Case A26034826

MICHAEL J. SKALTSOUNIS · 2026 · Case ID: A26034826

MIXED

Summary

The Veteran served from August 2010 to February 2011, including service in the Southwest Asia theater of operations as a firefighter and Aerospace Medical Service Journeyman. The Veteran appeals the denial of service connection for hyperlipidemia, cervical strain (also claimed as pinched nerve), prostatitis, GERD, diabetes mellitus type II, kidney stone, left shoulder strain, canker sores/mouth ulcers, lumbar spine disorder, and peripheral neuropathy in the left lower and upper extremities. The Board dismissed the hyperlipidemia claim due to withdrawal by the Veteran. Service connection for cervical strain was granted, with the Board finding the private medical opinion more probative than the VA examination, which was deemed inadequate for failing to fully address the Veteran's service history and symptoms. Service connection for prostatitis was also granted, with the Board finding the VA examiner's negative nexus opinion insufficiently reasoned and giving the Veteran the benefit of the doubt based on his testimony and a fellow service member's statement. Service connection for GERD was granted as secondary to the Veteran's service-connected PTSD, relying on a private medical opinion that linked the two conditions through the physiological effects of chronic stress. The remaining claims for diabetes mellitus type II, kidney stone, left shoulder strain, canker sores/mouth ulcers, lumbar spine disorder, and peripheral neuropathy in the left lower and upper extremities were remanded for further development, including new VA examinations and opinions, due to inadequate prior examinations and duty to assist errors.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210527-162701

Full Decision Text

Citation Nr: A26034826
Decision Date: 04/15/26 Archive Date: 04/15/26

DOCKET NO. 210527-162701
DATE: April 15, 2026

ORDER

Service connection for hyperlipidemia is dismissed.

Service connection for cervical strain (also claimed as pinched nerve) is granted.

Service connection for prostatitis is granted.

Service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected posttraumatic stress disorder (PTSD), is granted.

REMANDED

Service connection for diabetes mellitus, type II, is remanded.

Service connection for kidney stone is remanded.

Service connection for shoulder strain, left, remanded.

Service connection for canker sores, ulcers in mouth, is remanded.

Service connection for lumbar spine disorder is remanded.

Service connection for peripheral neuropathy, left lower extremity, is remanded.

Service connection for peripheral neuropathy, left upper extremity, is remanded.

FINDINGS OF FACT

1. On November 29, 2024, prior to the promulgation of a Board of Veterans' Appeals (Board) decision in the appeal, the Board received notification from the Veteran's representative, requesting withdrawal of the Veteran's appeal of entitlement to service connection for hyperlipidemia.

2. The most probative and persuasive evidence shows that it is at least as likely as not that the Veteran's cervical strain (also claimed as pinched nerve) is a result of the Veteran's service.

3. The most probative and persuasive evidence shows that it is at least as likely as not that the Veteran's prostatitis is a result of the Veteran's service.

4. The most probative and persuasive evidence shows that it is at least as likely as not that the Veteran's gastroesophageal reflux disease (GERD) is a result of the Veteran's service or service-connected disability.

CONCLUSIONS OF LAW

1. The criteria for withdrawal of the appeal of entitlement to hyperlipidemia have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205.

2. The criteria for entitlement to service connection for cervical strain (also claimed as pinched nerve) have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.3.

3. The criteria for entitlement to service connection for prostatitis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.3.

4. The criteria for entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected PTSD, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310, 4.3.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from August 2010 to February 2011.

Also, the Board notes that the Veteran served in the Southwest Asia theater of operations; therefore, he is a Persian Gulf Veteran. See January 2023 VA Memo. Further, the Veteran has verified presumptive toxic exposure risk activity (TERA). See December 2022, May 2023 VA Memos. Finally, the Veteran had an MOS of Fire Protection Craftsman, and an MOS of Aerospace Medical Service Journeyman.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 18, 2021, Appeals Modernization Act (AMA) rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) of the Veterans Benefits Administration (VBA), which is the Agency of Original Jurisdiction (AOJ).

On May 27, 2021, the Veteran filed a VA Forms 10182, Decision Review Request: Board Appeal (Notice of Disagreement), reflecting his decision to appeal the previously indicated rating decision via the hearing docket. Under the AMA, when a claimant seeks appellate review through the Board's hearing review docket, the Board may consider the evidence of record at the time of the AOJ decision on appeal, additional evidence submitted on the date of the Board hearing (including testimony), and additional evidence submitted within 90 days following the hearing. 38 U.S.C. § 7113(b); 38 C.F.R. §§ 20.302(a), 3.2500, 3.250
On May 27, 2021, the Veteran filed a VA Forms 10182, Decision Review Request: Board Appeal (Notice of Disagreement), reflecting his decision to appeal the previously indicated rating decision via the hearing docket. Under the AMA, when a claimant seeks appellate review through the Board's hearing review docket, the Board may consider the evidence of record at the time of the AOJ decision on appeal, additional evidence submitted on the date of the Board hearing (including testimony), and additional evidence submitted within 90 days following the hearing. 38 U.S.C. § 7113(b); 38 C.F.R. §§ 20.302(a), 3.2500, 3.2501.

The Board issued its docket letter on May 28, 2021.

On December 9, 2024, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the claims file. The Veteran submitted additional evidence within the 90 days following the Board hearing, which has been considered by the Board.

Preliminary note

The Board notes that, on November 29, 2024, prior to the promulgation of a Board decision in the appeal, the Board received notification from the Veteran's representative, requesting withdrawal of the Veteran's claim of entitlement to service connection for hyperlipidemia. The Veteran confirmed this request for dismissal during the December 9, 2024, Board hearing. Accordingly, the Board will dismiss the Veteran's claim of entitlement to service connection for hyperlipidemia.

Also, the Board notes that another decision is being issued as to the Veteran's separate appeal in Docket No. 210714-172346.

1. Service connection for hyperlipidemia is dismissed.

As previously noted, on November 29, 2024, prior to the promulgation of a Board decision in the appeal, the Board received notification from the Veteran's representative, requesting withdrawal of the Veteran's claim of entitlement to service connection for hyperlipidemia. The Veteran confirmed this request for dismissal during the December 9, 2024, Board hearing.

The Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105.

An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.205. Withdrawal may be made by the appellant or by his authorized representative. Id.

The Board finds that the language used by the Veteran during the December 9, 2024, Board hearing is clear and unambiguous, and is indicative of the Veteran's informed and purposeful decision. DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011).

The Veteran has clearly withdrawn his claim of entitlement to service connection for hyperlipidemia. As such, the Board finds that it does not have jurisdiction to review the appeal pertaining to such claim. Accordingly, service connection for hyperlipidemia is dismissed.

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303.

Service connection may also be granted for any disease diagnosed after discharge from service when all of the evidence, including lay evidence, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d).

In order to establish service connection for a claimed disability, the following three elements must be satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship nexus) between the present disability and the disease or injury incurred or aggravated during service. Hickson v. West, 12 Vet. App. 246 (1999).

Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R.§ 3.310 (a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The governing regulation has been interpreted to permit a grant of service connection not only for a disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). In the case of Ward v. Wilkie, the United States Court of Appeals for Veterans Claims held that, for secondary service connection, "aggravation" need not be permanent in nature. 31 Vet. App. 233, 241-42 (2019).

In Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023), the United States Court of Appeals for the Federal Circuit held that secondary service connection under 38 U.S.C. § 1110 is warranted for any increase in a nonservice-connected disability that is due to a service-connected disability, including where a service-connected disability precludes treatment for a nonservice-connected disability. Id. at 1363-1365. That decision also found unlawful the VA regulation that required evidence establishing a pre-aggravation baseline before secondary service connection based on aggravation could be granted. Id. at 1366 ("We decide this case based on our interpretation of § 1110 alone. To the extent that the VA also applied 38 C.F.R. § 3.310(b) to reject Mr. Spicer's theory of compensation, that regulation is unlawful as inconsistent with 38 U.S.C. § 1110.").

In evaluating the evidence in an appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in doing so, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to the evidence. Jandreau v. Nicholson, 492 F.3d 1372 (2007).

Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-449 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, and a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). In concluding that no relationship between a current disability and military service exists, the examiner may not rely solely on an absence of medical records and not consider any available competent and credible lay statements. Dalton v. Nicholson, 21 Vet. App. 23 (2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336-1336 (2006).

Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).

In adjudicating a claim of service connection, the Board is required to evaluate evidence based on places, types, and circumstances of service, as shown by the veteran's military records and all pertinent medical and lay evidence. Hayes v. Brown, 5 Vet. App. 60, 66 (1993); see also 38 U.S.C. § 1154(a).

When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter
). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).

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. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in approximate balance, with the veteran prevailing in either event. 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

2. Service connection for cervical strain (also claimed as pinched nerve) is granted.

The Veteran claims entitlement to service connection for a cervical disability.

In a January 2021 VA neck (cervical spine) examination, a VA examiner diagnosed the Veteran with cervical strain. The VA examiner issued a negative nexus opinion and explained, as support for the opinion, that there were no symptoms of the claimed disability while the Veteran was in service.

During the December 9, 2024, Board hearing, the Veteran testified that he deployed to Oman as a firefighter and did training, rigorous training with pulling, lifting, shoving, all the while wearing an hour long air pack, which was heavier than a normal 30 minutes civilian air pack, and also the helmet being on the entire time, going from the top of the trucks down to the bottom of the trucks, multiple maneuvers that would require him to move his neck and back around. And also, there was an incident when he was at the base gym in Oman, playing basketball with a group of guys, and he had a significant impact with another person who came from his left to right, hit his head with his body, and immediately went down, clocked him very hard. Ever since then, he developed numbness, tingling, weakness on the left side, arm and leg, and sometimes there was pain that went with that, like a throbbing pain too.

In a March 2022 private opinion, a private examiner endorsed the Veteran's diagnosis of cervical strain. The private examiner addressed and considered the Veteran's military and medical history and explained that military service was notoriously difficult on the back and neck, with the heavy lifting and carrying of gear and ammunition, often over long periods, and sitting for extended periods in jeeps and tanks, often in uncomfortable non-ergonomic positions. The neck suffered a great deal due to the weight of the Kevlar bullet proof vest and helmet. Vertical loading on the cervical spine caused muscle fatigue and injury to the spinal column. As such, the private examiner opined that it was at least as likely as not that the claimed neck disability was incurred in or caused by military service.

After careful consideration, the Board finds the January 2021 VA neck (cervical spine) examination of reduced probative value as to the nature and etiology of the Veteran's claimed neck disability. Particularly, the VA examiner did not thoroughly address and consider the circumstances of the Veteran's service and his history of symptoms. Conversely, the Board finds the March 2022 private opinion of significant probative value. Particularly, the private examiner did address and consider the Veteran's service history and history of symptoms and diagnosis in rendering a positive nexus opinion.

Accordingly, giving the Veteran the benefit of the doubt, service connection for cervical strain (also claimed as pinched nerve) is warranted.

3. Service connection for prostatitis is granted.

The Veteran claims entitlement to service connection for prostatitis.

In a January 2021VA male reproductive organ conditions examination, the Veteran was diagnosed with prostatitis. The VA examiner issued a negative nexus opinion and explained, as supporting rationale, that there were no symptoms of the claimed disability while the Veteran was in service. Also, it was unlikely that such an infection would affect the Veteran while he was in service and then reoccur subsequently after service. As such, there were likely separate causes for in-service prostatitis and prostatitis after service. However
benefit of the doubt, service connection for cervical strain (also claimed as pinched nerve) is warranted.

3. Service connection for prostatitis is granted.

The Veteran claims entitlement to service connection for prostatitis.

In a January 2021VA male reproductive organ conditions examination, the Veteran was diagnosed with prostatitis. The VA examiner issued a negative nexus opinion and explained, as supporting rationale, that there were no symptoms of the claimed disability while the Veteran was in service. Also, it was unlikely that such an infection would affect the Veteran while he was in service and then reoccur subsequently after service. As such, there were likely separate causes for in-service prostatitis and prostatitis after service. However, the VA examiner did not explain the two different set of circumstances that would cause the Veteran to become ill with the same disorder, that is, prostatitis, while in service and after separation from service.

During the December 9, 2024, Board hearing, the Veteran testified that he developed symptoms in his prostate area onboard de aircraft on his way to Oman. It was a long flight and he remained seated pretty much the entire time. When he arrived in Oman he already had developed chafing, discomfort and ultimately pain and swelling in the perineum, frequent urination and a weak stream. He had never quite recovered. He would have pain on the way to the rest room. Eventually, he sought medical treatment, was diagnosed and told this would be a lifelong disorder.

In February 2025, the Veteran submitted a statement from a fellow service member stating that, while deployed to Oman along with the Veteran, he noticed that the Veteran was walking with a peculiar gait. He asked the Veteran about it. The Veteran explained that he was experiencing moderate to severe pain in his perineal area.

After careful consideration, the Board finds the January 2021VA male reproductive organ conditions examination of reduced probative values as to the negative conclusion regarding the nature and etiology of the Veteran's claimed prostatitis. Particularly, the VA examiner merely relied on the absence of symptoms while the Veteran was in service. Also, the Board finds that the VA examiner's assessment about how unlikely it was for the Veteran's disability to have its onset in service and to have persisted after separation from service, was not supported by substantial analysis. Moreover, the Board finds that such unsupported assessment can be reasonably interpreted as indirectly conceding the possibility that the Veteran's disability at present could have some relation with the circumstances of his service. Further, the Board finds that this interpretation has additional support in the statement of the Veteran's fellow service member.

Accordingly, giving the Veteran the benefit of the doubt, the Board finds that service connection for prostatitis is also warranted.

4. Service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected posttraumatic stress disorder (PTSD), is granted.

The Veteran claims entitlement to service connection for GERD.

At the outset, the Board notes that the Veteran is service connected for PTSD. See March 18, 2021, rating decision.

In a January 2021 VA esophageal conditions examination, a VA examiner diagnosed the Veteran with GERD. The VA examiner issued no nexus opinion as to the Veteran's GERD.

In a March 2025 private opinion, a private examiner endorsed the Veteran's GERD diagnosis. The private examiner addressed and considered the Veteran's military and medical history and explained that there was a definite link between psychological disorders and GERD through the chronic hyper activation of the sympathetic nervous system in PTSD, that is, "the fight or flight syndrome." Specifically, in a stressful situation, the body would carry energy to the heart, lungs and large muscles (arms, legs) to be able to fight or flee. Nonessential body processes such as digestion would be temporarily stopped. Digestion was a complex process involving digestive enzymes, peristalsis, etc. After the stress was relieved somewhat, the digestive process started again, however this stop-start action could cause the typical symptoms of GERD. Consistently, increasing research had drawn links between GERD and PTSD. Thus, the private examiner opined that it was at least as likely as not that the Veteran's GERD was secondary to his service-connected PTSD.

After careful consideration, the Board finds the March 2025 private opinion of significant probative value as to the nature and etiology of the Veteran's GERD. Particularly, the private examiner addressed and considered the Veteran's service history and history of symptoms and diagnosis in rendering a positive nexus opinion as to the relationship, on a secondary basis, between the Veteran's GERD and his service-connected PTSD.

Accordingly, giving the Veteran the benefit of the doubt, service connection for gastroesophageal
GERD. Consistently, increasing research had drawn links between GERD and PTSD. Thus, the private examiner opined that it was at least as likely as not that the Veteran's GERD was secondary to his service-connected PTSD.

Accordingly, giving the Veteran the benefit of the doubt, service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected posttraumatic stress disorder (PTSD), is also warranted.

REASONS FOR REMAND

1. Service connection for diabetes mellitus, type II, is remanded.

2. Service connection for kidney stone is remanded.

3. Service connection for shoulder strain, left, remanded.

The Veteran claims entitlement to service connection for diabetes mellitus, type II, kidney stone and left shoulder strain.

At the outset, the Board notes that the Veteran has diagnoses of diabetes mellitus, type II, kidney stone and left shoulder strain. See January 2021 VA diabetes mellitus examination, January 2021 VA kidney conditions examination and January 2021 VA shoulder and arm conditions examination.

However, the VA examiner merely relied on the absence of in-service symptoms as a rationale for the corresponding negative nexus opinions.

As such, these VA opinions are of reduced probative value as to the nature and etiology of the Veteran's claimed disabilities.

Under the AMA, the Board must remand to the AOJ to correct pre-decisional duty to assist errors (including when the AOJ failed to make reasonable efforts to obtain VA treatment records or relevant federal or private treatment records, failed to obtain a VA examination, or provided an inadequate VA examination or opinion). 38 C.F.R. § 20.802.

Thus, the Board finds that the AOJ's oversight in not developing the Veteran's service connection claims requires a remand of the claims to properly carry out VA's statutory duties under 38 C.F.R. § 20.802(a); that is, to provide the Veteran another examination and opinion. See also 38 C.F.R. § 3.159(c)(4); Stefl v. Nicholson, 21 Vet. App. 120, 124-125 (2007).

4. Service connection for canker sores, ulcers in mouth, is remanded.

The Veteran claims entitlement to service connection for canker sores, ulcers in mouth.

The Board notes that the Veteran has a diagnosis of aphthous ulcer. See VA treatment records, October 2017; March 18, 2021, rating decision.

The Veteran has not been afforded a VA examination to determine the nature and etiology of his claimed disability.

After due consideration, the Board finds that the evidence recounted above suffices the low threshold to trigger VA's duty to assist by providing a medical examination and opinion to determine the nature and etiology of the Veteran's claimed disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006).

5. Service connection for lumbar spine disorder is remanded.

6. Service connection for peripheral neuropathy, left lower extremity, is remanded.

7. Service connection for peripheral neuropathy, left upper extremity, is remanded.

The Veteran claims entitlement to service connection for a lumbar spine disability and peripheral neuropathy of the left lower and upper extremities.

VA treatment records show the Veteran's reporting of low back pain and episodes of paresthesias involving the left side of his body and the left side of his face. He also has reported pain in the left upper and lower extremities. See VA treatment records, August 2017, January and October 2018. Also, a January 2018 sensory nerve conduction study was interpreted as "abnormal." Particularly, no electrodiagnostic evidence of neuropathy or radiculopathy was noted. However, the examiner recommended: "[c]onsider obtaining baseline imaging for the lumbar spine as patient states he has on-and-off pain in this area."

neuropathy of the left lower and upper extremities.

In a January 2021 VA back (thoracolumbar spine) examination, a VA examiner asserted that there was insufficient evidence to diagnose a lumbar spine disability.

The Veteran also underwent a January 2021 VA peripheral nerves conditions examination in which the VA examiner asserted that, although the Veteran reported left peripheral neuropathy symptoms, there was insufficient evidence to diagnose a peripheral nerves disability. The VA examiner qualified the Veteran's symptoms as transient left arm and leg paresthesia.

After careful consideration, the Board finds the January 2021 VA back and peripheral nerves examinations of reduced probative value as to the nature and etiology of the Veteran's claimed back and peripheral nerve disabilities. Particularly, the VA examiner did not thoroughly address and consider the Veteran's medical history pertaining to his claimed back and peripheral nerve disabilities.

The matters are REMANDED for the following action:

1. The Veteran must be afforded a VA examination by another examiner with appropriate expertise to determine the nature and etiology of the Veteran's claimed diabetes mellitus, type II. Any and all studies, tests, and evaluations that are deemed necessary should be conducted. The claims file, including this remand, should be reviewed by the examiner. After a review of the Veteran's claims file and an examination of the Veteran, the examiner should provide an opinion responding to the following:

(a) Whether it is at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's diabetes mellitus, type II, originated during, or is etiologically related to, active-duty service.

(b) Whether it is at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's diabetes mellitus, type II, is proximately due to or the result of, or aggravated by, a service-connected disability.

2. The Veteran must be afforded a VA examination by another examiner with appropriate expertise to determine the nature and etiology of the Veteran's claimed kidney stone. Any and all studies, tests, and evaluations that are deemed necessary should be conducted. The claims file, including this remand, should be reviewed by the examiner. After a review of the Veteran's claims file and an examination of the Veteran, the examiner should provide an opinion responding to the following:

(a) Whether it is at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's kidney stone originated during, or is etiologically related to, active-duty service.

(b) Whether it is at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's kidney stone is proximately due to or the result of, or aggravated by, a service-connected disability.

3. The Veteran must be afforded a VA examination by another examiner with appropriate expertise to determine the nature and etiology of the Veteran's claimed left shoulder strain. Any and all studies, tests, and evaluations that are deemed necessary should be conducted. The claims file, including this remand, should be reviewed by the examiner. After a review of the Veteran's claims file and an examination
originated during, or is etiologically related to, active-duty service.

3. The Veteran must be afforded a VA examination by another examiner with appropriate expertise to determine the nature and etiology of the Veteran's claimed left shoulder strain. Any and all studies, tests, and evaluations that are deemed necessary should be conducted. The claims file, including this remand, should be reviewed by the examiner. After a review of the Veteran's claims file and an examination of the Veteran, the examiner should provide an opinion responding to the following:

(a) Whether it is at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's left shoulder strain originated during, or is etiologically related to, active-duty service.

(b) Whether it is at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's left shoulder strain is proximately due to or the result of, or aggravated by, a service-connected disability.

4. The Veteran must be afforded a VA examination by an examiner with appropriate expertise to determine the nature and etiology of any canker sores, ulcers in mouth. Any and all studies, tests, and evaluations that are deemed necessary should be conducted. The claims file, including this remand, should be reviewed by the examiner. After a review of the Veteran's claims file and an examination of the Veteran, the examiner should provide an opinion responding to the following:

(a) The examiner should confirm if the Veteran has a diagnosis of canker sores, ulcers in mouth and/or aphthous ulcers.

(b) Whether it is at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that any canker sores, ulcers in mouth and/or aphthous ulcers originated during, or are etiologically related to, active-duty service.

(c) Whether it is at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's canker sores, ulcers in mouth and/or aphthous ulcers are proximately due to or the result of, or aggravated by, a service-connected disability.

5. The Veteran must be afforded a VA examination by another examiner with appropriate expertise to determine the nature and etiology of the Veteran's claimed lumbar spine disability. Any and all studies, tests, and evaluations that are deemed necessary should be conducted. The claims file, including this remand, should be reviewed by the examiner. After a review of the Veteran's claims file and an examination of the Veteran, the examiner should provide an opinion responding to the following:

(a) The examiner should confirm if the Veteran has a diagnosis of a lumbar spine disability.

(b) Whether it is at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's lumbar spine disability originated during, or is etiologically related to, active-duty service.

(c) Whether it is at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's lumbar spine disability is proximately due to or the result of, or aggravated by, a service-connected disability.

6. The Veteran must be afforded a VA examination by another examiner with appropriate expertise to determine the nature and etiology of the Veteran's claimed peripheral left lower and upper extremities disability. Any and all studies, tests, and evaluations that are deemed necessary should be conducted. The claims file, including this remand, should be reviewed by the examiner. After a review of the Veteran's claims file and an examination of the Veteran, the examiner should provide an opinion responding to the following:

(a) The examiner should confirm if the Veteran has a diagnosis of peripheral left lower and upper extremities disability.

(b) Whether it is at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that any peripheral left lower and upper extremities disability originated during, or is etiologically related to, active-duty service.

(c) Whether it is at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that any peripheral left lower and upper extremities disability is proximately due to or the result of, or aggravated by, a service-connected disability.

*The examiner is advised that
provide an opinion responding to the following:

(a) The examiner should confirm if the Veteran has a diagnosis of peripheral left lower and upper extremities disability.

*The examiner is advised that the Veteran is considered competent to be able to report injuries and symptoms, and that his reports must be considered in formulating the requested opinions. If the Veteran's reports are discounted, the examiner should provide a reason for doing so.

*A complete rationale should be given for all opinions and conclusions expressed. If any opinion cannot be given without resorting to speculation, the examiner should explain why and 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), the record (additional facts are required), or the examiner does not have the knowledge or training that is necessary to provide the requested opinion.

Michael J. Skaltsounis

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Aquino Ramos, Carlos M.

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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