Case A26027283

MARIAH N. SIM · 2026 · Case ID: A26027283

MIXED

Summary

The veteran, who served in the United States Air Force from July 1958 to June 1962, appeals the denial of service connection for abnormal gait/mobility, anemia, cerebrovascular disease (stroke), gastroesophageal reflux disease (GERD), bilateral lower extremity atherosclerosis, and a low back disorder. The Board denied these claims, finding that the evidence persuasively weighed against a service connection, as the diagnoses for most conditions appeared decades after service and lacked in-service complaints or nexus opinions. The Board noted that while the veteran claimed exposure to herbicides in Thailand and toxic exposure risk activity (TERA) involving solvents and gear oils, the evidence did not establish herbicide exposure. VA medical examiners opined that the veteran's anemia, cerebrovascular disease, GERD, and bilateral lower extremity atherosclerosis were less likely than not related to TERA, citing a lack of medical literature supporting such a link and the late onset of diagnoses. For abnormal gait/mobility, the Board found no in-service complaints or nexus opinion, and the first complaint was decades after service. For the low back disorder, the Board found no current diagnosis or symptoms indicating functional impairment of earning capacity, noting the last reported back pain was over a decade before the claim was filed. The Board found the veteran incompetent to provide medical diagnoses or nexus opinions due to the complexity of the issues. The Board remanded claims for diabetes mellitus type II, coronary artery disease (CAD), angina, and hypertension, finding that the VA's prior opinions did not adequately consider the TERA memorandum or the veteran's in-service complaints, constituting a duty to assist error.

Rationale

Service treatment records silent for complaint, treatment, or diagnosis.; First complaint in 2019, decades after service.; VA examiner opined less likely than not caused by TERA; no nexus established.

Service Branch

AIR FORCE

Special Benefit

NO SPECIAL BENEFIT

Docket No.

251205-624133

Full Decision Text

Citation Nr: A26027283
Decision Date: 03/26/26 Archive Date: 03/26/26

DOCKET NO. 251205-624133
DATE: March 26, 2026

ORDER

Entitlement to service connection for abnormal gait/mobility is denied.

Entitlement to service connection for anemia is denied.

Entitlement to service connection for cerebrovascular disease (stroke) is denied.

Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied.

Entitlement to service connection bilateral lower extremity atherosclerosis is denied.

Entitlement to service connection for a low back disorder is denied.

REMANDED

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

Entitlement to service connection for coronary artery disease (CAD) is remanded.

Entitlement to service connection for angina (chest pain) is remanded.

Entitlement to service connection for hypertension is remanded.

FINDINGS OF FACT

1. The evidence persuasively weighs against finding that the Veteran's abnormal gait/mobility began during active service or is otherwise related to an in-service injury or disease.

2. The evidence persuasively weighs against finding that the Veteran's anemia began during active service or is otherwise related to an in-service injury or disease, to include toxic exposure risk activity (TERA).

3. The evidence persuasively weighs against finding that the Veteran's cerebrovascular disease began during active service or is otherwise related to an in-service injury or disease, to include toxic exposure risk activity.

4. The evidence persuasively weighs against finding that the Veteran's GERD began during active service or is otherwise related to an in-service injury or disease, to include toxic exposure risk activity.

5. The evidence persuasively weighs against finding that the Veteran's bilateral lower extremity atherosclerosis began during active service or is otherwise related to an in-service injury or disease, to include toxic exposure risk activity.

6. The evidence of record persuasively weighs against finding that the Veteran has had a low back disability or symptoms of a low back disability at any time during or approximate to the pendency of the claim.

CONCLUSIONS OF LAW

1. The criteria for service connection for abnormal gait/mobility are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for anemia are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

3. The criteria for service connection for cerebrovascular disease are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

4. The criteria for service connection for GERD are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

5. The criteria for service connection for bilateral lower extremity atherosclerosis are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

6. The criteria for service connection for a low back disability are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Air Force from July 1958 to June 1962.

In May 2025, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of a January 2025 special review decision. In June 2025, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal, which considered the evidence of record at the time of the prior January 2025 special review decision. Therefore, the Board may only consider the evidence of record at the time of the January 2025 special review decision and any evidence submitted during an applicable evidentiary window.

In the December 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the January 2025 agency of original jurisdiction (AOJ) special review decision, which was subsequently subject to higher-level review. 38 C.F.R. § 20.301. If evidence
LR decision on appeal, which considered the evidence of record at the time of the prior January 2025 special review decision. Therefore, the Board may only consider the evidence of record at the time of the January 2025 special review decision and any evidence submitted during an applicable evidentiary window.

In the December 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the January 2025 agency of original jurisdiction (AOJ) special review decision, which was subsequently subject to higher-level review. 38 C.F.R. § 20.301. If evidence was submitted during the period after the AOJ issued the decision, which was subsequently subject to higher-level review the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 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 claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

However, because the Board is remanding the claims of entitlement to service connection for diabetes, CAD, angina, and hypertension, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

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. § 1131; 38 C.F.R. § 3.303(a). "To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases, including psychosis, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). Generally, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3).

For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). When the disease identity is established, there is no requirement of evidentiary showing of continuity. Id. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. Continuity of symptomatology is only applicable to those diseases recognized as chronic for VA purposes. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309.

Pertinent to a claim for service connection, such a determination requires a finding of a current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; see also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability").

In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that the requirement of the existence of a current disability is satisfied when a claimant has a disability at the time he/she files his/her claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a claimant filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency.

The veteran can provide competent reports of factual matters of which he has first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Similarly, laypersons are competent to diagnose and provide nexus opinions to some extent, notably where the diagnosis or opinion is not of a complex nature. Id., see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).

When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F.3rd 1391 (2021).

The Board notes that pursuant to the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), a Veteran can establish participation in a toxic exposure related activity (TERA) explicitly or implicitly through service in a location presumed associated with toxic exposure, through records showing participation in a TERA, where VA has conceded exposure in a prior claim or file has a claim attribute for toxic exposure, where a Veteran's military occupational specialty (MOS) is associated with toxic exposure, where medical records suggest exposure to a toxic substance, chemical, or airborne hazard such as Veterans Health Administration (VHA) exposure screening, or based on any other relevant evidence of record. 38 U.S.C. § 1119.

1. Abnormal Gait/Mobility, Anemia, Cardiovascular Disease, GERD, and Bilateral Lower Extremity Atheroscleroses

The Veteran seeks entitlement to service connection for abnormal g
explicitly or implicitly through service in a location presumed associated with toxic exposure, through records showing participation in a TERA, where VA has conceded exposure in a prior claim or file has a claim attribute for toxic exposure, where a Veteran's military occupational specialty (MOS) is associated with toxic exposure, where medical records suggest exposure to a toxic substance, chemical, or airborne hazard such as Veterans Health Administration (VHA) exposure screening, or based on any other relevant evidence of record. 38 U.S.C. § 1119.

1. Abnormal Gait/Mobility, Anemia, Cardiovascular Disease, GERD, and Bilateral Lower Extremity Atheroscleroses

The Veteran seeks entitlement to service connection for abnormal gait/mobility, anemia, cardiovascular disease (stroke), GERD, and bilateral lower extremity atheroscleroses as etiologically related to his active service. Specifically, the Veteran contends that the above disabilities are the result of service, to include herbicide exposure in Thailand. See December 2020 Statement in Support of Claim and November 2023 Statement in Support of Claim.

The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease.

The Board concludes that, while the Veteran has diagnoses of abnormal gait/mobility, anemia, cerebrovascular disease, GERD, and bilateral lower extremity atherosclerosis, and the evidence of record persuasively weighs against finding that these disabilities began during active service, or are otherwise related to an in-service injury, event, or disease, to include TERA.

The service treatment records are silent for any complaint, treatment, or diagnoses of abnormal gait/mobility, anemia, cerebrovascular disease, GERD, or bilateral lower extremity atherosclerosis.

In a March 2020 private treatment record, the medical provider diagnosed the Veteran with unspecified abnormalities of gait and mobility.

In a February 2022 Statement in Support of Claim, the Veteran stated that he is unable to provide information about specific missions due to security clearance and instructions form superior officers that missions were not to be discussed. In a November 2023 Statement in Support of Claim, the Veteran stated that he flew covert missions from Texas to an air base in Thailand. He stated that because of the nature of the flights, he was not given information. He stated that the flights occurred from the last of 1961 to the first of 1962.

The November 2024 Records Research Center Response stated that after a professional search, to include a classified researcher, the Veteran and his squadron and combat support group did not have service in Thailand between December 1961 and March 1962.

The November 2024 VA TERA memorandum shows the Veteran to have experienced in-service TERA with exposure to solvents and gear oils. The memorandum did not find the Veteran to have been exposed to herbicide agents.

The December 2024 VA hematologic examiner opined that the Veteran's anemia is less likely than not caused by the indicated toxic exposure risk activities, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERA of the Veteran. The examiner reasoned that medical literature is not found to determine that anemia is due to TERA. The examiner explained that anemia is a condition of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues. The examiner stated that causes of anemia include iron deficiency anemia, vitamin deficiency anemia, and aplastic anemia. The examiner stated that the record shows the Veteran was diagnosed with anemia in 2020. Therefore, the examiner concluded that a nexus has not been established.

The December 2024 VA central nervous system and neuromuscular diseases examiner opined that the Veteran's cerebrovascular disease is less likely than not caused by the indicated toxic exposure risk activities, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERA of the Veteran. The examiner reasoned that medical literature is not found to determine that stroke is due to TERA. The examiner explained that stroke or cerebrovascular accident (CVA) is a condition which part of the brain does not have enough blood flow. In general terms, cerebrovascular disease condition includes stroke, brain aneurysm, brain bleed, and carotid artery disease. The examiner stated that this most commonly happens because of a blocked artery or bleeding in the brain and is considered a medical emergency. The examiner found that the claims file shows diagnosis of memory deficit due to cerebrovascular disease around 2020. The examiner concluded that a nexus has not been established.

The December 2024 VA esophageal examiner op
the Veteran. The examiner reasoned that medical literature is not found to determine that stroke is due to TERA. The examiner explained that stroke or cerebrovascular accident (CVA) is a condition which part of the brain does not have enough blood flow. In general terms, cerebrovascular disease condition includes stroke, brain aneurysm, brain bleed, and carotid artery disease. The examiner stated that this most commonly happens because of a blocked artery or bleeding in the brain and is considered a medical emergency. The examiner found that the claims file shows diagnosis of memory deficit due to cerebrovascular disease around 2020. The examiner concluded that a nexus has not been established.

The December 2024 VA esophageal examiner opined that it is less likely than not that the Veteran's GERD is caused by the indicated toxic exposure risk activities, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERA of the Veteran. The examiner reasoned that medical literature is not found to determine that GERD is due to TERA. The examiner explained that GERD is a condition which stomach acid frequently flows back into the tube that connects the mouth and stomach. The examiner concluded that a nexus has not been established.

The December 2024 VA artery and vein conditions examiner opined that it is less likely than not that the Veteran's bilateral lower extremity atherosclerosis is caused by the indicated toxic exposure risk activities, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERA of the Veteran. The examiner reasoned that the medical literature is not found to determine that lower extremity atherosclerosis is due to TERA. The examiner stated that atherosclerosis of the extremities, also known as peripheral artery disease or peripheral vascular disease, is a disease of the peripheral blood vessels that is characterized by narrowing and hardening of the arteries that supply the legs and feet. The examiner concluded that a nexus has not been established.

While the Veteran believes the above disabilities are related to exposures during service, the Board reiterates that the evidence of record persuasively weighs against findings that an in-service injury exposure to herbicides occurred.

The Board concludes that, while the Veteran has current diagnoses of abnormal gait/mobility, anemia, cerebrovascular disease, GERD, and bilateral lower extremity atherosclerosis, and evidence shows that no in-service injury, event, disease occurred, the evidence of record persuasively weighs against finding that the Veteran's diagnoses of abnormal gait/mobility, anemia, cerebrovascular disease, GERD, and bilateral lower extremity atherosclerosis began during service or is otherwise related to an in-service injury, event, or disease.

Private treatment records and VA examinations show the Veteran was not diagnosed with abnormal gait/mobility, anemia, cerebrovascular disease, GERD, and bilateral lower extremity atherosclerosis until around 2019 or 2020, decades after separation from service. While the Veteran is competent to report having experienced symptoms of abnormal gait/mobility, cerebrovascular disease, GERD, and bilateral lower extremity atherosclerosis consistently since an unknown date of onset, the Veteran is not competent to provide diagnoses in this case or determine that these symptoms were manifestations of the above disabilities. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007).

Further, the December 2024 VA examiner opined that the Veteran's anemia, cerebrovascular disease, GERD, and bilateral lower extremity atherosclerosis are less likely than not caused by the indicated toxic exposure risk activities, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERA of the Veteran. The examiner reasoned that the medical literature is not found to determine that the disabilities are due to TERA. The examiner's opinions are probative, because they are based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Accordingly, the Board affords these opinions high probative weight.

In addition, the Board recognizes that no VA examiner has examined or opined whether the Veteran's abnormal gait/mobility is the result of service. However, the Board finds that no such evaluation or opinion was required as the service treatment records are silent for any complaint, treatment, or diagnosis of this disability. And the first complaint of this disability occurred in 2019, decades
to TERA. The examiner's opinions are probative, because they are based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Accordingly, the Board affords these opinions high probative weight.

In addition, the Board recognizes that no VA examiner has examined or opined whether the Veteran's abnormal gait/mobility is the result of service. However, the Board finds that no such evaluation or opinion was required as the service treatment records are silent for any complaint, treatment, or diagnosis of this disability. And the first complaint of this disability occurred in 2019, decades after separation from service. As there is no opinion finding the abnormal gait/mobility is the result of service and there are no symptoms of the disability until 2019, the Board finds that the evidence persuasively weighs against finding that the Veteran's abnormal gait/mobility had its onset in service, began within one year of service, or is otherwise the result of service.

The Veteran believes the claimed disabilities are related to service. The Veteran in this case is not competent to provide a nexus opinion regarding these issues. The issue is medically complex, as it requires knowledge the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that the Veteran has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the December 2024 VA medical opinions.

In summary, the Board finds the evidence weighs persuasively against finding that the Veteran's abnormal gait/mobility, anemia, cerebrovascular disease, GERD, and bilateral lower extremity atherosclerosis had onset in service or is otherwise related to service, to include TERA. Accordingly, the evidence weighs persuasively against the claims. 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 back disability is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

2. Low Back Disorder

The Veteran contends that his low back disorder is the result of service. Specific argument in support of this appeal has not been provided.

The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease.

The Board concludes that the Veteran does not have a current diagnosis of a low back disability and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007).

In a May 1960 service treatment record, the Veteran was instructed to apply hot packs to the back three to four times a day. In a March 1961 service treatment record, the Veteran complained of lumbar pains.

Private treatment records show the Veteran last reported back pain in 2012.

Here, the clinical examinations demonstrate that the Veteran's symptoms related to his low back does not rise to a currently diagnosed disability. In considering Saunders v. Wilkie, 886 F.3d 1356, 1367-1369 (Fed. Cir. 2018), in which the Federal Circuit held that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of a functional impairment of earning capacity," the Boad finds that the Veteran last reported low back symptoms in 2012, over 10 years prior to the filing of this claim. Therefore, the Board finds there are no current complaints of the low back that result in functional impairment of earning capacity. There is no other report of a low back disorder at any time during the appeal period or prior to the appeal period.

As the record does not reflect current a low back disorder, the cornerstone element of service connection has not been met, and service connection is not warranted. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, supra. No further discussion of the remaining elements is necessary. The Board
reported low back symptoms in 2012, over 10 years prior to the filing of this claim. Therefore, the Board finds there are no current complaints of the low back that result in functional impairment of earning capacity. There is no other report of a low back disorder at any time during the appeal period or prior to the appeal period.

As the record does not reflect current a low back disorder, the cornerstone element of service connection has not been met, and service connection is not warranted. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, supra. No further discussion of the remaining elements is necessary. The Board acknowledges the Court's holding in Saunders but does not find a basis for determining that there is functional impairment related to a diagnosis of a low back disorder. See Saunders v. Wilkie, 886 F.3d. 1356 (2018). Moreover, the Veteran did not allege manifestations of similar severity, frequency and duration as those VA has determined by regulation would cause impaired earning capacity in an average person. Wait v. Wilkie, 33 Vet. App. 8 (2020).

The Board acknowledges the Veteran's contention that he has a low back disorder that is etiologically related to his active service. He is competent to describe symptoms such as pain, which is within the realm of his personal experience. 38 C.F.R. § 3.159. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Nonetheless, determining whether a low back disorder exists is not a simple medical determination because the diagnosis is based on results of medical testing.

In summary, the evidence fails to establish that the Veteran has a low back disorder for VA compensation purposes. In the absence of the claimed disability, service connection may not be granted. See Brammer v. Derwinski, supra; see also Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection cannot be granted if the claimed disability does not exist).

While the Veteran believes there is a current diagnosis of a low back disorder, the Veteran is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and the ability to interpret complicated 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.

In summary, the Board finds the evidence weighs persuasively against finding that the Veteran has a diagnosis or symptoms of a low back disorder. Accordingly, the evidence weighs 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 back disorder is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

REASONS FOR REMAND

1. Service Connection - Diabetes Mellitus, Type II, CAD, Angina (Chest Pain) and Hypertension.

As this appeal is governed by the AMA, remand is only permitted to correct an error in the duty to assist that occurred prior to the rating decision on appeal. 38 C.F.R. § 20.802. Accordingly, the Board finds the AOJ committed a pre-decisional duty to assist error in not obtaining adequate medical opinions. 38 C.F.R. § 20.802.

Remand is necessary to obtain an additional medical opinion. When VA undertakes to obtain an opinion, it must ensure that the opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is considered adequate "where it is based on consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007).

In a November 1960 service treatment record, the Veteran complained of chest pain.

The December 2024 VA diabetes examiner opined that the Veteran's diabetes is less likely than not caused by the indicated toxic
is based on consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007).

In a November 1960 service treatment record, the Veteran complained of chest pain.

The December 2024 VA diabetes examiner opined that the Veteran's diabetes is less likely than not caused by the indicated toxic exposure risk activities, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERA of the Veteran. The examiner reasoned that although diabetes is a presumptive condition of TERA, the TERA memorandum notes no evidence of toxic exposure. the examiner stated that the medical evidence shows a diagnosis of diabetes in 2019. Therefore, the examiner concludes that a nexus has not been established.

The December 2024 VA heart examiner opined that it is less likely than not that the Veteran's CAD is caused by the indicated toxic exposure risk activities, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERA of the Veteran. The examiner reasoned that although CAD is a presumptive condition for agent orange exposure under the condition of ischemic heart disease, however, the VA TERA memorandum notes no exposure. The examiner found that the medical evidence shoes that the Veteran was diagnosed with CAD around 2019. Therefore, the examiner concluded that a nexus has not been established.

The December 2024 VA heart examiner also opined that it is less likely than not that the Veteran's angina pectoris is caused by the indicated toxic exposure risk activities, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERA of the Veteran. The examiner stated that the Veteran's angina is a symptom of CAD. The examiner explained that when the heart muscle does not receive enough oxygen and blood, the arteries that carry blood to the heart become narrowed and blocked. The examiner further reasoned that angina is a symptoms of ischemic heart disease, and although ischemic heart disease is a presumptive condition for agent orange exposure, the VA TERA memorandum shows no toxic exposure. The examiner stated that the medical evidence shows diagnosis of angina around 2020. Therefore, the examiner found that a nexus has not been established.

The December 2024 VA hypertension examiner opined that it is less likely than not that the Veteran's hypertension is caused by the indicated toxic exposure risk activities, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERA of the Veteran. The examiner reasoned that although hypertension is a presumptive condition for agent orange exposure, the VA TERA memorandum notes no exposure. The examiner stated that the medical evidence shows that the Veteran was diagnosed with hypertension around 2019. Therefore, the examiner stated that no nexus has been established.

The medical opinion for diabetes and hypertension did not accurately consider the TERA memorandum that found the Veteran to have had in-service exposure to solvents and gear oils. Accordingly, these medical opinions are incomplete to decide the claim. As a result, an additional medical opinion is required.

In addition, the medical opinion for CAD and angina did not accurately consider the TERA memorandum stated that the Veteran was exposed to solvents and gear oils. Also, the service treatment records show the Veteran complained of chest pain during service and an opinion for direct service was not provided. As a result, an additional medical opinion is required.

The Board finds that the AOJ did not obtain medical opinions that accurately consider the medical history in order to describe the disability in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The AOJ's failure to obtain an adequate etiology opinion is a pre-decisional duty to assist error that necessitates a remand for development.

The matters are REMANDED for the following action:

1. Schedule the Veteran for a VA examination with an appropriate medical examiner and obtain an etiology opinion to determine the nature and etiology of the Veteran's claimed diabetes mellitus, type II. The need for physical examination or telehealth evaluation is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. All indicated tests and studies should be accomplished
. 120, 123 (2007). The AOJ's failure to obtain an adequate etiology opinion is a pre-decisional duty to assist error that necessitates a remand for development.

The matters are REMANDED for the following action:

The examiner should respond to the following question:

Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any currently present diabetes mellitus, type II had its onset during the Veteran's active service, or is otherwise etiologically related to such service, to include any in-service exposure to environmental hazards (notwithstanding the fact that there may not be a presumed association)? The examiner must consider the Veteran's lay statements regarding the onset and continuity of his symptoms.

The VA examiner must provide an opinion whether the Veteran's diabetes mellitus, type II is at least as likely as not related to in-service TERA of solvents and gear oils.

A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training).

The medical opinion must support the conclusions reached with an analysis that is adequate to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge.

2. Schedule the Veteran for a VA examination with an appropriate medical examiner and obtain an etiology opinion to determine the nature and etiology of the Veteran's claimed CAD. The need for physical examination or telehealth evaluation is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. All indicated tests and studies should be accomplished and the findings then reported in detail.

The examiner should respond to the following question:

Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any currently CAD had its onset during the Veteran's active service, or is otherwise etiologically related to such service, to include any in-service exposure to environmental hazards (notwithstanding the fact that there may not be a presumed association)? The examiner must consider the Veteran's lay statements regarding the onset and continuity of his symptoms.

The VA examiner must provide an opinion whether the Veteran's CAD is at least as likely as not related to in-service TERA of solvents and gear oils.

Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's CAD is at least as likely as not related to service, to include November 1960 complaint of chest pain or the in-service TERA of solvents and gear oils.

3. Schedule the Veteran for a VA examination with an appropriate medical examiner and obtain an etiology opinion to determine the nature and etiology of the Veteran's claimed angina. The need for physical examination or telehealth evaluation is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. All indicated tests and studies should be accomplished and the findings then reported in detail.

The examiner should respond to the following question:

Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any currently present angina had its onset during the Veteran's active service, or is otherwise etiologically related to such service, to include any in-service exposure to environmental hazards (notwithstanding the fact that there may not be a presumed association)? The examiner must consider the Veteran's lay statements regarding the onset and continuity of his symptoms.

The VA examiner must provide an opinion whether the Veteran's angina is at least as likely as not related to in-service TERA of solvents and gear oils.

Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's angina is at least as likely as not related to service, to include November 1960 complaint of chest pain or the in-service TERA of solvents and gear oils.

4. Schedule the Veteran for a VA examination with an appropriate medical examiner and obtain an etiology opinion to determine the nature and etiology of the Veteran's claimed hypertension. The need for physical examination or telehealth evaluation is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. All indicated tests and studies should be accomplished and the findings then reported in detail.

The examiner should respond to the following question:

Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any currently present hypertension had its onset during the Veteran's active service, or is otherwise etiologically related to such service, to include any in-service exposure to environmental hazards (notwithstanding the fact that there may not be a presumed association)? The examiner must consider the Veteran's lay statements regarding the onset and continuity of his symptoms.

The VA examiner must provide an opinion whether the Veteran's hypertension is at least as likely as not related to in-service TERA of solvents and gear oils.

(Continued on the next page)

The medical opinion must support the conclusions reached with an analysis that is adequate to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided,
the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training).

(Continued on the next page)

Mariah N. Sim

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board M. Thompson, 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.

Analyze in VA Law Explorer