Citation Nr: 24000672 Decision Date: 01/04/24 Archive Date: 01/04/24 DOCKET NO. 17-08 203 DATE: January 4, 2024 ORDER The appeal as to the claim of entitlement to service connection for adjustment disorder is dismissed for lack of jurisdiction. The appeal as to the claim of entitlement to service connection for left eyelid skin lesion, to include as due to exposure to toxic chemicals, is granted. The appeal as to the claim of entitlement to service connection for squamous cell carcinoma of the left ear, to include as due to exposure to toxic chemicals, is granted. The appeal as to the claim of entitlement to service connection for actinic keratosis of the head, face, shoulders, and neck, to include as due to exposure to toxic chemicals, is granted. The appeal as to the claim of entitlement to service connection for pulmonary hypertension, to include as due to exposure to toxic chemicals, to include as secondary to service-connected disabilities, is granted. The appeal as to the claim of entitlement to service connection for right dry eye syndrome, to include as secondary to the service-connected chronic obstructive pulmonary disease (COPD), is granted. The appeal as to the claim of entitlement to service connection for left dry eye syndrome, to include as secondary to the service-connected chronic obstructive pulmonary disease (COPD), is granted. The appeal as to the claim of entitlement to service connection for a right eye disorder other than dry eye syndrome, to include vitreous syneresis and cataracts, to include as due to exposure to toxic chemicals, is denied. The appeal as to the claim of entitlement to service connection for a left eye disorder other than eyelid skin lesion and dry eye syndrome, to include vitreous syneresis and cataracts, to include as due to exposure to toxic chemicals, is denied. The appeal as to the claim of entitlement to service connection for a right hip disorder, to include as due to exposure to toxic chemicals, is denied. The appeal as to the claim of entitlement to service connection for a left hip disorder, to include as due to exposure to toxic chemicals, is denied. The appeal as to the claim of entitlement to service connection for a cervical spine disorder, to include as due to exposure to toxic chemicals, is denied. The appeal as to the claim of entitlement to an initial evaluation in excess of 20 percent for the service-connected left shoulder disorder is denied. REMANDED The appeal as to the claim of entitlement to service connection for right eye pinguecula is remanded. The appeal as to the claim of entitlement to service connection for left eye pinguecula is remanded. The appeal as to the claim of entitlement to service connection for a sleep disorder, to include as secondary to the service-connected heart disease and/or allergic rhinitis, is remanded. The appeal as to the claim of entitlement to service connection for allergic rhinitis, to include as due to exposure to toxic chemicals, is remanded. The appeal as to the claim of entitlement to service connection for nasal polyps, to include as due to exposure to toxic chemicals, to include as secondary to the claimed allergic rhinitis disorder, is remanded. The appeal as to the claim of entitlement to service connection for a hernia, to include as secondary to the service-connected heart disease, is remanded. The appeal as to the claim of entitlement to service connection for a right shoulder disorder, to include as secondary to the service-connected left shoulder disability, is remanded. The appeal as to the claim of entitlement to service connection for a lumbar spine disorder, to include as due to exposure to toxic chemicals, is remanded. The appeal as to the claim of entitlement to service connection for a right knee disorder, to include as due to exposure to toxic chemicals, is remanded. The appeal as to the claim of entitlement to service connection for a left knee disorder, to include as due to exposure to toxic chemicals, is remanded. The appeal as to the claim of entitlement to an initial compensable evaluation for the service-connected left hand burn scar is remanded. FINDINGS OF FACT 1. The Veteran's claim of entitlement to service connection for adjustment disorder was granted in a Rating Decision issued by the Agency of Original Jurisdiction (AOJ) in May 2021, with an effective date of April 2, 2013. 2. The Veteran's current left eyelid skin lesion is etiologically related to his active service. 3. The Veteran's current squamous cell carcinoma of the left ear is etiologically related to his active service. 4. The Veteran's current actinic keratosis of the head, face, shoulders, and neck is etiologically related to his active service. 5. The Veteran's current pulmonary hypertension is caused by his service-connected heart disability. 6. The Veteran's current right dry eye syndrome disorder is caused by his service-connected COPD disability. 7. The Veteran's current left dry eye syndrome disorder is caused by his service-connected COPD disability. 8. The Veteran's current right eye vitreous syneresis and cataract disorders are not etiologically related to his active service, to include exposure to toxic chemicals. 9. The Veteran's current left eye vitreous syneresis and cataract disorders are not etiologically related to his active service, to include exposure to toxic chemicals. 10. The Veteran's current right hip degenerative arthritis and strain disorders are not etiologically related to his active service, to include exposure to toxic chemicals. 11. The Veteran's current left hip degenerative arthritis and strain disorders are not etiologically related to his active service, to include exposure to toxic chemicals. 12. The Veteran's current cervical spine degenerative disc disease and strain disorders are not etiologically related to his active service, to include exposure to toxic chemicals. 13. Throughout the pendency of the appeal, the Veteran's left shoulder disorder is manifested by limitation of motion of the arm to no more than 105 degrees from the Veteran's side; there is no evidence of impairment of the clavicle or scapula, impairment of the humerus, or ankylosis. CONCLUSIONS OF LAW 1. The Board lacks jurisdiction over the claim of entitlement to service connection for adjustment disorder because that claim has been granted and rendered moot. 38 U.S.C. §§ 7104 (a), 7105(d)(5) (2012); 38 C.F.R. §§ 19.7, 20.101, 20.200, 20.202 (2021). 2. The criteria for establishing entitlement to service connection for left eyelid skin lesion have been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2021). 3. The criteria for establishing entitlement to service connection for squamous cell carcinoma of the left ear have been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2021). 4. The criteria for establishing entitlement to service connection for actinic keratosis of the head, face, shoulders, and neck have been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2021). 5. The criteria for establishing entitlement to service connection for pulmonary hypertension have been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2021). 6. The criteria for establishing entitlement to service connection for right dry eye syndrome have been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2021). 7. The criteria for establishing entitlement to service connection for left dry eye syndrome have been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2021). 8. The criteria for establishing entitlement to service connection for right eye vitreous syneresis and cataract disorders have not been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2021). 9. The criteria for establishing entitlement to service connection for left eye vitreous syneresis and cataract disorders have not been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2021). 10. The criteria for establishing entitlement to service connection for a right hip disorder have not been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2021). 11. The criteria for establishing entitlement to service connection for a left hip disorder have not been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2021). 12. The criteria for establishing entitlement to service connection for a cervical spine disorder have not been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2021). 13. The criteria for an initial rating in excess of 20 percent for service-connected left shoulder disorder have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Navy from September 1966 to June 1970. His service was under honorable conditions. These matters are on appeal from a February 2014 rating decision issued by a VA Regional Office (RO). In March 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). A transcript of this hearing has been prepared and associated with the evidence of record. In June 2020, the Board remanded the issues on appeal for further evidentiary development. The issues have returned to the Board for further appellate consideration. In a May 2021 rating decision, the RO increased the evaluation for the Veteran's service-connected left shoulder disorder from noncompensable to 20 percent disabling, effective April 2, 2013. As this is not the maximum benefit available, the claim remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). On April 8, 2023, the Veteran submitted a Privacy Act (PA) and Freedom of Information Act (FOIA) request. On September 19, 2023, VA notified the Veteran in writing that such request was fulfilled, and provided the requested records on a compact disc. An unsigned PA/FOIA request was received shortly thereafter (in October 2023); however, no new evidence has been added to the record. Therefore, the Veteran's PA/FOIA request is complete, as per the September 2023 response, and the Board will continue with adjudication of the claim. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Appellant and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Dismissal as Moot 1. Entitlement to service connection for adjustment disorder. In this case, the Veteran's claim of entitlement to service connection for adjustment disorder was granted in a rating decision issued by the AOJ in May 2021, effective April 2, 2013. As a general matter, the grant of a claim of service connection constitutes an award of full benefits sought on an appeal of the denial of a service connection claim. Seri v. Nicholson, 21 Vet. App. 441, 447 (2007); see also Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection). 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 (2012); 38 C.F.R. § 20.202 (2021). Here, as a result of the AOJ's action, there no longer remains a case or controversy with respect to this claim. Therefore, the Board lacks jurisdiction over this issue because it has been granted and rendered moot on appeal. 38 U.S.C. § 7104, 7105 (2012); 38 C.F.R. § 19.7, 20.101, 20.200, 20.202 (2021). Therefore, dismissal of this claim is warranted. Service Connection - Legal Criteria Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (2021). This includes any increase in severity of a nonservice-connected disease that is proximately due to or the result of a service-connected disability as set forth in 38 C.F.R. § 3.310(b). See also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). A claimant is also entitled to service connection on a secondary basis when it is shown that a service-connected disability aggravates a nonservice-connected disability. 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 439. Also, 38 U.S.C. § 1154 (a) requires that VA give 'due consideration' to 'all pertinent medical and lay evidence' in evaluating a claim for disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Specifically, '[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.' Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2021); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 2. Entitlement to service connection for left eyelid skin lesion, to include as due to exposure to toxic chemicals. See argument Below at 4 3. Entitlement to service connection for squamous cell carcinoma of the left ear, to include as due to exposure to toxic chemicals. See argument Below at 4 4. Entitlement to service connection for actinic keratosis of the head, face, shoulders, and neck, to include as due to exposure to toxic chemicals. The Veteran contends that his current left eyelid skin lesion, squamous cell carcinoma of the left ear, and actinic keratosis of the head, face, shoulders, and neck disorders are related to service, to include his in-service exposure to hexavalent chromium (chromium 6) and other toxins. In this regard, during the March 2020 hearing before the Board, the Veteran asserted that he was exposed to chromium 6 and other chemicals as a result of his duties as an aviation mechanic, to include sanding and painting planes. He further indicates that he's experienced ongoing and chronic symptoms of pain, eye problems, and skin problems since his initial in-service exposure to these intoxicants. In support of his assertions, the Veteran submitted several articles, which are of record. Significantly, the article, Health Hazards of Chemicals Commonly Used on Military Bases, summarizes the toxic effects of chemicals as reported in medical journals and related reports. The AOJ has conceded the Veteran's exposure to chromium 6 based on his occupation in the Navy. See March 2016 rating decision. Among other conditions, the Veteran is in receipt of service connection for residuals of a stroke, COPD, ischemic heart disease and ischemic cardiomyopathy, and vertigo, which are due to his inservice exposure to chromium 6. Service treatment records include an April 1966 induction examination, which is negative for complaints of, or a diagnosis of a left eyelid disorder, or a skin disorder. A September 1968 record demonstrates that the Veteran sought treatment for his left eye. The examiner noted that the Veteran worked in the air frame shop, and had a particle embedded in his left eye. The report of a May 1970 separation examination is negative for complaints of, treatment for, or a diagnosis of a left eyelid disorder, squamous cell carcinoma, or actinic keratosis. Post-service records include a November 2010 VA biopsy that indicates diagnoses of left ear squamous cell carcinoma and actinic keratosis. VA outpatient treatment records dated in September 2012 note diagnoses of squamous cell carcinoma and actinic keratosis. VA outpatient treatment records dated December 2012 note diagnoses of squamous cell carcinoma and actinic keratosis. A June 2013 private eye evaluation notes a diagnosis of skin lesion of the left eyelid. A June 2013 private skin evaluation indicates diagnoses of squamous cell carcinoma and actinic keratosis. In an October 2013 private opinion, P.M., R.N., reviewed the record, to include the Veteran's service treatment records, post-service VA and private records, private evaluations dated June 2013 performed by the Veteran's physician of 20 years, and medical literature regarding chromium 6. P.M. discussed the Veteran's inservice exposure to chemical toxins, to include chromium 6, as a result of his duties as an aviation mechanic. Upon review of the aforementioned, she concluded that the Veteran's current left eyelid skin lesion, squamous cell carcinoma of the left ear, and actinic keratosis disorders are directly related to his chronic inservice exposure to chromium 6, as it causes known genetic mutation properties that result in these current disorders. In providing the opinions, P.M. noted the following information: the Veteran was not provided training during service related to chemical hazards in the workplace, to include for chromium 6; there were no control measures in place for monitoring the Veteran's environment or his biomedical responses to his work environment; there were no regulations in place regarding protective clothing, segregation of work clothing and the laundering of said contaminated work clothes; face masks provided suboptimal respiratory protection from inhalation of toxins and genetic mutants; there was no monitoring of air quality in the Veteran's workspace nor was there proper ventilation; and there was no ongoing medical surveillance of the Veteran during service. VA outpatient treatment records dated in October 2014 through April 2015 note diagnoses of actinic keratosis and squamous cell carcinoma. A March 2017 VA examination report notes a medical history and diagnosis of actinic keratosis. A May 2021 VA examination report notes a medical history and diagnosis of actinic keratosis and squamous cell carcinoma. Upon review of the record, the VA examiner found that the Veteran's current actinic keratosis and squamous cell carcinoma disorders were not related to his active service. In providing the opinion, the examiner noted that the Veteran's service treatment records are negative for a finding of actinic keratosis or squamous cell carcinoma. A January 2023 VA examination report notes a medical history and diagnosis of actinic keratosis of the head, face, shoulder, and neck. Upon review of the record, the VA examiner found that the Veteran's current actinic keratosis was not related to his active service. In providing the opinion, the examiner noted that there was scant data supporting such a nexus. In an August 2023 opinion, a VA examiner found that the Veteran's current actinic keratosis was less likely than not caused by inservice toxic exposure. The examiner noted that medical literature states that actinic keratosis predominately appear on chronically sun exposed bodies, particularly in older individuals who have experienced decades of sun exposure. The development of actinic keratosis is influenced by various independent risk factors, which may include increased age, male gender, fair-skinned individuals, and immunosuppression. The examiner concluded that a claimed condition with an etiology not associated with toxic exposure does not qualify as a TERA claim. In an August 2023 opinion, a VA examiner found that the Veteran's current squamous cell carcinoma of the left ear was less likely than not caused by inservice toxic exposure. The examiner noted that medical literature states that squamous cell carcinoma commonly appears after the age of 50 in areas of past sun exposure, and typically occurs in males with light skin and light eyes who have a history of UV solar radiation exposure. The examiner further noted that squamous cell carcinoma is also very prevalent in patients that are immunosuppressed or have a history of other skin conditions, as the Veteran does in that he has actinic keratosis. The examiner concluded that a claimed condition with an etiology not associated with toxic exposure does not qualify as a TERA claim. In an August 2023 opinion, a VA examiner found that the Veteran's eyelid skin tag had resolved years ago without sequelae, and was less likely than not caused by inservice toxic exposure. Upon review of the evidence of record, the Board finds that the evidence of record supports a grant of service connection for the Veteran's current left eyelid skin lesion, squamous cell carcinoma of the left ear, and actinic keratosis of the head, face, shoulders, and neck disorders, as a result of confirmed in-service exposure to chromium 6. The clinical evidence of record establishes that the Veteran has current diagnoses of left eyelid skin lesion, squamous cell carcinoma, and actinic keratosis disorders. See November 2010 VA biopsy, September 2012 and December 2012 VA outpatient treatment records, June 2013 private evaluations, March 2017 VA examination report, May 2021 VA examination reports, and January 2023 VA examination reports. In addition, the October 2013 private examiner's opinion is presented as in support of the Veteran's claim. In this regard, the private examiner reviewed the record, to include service treatment records, post-service VA and private records, private evaluations, and medical literature regarding chromium 6, and found that the Veteran's current left eyelid skin lesion, squamous cell carcinoma, and actinic keratosis disorders to be directly related to his inservice exposure to chromium 6 due to his duties as an aviation mechanic. Further, the Board finds the Veteran's statements concerning his ongoing symptoms of left eyelid skin lesion, squamous cell carcinoma, and actinic keratosis disorders since service, to be competent and credible, and the post-service records corroborate his contentions. The Board acknowledges that the May 2021, January 2023, and August 2023 VA examiners' opinions are presented as against the Veteran's claim. In this regard, the Board finds the opinions inadequate for adjudication of the claim. The May 2021 examiner in significant part, based his opinion that the Veteran's current actinic keratosis and squamous cell carcinoma were not related to his active service, on a lack of a diagnosis of actinic keratosis and squamous cell carcinoma in the service treatment records. Moreover, the January 2023 examiner reached the same conclusion as the May 2021 examiner; however, he failed to provide a sufficient rationale, and he did not offer an etiology for the Veteran's current actinic keratosis disorder. Further, while the August 2023 examiner found that the Veteran's left eyelid skin lesion resolved, he did not offer an opinion regarding the current diagnosis, which is documented during the appeal period. Similarly, the August 2023 examiner found that the Veteran's actinic keratosis was less likely than not caused by inservice toxic exposure, and noted that the development of actinic keratosis is influenced by various independent risk factors, which may include increased age, male gender, fair-skinned individuals, and immunosuppression. The examiner, however, failed to indicate which risk factors, if any, are attributable to the Veteran. Likewise, the August 2023 examiner found that the Veteran's current squamous cell carcinoma of the left ear was less likely than not caused by inservice toxic exposure. The examiner explained that squamous cell carcinoma is very prevalent in patients that are immunosuppressed or have a history of other skin conditions, as the Veteran does, in that he has actinic keratosis. However, as above, the examiner did not indicate which risk factors are attributable to the Veteran with respect to the development of actinic keratosis and therefore he did not provide a sufficient etiology of either skin disorder. Finally, the August 2023 VA examiner concluded that the claimed conditions with an etiology not associated with toxic exposure, does not qualify as a TERA claim. In this regard, the Veteran has not claimed that his current disorders are associated with such a claim. Accordingly, the Board concludes that the evidence of record supports direct service connection for left eyelid skin lesion, squamous cell carcinoma, and actinic keratosis and is at least in equipoise with that against the claim. As such, the benefit of the doubt must be resolved in the favor of the Veteran. Therefore, entitlement to service connection for left eyelid skin lesion, squamous cell carcinoma of the left ear, and actinic keratosis of the head, face, shoulders, and neck, is warranted. 5. Entitlement to service connection for pulmonary hypertension, to include as due to exposure to toxic chemicals, to include as secondary to service-connected disabilities. The Veteran contends that his current pulmonary hypertension disorder is related to service, to include his in-service exposure to chromium 6 and other toxins. During the aforementioned hearing, the Veteran asserts that he was exposed to chromium 6 as a result of his duties as an aviation mechanic, to include sanding and painting planes. He further asserts that he's experienced ongoing and chronic respiratory problems since his initial in-service exposure to these intoxicants. As above, the AOJ has conceded the Veteran's exposure to chromium 6 based on his occupation in the Navy. See March 2016 rating decision. Alternatively, the Veteran also contends that his current pulmonary hypertension disorder is due to his service-connected heart disease and/or right and/or left lower extremity peripheral vascular disease. Service treatment records include an April 1966 induction examination, which negative for complaints of, or a diagnosis of pulmonary hypertension. The report of a May 1970 separation examination is negative for complaints of, treatment for, or a diagnosis of pulmonary hypertension. Post-service records include VA outpatient treatment records dated December 2012, which notes diagnoses of pulmonary hypertension. A September 2013 private treatment record indicates a diagnosis of moderate pulmonary hypertension. A June 2013 private evaluation notes a diagnosis of pulmonary hypertension. In an October 2013 private opinion, P.M., R.N., reviewed the record, to include the Veteran's service treatment records, post-service VA and private records, private evaluations dated June 2013 performed by the Veteran's physician of 20 years, and medical literature via internet search. P.M. discussed the Veteran's inservice exposure to chemical toxins, to include chromium 6, as a result of his duties as an aviation mechanic. Upon review of the aforementioned, she concluded that the Veteran's current pulmonary hypertension is directly related to, or is a secondary medical condition resulting from his chronic inservice exposure to chromium 6, as it causes known genetic mutation properties that result in the current disorder. In providing the opinion, P.M. noted the following information: the Veteran was not provided training during service related to chemical hazards in the workplace, to include for chromium 6; there were no control measures in place for monitoring the Veteran's environment or his biomedical responses to his work environment; there were no regulations in place regarding protective clothing, segregation of work clothing and the laundering of said contaminated work clothes; face masks provided suboptimal respiratory protection from inhalation of toxins and genetic mutants; there was no monitoring of air quality in the Veteran's workspace nor was there proper ventilation; and there was no ongoing medical surveillance of the Veteran during service. VA outpatient treatment records dated in October 2014 through April 2015 note diagnoses of pulmonary hypertension. A May 2021 VA examination report notes a medical history and diagnosis of pulmonary hypertension. Upon review of the record, the VA examiner found that the Veteran's current pulmonary hypertension was not related to his active service, as his service treatment records, to include the separation examination report, are negative for a finding of pulmonary hypertension. She sited to the CDC, noting that pulmonary hypertension happens when the pressure in the blood vessels leading from the heart to the lungs is too high. The examiner explained that some common underlying causes of pulmonary hypertension include high blood pressure in the lungs' arteries due to some types of congenital heart disease, connective tissue disease, coronary artery disease, liver disease, blood clots to the lungs, and chronic diseases like emphysema. She further noted that pulmonary hypertension is commonly associated with many other diseases, such as lung and heart disease, and specified that pulmonary hypertension is common in heart failure. The Veteran has both heart and lung disabilities. The examiner explained that review of the literature does not ascribe pulmonary hypertension to be caused by toxic chemicals, and therefore, she concluded that it was not related to the Veteran's inservice exposure to toxic chemicals. A January 2023 VA examination report notes a medical history and diagnosis of pulmonary hypertension. The examiner noted that the Veteran was initially diagnosed in approximately 1990, when he suffered a heart attack. Upon review of the record, the VA examiner found that the Veteran's current pulmonary hypertension was not related to his active service. In providing the opinion, the examiner noted that there was scant data supporting such a nexus. In an August 2023 VA opinion, a VA examiner found that the Veteran's current pulmonary hypertension was less likely than not due to inservice exposure to toxins. The examiner noted that according to medical literature, the etiology of hypertension is classified as prehepatic, intrahepatic, or posthepatic. The examiner explained that the common causes of prehepatic hypertension are either due to increased blood flow or obstruction within portal vein or splenic vein. Instances of increased blood flow include idiopathic tropical splenomegaly, arterio-venous malformations, or fistula; a blockage within the portal or splenic vein may be due to the thrombosis or to invasion or compression of these veins by the tumor. The examiner concluded that a claimed condition with an etiology not associated with toxic exposure does not qualify as a TERA claim. Upon review of the evidence of record, the Board finds that the Veteran's current pulmonary hypertension is not the result of in-service exposure to chromium 6. In this regard, although the October 2013 private examiner found that the Veteran's pulmonary hypertension was the result of such exposure, the Board notes that the examiner did not cite to specific medial research, and bases her conclusion in part upon her "internet search." Further, the private examiner did not consider alternative and medically relevant causes of the Veteran's current pulmonary hypertension, such as heart or vascular disease, which is supported by the medical literature cited to by the aforementioned VA examiners. The Board, however, finds that the evidence of record supports a grant of service connection for pulmonary hypertension as directly related to the Veteran's service-connected ischemic heart disease and cardiomyopathy (heart failure). The clinical evidence of record establishes that the Veteran has a current diagnosis of pulmonary hypertension in December 2012, September 2013, June 2013, May 2021, January 2023, and August 2023. The May 2021 VA examiner found the Veteran's current pulmonary hypertension disorder to be due to his service-connected heart disease disability, and specified that pulmonary hypertension is common in heart failure, as supported by the medical evidence of record. In addition, the January 2023 VA examiner noted that the Veteran was initially diagnosed with pulmonary hypertension in approximately 1990, when he suffered a heart attack, further supporting the May 2021 VA examiner's finding, that the Veteran's current pulmonary hypertension is related to his heart disability. Moreover, the Board finds the Veteran's statements concerning his ongoing symptoms of respiratory problems, to be competent and credible, and the post-service records corroborate his contentions. The Board acknowledges that the August 2023 VA examiner's opinion is presented as against the Veteran's claim. In this regard, the Board finds the opinion inadequate for adjudication of the claim. In crafting his opinion, the examiner notes that according to medical literature, the etiology of hypertension is classified as prehepatic, intrahepatic, or posthepatic. The further examiner explained that common causes of prehepatic hypertension are either due to increased blood flow or obstruction within portal vein or splenic vein. Instances of increased blood flow include idiopathic tropical splenomegaly, arterio-venous malformations, or fistula; a blockage within the portal or splenic vein may be due to the thrombosis or to invasion or compression of these veins by the tumor. The examiner, however, failed to explain how such classifications are attributed to the Veteran's current pulmonary hypertension disorder. Accordingly, the Board concludes that the evidence of record supports secondary service connection for pulmonary hypertension and is at least in equipoise with that against the claim. As such, the benefit of the doubt must be resolved in the favor of the Veteran. Therefore, entitlement to service connection for pulmonary hypertension, is warranted. 6. Entitlement to service connection for right dry eye syndrome, to include as secondary to the service-connected COPD. See argument Below at 7 7. Entitlement to service connection for right dry eye syndrome, to include as secondary to the service-connected COPD. The Veteran contends that his current right and left dry eye syndrome disorders are due to his service-connected COPD disability. Specifically, the Veteran reports that he experiences symptoms of right and left eye burning (dry eye) as a result of the use of a CPAP machine, which is required treatment for his service-connected COPD. The Veteran does not contend, nor do service treatment records demonstrate, complaints of, treatment for, or a diagnosis of right or left dry eye syndrome during service. Post-service treatment records include an October 2014 VA outpatient treatment record that notes a diagnosis of right and left dry eye syndrome. A February 2021 VA outpatient treatment record notes the Veteran's report, that two months ago, he put on his CPAP mask and woke up in the middle of the night due to burning in his right eye. A March 2021 VA outpatient treatment record notes a diagnosis of right and left dry eye syndrome. A March 2021 VA eye examination report indicates a diagnosis of right and left meibomian gland dysfunction (dry eye). A January 2023 VA eye examination report demonstrates a diagnosis of right and left dry eye syndrome. Regarding the etiology of the Veteran's right and left dry eye syndrome disorders, in an August 2023 opinion, a VA examination concluded that the current disorders are due to the use of a CPAP machine, which is required to treat the Veteran's service-connected COPD disability. The Board finds that the evidence of record supports a grant of service connection for right and left dry eye disorders due to the Veteran's service-connected COPD disability. The clinical evidence of record establishes that the Veteran has a current diagnosis of right and left dry eye in 2023. The August 2023 VA examiner found the Veteran's current right and left dry eye disorders to be due to his service-connected COPD disability, as supported by the medical evidence of record. Moreover, the Board finds the Veteran's statements concerning his ongoing symptoms of right and left dry eye, to be competent and credible, and the post-service records corroborate his contentions. Accordingly, the evidence of record supports secondary service connection for right and left dry eye disorder. As such, the benefit of the doubt must be resolved in favor of the Veteran. Therefore, entitlement to service connection for right and left dry eye disorder, is warranted. 8. Entitlement to service connection for a right eye disorder other than dry eye syndrome, to include vitreous syneresis and cataracts, to include as due to exposure to toxic chemicals. See argument Below at 9 9. Entitlement to service connection for a left eye disorder other than eyelid skin lesion and dry eye syndrome, to include vitreous syneresis and cataracts, to include as due to exposure to toxic chemicals. The Veteran contends that service connection is warranted for his current right and left eye vitreous syneresis and cataract disorders. In this regard, during the March 2020 hearing before the Board, the Veteran asserted that he was exposed to the toxic chemicals during service as a result of his duties as an aviation mechanic. He further indicated that he experienced ongoing and chronic symptoms of eye pain, since his initial in-service exposure to these intoxicants. As above, the AOJ has conceded the Veteran's exposure to chromium 6 based on his occupation in the Navy. See March 2016 rating decision. Service treatment records include an April 1966 induction examination, which negative for complaints of, or a diagnosis of a right or left eye disorder. A September 1968 record demonstrates that the Veteran sought treatment for his left eye. The examiner noted that the Veteran worked in the air frame shop, and had a particle embedded in his left eye. The report of a May 1970 separation examination is negative for complaints of, treatment for, or a diagnosis of a right or left eye disorder. A September 2012 VA outpatient treatment record indicates diagnoses of cataracts of the right and left eye. A June 2013 private eye evaluation indicates diagnoses of right and left vitreous syneresis. An October 2014 VA outpatient treatment record notes a diagnosis of right and left cataracts. A March 2021 VA eye examination report indicates diagnoses of right and left cataracts. Upon review of the record, the examiner found that the Veteran's current right and left eye cataracts were less likely than not incurred in or caused by the Veteran's service. In providing the opinion, the examiner noted that the Veteran's cataracts were not diagnosed until 2016, several decades after separation from service. The examiner concluded that the current cataracts were at least as likely as not related to the Veteran's age, and unrelated to his active service. A January 2023 VA eye examination report indicates diagnoses of right and left eye vitreous syneresis and cataracts. Upon review of the record, the examiner found that the Veteran's current bilateral eye vitreous syneresis and cataract diagnoses were less likely than not incurred in or caused by the Veteran's service, to include exposure to toxic chemicals. In providing the opinion, the examiner explained that vitreous floater or PVD is due to vitreous syneresis (liquefaction), and the result of age. Specifically, the examiner noted that the aggregation of collagen fibrils may cause vitreous liquefaction, which undergoes an inevitable process of syneresis with aging. In an August 2023 opinion, a VA examiner reviewed the record and found that the Veteran's current right and left eye vitreous syneresis and cataracts were less likely than not caused by the Veteran's active service, to include toxic exposure. In providing the opinion, the examiner explained that the Veteran's right and left eye vitreous syneresis and cataracts are the result of his age. The Board finds that the evidence of record does not support entitlement to service connection for right or left eye vitreous syneresis or cataracts. In this regard, the Board notes that the Veteran's service treatment records are negative for complaints of, or a diagnosis of right or left eye vitreous syneresis and cataracts. Post-service records do not demonstrate a diagnosis of cataracts until September 2012, or a diagnosis of vitreous syneresis until June 2013, more than 40 years following separation from service. In addition, the March 2021, January 2023, and August 2023 VA examiners opined, that the Veteran's current right and left vitreous syneresis and cataracts are the result of his age, and unrelated to service, to include exposure to toxic chemicals. Despite the Veteran's assertions, there is no medical evidence of record that establishes an etiological relationship between the Veteran's current right and left vitreous syneresis and cataracts and his active service, to include the in-service treatment for a left eye injury in September 1968 when the Veteran sought treatment for a particle embedded into his left eye. Finally, the Board recognizes that the Veteran believes his right and left eye vitreous syneresis and cataract disabilities manifested as a result of his active service. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on his symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). While the Veteran is competent to provide testimony to establish the occurrence of medical symptoms, he is not medically qualified to prove a matter requiring medical expertise. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). The etiology of right and left eye vitreous syneresis and cataract disabilities is a complex medical determination outside the realm of common knowledge of a lay person. Further, the March 2021, January 2023, and August 2023 VA examiners determined that the etiology of the Veteran's current right and left eye vitreous syneresis and cataract disabilities is unrelated to his service. Instead, the March 2021 examiner placed greater weight on the Veteran's age, noting that his right and left cataracts were not diagnosed until several decades after separation from service, and were more likely related to the Veteran's age. Similarly, the January 2023 examiner found that the Veteran's current bilateral eye vitreous syneresis and cataract diagnoses were less likely than not incurred in or caused by the Veteran's service, to include exposure to toxic chemicals. In providing the opinion, the examiner explained that vitreous syneresis (liquefaction) is due to age. Likewise, the August 2023 examiner reached the same conclusion, and explained that the Veteran's right and left eye vitreous syneresis and cataracts are the result of his age. Thus, although the Board has carefully considered the lay contentions of record suggesting that the Veteran's right and left eye vitreous syneresis and cataract disabilities are related to his military service, the lay opinions are clearly of less probative value than the VA medical opinions against the claim. Accordingly, service connection for right eye vitreous syneresis, left eye vitreous syneresis, right eye cataracts, and left eye cataracts, is not warranted. 10. Entitlement to service connection for a right hip disorder, to include as due to exposure to toxic chemicals. See argument Below at 12 11. Entitlement to service connection for a left hip disorder, to include as due to exposure to toxic chemicals. See argument Below at 12 12. Entitlement to service connection for a cervical spine disorder, to include as due to exposure to toxic chemicals. The Veteran contends that his right hip, left hip, and cervical spine disorders are related to service, to include his in-service exposure to chromium 6. In this regard, during the March 2020 hearing before the Board, the Veteran asserted that he was exposed to toxic chemicals as a result of his duties as an aviation mechanic, to include sanding and painting planes. He further indicated that he experienced ongoing and chronic symptoms of pain since his initial in-service exposure to these intoxicants. As above, the AOJ has conceded the Veteran's exposure chromium 6 based on his occupation in the Navy. See March 2016 rating decision. Among other conditions, the Veteran is service connected for residuals of a stroke, COPD, ischemic heart disease and ischemic cardiomyopathy, and vertigo, which are due to the Veteran's chromium 6 exposure. Service treatment records, to include the April 1966 induction examination and the May 1970 separation examination, are negative for complaints of, treatment for, or a diagnosis of a right hip, left hip, or cervical spine disorder. Contemporaneous VA and private treatment records note current diagnoses of cervical spine degenerative disc disease, right hip degenerative joint disease, and left hip degenerative joint disease. In October 2013 private opinions, P.M., RN, opined that the Veteran's bilateral hip and cervical spine disorders were due to secondary injuries sustained during service. In March 2020, P.M., RN., examined the Veteran, reviewed of the record, to include the medical literature regarding chromium 6 and other chemical intoxicants, compared the Veteran's comprehensive health history to the current scientific research as to cause and effect, and she found there was a match observed between the Veteran's exposure to intoxicants and the resultant genetic alterations and defects deemed irreversible. In a March 2020 Private opinion, D.H., M.D., reported that he treated the Veteran for the past 36 years. D.H. opined that the Veteran's exposure to Chrome 6 during service was "more likely" primarily responsible for the Veteran's awarded disabilities. D.H. concluded that the Veteran's current disabilities are related to toxic exposure that began during active service. The Veteran underwent a VA cervical spine examination in May 2021, during which the examiner diagnosed cervical degenerative disc disease and cervical strain. At the time, the Veteran reported that he initially experienced cervical spine pain in approximately since 1990. He further indicated that he does not recall any event or injury causing his neck pain. Upon review of the record, the examiner found that the Veteran's current cervical spine degenerative disc disease was not incurred in or caused by service, to include exposure to toxic chemicals. In providing the opinion, the examiner noted that the Veteran's service treatment records are negative for complaints of, or a diagnosis of neck condition. The examiner explained that cervical degeneration is a normal part of aging. The examiner noted that other possible risk factors and causes include smoking, occupation, genetics, atherosclerosis, contact sports, and prior surgeries. The examiner noted that a medical literature review does not identify a cause of cervical spine degenerative disc disease to be due to exposure to toxic chemicals. The examiner concluded that the Veteran's current cervical spine degenerative disc disease is not the result of service, to include exposure to toxic chemicals. The Veteran underwent a VA cervical spine examination in January 2023, during which the examiner diagnosed cervical spine degenerative disc disease and cervical strain. Upon review of the record, the examiner found that the Veteran's current cervical spine strain was less likely than not incurred in or caused by service. In providing the opinion, the examiner noted that there is scant data supporting a nexus between the Veteran's current cervical spine strain diagnosis and his service. The examiner concluded that without chronicity during service or after service, a post-service event or injury is considered to be a more likely etiology of the Veteran's current cervical spine strain. The Veteran underwent a VA hip examination in May 2021, during which the examiner diagnosed bilateral degenerative arthritis and hip strain. At the time, the Veteran reported that his bilateral hip pain and weakness began in approximately 1983, while working. Upon review of the record, the examiner found that the Veteran's current bilateral hip degenerative arthritis was not related to his active service, to include exposure to toxins. In providing the opinion, the examiner noted that the service treatment records are negative for a diagnosis of a right or left hip disorder. The examiner explained that osteoarthritis is a joint disease that happens when the tissues in the joint break down over time, and it is more common in older adults. The examiner noted that certain factors may make it more likely to develop osteoarthritis to include age, being over-weight or obese, history of injury to a joint, overuse from repeated movements of the joint, joints that do not form correctly, and family history of osteoarthritis. The examiner noted that a medical literature review does not identify a cause of hip osteoarthritis to be due to exposure to toxic chemicals. The examiner concluded that it was less likely than not that the Veteran's current right or left hip osteoarthritis disorder manifested during or as a result of active service, to include exposure to toxic chemicals. The Veteran underwent a VA hip examination in January 2023, during which the examiner diagnosed left hip joint replacement, left hip degenerative arthritis, and bilateral hip strain. At the time, the Veteran reported that his bilateral hip pain began after separation from service. Upon review of the record, the examiner found that the Veteran's current bilateral hip strain and left hip degenerative joint disease is less likely than not incurred in or caused by service. In providing the opinion, the examiner noted that there is scant data supporting a nexus between the current bilateral hip strain diagnosis/left hip degenerative joint disease and the Veteran's service. The examiner concluded that without chronicity during service or after service, a post-service event or injury is considered to be a more likely etiology of the Veteran's current bilateral hip strain and left hip degenerative joint disease. The Board finds that the evidence of record does not support entitlement to service connection for a cervical spine disorder or a right or left hip disorder. In this regard, the Board notes that the Veteran's service treatment records are negative for complaints of, or a diagnosis of a cervical spine or a right or left hip disorder. Post-service records do not demonstrate a diagnosis of degenerative arthritis of the right and left hip until June 2013, or a diagnosis of degenerative disc disease of the cervical spine until November 2013, more than 40 years following separation from service. In addition, the May 2021 and January 2023 VA examiners opined, that the Veteran's current cervical spine degenerative disc disease and strain, and right and left hip degenerative arthritis and strain, are the result of his age, and unrelated to service, to include exposure to toxic chemicals. Despite the Veteran's assertions, there is no medical evidence of record that establishes an etiological relationship between the Veteran's current cervical spine and right and left hip disorders and his active service. Moreover, during the May 2021 VA cervical spine examination, the Veteran reported that he initially experienced cervical spine pain in approximately 1990, two decades following separation from service. Similarly, during the May 2021 VA hip examination, the Veteran reported that he initially experienced bilateral hip pain and weakness in approximately 1983 (while working), approximately 13 years after separation from service. Further, when the Board last review the claims in June 2020, it found the October 2013 private opinions inadequate to adjudicate the claim, as P.M. failed to indicate which injuries sustained in service caused the Veteran's current cervical spine and right and left hip disorders. Likewise, the Board also found the March 2020 private opinions inadequate to adjudicate the claim. Although P.M. and D.H. found that the Veteran was exposed to intoxicants during service, neither healthcare provider specified the disorders that the in-service exposure caused. Finally, the Board recognizes that the Veteran believes his cervical spine and right and left hip disabilities manifested as a result of his active service. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on his symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). While the Veteran is competent to provide testimony to establish the occurrence of medical symptoms, he is not medically qualified to prove a matter requiring medical expertise. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). The etiology of cervical spine degenerative disc disease and strain, and right and left hip degenerative arthritis and strain disabilities is a complex medical determination outside the realm of common knowledge of a lay person. Further, the May 2021 and January 2023 VA examiners determined that the etiology of the Veteran's current cervical spine and right and left hip disabilities is unrelated to his service. Instead, the May 2021 cervical spine examiner placed greater weight on the Veteran's age, noting that cervical degeneration is a normal part of aging. The examiner also noted that the Veteran did not recall an injury to his cervical spine or any symptoms during active service. Moreover, the examiner performed a relevant medical literature review, and found that it does not identify a cause of cervical spine degenerative disc disease or strain to be due to exposure to toxic chemicals. Similarly, the May 2021 VA hip examiner found that the Veteran's current bilateral degenerative arthritis and hip strain diagnoses were less likely than not incurred in or caused by the Veteran's service, to include exposure to toxic chemicals. In providing the opinion, the examiner explained that osteoarthritis is a joint disease that happens when the tissues in the joint break down over time, and it is more common in older adults. The examiner further noted that a medical literature review does not identify a cause of hip osteoarthritis or strain to be due to exposure to toxic chemicals. Thus, although the Board has carefully considered the lay contentions of record suggesting that the Veteran's cervical spine and right and left hip disabilities are related to his military service, the lay opinions are clearly of less probative value than the VA medical opinions against the claim. Accordingly, service connection for cervical spine degenerative disc disease, cervical spine strain, right hip degenerative arthritis, right hip strain, left hip degenerative arthritis, and left hip strain, is not warranted. Increased Rating - Legal Criteria Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2021). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321 (a), 4.1 (2021). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2021). In accordance with 38 C.F.R. §§ 4.1, 4.2 (2021) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disability. In both initial rating claims and subsequent increased rating claims, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2021). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2021). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45 (2021). The intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (2021). In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. 13. Entitlement to an initial evaluation in excess of 20 percent for the service-connected left shoulder disorder. The Veteran contends that his left shoulder disability is more severe than his current evaluation. In this regard, he is currently in receipt of an initial 20 percent rating for his left shoulder that is rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5201. The evidence of record demonstrates that the Veteran is right-handed, and his disability is his left shoulder. Thus, schedular ratings for the minor shoulder are for application. 38 C.F.R. § 4.69 (2021). Under Diagnostic Code 5201 (prior to the regulatory change on February 7, 2021), limitation of motion of the minor arm at shoulder level warrants a 20 percent disability rating; limitation of motion of the minor arm midway between side and shoulder level warrants a 20 percent disability rating; and limitation of motion of the minor arm to 25 degrees from side warrants a 30 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 "does not provide separate ratings for limitation of motion of flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm." Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). Under Diagnostic Code 5201 (as of February 7, 2021, under the amended regulatory criteria), limitation of motion may be shown by flexion and/or abduction. Limitation of motion at the shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating for the minor extremity. Limitation of motion of the arm midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) warrants a 20 percent rating for the minor extremity. Flexion and/or abduction limited to 25 degrees from the side warrants a maximum 30 percent rating for the minor joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2021). Normal ranges of upper extremity motion are flexion from zero to 180 degrees, abduction from zero to 180 degrees, and internal and external rotation from zero to 90 degrees. 38 C.F.R. § 4.71, Plate I. A May 2013 VA outpatient treatment record includes an x-ray that shows moderate left shoulder arthritis. The Veteran underwent a private evaluation in November 2013. At the time, the Veteran reported a history of chronic left shoulder pain since service. He further reported difficulty sleeping comfortably due to pain. Examination of the left shoulder did not include range of motion testing. There was no evidence of localized tenderness or pain on palpation of the joint or bicep. There was no evidence of guarding. Muscle strength testing revealed active movement against gravity (3/5). There was no evidence of ankylosis of the glenohumeral articulation (shoulder joint). There was no evidence of a rotator cuff condition. There was a history of clicking. There was no evidence of recurrent dislocation of the glenohumeral joint. There was no impairment of the AC joint or clavicle or scapula. There was no tenderness on palpation of the AC joint. Cross-body adduction test was positive. There was no evidence of total shoulder joint replacement. There was no evidence of arthroscopic or other shoulder surgery. There was no scarring. X-ray examination revealed degenerative or traumatic arthritis. The physician assessed left degenerative joint disease and partial infraspinatus tear. VA outpatient treatment records dated in 2013 through 2016 demonstrate complaints of left shoulder pain and diagnoses of osteoarthritis. The Veteran underwent a VA examination in May 2021. At the time, the Veteran reported a history of left shoulder pain. He further denied functional loss or impairment of the left shoulder. Examination of the left shoulder included range of motion testing, which revealed flexion from zero to 105 degrees, abduction from zero to 105 degrees, external rotation to 35 degrees, and internal rotation to 35 degrees. Passive range of motion resulted in the same findings as active range of motion. There was evidence of pain on active and passive motion that did not result in functional loss. There was no evidence of localized tenderness or pain on palpation of the joint or bicep. There was no evidence of crepitus. The examiner noted that the Veteran did not perform repetitive use testing due to suboptimal effort. Regarding repeated use over time and flare-up testing, the Veteran's statements did not suggest pain, fatigability, weakness, lack of endurance, or incoordination significantly limiting functional ability, nor was there any evidence of functional loss. There was no evidence of muscle atrophy. There was no evidence of ankylosis. There was no evidence of a rotator cuff condition. There was no evidence of instability, mechanical symptoms, or recurrent dislocation. There was no evidence of a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition. There was no evidence of impairment of the humerus. There was no evidence of surgical procedures or scars. The assessment was degenerative arthritis. The Veteran underwent a VA examination in January 2023. At the time, the Veteran reported a history of left shoulder pain that had worsened since the last VA examination. He reported that he took Advil for pain, as well as received steroid injections every three months. He denied flare-ups of the left shoulder. The Veteran reported that he experienced functional loss of his left shoulder due to the inability to lift objects. Examination of the left shoulder included range of motion testing, which revealed flexion from zero to 160 degrees, abduction from zero to 160 degrees, external rotation to 70 degrees, and internal rotation to 70 degrees. Passive range of motion resulted in the same findings as active range of motion. There was evidence of pain on active and passive motion that resulted in functional loss; specifically, the Veteran could not lift objects or perform certain chores. There was no evidence of localized tenderness or pain on palpation of the joint or bicep. There was no evidence of crepitus. The Veteran was able to perform repetitive use testing with three repetitions and there was no additional loss of function or range of motion. Regarding repeated use over time and flare-up testing, the Veteran's statements did not suggest pain, fatigability, weakness, lack of endurance, or incoordination significantly limiting functional ability, nor was there any evidence of functional loss or flare-ups. There was no evidence of muscle atrophy. There was no evidence of ankylosis. There was no evidence of a rotator cuff condition. There was no evidence of instability, mechanical symptoms, or recurrent dislocation. There was no evidence of a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition. There was no evidence of impairment of the humerus. There was no evidence of surgical procedures or scars. There was no evidence that the Veteran used or needed an assistive device. The examiner assessed a left shoulder strain. Upon review, the evidence of record shows that an initial rating in excess of 20 percent for the service-connected left shoulder disability, is not warranted. Here, in order the warrant the next higher 30 percent rating for the minor (left) shoulder, there must be flexion and/or abduction of the minor arm limited to 25 degrees from side. In this regard, the May 2021 VA examination report shows flexion to 105 degrees, and abduction to 105 degrees. The January 2023 VA examination report demonstrates flexion to 160 degrees and abduction to 160 degrees. Thus, while the record reflects the Veteran does have limitation of flexion to no more than 105 degrees, and abduction to no more than 105 degrees, it is not to the extent necessary for a rating in excess of 20 percent under Diagnostic Code 5201 prior to, or after the regulatory change on February 7, 2021. Further, the evidence of record does not demonstrate that the next higher 30 percent rating is warranted for the Veteran's left shoulder due to functional loss, even when taking into account the Veteran's complaints of pain and difficulty lifting objects. Here, there is no evidence of record of additional limitation of range of motion or functional impairment upon repetitive motion testing, repeated use over time testing, or flare-up testing. 38 C.F.R. §§ 4.71a, 4.40, 4.45, 4.59; see Mitchell, 25 Vet. App. at 32; Deluca, 8 Vet. App. at 202. Also, there is no evidence of ankylosis or evidence of the functional equivalent of ankylosis during flare-ups. See Chavis v. McDonough, 34 Vet. App. 1 (2021). The Board has also considered the other potentially applicable rating criteria to see if a higher or separate rating is warranted for the left shoulder. However, the evidence of record does not demonstrate malunion of the humerus, fibrous union of the minor humerus, false flail joint, flail shoulder, or impairment of the clavicle or scapula. Therefore, Diagnostic Codes 5200, 5202, and 5203, are not applicable. 38 C.F.R. § 4.71a. Further, the Board has considered the lay evidence offered by the Veteran in the form of correspondence and testimony, in addition to the medical evidence cited above. In this regard, the Board acknowledges the Veteran's consistent report of left shoulder pain, limitation of motion, and difficulty lifting objects. However, even affording the lay statements full competence and credibility, the evidence simply does not show entitlement to a higher rating under any applicable Code. Accordingly, an initial rating in excess of 20 percent for the service-connected left shoulder disability is not warranted, to include as a "staged" rating(s) pursuant to Fenderson and Hart. REASONS FOR REMAND 1. Entitlement to service connection for left eye pinguecula disorder. See argument Below at 2 2. Entitlement to service connection for right eye pinguecula disorder. The Veteran contends that his current right and left eye pinguecula disorders are the result of his active service. In this regard, during aforementioned hearing before the Board, the Veteran asserted that he was exposed to chromium 6 and other chemicals as a result of his duties as an aviation mechanic, to include sanding and painting planes. He further indicated that he experienced ongoing and chronic symptoms of eye pain since his initial in-service exposure to these intoxicants. As above, the AOJ has conceded the Veteran's exposure to chromium 6 based on his occupation in the Navy. See March 2016 rating decision. Service treatment records include an April 1966 induction examination, which negative for complaints of, or a diagnosis of a right or left eye disorder. A September 1968 record demonstrates that the Veteran sought treatment for his left eye. The examiner noted that the Veteran worked in the air frame shop, and had a particle embedded in his left eye. The report of a May 1970 separation examination is negative for complaints of, treatment for, or a diagnosis of a right or left eye disorder. A June 2013 private eye evaluation indicates diagnoses of right and left pinguecula. A January 2023 VA eye examination report indicates diagnoses of right and left eye pinguecula. Upon review of the record, the examiner found that the Veteran's current pinguecula were less likely than not incurred in or caused by the Veteran's service, to include exposure to toxic chemicals. In providing the opinion, the examiner explained that pinguecula is a benign and common degeneration of the conjunctiva. It appears as a grey-white-yellow mass on the bulbar conjunctiva. It presents in people exposed to wind, dust, sand, trauma, outdoor work, and ultraviolet light. Mild symptoms such as foreign body sensation and itching are treated with artificial tears. The examiner concluded that the Veteran did not receive a diagnosis of right or left eye pinguecula until 2016, many years after separation from service. The Board finds the January 2023 VA opinion inadequate for adjudication purposes. In this regard, the Veteran's service treatment records demonstrate the Veteran sought treatment for a particle imbedded in his left eye following an injury while working in a frame shop in September 1968; however, the examiner failed to consider this record. Moreover, the examiner did not consider the Veteran's service as an aviation mechanic, whereas his duties included sanding and painting planes. The Veteran was repeated exposed to sand, dust, and at least one trauma of his left eye during service. In addition, the examiner failed to consider the Veteran's ongoing assertions and testimony that this current bilateral eye pain began during active service following injuries, and has progressively worsened since service. Accordingly, another VA medical opinion is necessary to make a determination in this case. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 3. Entitlement to service connection for a sleep disorder, to include as secondary to the service-connected heart disease and/or allergic rhinitis. The Veteran contends that his current OSA is related to active service, and alternatively, due to his service-connected heart disease, service-connected COPD, and/or allergic rhinitis. Service treatment records include an April 1966 induction examination, which is negative for complaints of, treatment for, or a diagnosis of a sleep disorder. An August 1967 psychiatry record shows the Veteran reported that he sleeps quite soundly. The report of a May 1970 separation examination is negative for complaints of, treatment for, or a diagnosis of a sleep disorder. Post-service records include a December 2011 private evaluation that indicates a diagnosis of moderate OSA. The Veteran underwent a VA sleep examination in May 2021, during which the examiner diagnosed obstructive sleep apnea. Upon review of the record, the examiner opined that it is less likely than not that the Veteran's current OSA was incurred in or caused by service, to include inservice exposure to toxic chemicals. In providing the opinion, the examiner noted that the Veteran's service treatment records are negative for a sleep disorder. The examiner explained that sleep apnea can be caused by an individual's physical structure or medical conditions, to include obesity, large tonsils, endocrine disorders, neuromuscular disorders, heart or kidney failure, certain genetic syndromes, and premature birth. The examiner noted that a review of relevant literature does not include or identify exposure to chemicals as a cause of sleep apnea. The Veteran underwent a VA sleep examination in January 2023, during which the examiner diagnosed obstructive sleep apnea. Upon review of the record, the examiner found that the Veteran's current OSA was not due to service. In providing the opinion, the examiner noted that there was scant data supporting a nexus between the Veteran's current OSA diagnosis and his service. The examiner concluded that without chronicity during service or after service, a post-service event or injury is considered to be a more likely etiology of the Veteran's current OSA. In an August 2023 addendum opinion, a VA examiner reviewed the record and opined that it is less likely than not that the Veteran's current OSA was caused by his inservice exposure to toxic chemicals. The examiner explained that according to medical literature, OSA happens when your airway becomes blocked many times while you sleep, reducing or completely stopping airflow. The examiner noted that certain factors can cause OSA, such as genetic factors, colds and allergies, obesity, thyroid problems, heart or kidney failure, or large or swollen tonsils. The Board finds the May 2021, January 2023, and August 2023 VA opinions inadequate to adjudicate the claim. In this regard, the aforementioned examiners note several potential risk factors that can lead to the development of OSA, to include heart failure; however, the examiners failed to indicate which risk factors, if any, are attributable to the Veteran. In addition, the examiners also failed to offer an opinion addressing whether the Veteran's current OSA is caused or aggravated by his service-connected heart disease and/or COPD, and/or claimed allergic rhinitis. Accordingly, another VA medical opinion is necessary to make a determination in this case. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 4. Entitlement to service connection for allergic rhinitis, to include as due to exposure to toxic chemicals. See argument Below at 5 5. Entitlement to service connection for nasal polyps, to include as due to exposure to toxic chemicals, to include as secondary to the claimed allergic rhinitis disorder. The Veteran contends that his current allergic rhinitis had its onset during active service and has progressively worsened since service. The Veteran also contends that his current nasal polyps are related to his active service, and alternatively, due to his allergic rhinitis disorder. Service treatment records include an April 1966 induction examination, which is negative for complaints of, treatment for, or a diagnosis of allergic rhinitis or nasal polyps. A May 1967 record shows the Veteran sought treatment for a lump in his throat; laryngoscopy shows inflamed epiglottis. A March 1969 record shows the Veteran sought treatment for a sore throat; the assessment was sinusitis. The report of a May 1970 separation examination is negative for complaints of, treatment for, or a diagnosis of allergic rhinitis or nasal polyps. Post-service records include a February 2006 private record that shows the Veteran complained of nasal congestion, sore throat, and chest congestion; the assessment was bronchitis. A June 2012 VA outpatient treatment record notes a diagnosis of chronic bronchitis. A June 2013 private evaluation notes a diagnosis of nasal polyps (initially diagnosed in October 1984). The Veteran underwent a VA sinusitis/rhinitis and other conditions of the nose, throat, larynx and pharynx examination in May 2021, during which the examiner diagnosed allergic rhinitis. At the time, the Veteran reported a history of nasal polyps and symptoms of headaches, nasal congestion, and a sore throat since service. Upon review of the record, the examiner concluded that it was less likely than not that the Veteran's current allergic rhinitis was incurred in or caused by service. In providing the opinion, the examiner noted that the Veteran's separation examination is negative for a diagnosis of allergic rhinitis. The examiner concluded that examination for nasal polyps was normal and there is no diagnosis of nasal polyps, noting that the Veteran's symptoms are subjective only. The examiner also opined that the Veteran's nasal polyps are not due to service. In this regard, the examiner noted that nasal polyps are a subgroup of chronic rhinosinusitis, a condition where the nasal cavity and sinuses are inflamed for more than 4 to 12 weeks. The examiner noted that not all individuals with this condition develop nasal polyps. The examiner noted several risk factors that lead to the development of nasal polyps, to include, asthma, aspirin sensitivity, chronic sinus infection, cystic fibrosis, and allergic rhinitis (hay fever). The Veteran underwent a VA sinusitis/rhinitis and other conditions of the nose, throat, larynx and pharynx examination in January 2023, during which the examiner found that there was no diagnosis of allergic rhinitis or nasal polyps. Upon review of the record, the examiner found that the Veteran's allergic rhinitis and nasal polyps are not due to service. In providing the opinion, the examiner noted that there is scant data supporting a nexus between the current diagnoses and the Veteran's service. The examiner concluded that without chronicity during service or after service, a post-service event or injury is considered to be a more likely etiology of the Veteran's current allergic rhinitis and nasal polyps. In an August 2023 addendum opinion, a VA examiner reviewed the record and noted that according to the January 2023 examination, the Veteran does not have a current diagnosis of allergic rhinitis or nasal polyps. The examiner opined that it is less likely than not that the Veteran's current allergic rhinitis and nasal polyps are caused by inservice exposure to toxic chemicals. The Board finds the May 2021, January 2023, and August 2023 VA opinions inadequate to adjudicate the claim. In this regard, the aforementioned examiners failed to address whether the Veteran's documented inservice complaints of a lump in his throat and a sore throat, as well as an assessment of sinusitis were early manifestations of his current allergic rhinitis disorder. In addition, the May 2021 examiner failed to consider the Veteran's assertions, that he experienced nasal polyps, symptoms of headaches, nasal congestion, and a sore throat since service. Further, the May 2021 examiner indicates several risk factors that lead to the development of nasal polyps, to include a chronic sinus infection and allergic rhinitis; however, the examiner did not indicate which factors, if any, are attributable to the Veteran. Finally, the January 2023 and August 2023 examiners did not consider the evidence of record that demonstrates current diagnoses of allergic rhinitis and nasal polyps during the appeal period. Accordingly, additional VA medical opinions are necessary to make a determination in this case. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 6. Entitlement to service connection for a hernia, to include as secondary to the service-connected heart disease. The Veteran contends that his hernia condition and residuals thereof is the result of a surgery he underwent for his service-connected heart disease. He does not contend, nor does the evidence demonstrate that he sought treatment for, or was diagnosed with a hernia condition during service. Post-service records include the report of a May 2021 VA hernia examination. Upon examination, the examiner diagnosed status post incisional hernia. At the time, the Veteran reported that after a heart procedure, he developed an incisional abdominal hernia, which was repaired in 1998. He further reported that he does not have any current symptoms with respect to his hernia. Upon review of the record, the examiner found that the Veteran's current status post incisional hernia repair was not related to his active service. In providing the opinion, the examiner noted that the service treatment records are negative for a diagnosis of a hernia. The examiner further noted that the Veteran's hernia was repaired in 1998, many years after separation from service. The Veteran underwent a VA hernia examination in January 2023, during which the examiner diagnosed status post incisional hernia repair. At the time, the Veteran reported that post-heart surgery, he required an incisional hernia repair. The Board finds the May 2021 and January 2023 VA opinions inadequate to adjudicate the claim. In this regard, the aforementioned examiners failed to offer an opinion addressing whether the Veteran's current residuals of an incisional hernia condition was caused or aggravated by his service-connected heart disease. Accordingly, another VA medical opinion is necessary to make a determination in this case. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 7. Entitlement to service connection for a right shoulder disorder, to include as secondary to the service-connected left shoulder disability. The Veteran contends that his current right shoulder disorders are related to his active service, and alternatively, due to his service-connected left shoulder disability. Service treatment records, to include the April 1966 induction examination and May 1970 separation examination, are negative for complaints of, treatment for, or a diagnosis of a right shoulder disorder. Post-service records include a November 2013 private evaluation that notes a diagnoses of right shoulder degenerative joint disease. The Veteran underwent a VA shoulder examination in May 2021, during which the examiner diagnosed degenerative arthritis of the right shoulder. At the time, the Veteran reported that his right shoulder pain began during active service, in approximately 1968. Upon review of the record, the examiner found that the Veteran's current right shoulder degenerative arthritis was less likely than not incurred in or caused by service, to include as due to inservice exposure to toxic chemicals. In providing the opinion, the examiner noted that the Veteran's service treatment records are negative for a right shoulder disorder. The examiner further noted that certain factors may make it more likely that an individual will develop osteoarthritis, to include, age, being overweight or obese, history of injury or surgery to a joint, overuse from repeated movements of the joint, and family history of osteoarthritis. The examiner noted that a review of relevant literature does not include or identify exposure to chemicals as a cause of right shoulder osteoarthritis. The examiner found that the Veteran's right shoulder arthritis was not caused by his service-connected left shoulder disability. The Veteran underwent a VA shoulder examination in January 2023, during which the examiner diagnosed degenerative arthritis and shoulder strain of the right shoulder. Upon review of the record, the examiner found that the Veteran's current right shoulder degenerative arthritis was less likely than not incurred in or caused by service. In providing the opinion, the examiner noted that there is scant data supporting a nexus between the current right shoulder arthritis diagnosis and the Veteran's service. The examiner concluded that without chronicity during service or after service, a post-service event or injury is considered to be a more likely etiology of the Veteran's current right shoulder arthritis. The Board finds the May 2021 and January 2023 VA opinions inadequate to adjudicate the claim. In this regard, the aforementioned examiners failed to offer an etiology for the Veteran's current right shoulder degenerative joint disease. In addition, the examiners also failed to consider the Veteran's assertions, that his right shoulder pain began during active service in 1968. Finally, while the May 2021 examiner found that the Veteran's current right shoulder disorder was not caused by his service-connected left shoulder disability, he did not offer a rationale for his opinion, nor did he provide an opinion addressing whether the Veteran's current right shoulder disorder was aggravated by his service-connected left shoulder disability. Accordingly, another VA medical opinion is necessary to make a determination in this case. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 8. Entitlement to service connection for a lumbar spine disorder, to include as due to exposure to toxic chemicals. See argument Below at 10 9. Entitlement to service connection for a right knee disorder, to include as due to exposure to toxic chemicals. See argument Below at 10 10. Entitlement to service connection for a left knee disorder, to include as due to exposure to toxic chemicals. The Veteran contends that his current lumbar spine, right knee, and left knee disorders are related to service, to include his in-service exposure to chromium 6. In this regard, during the March 2020 hearing before the Board, the Veteran asserted that he was exposed to toxic chemicals as a result of his duties as an aviation mechanic, to include sanding and painting planes. He further indicated that he experienced ongoing and chronic symptoms of pain since his initial in-service exposure to these intoxicants. As above, the AOJ has conceded the Veteran's exposure chromium 6 based on his occupation in the Navy. See March 2016 rating decision. Contemporaneous VA and private treatment records note current diagnoses of lumbar spine degenerative disc disease and left knee osteoarthritis. In October 2013 private opinions, P.M., RN, opined that the Veteran's bilateral knee and lumbar spine disorders were due to secondary injuries sustained during service. In March 2020, P.M., RN., examined the Veteran, reviewed of the record, to include the medical literature regarding chromium 6 and other chemical intoxicants, compared the Veteran's comprehensive health history to the current scientific research as to cause and effect, and she found there was a match observed between the Veteran's exposure to intoxicants and the resultant genetic alterations and defects deemed irreversible. In a March 2020 Private opinion, D.H., M.D., reported that he treated the Veteran for the past 36 years. D.H. opined that the Veteran's exposure to Chrome 6 during service was "more likely" primarily responsible for the Veteran's awarded disabilities. D.H. concluded that the Veteran's current disabilities are related to toxic exposure that began during active service. When the Board last review the claims in June 2020, it found the October 2013 private opinions inadequate to adjudicate the claim, as P.M. failed to indicate which injuries sustained in service caused the Veteran's current disorders. Likewise, the Board also found the March 2020 private opinions inadequate to adjudicate the claim. Although P.M. and D.H. found that the Veteran was exposed to intoxicants during service, neither healthcare provider specified the disorders that the in-service exposure caused. Thus, the Board remanded the case in order for the Veteran to be afforded VA examinations with medical opinions, in order to determine the etiology of his claimed disorders. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4). The Veteran underwent a VA lumbar spine examination in May 2021, during which the examiner diagnosed degenerative disc disease and lumbar strain. At the time, the Veteran reported that he initially experienced back pain in service when he was required to lift heavy items for planes, especially during sea duty. He further reported that his low back pain has persisted since active service. Upon review of the record, the examiner found that the Veteran's current degenerative disc disease of the lumbar spine was less likely than not incurred in or caused by service, to include as due to exposure to toxic chemicals. In providing the opinion, the examiner noted that the service treatment records are negative for treatment for or a diagnosis of a lumbar spine disorder. The examiner noted that the prevalence of degenerative disc disease is roughly described in proportion to age such that 40 percent of people aged 40 years have it, increasing to 80 percent among those aged 80 years or older. The examiner noted that a review of relevant literature does not include or identify exposure to chemicals as a cause of degenerative disc disease of the lumbar spine. The Veteran underwent a VA lumbar spine examination in January 2023, during which the examiner diagnosed degenerative disc disease and lumbar strain. At the time, the Veteran reported that he initially experienced back pain in service in approximately 1966. He reported that his low back pain has continued since service. Upon review of the record, the examiner found that the Veteran's current lumbar spine strain was less likely than not incurred in or caused by service. In providing the opinion, the examiner noted that there is scant data supporting a nexus between the Veteran's current lumbar spine strain diagnosis and his service. The examiner concluded that without chronicity during service or after service, a post-service event or injury is considered to be a more likely etiology of the Veteran's current lumbar spine strain. The Veteran underwent a VA knee examination in May 2021, during which the examiner diagnosed bilateral knee strain and bilateral total knee replacement. At the time, the Veteran reported that his bilateral knee pain and swelling began during service in approximately 1967, and he sought treatment for it during service. He further reported that he underwent a bilateral total knee replacement in 1995, and he continues to have symptoms of pain and swelling. Upon review of the record, the examiner found that the Veteran's current bilateral knee strain and total knee replacements were not related to his active service, to include exposure to toxic chemicals. In providing the opinion, the examiner noted that the service treatment records are negative for a diagnosis of a right or left knee disorder. The examiner noted that a medical literature review does not identify a cause of knee replacement surgery to be due to exposure to toxic chemicals. The Veteran underwent a VA knee examination in January 2023, during which the examiner diagnosed bilateral knee strain and status post bilateral total knee replacement. At the time, the Veteran reported that his bilateral knee pain began during service as a result of strenuous activities, and such pain has progressively worsened. Upon review of the record, the examiner found that the Veteran's current bilateral knee strain is less likely than not incurred in or caused by service. In providing the opinion, the examiner noted that there is scant data supporting a nexus between the current bilateral knee strain diagnosis and the Veteran's service. The examiner concluded that without chronicity during service or after service, a post-service event or injury is considered to be a more likely etiology of the Veteran's current bilateral knee strain. The Board finds the May 2021 and January 2023 VA lumbar spine and knee opinions inadequate to adjudicate the claim. In this regard, the aforementioned examiners failed to offer an etiology for the Veteran's current lumbar spine degenerative disc disease, lumbar spine strain, right knee strain, right knee total replacement, left knee strain, or left knee total replacement disorders. In addition, the examiners also failed to consider the Veteran's assertions, that his lumbar spine and bilateral knee pain began during active service. Specifically, regarding his lumbar spine, the Veteran asserted that he initially experienced back pain in service in approximately 1966, when he was required to lift heavy items for planes, especially during sea duty. With respect to his right and left knees, he asserted that his bilateral knee pain and swelling began in approximately 1967, as a result of strenuous activities, and he sought treatment for it during service. The Veteran also asserted that his lumbar spine and right and left knee pain continued since service has progressively worsened. Accordingly, additional VA medical opinions are necessary to make a determination in this case. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 11. Entitlement to an initial compensable evaluation for the service-connected left hand burn scar. When the Board last reviewed the claim in June 2020, it noted the Veteran's contentions that his left hand burn scar was more severe than his current noncompensable evaluation, and remanded the issue for a VA examination. The Veteran underwent VA scar examinations in March 2021, May 2021, and January 2023, which assessed his bilateral knee, bilateral lower extremity, and trunk scars with respect to his vascular disabilities. The examinations do no assess nor indicate whether an examination was performed regarding the Veteran's left hand burn scar. In this regard, the most recent VA examination that assessed the left hand burn scar is dated in November 2013. In light of the foregoing, a more contemporaneous examination is warranted in order to ensure that the record reflects the current severity of the Veteran's service-connected left hand burn scar disability. Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (holding that where the record does not adequately reveal the current state of that disability, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination). The matters are REMANDED for the following actions: 1. This case is advanced on the docket. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claim, to include updated VA outpatient treatment records, as well as any private treatment records identified by the Veteran. If any requested records are unavailable, or the search for such records otherwise yields negative results, that fact should clearly be documented in the record and the Veteran so notified in accordance with 38 C.F.R. § 3.159(e). All steps taken to attempt to obtain the above records should clearly be documented in the record. 2. Obtain an addendum medical opinion by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following a review of the record, the physician should state a medical opinion with respect to the right and left eye pinguecula disorders present during the period of the claim. The examiner must address the following: The examiner must provide an opinion as to whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's right and left eye pinguecula disorders manifested during, or as a result of, active military service, to include exposure to toxins. In providing the opinion, the examiner must comment on the September 1968 service treatment record that shows the Veteran sought treatment for a particle imbedded in his left eye following an injury while working in a frame shop. The examiner must also comment on the Veteran's military occupational specialty as an aviation mechanic, whereas his duties included sanding and painting planes, and he was exposed to sand and dust from sanding and painting planes. The examiner must comment on the Veteran's assertions and testimony, that this current bilateral eye pain began during active service following injuries, and has progressively worsened since service. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 3. Obtain an addendum medical opinion by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following a review of the record, the physician should state a medical opinion with respect to the OSA disorder present during the period of the claim. The examiner must address the following: The examiner must provide an opinion as to whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's OSA disorder manifested during, or as a result of, active military service, to include exposure to toxins. If not, the physician should state a medical opinion as to whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or near equal, if not higher) that the OSA disorder, was caused or permanently worsened by the service-connected heart and/or COPD and/or claimed allergic rhinitis disabilities. If the physician believes that OSA disorder was permanently worsened by a service-connected disorder(s), the physician should attempt to identify the baseline level of disability that existed prior to the onset of aggravation and the extent of disability that is attributable to aggravation. In providing the opinion, the examiner must comment on the May 2021 VA examiner's opinion that OSA can be caused by an individual's physical structure or medical conditions, to include obesity, large tonsils, endocrine disorders, neuromuscular disorders, heart or kidney failure, certain genetic syndromes, and premature birth. The examiner must also comment on the August 2023 VA examiner's opinion, that certain risk factors can cause OSA, to include genetic factors, colds and allergies, obesity, thyroid problems, heart or kidney failure, or large or swollen tonsils. To the extent possible, the examiner is asked to indicate which risk factors, if any, can be attributable to the Veteran with respect to his claimed OSA disability. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. Obtain an addendum medical opinion by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following a review of the record, the physician should state a medical opinion with respect to the allergic rhinitis disorder present during the period of the claim. The examiner must address the following: The examiner must provide an opinion as to whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's allergic rhinitis disorder manifested during, or as a result of, active military service, to include exposure to toxins. In providing the opinion, the examiner must comment of the following service treatment records: a May 1967 record that shows that the Veteran sought treatment for a lump in his throat; laryngoscopy shows inflamed epiglottis; and a March 1969 record that shows the Veteran sought treatment for a sore throat; the assessment was sinusitis. To the extent possible, the examiner must indicate whether the Veteran's inservice symptoms and assessment of sinusitis were early manifestations of his current allergic rhinitis disorder. In addition, the examiner must also comment on the Veteran's assertions and testimony, that he experienced nasal polyps, symptoms of headaches, nasal congestion, and a sore throat since service. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 5. Obtain an addendum medical opinion by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following a review of the record, the physician should state a medical opinion with respect to the nasal polyps disorder present during the period of the claim. The examiner must address the following: The examiner must provide an opinion as to whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's nasal polyps disorder manifested during, or as a result of, active military service, to include exposure to toxins. If not, the physician should state a medical opinion as to whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or near equal, if not higher) that the nasal polyps disorder, was caused or permanently worsened by the claimed allergic rhinitis disability. If the physician believes that nasal polyp disorder was permanently worsened by a service-connected disorder(s), the physician should attempt to identify the baseline level of disability that existed prior to the onset of aggravation and the extent of disability that is attributable to aggravation. In providing the opinion, the examiner must comment on the June 2013 private evaluation that notes a diagnosis of nasal polyps, which the examiner indicates were initially diagnosed in October 1984. The examiner must also comment on the May 2021 VA examiner's finding, that several risk factors that lead to the development of nasal polyps, to include a chronic sinus infection and allergic rhinitis, and to the extent possible, indicate which factors, if any, are attributable to the Veteran. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 6. Obtain an addendum medical opinion by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following a review of the record, the physician should state a medical opinion with respect to the residuals of an incisional hernia disorder present during the period of the claim. The examiner must address the following: The examiner must provide an opinion as to whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's residuals of an incisional hernia disorder manifested during, or as a result of, active military service, to include exposure to toxins. If not, the physician should state a medical opinion as to whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or near equal, if not higher) that the residuals of an incisional hernia disorder, was caused or permanently worsened by the service-connected heart disease disability. If the physician believes that residuals of an incisional hernia disorder was permanently worsened by a service-connected disorder(s), the physician should attempt to identify the baseline level of disability that existed prior to the onset of aggravation and the extent of disability that is attributable to aggravation. In providing the opinion, the examiner must comment on the May 2021 and January 2023 VA hernia examination reports, which indicate diagnoses of status post incisional hernia, and noted the Veteran's report that following heart surgery, he developed an incisional abdominal hernia, which was repaired in 1998. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 7. Obtain an addendum medical opinion by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following a review of the record, the physician should state a medical opinion with respect to the right shoulder degenerative arthritis disorder present during the period of the claim. The examiner must address the following: The examiner must provide an opinion as to whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's right shoulder degenerative arthritis disorder manifested during, or as a result of, active military service, to include exposure to toxins. If not, the physician should state a medical opinion as to whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or near equal, if not higher) that the right shoulder degenerative arthritis disorder, was caused or permanently worsened by the service-connected left shoulder disability. If the physician believes that a right shoulder degenerative arthritis disorder was permanently worsened by a service-connected disorder(s), the physician should attempt to identify the baseline level of disability that existed prior to the onset of aggravation and the extent of disability that is attributable to aggravation. In providing the opinion, the examiner must comment on the Veteran's assertions and testimony, that his right shoulder pain began during active service in 1968. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 8. Obtain an addendum medical opinion by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following a review of the record, the physician should state a medical opinion with respect to the lumbar spine disorders present during the period of the claim. The examiner must address the following: The examiner must provide an opinion as to whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's lumbar spine degenerative disc disease, and lumbar spine strain manifested during, or as a result of, active military service, to include exposure to toxins. In providing the opinion, the examiner must comment on the Veteran's assertions and testimony, that this current lumbar spine pain began during active service in approximately 1966, when he was required to lift heavy items for planes, especially during sea duty. He further asserts that his low back pain has progressively worsened since service. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 9. Obtain an addendum medical opinion by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following a review of the record, the physician should state a medical opinion with respect to the right and left knee disorders present during the period of the claim. The examiner must address the following: The examiner must provide an opinion as to whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's right and left knee strain and right and left total knee replacement disorders manifested during, or as a result of, active military service, to include exposure to toxins. In providing the opinion, the examiner must comment on the Veteran's assertions and testimony, that this current bilateral knee pain and swelling began during active service in approximately 1967, as a result of strenuous activities, and for which he sought treatment during service. The Veteran also asserts that his right and left knee pain has progressively worsened since service. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 10. Schedule the Veteran for a VA examination with an appropriate physician to assess the present nature and severity of his left hand burn scar disability. The examiner must review the record, to include service treatment records, VA and private treatment records, VA examination reports, and the Veteran's assertions and testimony. The examiner must also consideration the Veteran's documented medical history, assertions, and reported symptoms. All necessary tests and studies should be completed, and all clinical findings reported in detail. After a thorough review of the medical and lay evidence of record, the examiner should opine as to the following: The examiner is requested to describe all manifestations and symptoms of the left hand burn scar disability, as well as information required for rating purposes. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she should be directed to clearly explain why that is so. 11. The AOJ should ensure that the Veteran is provided with adequate notice of the date and place of all scheduled examinations. A copy of all notifications, including the address where the notice was sent, must be associated with the record if the Veteran fails to report for any examination. The Veteran is to be advised that failure to report for a scheduled VA examination without good cause may have adverse effects on his claim. 12. Then, the AOJ should readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran's satisfaction, he and his representative should be provided a supplemental statement of the case and an appropriate period for response before the case is returned to the Board for further appellate action. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sara Schinnerer, 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.