PERIPHERAL VESTIBULAR DISORDERS

DAVID GRATZ · 2026 · Case ID: A26002450

MIXED

Summary

The Veteran served on active duty from October 1986 to October 1995. This case involves appeals for service connection for multiple conditions, including dizzy spells, diabetic neuropathy, acquired psychiatric disorder (other than PTSD), PTSD, vision condition, obstructive sleep apnea (OSA), cirrhosis of the liver, lower back condition, right knee condition, left knee condition, atrial fibrillation, bilateral hearing loss, and tinnitus. The Board denied service connection for most conditions, finding the evidence weighed against the claims or that the Veteran failed to report for necessary examinations. Specifically, the Board found the evidence persuasively weighed against a diagnosis of diabetic neuropathy, PTSD, vision condition, OSA, cirrhosis of the liver, lower back condition (finding it pre-existed service and was not aggravated), right knee disability, left knee disability, and atrial fibrillation. The Board also denied an increased rating for bilateral hearing loss and tinnitus. However, the Board remanded the claim for service connection for diabetes mellitus, type II, due to an inadequate VA medical opinion. The examiner acknowledged the diabetes diagnosis and prescribed medication but failed to provide adequate reasoning for the nexus opinion regarding TERA exposure. The Board requires an addendum opinion to clarify the etiology and nexus of the diabetes mellitus, type II, in relation to lead exposure during service.

Rationale

Evidence weighed against diagnosis of dizzy spells; Dizziness is a symptom of other conditions

Special Benefit

NO SPECIAL BENEFIT

Docket No.

240104-407871

Full Decision Text

Citation Nr: A26002450
Decision Date: 01/09/26 Archive Date: 01/09/26

DOCKET NO. 240104-407871
DATE: January 9, 2026

ORDER

Entitlement to service connection for dizzy spells is denied.

Entitlement to service connection for diabetic neuropathy is denied.

Entitlement to service connection for an acquired psychiatric disorder, other than PTSD is denied.

Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied.

Entitlement to service connection for vision is denied.

Entitlement to service connection for obstructive sleep apnea (OSA) is denied.

Entitlement to service connection for cirrhosis of the liver is denied.

Entitlement to service connection for lower back is denied.

Entitlement to service connection for right knee condition is denied.

Entitlement to service connection for left knee condition is denied.

Entitlement to service connection for atrial fibrillation is denied.

Entitlement to an initial rating in excess of 10 percent for bilateral hearing loss is denied.

Entitlement to an initial rating in excess of 10 percent for tinnitus is denied.

REMANDED

Entitlement to service connection for diabetes mellitus, type II, is remanded.

FINDINGS OF FACT

1. The Veteran's dizziness is a symptom of his diagnosed obstructive sleep apnea, atrial fibrillation, and hypertension, which all are associated with intermittent dizzy spells.

2. The evidence of record persuasively weighs against finding that the Veteran has had a diagnosis of diabetic neuropathy.

3. The Veteran failed to report for a necessary examination in connection with his claim for service connection for an acquired psychiatric disorder, to include PTSD, without evidence of good cause for his failure to report.

4. The evidence of record persuasively weighs against finding that the Veteran has had a diagnosis of PTSD at any time during or approximate to the pendency of the claim.

5. The Veteran failed to report for a necessary examination in connection with his claim for service connection for a vision condition without evidence of good cause for his failure to report.

6. The evidence of record persuasively weighs against finding a nexus between the Veteran's OSA and service.

7. The evidence of record persuasively weighs against finding a nexus between the Veteran's cirrhosis of the liver and service.

8. A lower back condition clearly and unmistakably pre-existed service and the weight of the evidence is against a finding that the disorder was aggravated therein.

9. The evidence of record persuasively weighs against finding that the Veteran has a right knee disability.

10. The evidence of record persuasively weighs against finding that the Veteran has a left knee disability.

11. The evidence of record persuasively against finding a nexus between the Veteran's atrial fibrillation and service.

12. The Veteran's bilateral hearing loss disability has been manifested by hearing acuity of no worse than Level IV in the right ear and no worse than Level IV in the left ear.

13. The Veteran's tinnitus is assigned the maximum rating possible under the rating schedule.

CONCLUSIONS OF LAW

1. The criteria for service connection for dizzy spells have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303.

2. The criteria for service connection for diabetes with neuropathy have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303.

3. The criteria for service connection for an acquired psychiatric disorder is denied. have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303.

4. The criteria for service connection for PTSD have not been met. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125.

5. The criteria for entitlement to service connection for vision have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303.

6. The criteria for service connection for OSA have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303.

7. The criteria for service connection for cirrhosis of the liver have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303.

8. The criteria for service connection for lower back have been met. 38 U.S.C. §§
for entitlement to service connection for vision have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303.

6. The criteria for service connection for OSA have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303.

7. The criteria for service connection for cirrhosis of the liver have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303.

8. The criteria for service connection for lower back have been met. 38 U.S.C. §§ 1110, 1111, 1132; 38 C.F.R. § 3.304.

9. The criteria for service connection for right knee condition have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303.

10. The criteria for service connection for left knee condition have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303.

11. The criteria for an initial rating in excess of 10 percent for bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100.

12. The criteria for an initial disability rating higher than 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.87, Diagnostic Code 6260.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from October 1986 to October 1995.

This case comes before the Board of Veterans' Appeals (Board) on appeal from the January 2023 and March 2023 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office, the Agency of Original Jurisdiction (RO or AOJ).

In the January 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket.

Therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decisions on appeal, as well as any evidence submitted by the Veteran or representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim[s], considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d).

1. Entitlement to service connection for dizzy spells.

The Veteran seeks
(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d).

1. Entitlement to service connection for dizzy spells.

The Veteran seeks service connection for dizzy spells that he asserts is due to exposure to the elements. See December 2022 VA Form 21-526 EZ: Application for Disability Compensation and Related Compensation Benefits.

Initially, the Board notes the AOJ, in the March 2023 rating decision, made the favorable finding that the Veteran was exposed to lead during military service. The Board is bound by this favorable finding. See AMA, Pub. L. No. 115-55, § 5104A, 131 Stat. 1105, 1106-07.

Disability Manifested by Dizziness

After careful review of the record, the Board finds that the Veteran's dizziness is not a separate and distinct disability, and rather is a symptom of the Veteran's diagnosed obstructive sleep apnea, atrial fibrillation, and hypertension. Given such, the Board finds that the record does not reflect a separate and distinct diagnosis related to a disability manifested by dizziness.

Here, the Veteran's service treatment records do not show complaint, treatment, or diagnosis of dizziness or dizziness symptoms.

The November 2022 post-service treatments records show the Veteran negative for dizziness, and the Veteran denied dizziness at that treatment visit. See also March 2023 History and Physical note.

In the February 2023 VA opinion, the examiner opined that the Veteran's claimed condition was less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner acknowledged the Veteran's statement that he experienced onset of dizzy spells in June 1995. However, the examiner explained that the Veteran has been diagnosed with OSA, atrial fibrillation, and hypertension which are all associated with intermittent dizzy spells. The examiner noted that the November 2022 primary care patient appointment, the Veteran denied episodes of dizziness. The examiner explained that she was unable to find record of the Veteran making complaints of dizziness in his medical record, and unable to establish a chronic condition.

The Board finds the February 2023 VA examiner's opinion is highly probative because it is based on a clinical a review of the claims file, consideration of the relevant medical history, and the opinion was accompanied by a detailed rationale and is consistent with the competent and credible evidence of record. There is no competent opinion to the contrary.

The Veteran's lay history of symptomatology regarding his dizziness has been considered, and he is competent to report such symptoms and observations because this requires only personal knowledge as it comes through an individual's senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the Veteran is not competent to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran, who has not been shown by the evidence of record to have medical training or skills.

In conclusion, the probative medical evidence shows that the Veteran's dizziness is a symptom associated with diagnoses of OSA, atrial fibrillation, and hypertension and is not a separate and distinct disability for which service connection may be granted. As the evidence is not in approximate balance and is persuasively against the claim, the benefit of the doubt rule is inapplicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

In reaching this conclusion, the Board has considered the lay statements to the extent they are competent. However, the Veteran has neither provided sufficient evidence to meet the nexus element, nor attended the VA examination scheduled for that purpose. Therefore, service connection for dizziness is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

2
persuasively against the claim, the benefit of the doubt rule is inapplicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

2. Entitlement to service connection for diabetic neuropathy.

Initially, the Board notes the AOJ, in the March 2023 rating decision, made the favorable finding that the Veteran has a diagnosis of diabetes mellitus, type II. The Board is bound by this favorable finding. See AMA, Pub. L. No. 115-55, § 5104A, 131 Stat. 1105, 1106-07.

A VA medical opinion was obtained in March 2022. The VA examiner reported that the Veteran did not have a diagnosis of diabetic neuropathy.

A threshold requirement for the granting of service connection is evidence of a current disability. In the absence of evidence of a current disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). There is no current diagnosis of any neuropathy disability contained in the evidence of record and no underlying disability has been clinically diagnosed during the appeal period or proximate thereto. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013).

While the Veteran was competent to report observable symptoms, he was not competent to determine a diagnosis of diabetic neuropathy. This issue is medically complex, as it requires specialized medical education and the ability to interpret the results of diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence showing the Veteran did not have a current diagnosis of neuropathy disability.

Accordingly, entitlement to service connection for bilateral lower extremity diabetic neuropathy is not warranted.

The Board will address entitlement to service connection for diabetes mellitus, type II, in the remand section below.

3. Entitlement to service connection for an acquired psychiatric disorder (other than PTSD).

The Veteran's claim of entitlement to service connection for mental health and depression has been recharacterized to broadly reflect that the scope of the claim includes any acquired psychiatric disorder (other than PTSD), pursuant to Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009).

Initially, the Board notes the AOJ, in the March 2023 rating decision, made the following favorable findings: 1) The evidence shows that a qualifying event, injury, or disease had its onset during service. The Veteran's service treatment records (STRs) show the Veteran was treated for an anxiety reaction; and 2) the Veteran has a diagnosis of alcohol dependence, anxiety and a mood disorder. The Board is bound by these favorable findings. See AMA, Pub. L. No. 115-55, § 5104A, 131 Stat. 1105, 1106-07.

The Board notes that the first element of service connection is met, as the favorable findings noted the Veteran has diagnoses of alcohol dependence, anxiety, and a mood disorder.

Regarding an in-service event, the Board notes that the favorable findings indicated the Veteran's October 1989 STRs show the Veteran was seen for an anxiety reaction during service.

The Board observes the AOJ scheduled the Veteran for a VA examination for his claimed psychiatric disorder ("mental health disease") in February 2023 and the Veteran was a "no show." Further, a January 2023 Exam Scheduling Request clearly states that "The Veteran needs to report for all examinations for the following Contention: ptsd." Under 38 C.F.R. § 3.655, when a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. The Veteran's failure to report for the VA examination for his claim for service connection for acquired psychiatric disorder, to include alcohol dependence, anxiety, and a mood disorder, has deprived the Board of potentially favorable and dispositive evidence. The
examination for his claimed psychiatric disorder ("mental health disease") in February 2023 and the Veteran was a "no show." Further, a January 2023 Exam Scheduling Request clearly states that "The Veteran needs to report for all examinations for the following Contention: ptsd." Under 38 C.F.R. § 3.655, when a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. The Veteran's failure to report for the VA examination for his claim for service connection for acquired psychiatric disorder, to include alcohol dependence, anxiety, and a mood disorder, has deprived the Board of potentially favorable and dispositive evidence. The Board notes the duty to assist is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190 (1991). The Veteran has not provided additional explanation for his failure to attend the scheduled VA examination or shown that he tried to reschedule a VA examination. As such, this original claim shall be rated based on the evidence of record. See 38 C.F.R. § 3.655 (b).

The evidence does not establish through a competent and credible nexus opinion that a present disorder, to include alcohol dependence, anxiety, and a mood disorder is connected to the Veteran's service. Shedden v. Principi, 381 F.3d 1163.

In sum, the Board finds that the Veteran failed to report for a VA examination in February 2023 without good cause and thus, has failed to cooperate to the full extent in the development of his claim. Wood v. Derwinski, 1 Board. App. 190, 193 (1991). The evidence of record, as it stands, is insufficient to substantiate the Veteran's claim. Accordingly, entitlement to service connection for an acquired psychiatric disorder, to include alcohol dependence, anxiety, and a mood disorder is denied.

In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the evidence persuasively weighs against the Veteran's claim, the doctrine is not for application. Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021).

4. Entitlement to service connection for PTSD.

Initially, the Board notes the AOJ, in the March 2023 rating decision, made the following favorable findings: 1) The evidence shows that a qualifying event, injury, or disease had its onset during service. The Veteran's service treatment records (STRs) show the Veteran was treated for an anxiety reaction; and 2) the Veteran has a diagnosis of alcohol dependence, anxiety, and a mood disorder. The Board is bound by these favorable findings. See AMA, Pub. L. No. 115-55, § 5104A, 131 Stat. 1105, 1106-07.

In addition to establishing service connection on a direct basis for a psychiatric disorder, service connection for PTSD requires three elements: (1) a current medical diagnosis of PTSD, (2) credible supporting evidence that the claimed in-service stressor(s) occurred, and (3) medical evidence of a causal relationship between current symptomatology and the specific claimed in-service stressor(s). See 38 C.F.R. § 3.304 (f).

Initially, the Board finds that there is no current medical diagnosis of PTSD of record in accordance with 38 C.F.R. § 4.125. The Board has considered that the Veteran has asserted as such, however, there is no evidence of a diagnosis under the DSM criteria as required by 38 C.F.R. § 4.125. The medical evidence of record does not provide any diagnosis of PTSD. The Veteran's statements alone are not sufficient to prove that he had a current diagnosis of PTSD that conforms to DSM. As a layperson, he is competent to describe his mental health symptoms. However, medical diagnosis and causation involve questions that are beyond the range of common experience and common knowledge and require the special knowledge and experience of a trained physician. As he is a layperson, and not a physician, he is not competent to make a diagnosis of PTSD, certainly not in conformance with DSM criteria.

In October 2022, the Veteran described "being down in ICMB III missles silos." See October 2022, and September 2022 VA 21-0781, Statement in Support of Claim of PTSD.

Review of the record does not demonstrate the Veteran experienced psychiatric symptoms associated with PTSD. The probative and competent evidence of record do not show a diagnosis of PTSD based upon the DSM-5. Thus, the Board finds as fact that the Veteran does not have a diagnosis of PTSD in accordance with the DSM-5 for the purposes of his service-connection claim, and as such, service connection for PTSD is not warranted.

The evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for a PTSD condition is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

5. Entitlement to service connection for vision.

Initially, the Board notes the AOJ, in the March 2023 rating decision, made the favorable finding that the Veteran was exposed to lead during active service. The Board is bound by this favorable finding. See AMA, Pub. L. No. 115-55, § 5104A, 131 Stat. 1105, 1106-07.

The first element required for service connection is a current disability.

The Board finds that the persuasive weight of the evidence does not show a current vision disability, either by diagnosis or by functional impairment, including based on lay evidence reports. See Saunders v. Wilkie, 886 F.3d 1356 (2018).

The competent evidence of record does not demonstrate a current vision disability in any of the medical treatment records and the Veteran is not competent to render his own diagnosis. See generally King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2009) (holding that it was not erroneous for the Board to find that a lay veteran claiming service connection for a back disorder and his wife lacked the "requisite medical training, expertise, or credentials needed to render a diagnosis" and that their testimony "could not establish medical causation nor was it a competent opinion as to medical causation").

The Veteran was scheduled for a March 2023 VA examination and was a "no show."

The Board is cognizant that an adequate VA examination is not of record that assesses the nature and etiology of the Veteran's claimed vision condition. However, despite adequate notice and opportunity to attend a VA examination for his vision condition the Veteran was a "no show" to his March 2023 appointment. As the Court has held, "[t]he duty to assist in the development and adjudication of a claim is not a one-way street." Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996). "If a [claimant] wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991).

Under 38 C.F.R. § 3.655(a), when entitlement to a benefit cannot be established without a current VA examination or reexamination, and a claimant, without good cause, fails to report for such examination or reexamination, action shall
and adjudication of a claim is not a one-way street." Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996). "If a [claimant] wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991).

Under 38 C.F.R. § 3.655(a), when entitlement to a benefit cannot be established without a current VA examination or reexamination, and a claimant, without good cause, fails to report for such examination or reexamination, action shall be taken in accordance with 38 C.F.R. § 3.655(b) or (c) as appropriate. Under 38 C.F.R. § 3.655(b), when a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record, but when a claimant fails to report without good cause for an examination scheduled in conjunction with a reopened claim or a claim for increase, the claim shall be denied.

In sum, the evidentiary requirement of demonstrating a diagnosis of a vision disability related to service has not been satisfied. In reaching this conclusion, the Board has considered the lay statements to the extent they are competent.

Accordingly, as the persuasive weight of the evidence is against a finding of entitlement to service connection for a vision condition, the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). The Board finds that the evidence is not in approximate balance and there is no reasonable doubt to resolve in favor of the Veteran.

6. Entitlement to service connection for a sleep disorder is denied.

The Veteran seeks service connection for a sleep disorder that he asserts is due to "exposure to elements." See December 2022 VA 21-526EZ, Fully Developed Claim.

Initially, the Board notes the AOJ, in the March 2023 rating decision, made the following favorable findings: 1) the Veteran has a diagnosis of obstructive sleep apnea (OSA); and 2) the Veteran was exposed to lead during military service. The Board is bound by these favorable findings. See AMA, Pub. L. No. 115-55, § 5104A, 131 Stat. 1105, 1106-07.

With respect to an in-service incurrence, service treatment records (STRs) are silent for complaints, diagnosis, or treatment for a sleep disorder.

Under 38 C.F.R. § 3.655(a), when entitlement to a benefit cannot be established without a current VA examination or reexamination and a claimant, without good cause, fails to report for such examination or reexamination, action shall be taken in accordance with 38 C.F.R. § 3.655(b) or (c) as appropriate. Title 38 C.F.R. § 3.655(b) applies to original or reopened claims or claims for increase, while 38 C.F.R. § 3.655(c) applies to running awards, when the issue is continuing entitlement. More specifically, when a claimant fails to report for a medical examination scheduled in conjunction with an original compensation claim, without good cause, the claim shall be rated based on the evidence of record. See 38 C.F.R. § 3.655(b). Examples of good cause include, but are not limited to, illness or hospitalization of the claimant, or death of an immediate family member. See 38 C.F.R. § 3.655(a).

The record reflects that the Veteran was scheduled for a VA examination regarding his sleep disorder in February 2023 VA examination. The Veteran was a "no show" for his scheduled VA examination. To date, neither the Veteran nor his representative have provided good cause for his failure to report for the examinations. 38 C.F.R. § 3.655. There is nothing in the claims file to suggest that the Veteran did not receive notification of the examinations, and the Veteran has not indicated that he did not receive proper notice and has not requested the examination to be rescheduled. Accordingly, the service connection claim will be decided on the evidence of record.

The first element required for service connection is a current disability. The March 2023 contained the favorable finding that the Veteran has a diagnosis of OSA. The first element of service connection is met.

The Veteran's service treatment records
his scheduled VA examination. To date, neither the Veteran nor his representative have provided good cause for his failure to report for the examinations. 38 C.F.R. § 3.655. There is nothing in the claims file to suggest that the Veteran did not receive notification of the examinations, and the Veteran has not indicated that he did not receive proper notice and has not requested the examination to be rescheduled. Accordingly, the service connection claim will be decided on the evidence of record.

The Veteran's service treatment records do not show treatment for or diagnosis of a sleep disorder, to include OSA.

The March 2023 rating decision contained the favorable finding that the Veteran was exposed to lead during military service. See March 2023 Rating Decision.

The Board finds that there is no competent, credible, and probative evidence of record establishing that the Veteran's OSA is related to his active service. In making this determination, the Board has considered the Veteran's statements, and the evidence of record. However, as a lay person, he is not competent to offer an opinion as to the etiology of his OSA, as such a determination requires a level of medical expertise which the Veteran, as a layperson, does not possess. See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration, and that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007) (observing that a layperson can be competent to identify conditions that are simple, such as a broken leg, but is not competent to identify more complex conditions such as a form of cancer); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that lay testimony is competent as to matters capable of lay observation, but not with respect to determinations that are "medical in nature").

As previously stated, the Veteran failed to report for a VA examination in February 2023 without good cause and thus, has failed to cooperate to the full extent in the development of his claim. Wood v. Derwinski, 1 Board. App. 190, 193 (1991). The evidence of record, as it stands, is insufficient to substantiate the Veteran's claim.

Therefore, in the absence of competent probative evidence relating the Veteran's OSA to his active service, and in light of the Veteran's failure to participate in a VA examination scheduled for the purpose of making such an etiological determination, the Veteran's claim for service connection for OSA must be denied.

As the persuasive weight of the evidence is against a finding of entitlement to service connection for OSA, the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). The Board finds that the evidence is not in approximate balance and there is no reasonable doubt to resolve in favor of the Veteran.

7. Entitlement to service connection for a liver disorder.

Initially, the Board notes the AOJ, in the January 2023 rating decision, made the following favorable findings: 1) the Veteran has a diagnosis of cirrhosis of the liver; and 2) the Veteran was exposed to lead during military service. The Board is bound by these favorable findings. See AMA, Pub. L. No. 115-55, § 5104A, 131 Stat. 1105, 1106-07.

The Veteran asserts that he developed a liver disorder due to "exposure to elements." See December 2022 VA 21-526EZ, Fully Developed Claim.

The period on appeal began with the filing of the Veteran's December 2022 Fully Developed Claim. With respect to an in-service incurrence, service treatment records (STRs) are silent for complaints, diagnosis, or treatment for a liver condition. The Veteran's November 2022 post-service treatment records note a history of alcoholic cirrhosis of the liver.

The Veteran asserts that he developed a liver disorder due to "exposure to elements." See December 2022 VA 21-526EZ, Fully Developed Claim.

What is missing is competent medical evidence linking the Veteran's cirrhosis of the liver to service. With regard to obtaining a VA examination, while there is competent medical evidence of a current disability, there is no indication in the record, to include no competent evidence (other than the Veteran's lay assertions, which have been vague and non-specific in this regard) showing that his history of alcoholic cirrhosis is related to service. As noted above, there is not a duty to provide a VA examination in every case. Waters v. Shinseki, supra. The Board acknowledges the Veteran's contentions that his cirrhosis is related to service. While he is competent to describe any symptoms he experiences, determining the causation or etiology of any such symptoms or of a liver condition, to include cirrhosis, is not subject to lay observation. Jandreau v. Nicholson, supra. The Board concludes that obtaining a VA examination is not necessary or warranted for this claim.

The Board acknowledges the Veteran raised a new theory of entitlement in the January 2024 10182, NOD, namely that the Veteran's cirrhosis of the liver was due to alcoholism due to PTSD. This theory was not raised prior to the rating decision on appeal and, therefore, was not considered or developed by the AOJ. Significantly, the Veteran is not service connected for the underlying condition of PTSD. To the extent the Veteran raised a new theory of entitlement, such cannot constitute a pre-decisional duty to assist error as this theory of entitlement was not before the AOJ at the time of the decision on appeal, and remand for development is not appropriate. However, if additional evidence is obtained, the Veteran may file a Supplemental Claim regarding this new theory of entitlement. 38 C.F.R. § 3.2501.

8. Entitlement to service connection for a lower back disorder.

In March 2023, the Veteran claimed service connection for bilateral knee condition on a direct theory of entitlement, based upon "repelling from A/C helicopters." See September 2022 VA 21-526EZ, Fully Developed Claim.

Initially, the Board notes that the AOJ, in the March 2023 rating decision, made the favorable finding that the Veteran's lower back condition existed prior to service based upon the Veteran's June 1986 entrance examination which noted a back injury prior to service. The Board is bound by this favorable finding. See AMA, Pub. L. No. 115-55, § 5104A, 131 Stat. 1105, 1106-07.

The period on appeal began with the filing of the Veteran's September 2022 Fully Developed Claim.

Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b). To rebut the presumption of sound condition, VA must show by clear and unmistakable evidence (1) that the disease or injury existed prior to service, and (2) that the disease or injury was not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004).

To satisfy the second requirement for rebutting the presumption of soundness, the government must show, by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or that (2) any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845 (Fed. Cir. 2006). The claimant is not required to show that the disease or injury increased in severity during service before VA meets both of these burdens. See VAOPGCPREC 3-2003.

A pre-existing injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during
for rebutting the presumption of soundness, the government must show, by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or that (2) any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845 (Fed. Cir. 2006). The claimant is not required to show that the disease or injury increased in severity during service before VA meets both of these burdens. See VAOPGCPREC 3-2003.

A pre-existing injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306.

Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. Id.; Falzone v. Brown, 8 Vet. App. 398, 402 (1995).

Turning to the facts, back strain was noted on the Veteran's June 1986 enlistment examination. The examiner noted that the back strain was noted based upon a February 1986 emergency room visit, which resulted in 3 days off work and no recurrence. Id.

Upon a review of the evidence of record, the Board finds that there is no evidence demonstrating that the Veteran's pre-existing back strain underwent an increase in the underlying pathology during his military service. Service treatment records and post-service treatment records are silent for complaints, diagnosis, or treatment of back pain. The Board finds that the evidence weighs against a finding that the Veteran's pre-existing back strain was aggravated in service.

Although the Veteran was not afforded a VA examination with regards to the etiology of his back strain, a VA examination was not required in this case, as the evidence does not suggest a worsening of the underlying pathology of the Veteran's back strain during military service. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006).

To the extent the Veteran opines on the matter, the Veteran has not shown himself to possess the education, training, and experience to offer a medical opinion on complex matters such as the ability differentiate between degrees of back strain to service, particularly in the absence of acute or traumatic injury. Accordingly, his assertions are not competent or probative evidence of back strain worsening during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4

Without some competent evidence demonstrating a worsening of the underlying pathology of the Veteran's back strain in service, the Board concludes that the evidence clearly and unmistakably does not support a finding of aggravation. Thus, because the Veteran's back strain was noted to have pre-existed his active military service, and was not aggravated therein, the Board finds that the Veteran's claim for service connection for aggravation of a pre-existing back strain in service must be denied. See 38 C.F.R. §§ 3.303, 3.304, 3.306.

9. Entitlement to service connection for right knee and left knee disability.

In March 2023, the Veteran claimed service connection for bilateral knee condition on a direct theory of entitlement, contending "repelling from A/C helicopters." See September 2022 VA 21-526EZ, Fully Developed Claim.

The January 2023 rating decision did not contain any favorable findings for these claims.

For the reasons that follow, the Board finds that the Veteran's service connection claims for right knee and left knee must be denied.

Significantly, the element of a current diagnosis is not met. With respect to an in-service incurrence, service treatment records (STRs) are silent for complaints, diagnosis, or treatment for a right or left knee condition. No lay or medical evidence of record supports that the Veteran had a right or left knee disability during the period on appeal.

The Veteran's post-service medical records also do not show evidence of a right knee or left knee injury, or disability. The only lay evidence is the notation of "bilateral knees residuals" on the Veteran's December 2022 claim form.

The Board acknowledges that the Veteran has not been afforded a VA examination for his claimed right knee or left knee condition. However, the standards
Significantly, the element of a current diagnosis is not met. With respect to an in-service incurrence, service treatment records (STRs) are silent for complaints, diagnosis, or treatment for a right or left knee condition. No lay or medical evidence of record supports that the Veteran had a right or left knee disability during the period on appeal.

The Board acknowledges that the Veteran has not been afforded a VA examination for his claimed right knee or left knee condition. However, the standards of McLendon are not met in this case as the Veteran is not shown to have a current disability, or that he has a current disability or persistent or recurrent symptoms of a current disability that may be associated with an event, injury, or disease in service. McLendon, 20 Vet. App. at 76. Under McLendon v. Nicholson, 20?Vet. App.?79 (2006), in initial service connection claims, the VA must provide a VA medical examination where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service; and (4) insufficient competent medical evidence on file for VA to make a decision on the claim.

The Board notes that the Veteran is competent, as a lay person, to attest to factual matters of which he has first-hand knowledge. In addition, lay assertions may serve to support a claim for service connection by demonstrating the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau,492 F.3d at 1372. However, the Veteran is not competent to render a diagnosis and attribute a diagnosis to service or any event of service. As noted, the Veteran's STRs and post-service treatment records do not reflect any complaints of, diagnoses of, or any references to, a right knee, or left condition or injury. Further, to the extent that the Veteran's statements may be broadly construed as expressing experiencing knee pain, the record does not show that such pain rises to the level of functional impairment of earning capacity at any point during or proximate to the pendency of the claim.

The Veteran has not provided any competent or credible evidence of a current disability or persistent or current symptoms of a disability during the period on appeal. The record is devoid of any descriptions of the symptoms experienced by the Veteran related to his claimed right knee and left knee disabilities other than the actual claim for "knees." The Veteran has not described any symptoms, frequency of symptoms, or functional impairment due to any symptoms. In this regard, the Board finds that the Veteran has submitted insufficient, lay, or medical, evidence to indicate that he has a right knee or left knee disability. Accordingly, the Board finds that no further development of the Veteran's claim for service connection for a right knee or left knee disability is required.

As the persuasive weight of the evidence is against a finding of entitlement to service connection for a right or left knee disability, the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). The Board finds that the evidence is not in approximate balance and there is no reasonable doubt to resolve in favor of the Veteran.

10. Entitlement to service connection for atrial fibrillation.

The Veteran seeks service connection for a heart condition as due to "exposure to elements." See December 2022 VA 21-526EZ, Fully Developed Claim.

Initially, the Board notes the AOJ, in the March 2023 rating decision, made the following favorable findings: 1) the Veteran was exposed to lead during military service; and 2) the Veteran has a current diagnosis of atrial fibrillation. The Board is bound by these favorable findings. See AMA, Pub. L. No. 115-55, § 5104A, 131 Stat. 1105, 1106-07.

The first element of service connection has been met, as the evidence shows a current diagnosis of atrial fibrillation (Veteran diagnosed in March 2022). See February 2023 VA opinion.

As a procedural starting point for this claim, in December 2022, the Veteran submitted a fully developed claim for service connection for heart condition,
the following favorable findings: 1) the Veteran was exposed to lead during military service; and 2) the Veteran has a current diagnosis of atrial fibrillation. The Board is bound by these favorable findings. See AMA, Pub. L. No. 115-55, § 5104A, 131 Stat. 1105, 1106-07.

The first element of service connection has been met, as the evidence shows a current diagnosis of atrial fibrillation (Veteran diagnosed in March 2022). See February 2023 VA opinion.

As a procedural starting point for this claim, in December 2022, the Veteran submitted a fully developed claim for service connection for heart condition, to include atrial fibrillation.

In February 2023, the Veteran underwent a VA heart conditions examination. The VA examiner confirmed the Veteran had a diagnosis of atrial fibrillation

In February 2023, a VA examiner provided an opinion based on a review of the record. The examiner opined that the Veteran's claimed condition was less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner explained that the Veteran has also been diagnosed with hypertension, OSA, and has a significant history for alcohol abuse and alcoholic cirrhosis of the liver, and these conditions are significant risk factors for developing atrial fibrillation. The Board notes that the Veteran is not service-connected for these conditions. Additionally, the VA examiner opined that, after reviewing the available toxic exposure resources, there is not currently evidence to indicate atrial fibrillation is caused by exposures experienced by the Veteran (lead) during service. See February 2023 VA opinion.

Upon review, the Board finds the entitlement to service connection for atrial fibrillation is not warranted. It has been conceded that the Veteran has been diagnosed with atrial fibrillation. Further, it has been stipulated that the Veteran participated in a TERA based upon exposure to lead during service. The Board is bound by these favorable findings. However, there is controversy as to the onset of the before-mentioned conditions and whether they are related to the Veteran's time in service. In reaching this determination, the Board notes that the only competent opinions addressing the etiology of the Veteran's atrial fibrillation is the February 2023 VA medical opinion, which is against the Veteran's claim. Inasmuch as the opinion was based on a review of the Veteran's claims file, provided by a medical professional competent to opine as to the etiology of the Veteran's atrial fibrillation, and supported by rationale, the Board finds the February 2023 VA opinion to be persuasive. Overall, the evidence does not indicate that the Veteran's atrial fibrillation is related to service, to include his presumed exposure to lead during service. The Board considers that the examiner's reasoning that the non-service-connected hypertension, OSA, and significant history for alcohol abuse and alcoholic cirrhosis of the liver are significant risk factors for developing atrial fibrillation, rather than any in-service TERA or in-service incident, to be both adequate and the most probative opinion of record.

As the persuasive weight of the evidence is against a finding of entitlement to service connection for atrial fibrillation, the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). The Board finds that the evidence is not in approximate balance and there is no reasonable doubt to resolve in favor of the Veteran.

11. Entitlement to an initial rating in excess of 10 percent for bilateral hearing loss.

The Veteran filed a timely NOD (VA 10182) to the January 2023 rating decision which granted service connection for bilateral hearing loss at 10 percent, effective September 27, 2022.

Ratings for hearing impairment are derived by the mechanical application of the Rating Schedule to the numeric designations assigned after audiometry evaluations are rendered. Lendenmann v. Principi, 3?Vet. App.?345 (1992). In addition to dictating objective test results, a VA audiologist must describe the functional effects caused by a hearing disability. Martinak v. Nicholson, 21?Vet. App.?447 (2007).

In cases for which the evaluation of hearing loss is at issue, an examination for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. Examinations will be conducted without the use of hearing aids. 38 C.F.R. § 4.85(a). The Rating Schedule provides a table (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, based on pure tone thresholds and controlled speech discrimination (Maryland CNC) testing. 38 C.F.R. § 4.85(b). Table VII is used to determine the rating assigned by combining the Roman numeral designations for hearing impairment of each ear. 38 C.F.R. § 4.85(e). The "pure tone threshold average" as used in Table VI, is the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. This average is used in all cases to determine the Roman numeral designation for hearing impairment from Table VI or VIa. 38 C.F.R. § 4.85(d).

If impaired hearing is service-connected in only one ear, in order to determine the percentage evaluation from Table VII, the non-service-connected ear will be assigned a Roman Numeral designation for hearing impairment of I. 38 C.F.R. § 4.85(f).

Table VIa, "Numeric Designation of Hearing Impairment Based Only on Puretone Threshold Average," is used to determine a Roman numeral designation (I through XI) for hearing impairment based only on the pure tone threshold average. Table VIa will be used when the examiner certifies that use of the speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of §4.86. See 38 C.F.R. § 4.85(c).

Where there is an exceptional pattern of hearing impairment as defined in 38 C.F.R. § 4.86, the rating may be based solely on pure tone threshold testing. An exceptional pattern of hearing impairment occurs when the pure tone thresholds in each of the four frequencies 1000, 2000, 3000, and 4000 Hertz are 55 decibels or greater; or when the pure tone threshold at 1000 Hertz is 30 decibels or less, and the threshold at 2000 Hertz is 70 decibels or more. 38 C.F.R. § 4.86(a), (b).

An October 2022 VA examination report reveals the Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows:

HERTZ 1000 2000 3000 4000

RIGHT 15 45 65 60

LEFT 15 30 75 100

The average pure tone thresholds were 46 in the right ear, and 55 in the left ear. Speech audiometry revealed speech recognition ability of 72 percent in the right ear and 80 in the left ear.

Applying the results to Table VI, findings yield numeric designation of Level IV in the right ear and Level IV in the left ear. Entering the resulting bilateral numeric designation of Level IV for the right ear and Level IV for the left ear to 38 C.F.R. § 4.85, Table VII equates to a 10 percent disability rating under Diagnostic Code 6100.

Accordingly, the most probative evidence of record persuasively weighs against the claim of entitlement to an initial rating in excess of 10 percent for bilateral hearing loss. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt rule does not apply, and the appeal is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

12. Entitlement to a rating in excess of 10 percent for tinnitus.

The Veteran filed a timely NOD (VA 10182) to the January 2023
ative evidence of record persuasively weighs against the claim of entitlement to an initial rating in excess of 10 percent for bilateral hearing loss. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt rule does not apply, and the appeal is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

12. Entitlement to a rating in excess of 10 percent for tinnitus.

The Veteran filed a timely NOD (VA 10182) to the January 2023 rating decision which granted service connection for tinnitus at 10 percent, effective September 27, 2022.

Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Under Diagnostic Code 6260, a 10 percent evaluation is assigned for recurrent tinnitus. 38 C.F.R. § 4.87, Diagnostic Code 6260. Only a single evaluation may be assigned for recurrent tinnitus, whether the sound is perceived in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note (2). Thus, the Veteran is receiving the maximum rating available for tinnitus, and no higher rating is legally available.

As tinnitus has its own code, Diagnostic Code 6260, no rating by analogy under other codes is permissible; thus, a higher rating under another code provision is not warranted. Copeland v. McDonald, 27 Vet. App. 333, 338 (2015).

The Veteran has not raised, nor does the evidence otherwise reflect, that he has experienced symptoms outside of those listed in the rating criteria. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Consequently, the claim for a higher initial rating for tinnitus must be denied. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994).

REASONS FOR REMAND

Entitlement to service connection for diabetes mellitus, type II.

The Veteran seeks service connection for diabetes with neuropathy as due to "exposure to elements." See VA 21-526EZ, Fully Developed Claim.

In February 2023, a VA Examiner provided a nexus opinion based on a review of the record. The VA examiner opined that the Veteran's diabetes mellitus, type II, is less likely than not caused by the indicated TERA, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. However, the examiner did not provide adequate reasoning. The examiner acknowledged that the Veteran was diagnosed with diabetes mellitus, type II, and was prescribed medication. He described the Veteran's condition as well controlled with diet and exercise alone, and that he was no longer taking Metformin or using any other treatment for diabetes, but did not discuss the etiology of the Veteran's diabetes mellitus, type II. As such, the Board is not informed as to the rationale for the opinion.

Here, the Board finds that the February 2023 VA opinion is inadequate for adjudication purposes. As such, the Board finds that another addendum opinion is necessary.

The matters are REMANDED for the following action:

1. Obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of the Veteran's diabetes mellitus, type II. An in-person examination of the Veteran should be arranged, if determined necessary.

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Following a review of the complete claims file, the examiner is asked to opine on whether the Veteran's diabetes mellitus, type II is at least as likely as not related to service, to include related to or otherwise caused by his acknowledged exposure to lead during military service.

A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must
necessary.

The matters are REMANDED for the following action:

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A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion.

David Gratz

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Jordan, Jacquelynn

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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