MULTIPLE SCLEROSIS

L. STEPANICK · 2026 · Case ID: A26035945

MIXED

Summary

The veteran, an Army veteran who served from June 1998 to July 2004, including service in Korea and the Georgia Army National Guard, appeals the denial of service connection for multiple sclerosis (MS), headaches, and an eye disability, and the remand of claims for sarcoidosis, hiatal hernia, lumbar spine, right knee, left knee, cervical spine, and bilateral lower extremity peripheral neuropathy. The Board granted service connection for MS, finding the evidence in equipoise and resolving doubt in the veteran's favor. This decision was based on a private physician's report linking the veteran's in-service neurological symptoms, including exposure to the anthrax vaccine, to the subsequent MS diagnosis, and the veteran's credible lay testimony regarding symptom onset and continuity. Service connection for headaches and an eye disability was also granted as secondary to MS, based on similar reasoning and a private nurse practitioner's report. The Board found the private physician's opinions probative and adequately reasoned. The remaining claims for sarcoidosis, hiatal hernia, and spinal/extremity conditions were remanded due to inadequate VA medical opinions, which failed to provide fully articulated rationales for their conclusions regarding service connection and toxic exposure risk activities (TERAs). The Board instructed the AOJ to obtain addendum opinions addressing the etiology of these conditions in relation to service and TERAs, and to adjudicate the knee and spine claims after the MS rating is finalized.

Rationale

Evidence in equipoise; Benefit of the doubt applied; Probative private physician opinion

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

240722-456858

Full Decision Text

Citation Nr: A26035945
Decision Date: 04/16/26 Archive Date: 04/16/26

DOCKET NO. 240722-456858
DATE: April 16, 2026

ORDER

Service connection for multiple sclerosis (MS) is granted.

Service connection for a headache disability as secondary to service-connected MS is granted.

Service connection for an eye disability as secondary to service-connected MS is granted.

REMANDED

Entitlement to service connection for sarcoidosis is remanded.

Entitlement to service connection for hiatal hernia is remanded.

Entitlement to service connection for a lumbar spine disability is remanded.

Entitlement to service connection for a right knee disability is remanded.

Entitlement to service connection for a left knee disability is remanded.

Entitlement to service connection for a cervical spine disability is remanded.

Entitlement to service connection for right lower extremity peripheral neuropathy is remanded.

Entitlement to service connection for left lower extremity peripheral neuropathy is remanded.

FINDINGS OF FACT

1. The Veteran has a current diagnosis of MS, and the evidence is at least in relative equipoise regarding whether such disability is causally related to her active military service.

2. The Veteran has a current diagnosis of a headache disability, and the evidence is at least in relative equipoise regarding whether such disability is causally related to her active military service, to include her service-connected MS.

3. The Veteran has a current diagnosis of an eye disability, and the evidence is at least in relative equipoise regarding whether such disability is causally related to her active military service, to include her service-connected MS.

CONCLUSIONS OF LAW

1. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for MS have been met. 38 U.S.C. §§ 1110, 1111, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for a headache disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for an eye disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served honorably in the United States Army from June 1998 to July 2004, including service in the Republic of Korea (Korea). The Veteran also served in the Georgia Army National Guard.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2024 rating decision issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) (the "March 2024 Rating Decision").

In July 2024, the Veteran submitted a Decision Review Request: Board Appeal, (Notice of Disagreement), VA Form 10182, and elected the Hearing docket (the "July 2024 NOD"). On October 30, 2025, the Veteran testified before the undersigned Veterans Law Judge (the "October 2025 Hearing"); a transcript of that hearing is of record.

Therefore, the Board may only consider (1) the evidence of record at the time of the March 2024 Rating Decision; and (2) any evidence submitted by the Veteran or her representative within ninety (90) days following the October 2025 Hearing. See 38 C.F.R. §?20.302(a).

If evidence was associated with the claims file during a period of time when additional evidence was not allowed, the Board has not considered it in this decision. See 38 C.F.R. § 20.300. Regarding the issues the Board is remanding, any such evidence will be considered by the AOJ on remand. Regarding the issues the Board is deciding, if the Veteran would like VA to consider any evidence that was added to the claims file that the Board could not consider, the Veteran may file a supplemental claim (VA Form 20-0995) and submit or identify this evidence. See 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the related claim, considering the new evidence in addition to the evidence previously considered. See id. Specific instructions for filing a supplemental claim are included with this decision.

SERVICE CONNECTION

Service
300. Regarding the issues the Board is remanding, any such evidence will be considered by the AOJ on remand. Regarding the issues the Board is deciding, if the Veteran would like VA to consider any evidence that was added to the claims file that the Board could not consider, the Veteran may file a supplemental claim (VA Form 20-0995) and submit or identify this evidence. See 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the related claim, considering the new evidence in addition to the evidence previously considered. See id. Specific instructions for filing a supplemental claim are included with this decision.

SERVICE CONNECTION

Service connection is warranted where the evidence of record demonstrates that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty during active military service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303.

Service connection for a disability requires competent and credible evidence of the following: (1) the existence of a current disability; (2) the existence of the disease or injury in service; and (3) a relationship or nexus between the current disability and any injury or disease during service. See Hickson v. West, 12 Vet. App. 247, 252 (1999).

Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability results from the service-connected disability. See 38 U.S.C. § 1110; Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023) (holding that section 1110 "requires compensation when a service-connected disease or injury is a but-for cause of a present-day disability"); see also 38 C.F.R. § 3.310.

1. Service connection for MS is granted.

The Veteran asserts that she is entitled to service connection for her current MS that is related to her active military service and which developed as a result of her toxic exposure risk activities (TERAs) during service, including her pre-deployment exposure to the anthrax vaccine.

After careful review, and for the reasons set forth below, the Board finds that service connection for the Veteran's MS is warranted in this case.

As an initial matter, regarding the element of a current diagnosis, in January 2026, the Veteran submitted a written statement authored by a private physician (M.M., M.D.) ("Dr. M.'s January 2026 Report") stating as follows: (1) the Veteran was diagnosed with MS in January 2024; (2) the Veteran's current MS symptomatology includes dizziness; fatigue; numbness; headaches; balance impairment; and visual disturbances; (3) the Veteran's MS symptoms during service included the following: dizziness; fatigue; and numbness; (4) the Veteran's MS symptoms during service are "well-recognized" as "early manifestations of MS" and were "present prior to formal diagnosis; and (5) the Veteran's MS symptoms have progressively worsened" since the Veteran's separation from service. Accordingly, in light of the foregoing, the Board finds that the first element required for the Veteran's service connection claims, a current diagnosis, has been established.

Turning to the second element of an in-service incident, the Veteran testified at the October 2025 Hearing as follows: (1) she was exposed to the anthrax vaccine during service and prior to her deployment to Korea; (2) the onset of her fatigue occurred in 2001 during her deployment to Korea; (3) the onset of her lower leg pain began in service during basic training and has continued ever since; and (4) the Veteran was treated for her lower leg pain during service with ice and motrin but kept running and experiencing leg pain, numbness, and lower extremity pain.

The Veteran's STRs confirm the following: (1) she received the anthrax vaccine in November 2000 prior to her deployment to Korea; (2) she was treated for extremity non-joint pain in August 1998; and (3) she was treated for a right tibia fracture in 1990.

In addition, Dr. M.'s January 2026 Report states that the Veteran experienced neurologic symptoms during active duty, including dizziness, fatigue, numbness, balance impairment, and visual disturbances, which are "well recognized as early manifestations" of MS and which "commonly precede formal diagnosis by years."

The Board finds that the Veteran is competent to describe the circumstances surrounding the onset of the symptoms of her MS, including her
following: (1) she received the anthrax vaccine in November 2000 prior to her deployment to Korea; (2) she was treated for extremity non-joint pain in August 1998; and (3) she was treated for a right tibia fracture in 1990.

The Board finds that the Veteran is competent to describe the circumstances surrounding the onset of the symptoms of her MS, including her in-service exposure to the anthrax vaccine, see Layno v. Brown, 6 Vet. App. 465, 469 (1994), as well as the observable and continued symptoms of her MS, including dizziness, fatigue, numbness, balance impairment, pain, and visual disturbance. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In addition, the Board finds the lay evidence submitted by the Veteran to be credible, as the statements are consistent with the facts and circumstances of her service as well as with the other evidence of record. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996); see also 38 U.S.C. § 1154(a). Accordingly, the Board finds the evidence of record to at least be in relative equipoise on this issue, and therefore, affording the Veteran the benefit of the doubt, the second element of the claim, an in-service incident, has also been established.

Finally, turning to the third element of a nexus between the Veteran's current MS and her active military service, the Board finds that this element has also been satisfied. Regarding that issue, Dr. M.'s January 2026 Report states that, given the Veteran's diagnosis of MS, her credible report of neurological symptoms that onset during service, and her exposure to the anthrax vaccine, it is Dr. M.'s opinion that "the Veteran's in-service neurologic symptoms, subsequent anthrax vaccination-related immune activation, and post-service progression to a definitive MS diagnosis represent a single, continuous disease process that began during active military service." Therefore, Dr. M. concludes, the Veteran's MS "is at least as likely as not related to active-duty service, with anthrax vaccination acting as an aggravating or triggering factor in the clinical manifestation of the disease, rather than a de novo cause." As grounds, Dr. M.'s January 2026 Report states as follows: (1) "in my review of her post-service records, no other risk factors for the development of MS were present/noted;"(2) "[w]hile there is consensus in the medical literature that vaccines do not directly cause [MS], peer-reviewed evidence supports the medically accepted principle that immune stimulation from vaccination may, in susceptible individuals, unmask or accelerate the clinical expression of pre-existing, subclinical autoimmune disease;" and (3) "[t]his mechanism is consistent with the Autoimmune/Inflammatory Syndrome Induced by Adjuvants (ASIA) framework and is particularly relevant in diseases such as MS, which are known to have a prolonged prodromal phase."

The Board finds that the positive findings contained in Dr. M.'s January 2026 Report carry significant probative weight, as the opinion was authored by a licensed physician possessing the necessary education, training, and expertise to provide a medical opinion and was based upon accurate factual premises with respect to the Veteran's service and medical history. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008); 38 C.F.R. § 3.159(a)(2). Moreover, the Veteran's lay statements carry significant probative weight, as they are consistent with other evidence of record regarding the location, type, and circumstances of the Veteran's military service. See 38 U.S.C. § 1154(a); see also Caluza, 7 Vet. App. at 511.

Accordingly, in light of the probative weight of Dr. M.'s January 2026 Report and the Veteran's STRs corroborating her exposure to the anthrax vaccine, as well as her active military service in Korea and in-service onset of MS symptomology, the Board finds that the evidence of record addressing whether her current diagnosis of MS arose in service is at least in approximate balance. See Guerrier
the Veteran's lay statements carry significant probative weight, as they are consistent with other evidence of record regarding the location, type, and circumstances of the Veteran's military service. See 38 U.S.C. § 1154(a); see also Caluza, 7 Vet. App. at 511.

Accordingly, in light of the probative weight of Dr. M.'s January 2026 Report and the Veteran's STRs corroborating her exposure to the anthrax vaccine, as well as her active military service in Korea and in-service onset of MS symptomology, the Board finds that the evidence of record addressing whether her current diagnosis of MS arose in service is at least in approximate balance. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Therefore, resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for MS is warranted, and the claim is granted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303(d).

2. Service connection for a headache disability as secondary to service-connected MS is granted.

The Veteran asserts that her current headache disability is causally related to her service-connected MS. After careful review and resolving all reasonable doubt in favor of the Veteran, the Board agrees and finds that the evidence of record is in relative equipoise regarding whether the Veteran's current headache disability is causally related to her service-connected MS.

As an initial matter, the Board notes that the Veteran has been awarded service connection for MS as set forth above.

In addition, the Board concludes that it is bound by the favorable finding in the March 2024 Rating Decision that the Veteran has a current diagnosis of a headache disability, as the report of a VA January 2024 VA headache examination (the "January 2024 VA Headache Report") confirms a diagnosis of migraine headache. See 38 C.F.R. § 3.104(c).

Therefore, the sole remaining question is whether the Veteran's diagnosed headache disability is causally related to her service-connected MS. See 38 C.F.R. § 3.310.

Regarding that question, Dr. M.'s January 2026 Report opines as follows: (1) the Veteran's headaches are a symptom of her now service-connected MS; (2) neurologic symptoms such as headaches are "well recognized as early manifestations" of MS and which "commonly precede formal diagnosis by years;" and (3) MS is "well recognized to have a prolonged prodromal phase with nonspecific neurologic symptoms that may precede diagnosis by many years."

In addition, in January 2026, the Veteran also submitted the report of a private nurse practitioner (T.D., N.P.) which also states that the Veteran's headaches are a symptom of her now service-connected MS.

The Board finds that, in conjunction with the relevant evidence of record, Dr. M.'s January 2026 Report offers probative medical evidence, as it was authored by an expert possessing the necessary education, training, and expertise to provide the requested opinion, it was based upon a review of the Veteran's medical treatment record and current medical history, and it adequately relied upon the relevant lay and medical evidence of record. See Nieves-Rodriguez, 22 Vet. App. at 302; 38 C.F.R. § 3.159(a)(2). The Board further finds that Dr. M.'s January 2026 Report establishes at least an approximate balance of positive and negative evidence regarding the merits of the issues material to the determination of the Veteran's claim. See Guerrieri, 4 Vet. App. at 470-71.

Accordingly, resolving all reasonable doubt in the Veteran's favor, the Board finds that her headache disability warrants service connection as secondary to her service-connected MS, and the claim is granted. See 38 C.F.R. §§ 3.102, 3.310.

3. Service connection for an eye disability as secondary to service-connected MS is granted.

The Veteran asserts that her current eye disability, claimed as visual disturbances, is causally related to her service-connected MS. After careful review and resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence of record is in relative equipoise regarding whether the Veteran's current eye disability is causally related to her service-connected MS.

As an initial matter, the Board notes that the Veteran has been awarded service connection for MS as set forth above.

Regarding the element of a current diagnosis, the Veteran's private treatment records dated January 2024 reflect that the Veteran's private neurologist diagnosed her with visual changes.

In addition, Dr. M.'s January 202
disability as secondary to service-connected MS is granted.

As an initial matter, the Board notes that the Veteran has been awarded service connection for MS as set forth above.

Regarding the element of a current diagnosis, the Veteran's private treatment records dated January 2024 reflect that the Veteran's private neurologist diagnosed her with visual changes.

In addition, Dr. M.'s January 2026 Report states that the Veteran's current MS symptomatology includes dizziness; fatigue; numbness; headaches; balance impairment; and visual disturbances. Accordingly, in light of the foregoing, the Board finds that the first element required for the Veteran's service connection claim, a current diagnosis, has been established.

Thus, the sole remaining question is whether the Veteran's diagnosed eye disability is causally related to her service-connected MS. See 38 C.F.R. § 3.310.

Regarding that question, Dr. M.'s January 2026 Report opines as follows: (1) neurologic symptoms such as visual disturbances are "well recognized as early manifestations" of MS and which "commonly precede formal diagnosis by years;" (2) MS is "well recognized to have a prolonged prodromal phase with nonspecific neurologic symptoms that may precede diagnosis by many years;" and (3) these symptoms were "present prior to formal diagnosis and have progressively worsened" since the Veteran's separation from service.

In addition, in January 2026, the Veteran also submitted the report of a private nurse practitioner (T.D., N.P.) which also states that the Veteran's visual disturbances are a symptom of her service-connected MS.

Accordingly, resolving all reasonable doubt in the Veteran's favor, the Board finds that her eye disability warrants service connection as secondary to her service-connected MS, and the claim is granted. See 38 C.F.R. §§ 3.102, 3.310.

REASONS FOR REMAND

The Board must remand an appeal to the AOJ for correction of an error on the part of the AOJ to satisfy its duties under 38 U.S.C. § 5103A if the error occurred prior to the date of the AOJ decision on appeal. See 38 C.F.R. § 20.802. Although the Board sincerely regrets the delay, the remaining claims must be remanded for correction of such errors.

1. Entitlement to service connection for sarcoidosis is remanded.

The Veteran asserts that she is entitled to service connection for sarcoidosis that is related to active military service.

In January 2024, the Veteran was afforded a VA respiratory examination which culminated in a report (the "January 2024 VA Respiratory Report") diagnosing the Veteran with sarcoidosis and opining that it is "less likely than not (likelihood is less than approximately balanced or nearly equal)" that the Veteran's sarcoidosis is "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." As grounds, the January 2024 VA Respiratory Report states as follows: (1) the cause of sarcoidosis is "unknown, but experts think it results from the body's immune system responding to an unknown substance;" (2) "[s]ome research suggests that infectious agents, chemicals, dust and a potential abnormal reaction to the body's own proteins (self-proteins) could be responsible for the formation of granulomas in people who are genetically predisposed; (3) "[t]here is
"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." As grounds, the January 2024 VA Respiratory Report states as follows: (1) the cause of sarcoidosis is "unknown, but experts think it results from the body's immune system responding to an unknown substance;" (2) "[s]ome research suggests that infectious agents, chemicals, dust and a potential abnormal reaction to the body's own proteins (self-proteins) could be responsible for the formation of granulomas in people who are genetically predisposed; (3) "[t]here is no cure for sarcoidosis, but most people do very well with no treatment or only modest treatment;" and (4) "[h]owever, sarcoidosis may last for years and may cause organ damage."

When VA undertakes to provide a VA medical opinion, it must ensure that the opinion is adequate, see Barr v. Nicholson, 21 Vet. App. 303, 312 (2007), which in this context requires that an examination report sufficiently inform the Board of a medical expert's judgment on a medical question, address all relevant theories of entitlement, rely upon accurate factual premises, including the Veteran's lay statements regarding symptomatology, and present a fully articulated, sound rationale. See Nieves-Rodriguez, 22 Vet. App. at 304.

However, in this case, the January 2024 VA Respiratory Report falls short of the requisite adequacy as it fails to provide a fully articulated rationale for the conclusion that the Veteran's current sarcoidosis is not due to or the result of her active military service, to include her specific TERA. See id.

Accordingly, the failure to procure an adequate medical opinion in connection with the Veteran's sarcoidosis claim prior to the March 2024 Rating Decision constituted a pre-decisional duty to assist error, and remand is required to obtain the medical opinion necessary to determine whether the Veteran's current sarcoidosis is related to active military service. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991); 38 C.F.R. § 20.802(a).

2. Entitlement to service connection for hiatal hernia is remanded.

The Veteran asserts that she is entitled to service connection for a hiatal hernia that is related to active military service.

In January 2024, the Veteran was afforded VA hernia examination which culminated in a report (the "January 2024 VA Hernia Report") diagnosing the Veteran with a hiatal hernia and opining that it is "less likely than not (likelihood is less than approximately balanced or nearly equal)" that the Veteran's hernia is "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." As grounds the January 2024 VA Hernia Report states that "[t]here are risk factors outside of military service (weight) that either far outweigh the factors identified in the TERA [sic]." However, the VA examiner did not address whether such outside risk factors are responsible for the Veteran's hiatal hernia or otherwise address their involvement in the disease progression.

When VA undertakes to provide a VA medical opinion, it must ensure that the opinion is adequate, see Barr, 21 Vet. App. at 312, which in this context requires that an examination report sufficiently inform the Board of a medical expert's judgment on a medical question, address all relevant theories of entitlement, rely upon accurate factual premises, including the Veteran's lay statements regarding symptomatology, and present a fully articulated, sound rationale. See Nieves-Rodriguez, 22 Vet. App. at 304.

However, in this case, the January 2024 VA Hernia Report falls short of the requisite adequacy as it fails to provide a fully articulated rationale for the conclusion that the Veteran's current hernia is not due to or the result of her TERAs and it fails to address whether the Veteran's current hiatal hernia is otherwise related to active military service. See id.

Accordingly, the failure to procure an adequate medical opinion in connection with the Veteran's hiatal hernia claim prior to the March 2024 Rating Decision constituted a pre-decisional duty to assist error, and remand is required to obtain the medical opinion necessary to determine whether the Veteran's current hiatal hernia condition is directly related to active military service. See Colvin, 1 Vet. App. at 175; 38 C.F.R. § 20
to provide a fully articulated rationale for the conclusion that the Veteran's current hernia is not due to or the result of her TERAs and it fails to address whether the Veteran's current hiatal hernia is otherwise related to active military service. See id.

3. Entitlement to service connection for a lumbar spine disability is remanded.

The Veteran asserts that she is entitled to service connection for a lumbar spine condition that is related to active military service.

In January 2024, the Veteran was afforded a VA spine examination which culminated in a report (the "January 2024 VA Spine Report") diagnosing the Veteran with a lumbosacral strain and opining that it is "less likely than not (likelihood is less than approximately balanced or nearly equal)" that the Veteran's lumbar spine disability is "caused by the claimed in-service injury, event, or illness" on the following grounds: (1) the Veteran's service treatment records dated March 1999 reflect her report of low back pain for three (3) days; (2) private treatment records dated September 2016 reflect that the Veteran starting having low back pain in March 2016; (3) despite the Veteran's in-service treatment for low back pain, "it was the only complaint" related to her lumbar spine condition and "was an acute state;" (4) there are "no findings" in the record "to establish chronicity of care;" and (5) treatment records are silent for back pain between 1999 to 2016, and "thus a connection cannot be established."

However, in this case, the January 2024 VA Spine Report falls short of the requisite adequacy as fails to adequately address whether the Veteran's current lumbar spine disability is related to active military service with consideration of other factors in addition to the absence of documented ongoing treatment. See id.

Accordingly, the failure to procure an adequate medical opinion in connection with the Veteran's lumbar spine claim prior to the March 2024 Rating Decision constituted a pre-decisional duty to assist error, and remand is required to obtain the medical opinion necessary to determine whether the Veteran's current lumbar spine condition is directly related to active military service. See Colvin, 1 Vet. App. at 175; 38 C.F.R. § 20.802(a).

4. Entitlement to service connection for a right knee disability is remanded.

5. Entitlement to service connection for a left knee disability is remanded.

6. Entitlement to service connection for a cervical spine disability is remanded.

7. Entitlement to service connection for right lower extremity peripheral neuropathy is remanded.

8. Entitlement to service connection for left lower extremity peripheral neuropathy is remanded.

The Veteran has described symptoms associated with her left and right lower extremities and her spine. As service connection for MS has been granted herein, and the record raises the question of whether these symptoms are secondary to that condition, the claims are remanded as inextricably intertwined with the rating activity for that now service-connected condition. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue).

Accordingly, these matters are REMANDED for the following action:

1. Obtain an addendum opinion from an appropriate clinician to address the etiology of the Veteran's current respiratory disability. If an examination is deemed necessary to respond to the question posed, one should be scheduled. The clinician is asked to address the following after reviewing the claims file:

Is it as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher
-connected condition. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue).

Accordingly, these matters are REMANDED for the following action:

Is it as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's respiratory disability was incurred in service or caused by an in-service injury, event, or illness? Please explain why or why not, specifically considering and discussing the following: (i) the totality of the respiratory diagnoses of record, including but not limited to sarcoidosis; and (ii) the Veteran's total potential toxic exposure throughout her military service and the synergistic, combined effect of all of the Veteran's toxic exposure risk activities (TERAs), to include in her role as a combat nurse.

Please include a complete rationale for the opinion provided. If you cannot provide the requested opinion without resorting to speculation, please expressly indicate this and state why it is so.

2. Obtain an addendum opinion from an appropriate clinician to address the etiology of the Veteran's hiatal hernia. If an examination is deemed necessary to respond to the question posed, one should be scheduled. The clinician is asked to address the following after reviewing the claims file:

Is it as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's hiatal hernia was incurred in service or caused by an in-service injury, event, or illness? Please explain why or why not, specifically considering and discussing the Veteran's total potential toxic exposure throughout her military service and the synergistic, combined effect of all of the Veteran's toxic exposure risk activities (TERAs), to include in her role as a combat nurse.

Please include a complete rationale for the opinion provided. If you cannot provide the requested opinion without resorting to speculation, please expressly indicate this and state why it is so.

3. Obtain an addendum opinion from an appropriate clinician to address the etiology of the Veteran's current lumbar spine disability. If an examination is deemed necessary to respond to the question posed, one should be scheduled. The clinician is asked to address the following after reviewing the claims file:

Is it as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's lumbar spine disability was incurred in service or caused by an in-service injury, event, or illness? Please explain why or why not.

Please include a complete rationale for the opinions provided. If you cannot provide the requested opinions without resorting to speculation, please expressly indicate this and state why it is so.

The clinician is reminded that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, may be considered an insufficient rationale. Likewise, the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, may be considered an insufficient rationale.

4. Adjudicate the issues of entitlement to service connection for right and left knee disabilities, right and left lower extremity peripheral neuropathy, and a cervical spine disability after completion of the rating activity for the award of service connection for multiple sclerosis.

L. STEPANICK

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board H. Marsdale, 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