obesity was a significant risk factor for the development of hypertension as it could lead to overactivation of the sympathetic nervous system, which played a role in regulating blood pressure. He further stated that heightened sympathetic activity could lead to vasoconstriction and an increase in heart rate, both of which could raise blood pressure. See September 2025 C&P examination.

VA last obtained an addendum medical opinion in October 2025. After reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed hypertension was aggravated beyond its natural progression by his service-connected unspecified anxiety disorder. In support of his opinion, the examiner noted that the Veteran was obese and that he had a BMI of 31. In this regard, he explained that obesity was a significant risk factor for the development of hypertension and could lead to overactivation of the sympathetic nervous system, which plays a role in regulating blood pressure. He further explained that the heightened sympathetic activity could lead to vasoconstriction and an increase in heart rate
See September 2025 C&P examination.

In addition, the examiner found that there was a lack of clear evidence in the medical records to show that the Veteran's hypertension was worsened by his service-connected anxiety. In this regard, he acknowledged that the private medical opinion from Dr. Hsu indicated that there were times when the Veteran became so agitated that his blood pressure was out of control, but emphasized that transient spikes were not the same as a chronic worsening of the disease. He further explained that current medical knowledge did not establish anxiety as a proximate cause of worsening sustained hypertension. See October 2025 C&P examination.

After a review of the evidence of record, the Board finds that entitlement to service connection for hypertension is not warranted.

Initially, the Board recognizes the Veteran's reports that he was diagnosed with hypertension in the 1960s, immediately after he was discharged from active duty. However, the Board finds no indication, beyond the Veteran's lay assertions, that he was diagnosed with hypertension shortly after service. Rather, the Veteran's STRs are silent for any findings or diagnoses of hypertension, and the evidence of record indicates that he was initially diagnosed with hypertension in or around 2000, approximately 41 years after he was discharged from active duty. Therefore the Board is unable to credit the Veteran's later reports that he had hypertension beginning during service or shortly therefore. Thus, the Board finds that presumptive service connection is not warranted for the Veteran's hypertension because it was not diagnosed in service or within one year thereafter.

In addition, for the reasons discussed above, the evidence is persuasively against finding that the Veteran was exposed to ionizing radiation during service, and as such, the provisions of 38 C.F.R. § 3.309(d) relating certain diseases to radiation exposure do not apply.

With regard to the Veteran's reports that his hypertension is etiologically related to exposure to contaminated drinking water at Camp Lejeune, the Board notes that hypertension is not listed in 38 C.F.R. § 3.309(f) as a disease recognized by exposure to contaminated drinking water at Camp Lejeune. Further, the medical evidence of record does not support a finding that the Veteran has a diagnosis of hypertension related to his military service, or secondary to a service-connected disorder.

In reaching the above conclusions, the Board finds the June 2019 VA examiner's opinion regarding whether the Veteran's service-connected psychiatric disorder caused his hypertension, considered in connection with the June 2022 and October 2025 VA examiners' opinions as to aggravation, to be the most probative evidence of record. In this regard, the Board affords the undated letter from Dr. Hsu reduced probative weight. Specifically, the Board finds that Dr. Hsu did not proffer an opinion as to whether the Veteran's hypertension was caused or aggravated by his service-connected unspecified anxiety disorder or reference any evidence to explain how he determined that the Veteran was sometimes so agitated that his blood pressure was out of control. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).

The Board further acknowledges the May 2019 private medical record, which states that the Veteran's renal dysfunction may be the basis of his chronic hypertension. However, the Board finds the opinion to be inadequate as it is speculative in nature. Specifically, the Board notes that speculative language, such as "may be the basis" does not create an adequate nexus for the purposes of establishing service connection, as it does little more than suggest the possibility of a relationship. See Warren v. Brown, 6 Vet. App. 4, 6 (1993); Utendahl v. Derwinski, 1 Vet. App. 530, 531 (1991); Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993). It is not the same as stating that the Veteran's renal disorder, to
, the Board notes that speculative language, such as "may be the basis" does not create an adequate nexus for the purposes of establishing service connection, as it does little more than suggest the possibility of a relationship. See Warren v. Brown, 6 Vet. App. 4, 6 (1993); Utendahl v. Derwinski, 1 Vet. App. 530, 531 (1991); Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993). It is not the same as stating that the Veteran's renal disorder, to include his service-connected kidney condition, causes or aggravates his diagnosed hypertension.

In contrast, the Board finds the June 2019 VA examiner's opinion, considered in connection with the June 2022 and October 2025 VA examiners' opinions, to be the most probative evidence of record with regard to an association between the Veteran's psychiatric disorder and hypertension. They provided sufficient rationales supported by medical evidence and their opinions are therefore accorded probative value.

With regard to whether the hypertension is related to a TERA, to include contaminated water, the Board finds the August 2025 opinion the most probative. In this regard, the Board finds that the August 2025 VA examiner considered all pertinent evidence of record, to include his relevant medical history and provided complete rationales, relying on and citing to the records reviewed. Moreover, the opinions include clear conclusions with supporting data, as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions").

In reaching the above conclusions, the Bord acknowledges and has considered the Veteran's statements that his diagnosed hypertension was caused by exposure to contaminated water at Camp Lejeune or that it may have been caused or aggravated by his service-connected unspecified anxiety disorder. However, the Board finds that the question of whether such a relationship exists is a complex medical issue that is far beyond the purview of a lay person.

Here, the Board concludes that any lay assertions by the Veteran in the present case are outweighed by the medical evidence of record, including the June 2019, June 2022, August 2025, and October 2025 VA examiners' opinions. As stated above, the examiners have the training, knowledge, and expertise on which they relied to form their opinions, and they provided persuasive rationales.

Based on the foregoing, the Board finds that the weight of the evidence is persuasively against the Veteran's claim of entitlement to service connection for hypertension. Therefore, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F.3d 1391, 1394 (Fed. Cir. 2021).

REASONS FOR REMAND

4. Entitlement to service connection for a lumbar spine disability, to include on a secondary basis, is remanded.

5. Entitlement to service connection for a bilateral shoulder disability, to include on a secondary basis, is remanded.

6. Entitlement to service connection for a right hip disability, to include on a secondary basis, is remanded.

The Board last remanded the Veteran's service connection claims to obtain addendum medical opinions in July 2025. Specifically, the Board asked the examiner to opine as to whether it was at least as likely as not that the Veteran's low back and bilateral shoulder disabilities were caused or aggravated by his service-connected left knee and/or left hip disabilities. In addition, the Board asked the examiner to proffer an opinion as to whether it was at least as likely as not that the Veteran's claimed right hip disability was etiologically related to an in-service injury, event, or disease, to include as due to a fall off a truck while he was wearing a full field pack (60 or 70 pounds). The Board also asked the examiner to opine as to whether it was at least as likely as not that the Veteran's claimed right hip disability was caused by, due to, or aggravated by, his service-connected left hip and left knee disabilities. See July 2025 BVA Decision.

Following a review of the evidence of record, the Board notes that
hip disabilities. In addition, the Board asked the examiner to proffer an opinion as to whether it was at least as likely as not that the Veteran's claimed right hip disability was etiologically related to an in-service injury, event, or disease, to include as due to a fall off a truck while he was wearing a full field pack (60 or 70 pounds). The Board also asked the examiner to opine as to whether it was at least as likely as not that the Veteran's claimed right hip disability was caused by, due to, or aggravated by, his service-connected left hip and left knee disabilities. See July 2025 BVA Decision.

Following a review of the evidence of record, the Board notes that the requested addendum medical opinions have not been obtained. In this regard, VA examination scheduling request contention cancellation forms show that the Veteran failed to attend VA examinations for back, shoulder, and hip conditions that had been scheduled to take place in September 2025. See September 2025 Examination Requests. However, the Board notes that there is no indication that the AOJ made any attempts to contact the Veteran to notify him of his scheduled VA examination or of the consequences for failure to report.

Thereafter, an October 2025 report of general information shows that the Veteran's son stated that the Veteran had significant dementia, which was especially apparent after his wife passed away in July 2025. However, he also stated that he was open to rescheduling and helping coordinate the Veteran's missed examinations. See October 2025 VA Form 27-0820 Report of General Information; see also October 2025 Web/HTML Documents.

A subsequent January 2026 report of general information shows that VA contacted compensation and pension regarding a VA examination that was cancelled in January 2026. However, no additional details about the information discussed was included in the report. See January 2026 VA Form 27-0820 Report of General Information. The AOJ sent a letter to the Veteran in January 2026 advising him that the Veterans Health Administration in Miami canceled his appointment regarding his pending claims on appeal as "no show/cancelled/claimant unavailable/MAS" and asking if he had any intention of attending any examination, present or future, in connection with his pending claim. The letter also indicates that a reply was needed within 30 days. See January 2026 Subsequent Development Letter. The Veteran did not respond to the January 2026 letter.

Thereafter, VA examination scheduling request contention cancellation forms show that the Veteran failed to attend VA examinations for back, shoulder, and hip conditions that had been scheduled to take place in February 2026. See February 2026 Examination Requests. However, there is no indication in the claims file as to whether the Veteran was actually provided proper notice of the scheduled examinations. Additionally, no attempts at obtaining an addendum medical opinion without an examination were conducted.

Based on the foregoing, the Board finds that there is insufficient evidence of record to conclude that the AOJ complied with the July 2025 Board Remand. Compliance with a remand is not discretionary, and failure to comply with the terms of a remand necessitates remand for corrective action. Stegall v. West, 11 Vet. App. 268 (1998). Thus, the Board finds that a remand is warranted to obtain addendum medical opinions for full compliance with the Board's previous remand instructions.

The matters are REMANDED for the following action:

1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the claims file from the Veteran's VA treatment facilities, and all private treatment records from the Veteran not already associated with the claims file.

2. After completion of the above development, obtain addendum medical opinions from an appropriately qualified examiner to determine the nature and etiology of the Veteran's diagnosed lumbar spine and bilateral shoulder disabilities. It is noted that the Veteran has dementia and therefore efforts to obtain addendum opinions without scheduling the Veteran for an in-person examination should be made.

The examiner should provide the following opinions:

(a.) Is it at least as likely as not that the Veteran's diagnosed lumbar spine disability was (i) caused or (ii) aggravated by his service-connected left and right knee and left hip disabilities? Please explain why or why not. The examiner should observe that permanent aggravation is not required.

(b.) Is it at least as likely as not that the Veteran's diagnosed bilateral shoulder disability was (i) caused or (ii) aggravated by his service-connected left and right knee and left hip disabilities? Please explain why or why not. The examiner should observe that permanent aggravation is not required.

The Board notes that separate rationales should be provided for the causation question, and
The examiner should provide the following opinions:

The Board notes that separate rationales should be provided for the causation question, and for the aggravation question.

If aggravation is found, the examiner should identify, to the extent possible, the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the Veteran's service-connected left and right knee and left hip disabilities.

The examiner should review the Veteran's claims file in connection with the examination. The examiner should specifically consider the Veteran's reports of gait changes caused by his service-connected disabilities.

3. After completion of the development in #1, obtain an addendum medical opinion from an appropriately qualified examiner to determine the nature and etiology of the Veteran's claimed right hip disability. It is noted that the Veteran has dementia and therefore efforts to obtain addendum opinions without scheduling the Veteran for an in-person examination should be made.

The examiner should provide the following opinions:

(a.) Identify all diagnoses pertaining to the Veteran's claimed right hip disability.

(b.) For each diagnosed right hip disability, the examiner should offer an opinion as to whether it is at least as likely as not that such had its onset during service or is otherwise etiologically related to the Veteran's service, to include as due to falling off a truck while wearing a full field pack weighing 60 to 70 pounds in service? Please explain why or why not.

(c.) For each diagnosed right hip disability, the examiner should offer an opinion as to whether it is at least as likely as not that such was (i) caused or (ii) aggravated by his service-connected left and right knee and left hip disabilities? Please explain why or why not. The examiner should observe that permanent aggravation is not required.

The Board notes that separate rationales should be provided for the causation question, and for the aggravation question.

S. HENEKS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board K. Justis, 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.

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