Citation Nr: 22023713 Decision Date: 04/22/22 Archive Date: 04/22/22 DOCKET NO. 18-41 716 DATE: April 22, 2022 ORDER Entitlement to an initial rating in excess of 10 percent for tinnitus is dismissed. Entitlement to service connection for chronic kidney disease as due to exposure to contaminated drinking water at Camp LeJeune is granted. Entitlement to service connection for obstructive sleep apnea as secondary to service-connected depressive disorder with traumatic brain injury (TBI) is granted. Entitlement to service connection for a colon disorder, namely chronic constipation and hemorrhoids, as secondary to service-connected depressive disorder with TBI is granted. Entitlement to service connection for an acquired psychiatric disorder, namely generalized anxiety disorder and somatic symptom disorder, is granted. REMANDED Entitlement to service connection for pseudofolliculitis barbae, to include as due to exposure to contaminated drinking water at Camp LeJeune, is remanded. Entitlement to service connection for a lumbar spine disorder is remanded. Entitlement to service connection for a prostate disorder, to include as due to exposure to contaminated drinking water at Camp LeJeune, is remanded. Entitlement to service connection for a urinary tract disorder, to include as due to exposure to contaminated drinking water at Camp LeJeune, is remanded. FINDINGS OF FACT 1. During the December 2021 hearing, and prior to the promulgation of a decision in the appeal, the Veteran withdrew his claim of entitlement to a rating in excess of 10 percent for tinnitus. 2. Resolving reasonable doubt in favor of the Veteran, the Veteran's currently diagnosed chronic kidney disease is etiologically related to in-service exposure to contaminated drinking water at Camp LeJeune. 3. The Veteran's currently diagnosed obstructive sleep apnea was caused and/or aggravated by service-connected depressive disorder with TBI. 4. The Veteran's currently diagnosed colon disorder, namely chronic constipation and hemorrhoids, was caused and/or aggravated by service-connected depressive disorder with TBI. 5. The Veteran's acquired psychiatric disorder, namely generalized anxiety disorder and somatic symptom disorder, had its onset during service or is etiologically related to his active service or is caused or aggravated by his service connected disabilities. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the Veteran have been met as to the issue of a rating in excess of 10 percent for tinnitus. 38 U.S.C.§ 7105; 38 C.F.R. § 19.55. 2. The criteria for service connection for chronic kidney disease, to include as due to exposure to contaminated drinking water at Camp LeJeune, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 3. The criteria for service connection for obstructive sleep apnea as secondary to service-connected depressive disorder with TBI have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for a colon disorder, namely chronic constipation and hemorrhoids, as secondary to service-connected depressive disorder with TBI have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for service connection for an acquired psychiatric disorder, namely generalized anxiety disorder, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from August 1977 to August 1981. These matters come to the Board of Veterans' Appeals (Board) on appeal from April 2017, May 2017, and January 2018 rating decisions issued by the Department of Veterans Affairs (VA). In December 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is included in the claims file. Following the hearing, the record was held open for 30 days to allow for the submission of additional evidence and argument. This requested extension period has now expired. The Veteran asserts that he has PTSD as a result of in-service events. Post-service treatment records reveal a diagnosis of PTSD, depressive disorder, and generalized anxiety disorder. The Board notes that the Veteran is already service-connected for depressive disorder. As the record reflects various psychiatric claims, the issue has been recharacterized to encompass all the Veteran's psychiatric diagnoses under a single claim for an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Withdrawal The Board may dismiss any appeal which 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. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. Id. The Veteran withdrew his appeal for entitlement to a rating in excess of 10 percent for tinnitus during his December 2021 Board hearing. The Veteran was accompanied by his representative and the Board apprised him of the consequences of withdrawing his appeal. The Board thus concludes that his withdrawal was made with knowledge of the consequences. See DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011); Acree v. O'Rourke, 891 F.3d 1009 (Fed. Cir. 2018). As there remains no allegations of errors of fact or law for appellate consideration regarding the above-mentioned issues, the Board does not have jurisdiction over the issue, and it 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. § 1131; 38 C.F.R. § 3.303(a). Service connection requires: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Veterans who, during active service, had no less than 30 days (consecutive or nonconsecutive) of service at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987, shall be presumed to have been exposed to contaminants in the water supply during such service, unless there is affirmative evidence of non-exposure. 38 C.F.R. § 3.307(a)(7)(iii). "Contaminants in the water supply" means the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride, that were in the on-base water-supply systems located at United States Marine Corps Base Camp Lejeune, during the period beginning on August 1, 1953, and ending on December 31, 1987. 38 C.F.R. § 3.307(a)(7)(i). If a veteran was exposed to contaminants in the water supply at Camp Lejeune during the prescribed period, certain enumerated diseases shall be presumptively service-connected even where there is no record of such disease during service, provided that the disease is manifested to a compensable degree at any time after service and the rebuttable presumption provisions of 38 C.F.R. § 3.307 are met. 38 C.F.R. §§ 3.307(a)(7)(ii), 3.309(f). These enumerated diseases are kidney cancer, liver cancer, non-Hodgkin's lymphoma, adult leukemia, multiple myeloma, Parkinson's disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer. 38 C.F.R. § 3.309(f)(1)-(8). Finally, exposure to contaminants in the water supply at Camp Lejeune constitutes an "injury" for purposes of VA benefits. 38 C.F.R. § 3.307(a)(7)(iv). Until scientific evidence shows otherwise, it will be assumed by VA that any given Veteran-claimant who served at Camp Lejeune was potentially exposed in some manner to the full range of chemicals known to have contaminated the water there between 1957 and 1987. See VBA Training Letter 11-03 (Revised) (November 29, 2011) (citing the National Academy of Sciences' National Research Council (NRC)'s report, "Contaminated Water Supplies at Camp Lejeune, Assessing Potential Health Effects."). Fourteen diseases have been placed into the category of limited/suggestive evidence of an association with the contaminating water-supply system at Camp Lejeune. These fourteen diseases are: esophageal cancer, lung cancer, breast cancer, bladder cancer, kidney cancer, adult leukemia, multiple myeloma, myelodysplastic syndromes, renal toxicity, hepatic steatosis, female infertility, miscarriage with exposure during pregnancy, scleroderma, and neurobehavioral effects. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for chronic kidney disease as due to exposure to contaminated drinking water at Camp LeJeune is granted. The Veteran asserts that he has a chronic kidney disorder that is related to his active service, to include exposure to contaminated water at Camp LeJeune. Post-service treatment records reflect a diagnosis of chronic kidney disease. Turning to the question of whether there is an etiological relationship between the Veteran's chronic kidney disorder and service, the Board notes that the record contains several opinions which must be considered and weighed. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (stating that the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board will consider each of these opinions below. A January 2018 VA examiner opined that the claimed chronic kidney disease was less likely than not (less than 50 percent probability) caused by or a result of the Veteran's exposure to contaminated water at Camp LeJeune. The examiner reasoned that although some contaminates found in contaminated water at Camp LeJeune have been associated with chronic kidney disease, the pathophysiological link is not strong. The examiner commented that it was more likely that the Veteran's chronic kidney disease was due to his hypertension, as hypertension is a risk factor for chronic kidney disease. However, the Board finds this opinion to be inadequate for adjudication purposes. In this regard, the opinion was provided without an adequate rationale to explain why hypertension was more likely the cause of chronic kidney disease and not exposure to contaminated water at Camp LeJeune. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). This opinion is therefore afforded little, if any, probative weight. A September 2018 private opinion from R.V., a registered nurse, indicates that the Veteran was diagnosed with an adrenal tumor and renal (kidney) tumor and that he underwent a left adrenalectomy in 2008. The provider reported that as a result of the tumor and removal, the Veteran then developed chronic stage III kidney disease with underlying nephrosclerosis. The provider commented that there was an association between exposure to the contaminates found in the water in Camp LeJeune and the development of soft-tissue tumors and that it often took many years for the development of these types of tumors following exposure to the carcinogens/toxins. The provider noted that the Veteran had no other known risk factors for development of the kidney tumor, and that it was therefore most likely due to his exposure to contaminated water at Camp LeJeune. Next, the provider commented that based on the pathogenesis of the Veteran's kidney disease (excess aldosterone production by the adrenal tumor and surgical insult due to adrenalectomy to remove the adrenal tumor), there is no other plausible etiology for the deterioration of the Veteran's kidney function. This opinion reflects an adequate rationale. Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. This opinion is therefore probative weight. Therefore, entitlement to service connection for a chronic kidney disorder is at least in equipoise and reasonable doubt must be resolved in the Veteran's favor. The Board is prohibited from developing additional evidence for the purpose of obtaining evidence against a claimant's case. See Mariano v. Principi, 17 Vet. App. 305 (2003). The Board resolves all reasonable doubt in the Veteran's favor. As such, the Veteran's claim of entitlement to service connection for a chronic kidney disorder is granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Entitlement to service connection for obstructive sleep apnea as secondary to service-connected depressive disorder with TBI is granted. The Veteran asserts that his diagnosed obstructive sleep apnea is related to his TBI residuals. Post-service treatment records reflect a diagnosis of obstructive sleep apnea. A November 2021 private opinion from Dr. T.F., a private clinical psychologist, indicates that the Veteran was diagnosed with obstructive sleep apnea and prescribed a continuous positive airway pressure (CPAP). The provider opined that the Veteran's obstructive sleep apnea was more likely than not related to his service connected mental health difficulties, to include depressive disorder with TBI. The provider noted that the Veteran's mental health difficulties have likely had a profound impact on the development and subsequent aggravation of his obstructive sleep apnea. In this regard, the provider indicated that people with sleep apnea often experience hyperarousal concerns and that his mental health condition contributed to his hyperarousal. The provider reported that the medical literature showed an association between the Veteran's mental health condition and the development of obstructive sleep apnea, and he provided text from numerous medical studies to demonstrate this point. This opinion reflects adequate rationale. Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. This opinion is therefore afforded great probative weight. The Board notes that there is one contrary etiology opinion from S.C., a registered nurse practitioner, dated in September 2018. However, in a December 2021 statement, this provider indicated that she wished to change her prior etiology opinion to a positive nexus opinion, as she agreed with the opinion and rationale expressed by Dr. T.F. Therefore, entitlement to service connection for obstructive sleep apnea as secondary to service-connected depressive disorder with TBI is at least in equipoise and reasonable doubt must be resolved in the Veteran's favor. The Board is prohibited from developing additional evidence for the purpose of obtaining evidence against a claimant's case. See Mariano v. Principi, 17 Vet. App. 305 (2003). As such, the Veteran's claim of entitlement to service connection for obstructive sleep apnea as secondary to service-connected depressive disorder with TBI is granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Entitlement to service connection for a colon disorder, to include chronic constipation and hemorrhoids, as secondary to service-connected depressive disorder with TBI is granted. The Veteran asserts that he has a colon disorder that is related to active service, to include his depressive disorder. Post-service treatment records reflect diagnoses of chronic constipation and hemorrhoids. A September 2020 private opinion from R.V., a registered nurse practitioner, indicates that the Veteran was diagnosed with chronic constipation and hemorrhoids. The provider opined that the Veteran's chronic constipation and hemorrhoids were more likely than not related to his service-connected depressive disorder. The provider cited numerous medical studies showing a correlation between mental health conditions and gastrointestinal disorders that result in constipation. Additionally, the provider noted that straining of the bowels due to constipation often caused hemorrhoids. This opinion reflects adequate rationale. Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. This opinion is therefore afforded probative weight. There are no contrary opinions of record. Therefore, entitlement to service connection for a colon disorder is at least in equipoise and reasonable doubt must be resolved in the Veteran's favor. The Board is prohibited from developing additional evidence for the purpose of obtaining evidence against a claimant's case. See Mariano v. Principi, supra. The Board resolves all reasonable doubt in the Veteran's favor. As such, the Veteran's claim of entitlement to service connection for a colon disorder, namely chronic constipation and hemorrhoids, is granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 187682 Entitlement to service connection for an acquired psychiatric disorder, namely a generalized anxiety disorder, is granted. The Veteran asserts that he has an acquired psychiatric disorder, that is related to his active service or had its onset during service. Specifically, the Veteran reported that he witnessed a fellow servicemember be beaten to death. Post-service treatment records reflect diagnoses of, in pertinent part, posttraumatic stress disorder (PTSD) and generalized anxiety disorder. The Board notes that the Veteran is already service connected for depressive disorder. A December 2018 private opinion from Dr. B.I. indicates that the Veteran was diagnosed with PTSD, major depression, and generalized anxiety disorder. The provider opined that these disorders were related to the Veteran's active service. In reaching this conclusion, the examiner noted that the Veteran did not experience any psychological issues prior to military service and that he continued to experience flashbacks of the traumatic in-service event of witnessing a fellow servicemember be beaten to death while stationed in North Carolina. The provider noted that the Veteran experienced nightmares, depressed mood, insomnia, poor concentration, sleep disturbance and social disturbances following his period of active service. The provider reasoned that in-service trauma in the form of watching a servicemember be beaten to death caused these issues and the Veteran's anxiety disorder. This opinion reflects an adequate rationale. Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. This opinion is therefore probative weight. In addition, an opinion from Dr. C.S., a private psychologist, found that the Veteran's somatic symptom disorder was proximately due to or aggravated by his current service connected disabilities or injuries. Service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). The evidence required to support the occurrence of an in-service stressor varies depending on whether the veteran was engaged in combat with the enemy. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(f). The Board finds that there is no competent and credible evidence corroborating the Veteran's claimed in-service stressor and that he does not have a diagnosis of PTSD based on a verified stressor. As such, service connection for PTSD is not warranted. Therefore, entitlement to service connection for an acquired psychiatric disorder, namely generalized anxiety disorder, is at least in equipoise and reasonable doubt must be resolved in the Veteran's favor. The Board is prohibited from developing additional evidence for the purpose of obtaining evidence against a claimant's case. See Mariano v. Principi, supra. The Board resolves all reasonable doubt in the Veteran's favor. As such, the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, namely generalized anxiety disorder, is granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND The Board finds that additional information is required before the remaining claims on appeal are decided. Service Connection Entitlement to service connection for pseudofolliculitis barbae is remanded. The Veteran asserts that his diagnosed pseudofolliculitis barbae is the result of service in his February 2016 Application for Disability Compensation and Related Compensation Benefits (VA Form 21-526EZ). At a May 2017 VA examination, the examiner diagnosed pseudofolliculitis barbae and opined that it was less likely than not related to service. In reaching this conclusion, the examiner commented that that the Veteran's service treatment records were silent for complaints of pseudofolliculitis barbae. The Board is unable to decide the claim based on the May 2017 opinion. In this regard, the examiner relied on the absence of in-service treatment as the sole rationale for the negative nexus opinion. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner did not comment on a Veteran's reports of in-service injury and instead relied on the absence of evidence in a Veteran's service treatment records to provide a negative opinion). Moreover, the opinion was provided without an adequate rationale. See Nieves-Rodriguez v. Peake, supra. Therefore, the Board finds that an additional medical opinion is warranted to address the nature and etiology of his pseudofolliculitis barbae. Entitlement to service connection for a lumbar spine disorder is remanded. The Veteran asserts that he has chronic lower back pain that is the result of service in his February 2016 VA Form 21-526EZ. At his December 2021 hearing before the Board, the Veteran reported that he injured his back during an in-service motor vehicle accident in Florida and that he has experienced back pain since that time. The Veteran submitted a September 2018 private Disability Benefits Questionnaire (DBQ) report with an attached medical opinion in support of his claim. The report shows that the Veteran was diagnosed with intervertebral disc syndrome (IVDS), radiculopathy and multifactorial stenosis. Private treatment records also note a diagnosis of degenerative changes at L4-L5. In the medical opinion report, the private provider opined that it is as likely as not that the Veteran's current chronic lower back pain due to intervertebral disc syndrome and possible herniated disc could have been aggravated during his military service. The provider also commented that it is likely that the multiple injuries the Veteran sustained to his spinal structures, as well as degenerative changes to his spinal cord, could be the etiology of his chronic back condition. However, the provider provided no supporting rationale for the opinion that the Veteran's lumbar spine disorder was related to his military service. Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012). Moreover, as the opinion only states that the Veteran's service could have contributed to his lumbar spine disorder and not that it is more likely than not, the opinion does not provide the Board with sufficient detail to allow the Board to make an informed decision. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992); see also Bloom v. West, 12 Vet. App. 185, 187 (1999) (holding that use of the term "could", without other rationale or supporting data, is too speculative to support the award of benefits). To date, the Veteran has not been afforded a VA examination. Therefore, the Board finds that the Veteran should be afforded a VA examination to determine the nature and etiology of any lumbar spine disability that may be present, to include degenerative disc disease. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, the Board finds that a remand is necessary to obtain an adequate medical opinion regarding the nature and etiology of the Veteran's lumbar spine disorder. Entitlement to service connection for a prostate disorder is remanded. Entitlement to service connection for a urinary tract disorder is remanded. The Veteran asserts that he has a urinary tract condition and a prostate condition that is the result of service, to include exposure to contaminated drinking water at Camp LeJeune, in his February 2016 VA Form 21-526EZ. At his December 2021 hearing before the Board, the Veteran reported that he was on medication for urinary tract infections as well as a prostate disorder, which is reflected in post-service treatment records. The Veteran also reported that he experienced an enlarged prostate and urinary difficulties. To date, no VA etiology opinions have been obtained with regard to the Veteran's claimed prostate disorder and urinary tract disorder. Therefore, the Board finds that VA medical opinions are warranted to address the nature and etiology of his claimed prostate and urinary tract conditions. See McLendon v. Nicholson, supra. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and her representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, obtain an opinion from an appropriate medical examiner to determine the nature and etiology of the Veteran's pseudofolliculitis barbae. 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 need for physical examination or telehealth evaluation is left to the discretion of the medical professional offering the medical opinion. Based on the review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran's pseudofolliculitis barbae had its onset during his active service, or is otherwise etiologically related to such service, to include to include his in-service exposure to contaminated water at Camp Lejeune (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, to include his report that he sustained injuries from shaving equipment during service. 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. 3. Following the receipt of outstanding records, obtain an etiology opinion from an appropriate medical examiner to determine the nature and etiology of the Veteran's lumbar spine disorder. 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 need for physical examination or telehealth evaluation is left to the discretion of the medical professional offering the medical opinion. Based on the review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present lumbar spine disorder, to include IVDS, stenosis, and degenerative arthritis, had its onset during his active service, or is otherwise etiologically related to such service. The examiner must consider the Veteran's lay statements regarding the onset and continuity of his symptoms, to include his reports that he injured his back during an in-service motor vehicle accident in Florida and that he has had problems with his back since that time. 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. 4. Following the receipt of outstanding records, obtain an etiology opinion from an appropriate medical examiner to determine the nature and etiology of the Veteran's claimed prostate disorder. 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. Based on the review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present prostate disorder, to include an enlarged prostate, had its onset during his active service, or is otherwise etiologically related to such service, to include to include his in-service exposure to contaminated water at Camp Lejeune (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. 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. 5. Following the receipt of outstanding records, obtain an etiology opinion from an appropriate medical examiner to determine the nature and etiology of the Veteran's claimed urinary tract disorder. 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. Based on the review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present urinary tract disorder had its onset during his active service, or is otherwise etiologically related to such service, to include to include his in-service exposure to contaminated water at Camp Lejeune (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. 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. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher O'Donnell, 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.