Entitlement to service connection for chronic fatigue syndrome, to include as secondary to rheumatoid arthritis, is denied.

Citation Nr: 26001422 Decision Date: 01/30/26 Archive Date: 01/30/26 DOCKET NO. 17-60 765 DATE: January 30, 2026 ORDER Entitlement to service connection for chronic fatigue syndrome, to include as secondary to rheumatoid arthritis, is denied. Entitlement to service connection for a hysterectomy, to include as due to in-service exposure to toxic substances, is denied. REMANDED Entitlement to service connection for herpes, to include as secondary to adjustment disorder with mixed anxiety and depressed mood, is remanded. Entitlement to service connection for kidney stones, to include as due to in-service exposure to toxic substances, is remanded. Entitlement to service connection for epilepsy, to include as due to in-service exposure to toxic substances, is remanded. Entitlement to service connection for breast cancer, to include as due to in-service exposure to toxic substances, is remanded. Entitlement to service connection for a gallbladder disability, to include as due to in-service exposure to toxic substances, is remanded. Entitlement to service connection for hypothyroidism, to include as due to in-service exposure to toxic substances, is remanded. Entitlement to service connection for rheumatoid arthritis, to include as due to in-service exposure to toxic substances, is remanded. FINDINGS OF FACT 1. The most persuasive evidence demonstrates that the Veteran does not have a current diagnosis for chronic fatigue syndrome. 2. The most persuasive evidence demonstrates that the Veteran's currently diagnosed hysterectomy did not have its onset during active duty service and was not otherwise etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for chronic fatigue syndrome, to include as secondary to rheumatoid arthritis, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. The criteria for entitlement to service connection for a hysterectomy have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from June 1970 to June 1973 with additional periods of service in the Army Reserve from July 1977 to December 1982. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge at a December 2019 Travel Board hearing. A transcript of this hearing is of record. This case has an extensive procedural history. Most recently, in January 2023, the Board remanded the issues on appeal for additional development. As discussed below, there has not been substantial compliance with the January 2023 remand instructions with respect to the issues of entitlement to service connection for herpes, kidney stones, epilepsy, breast cancer, a gallbladder disability, hypothyroidism, and rheumatoid arthritis, so these matters must be remanded. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Nevertheless, as the actions specified in the remand for the issues of entitlement to service connection for chronic fatigue syndrome and a hysterectomy and have been substantially completed, the matters have been properly returned to the Board for appellate consideration. Id. Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. In compliance with the January 2023 remand, VA performed the requested develop to verify the Veteran's assertions of exposure to chemicals and toxins, including polychlorinated biphenyls (PCBs), at Fort McClellan. In addition, the Board directed the RO to contact the Environmental Protection Agency (EPA) for information, to include whether the EPA has found Fort McClellan to be a chemical (including PCBs) waste dump, and if they have declared that Fort McClellan is a federal Superfund cleanup site. Based on VA's finding that the Veteran participated in a toxic risk exposure activity (TERA) due to her service at Fort McClellan and included information in the record from the VA's Public Health website as well as a PowerPoint presentation on Fort McClellan, the Board accepts that the necessary and required development was completed. Neither the Veteran nor her representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). For the above reasons, the Board finds that VA has fulfilled its duties to notify and assist the Veteran. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of the claims. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). In determining whether service connection is warranted, the Board shall consider the benefit-of-the-doubt doctrine. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claimant is entitled to the benefit-of-the-doubt when the competing evidence is in "approximate balance" or "nearly equal." That is, exact equipoise is not required to trigger the favorable benefit-of-the-doubt rule. Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021) (en banc). 1. Entitlement to service connection for chronic fatigue syndrome, to include as secondary to rheumatoid arthritis The Veteran asserts that her chronic fatigue syndrome was caused by her rheumatoid arthritis. During the December 2019 Board hearing, the Veteran testified that when she experienced flare-ups of rheumatoid arthritis, she became tired. She would have to remain in bed and rest. She said that after her discharge from service, she sought treatment from different doctors who attributed her constant tiredness to her age or working too long. The question before the Board is whether the Veteran has a current diagnosis for chronic fatigue syndrome. Based on a careful review of all the subjective and clinical evidence, the Board finds that the most persuasive evidence weighs against finding service connection for chronic fatigue syndrome is warranted. The Veteran's service treatment records (STRs) document that she entered active duty service with no pertinent symptomatology noted. See June 1970 enlistment examination. At a January 1972 clinic visit, the Veteran reported having fatigue, headache, sinus blockage, sore throat, nausea, and cough with yellow phlegm. After conducting an objective evaluation, the Veteran was diagnosed with influenza with bronchitis. At an August 1972 clinic visit, the Veteran reported having a headache for the past four days with fatigue, nausea and fever. At a March 1973 separation examination, the Veteran had no pertinent abnormal clinical evaluation findings. On a June 1973 Statement of Medical Condition, the Veteran noted that to the best of her knowledge, since her last separation examination, there had been no change in her medical condition. The record also includes STRs from the Veteran's Army Reserve service. At a May 1977 enlistment examination, the Veteran had no pertinent abnormal clinical evaluation findings, and on her associated report of medical history, no pertinent symptomatology was reported. At a November 1981 examination, the Veteran had no pertinent abnormal clinical evaluation findings, and on her associated report of medical history, no pertinent symptomatology was reported. Post-service VA treatment records document the Veteran's treatment for fatigue. At a November 2014 VA rheumatology clinic visit, the Veteran reported how she had been in bed over the weekend with fatigue and nausea. She had no fever. The VA treating provider noted that her symptoms had resolved. She was diagnosed with rheumatoid arthritis. At an October 2015 VA rheumatoid clinic visit, the Veteran \ presented with a flare-up rheumatoid arthritis with pain and stiffness in the hands and feet and increased fatigue. The VA treating provider diagnosed the Veteran with seropositive, nonerosive rheumatoid arthritis. An August 2016 VA treatment record noted that the Veteran had fatigue associated with a viral illness. At a January 2020 VA rheumatology clinic visit, the Veteran reported how she had a respiratory infection over the holidays, was seen by a private physician and was diagnosed with influenza. She also had an upset stomach and loss of appetite. She presented to the clinic with recovery of her appetite, but still felt fatigued. She had held her rheumatoid arthritis medications, but she had now restarted taking them. At a November 2021 VA mental health clinic visit, the Veteran reported having an increased frequency of trauma-related dreams, which was impacting her sleep and resulting in increased fatigue and a lowered motivation for activities. The VA treating provider diagnosed the Veteran with other specified trauma and stressor related disorder. A November 2022 VA treatment record documents that the Veteran reported having some fatigue, which was likely connected with her rheumatoid arthritis. Regarding the Veteran's claim for chronic fatigue syndrome, no underlying disability has been clinically diagnosed during the appeal period or proximate thereto. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Notably, the clinical evidence shows that the Veteran's fatigue symptoms have been associated with other illnesses, including a viral illness, rheumatoid arthritis, influenza and/or a respiratory infection, and a psychiatric disorder. Thus, the most persuasive evidence does not support a finding of a current diagnosis for chronic fatigue syndrome. Accordingly, the Board finds that service connection for chronic fatigue syndrome is not warranted. The Veteran is certainly competent to report her history of symptoms of fatigue and any treatment that she may have undergone. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the Veteran has not demonstrated that she has the requisite specialized knowledge to diagnose chronic fatigue syndrome. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran has not presented any competent and credible evidence of a current diagnosis for chronic fatigue syndrome, and the available evidence does not support that she has any persistent symptomatology that would suggest that she has an underlying chronic disability. Accordingly, the Veteran's assertions that she has a current diagnosis for chronic fatigue syndrome have little probative value. In summary, the evidence is neither evenly balanced or approximately so with regard to whether the Veteran's claim for service connection for chronic fatigue syndrome is warranted. Rather, the evidence persuasively weighs against service connection for chronic fatigue syndrome. The benefit of the doubt doctrine, see 38?U.S.C. §?5107(b), is therefore not for application as to this claim. Lynch v. McDonough, 21 F.4th (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). Accordingly, the service connection claim for chronic fatigue syndrome is denied. 2. Entitlement to service connection for a hysterectomy The Veteran asserts that her hysterectomy was related to her active duty service. During the December 2019 Board hearing, the Veteran testified that after being transferred to Fort Meade in 1971, she began to experience heavy menstrual periods and severe pain. She said that she was placed on birth control pills to alleviate her heavy menstrual bleeding and pain. Alternatively, the Veteran testified that she was exposed to toxins while stationed at Fort McClellan and that she believed that her exposure led her to having a hysterectomy following service in or around 1984 or 1985. The question before the Board is whether the Veteran's current hysterectomy is etiologically related to his active duty service. Based on a careful review of all the subjective and clinical evidence, the Board finds that the most persuasive evidence weighs against finding service connection for a hysterectomy is warranted. The Veteran's service records document that she was stationed at Fort McClellan from June 1970 to October 1970. As noted above, the record shows that the Veteran was exposed to toxic substances while stationed at Fort McClellan. The Veteran's STRs document that she entered active duty service with a normal pelvic clinical evaluation. See June 1970 enlistment examination. At a May 1972 clinic visit, the Veteran reported gaining weight with her period, approximately five to eight pounds. She had gained 25 pounds in the past year. She took birth control pills. At an August 1972 clinic visit, the Veteran sought treatment for sharp pains to the right side of her abdomen. At a February 1973 clinic visit, the Veteran reported having had vaginal discharge for the past two weeks. Her menses were regular. After conducting a pelvic examination, the Veteran was diagnosed with non-specific vaginitis. At a March 1973 separation examination, the examining physician noted that the Veteran had an abnormal pelvic clinical evaluation due to non-specific vaginitis. On her associated report of medical history, the examining physician explained that the Veteran had a vaginal infection, which was treated in February. The examining physician also noted that the Veteran had periodic lower abdominal pain with the last episode occurring three months ago. On a June 1973 Statement of Medical Condition, the Veteran noted that to the best of her knowledge, since her last separation examination, there had been no change in her medical condition. The record also includes STRs from the Veteran's Army Reserve service. At a May 1977 enlistment examination, the Veteran had a normal pelvic clinical evaluation. On her associated report of medical history, the examining physician noted that the Veteran's periods were "ok" and her last menstrual period was in May 1977. She also had a benign tumor removed from her cervix in March 1977. At a November 1981 examination, the Veteran had a normal pelvic clinical evaluation, and on her associated report of medical history, no pertinent symptomatology was reported. At an October 2022 VA gynecological conditions examination, the Veteran reported that in or around 1984 or 1985, she had undergone a total abdominal hysterectomy due to heavy vaginal bleeding. She denied having any residuals of the hysterectomy. Following an objective evaluation, the October 2022 VA examiner diagnosed the Veteran with total abdominal hysterectomy with bilateral ovary removal. The October 2022 VA examiner opined that the Veteran's hysterectomy was less likely than not incurred or caused by her active duty service, to include her in-service abdominal pain and herpes. In providing a rationale, the October 2022 VA examiner found that the Veteran had not been treated for herpes during service, that according to the Veteran, her herpes was diagnosed in the 1980's, and that there were no medical records for symptoms of, evaluation for, or treatment for a chronic herpes condition during or after service until the 1980's. Referencing medical literature, the October 2022 VA examiner explained that herpes genitalis does not necessitate a hysterectomy as the cells that the genital herpes virus likes to infect remain present in the lower genital tract, even if the cervix has been removed. If the ovaries were removed, the lack of estrogen may cause dryness of the lower genital tract further increasing the risk of acquiring genital herpes, but genital herpes does not result in a hysterectomy. The October 2022 VA examiner also found that during service, the Veteran had an essentially normal gynecological examination and normal pap smears. The only exception was one treatment of nonspecific vaginitis in 1973 with no sequalae. There was also no evidence of chronic lower abdominal pain, as it would follow that the Veteran would be evaluated and treated periodically for the chronic condition. The October 2022 VA examiner found that there were no notations for recurrent lower abdominal pain the STRs. In a February 2023 VA addendum opinion, the VA examiner opined that the Veteran's hysterectomy was less likely than not incurred in or caused by active duty service, to include treatment for recurrent abdominal pain in service and as due to exposure to toxic substances. In providing a rationale, the February 2023 VA examiner found that the Veteran's STRs show that she was treated for abdominal pain in August 1972 and periodic abdominal pain three months prior to her separation report of medical history. Referencing medical literature, the February 2023 VA examiner found that the Veteran's hysterectomy had to be from one of the indications for a hysterectomy, including uterine leiomyomas, abnormal uterine bleeding, pelvic organ prolapse, pelvic pain or infection, and malignant and premalignant disease. Noting that the Veteran had claimed her hysterectomy was related to "abdominal" pain, the February 2023 VA examiner found that there was no history of chronic recurrent "pelvic" pain. Further, the February 2023 VA examiner indicated that the Veteran said that her recurrent abdominal pain eventually led to the removal of her gallbladder. Finally, the February 2023 VA examiner explained that exposure to toxic substances, including chemicals, toxins, and PCBs, have not been shown to related to any of the indications for a hysterectomy. In an April 2023 VA addendum opinion, the VA examiner opined that the Veteran's hysterectomy was less likely than not caused by the indicated toxic exposure risk activities, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. In providing a rationale, the April 2023 VA examiner explained that his review of medical literature did not demonstrate a definitive causal relationship between a hysterectomy and her potential exposure to toxic substances. Overall, the April 2023 VA examiner found that there was insufficient evidence to support the claim. The Board finds that collectively, the October 2022, February 2023, and April 2023 VA opinions provide the most persuasive evidence regarding the etiology of the Veteran's hysterectomy. The opinions were based on a review of the Veteran's relevant medical records, an objective evaluation, a discussion of relevant medical literature, and consideration of her lay assertions. Notably, the Veteran's assertions as well as the medical evidence show that her in-service symptoms consisted of abdominal pain, not pelvic pain. Indeed, no abnormal gynecological findings were found during service, except for vaginitis. Even though the Veteran said that her hysterectomy was due to heavy menstrual bleeding, which was an identified indication for a hysterectomy, her STRs do not document any issues with her menstruation, despite seeking treatment for other gynecological problems and receiving gynecological examinations. Finally, there was no evidence that her hysterectomy was caused by her in-service exposure to toxic substances. Accordingly, the Board finds that the most persuasive evidence demonstrates that service connection for a hysterectomy is not warranted. The Veteran is competent to report her history of gynecological problems and any treatment that she may have undergone. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Generally, lay evidence can be competent and sufficient evidence of a diagnosis, or to establish etiology, if (1) the 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, 1376-77 (Fed. Cir. 2007). However, given that the Veteran has not demonstrated that she has specialized medical training or expertise, the Board must find that she is not competent to provide such a medically complex opinion regarding the etiology of her hysterectomy. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Thus, the Veteran's lay assertions have little probative value. In summary, the evidence is neither evenly balanced or approximately so with regard to whether the Veteran's claim for service connection for a hysterectomy is warranted. Rather, the evidence persuasively weighs against service connection for a hysterectomy. The benefit of the doubt doctrine, see 38?U.S.C. §?5107(b), is therefore not for application as to this claim. Lynch v. McDonough, 21 F.4th (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). Accordingly, the service connection claim for a hysterectomy is denied. REASONS FOR REMAND 1. Entitlement to service connection for herpes, to include as secondary to adjustment disorder with mixed anxiety and depressed mood, is remanded. 2. Entitlement to service connection for kidney stones, to include as due to in-service exposure to toxic substances, is remanded. 3. Entitlement to service connection for epilepsy, to include as due to in-service exposure to toxic substances, is remanded. 4. Entitlement to service connection for breast cancer, to include as due to in-service exposure to toxic substances, is remanded. 5. Entitlement to service connection for a gallbladder disability, to include as due to in-service exposure to toxic substances, is remanded. 6. Entitlement to service connection for hypothyroidism, to include as due to in-service exposure to toxic substances, is remanded. 7. Entitlement to service connection for rheumatoid arthritis, to include as due to in-service exposure to toxic substances, is remanded. The Board regrets the further delay in the adjudication of the Veteran's appeal; however, additional development is required. First, in the January 2023 remand, the Board directed the RO to obtain an opinion addressing whether the Veteran's herpes was caused by her conceded sexual assault in service or was caused or aggravated by her service-connected acquired psychiatric disorder. In February 2023, the VA examiner opined that the Veteran's herpes was not related to her in-service sexual assault as herpes has an incubation period of a few days and would warrant seeking medical help quickly. However, the February 2023 VA examiner did not address the Veteran's February 1973 treatment for vaginitis and her February 1977 treatment for chronic cervicitis and whether these conditions were indications of herpes. Because the February 2023 VA examiner did not discuss relevant medical records, the Board finds that the opinion is inadequate. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Additionally, the February 2023 VA examiner opined that the Veteran's herpes was not caused or aggravated by her service-connected acquired psychiatric disorder. However, the February 2023 VA examiner did not address the Veteran's specific contention and her December 2019 Board testimony that her "anxiety disorder it will bring on a breakout of herpes." Thus, the Board finds that the February 2023 VA examiner did not address the Veteran's lay assertions. Miller v. Wilkie, 32 Vet. App. 249 (2020). Accordingly, a remand is required to obtain a supplemental VA opinion to determine the nature and etiology of the Veteran's herpes and to substantially comply with the January 2023 Board remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Next, the Board finds that the March 2023 VA opinions did not substantially comply with the January 2023 remand instructions to obtain VA opinions after developing the Veteran's assertions of exposure to toxic substances during service. The Veteran asserts that her kidney stones, epilepsy, breast cancer, gallbladder disability, hypothyroidism, and rheumatoid arthritis all developed due to her in-service exposure to toxic substances while serving at Fort McClellan. The record shows that the Veteran's in-service exposure to toxic substances at Fort McClellan has been established. However, in providing unfavorable nexus opinions, the March 2023 VA examiner relied in part on the finding that VA does not "presume any adverse health conditions are associated with service at Fort McClellan." The March 2023 VA examiner further listed risk factors for developing the individual conditions, but did not identify whether the Veteran had any of the risk factors and did not discuss how those risk factors were more likely causes for developing the conditions than the exposure to toxic substances during service. Although VA has not established that health problems were caused by service at Fort McClellan on a presumptive basis, the Veteran can still establish service connection for her claimed disabilities on a direct basis. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The record does not currently include a VA opinion addressing whether the Veteran's kidney stones, epilepsy, breast cancer, gallbladder disability, hypothyroidism, and rheumatoid arthritis are directly related to her conceded exposure to toxic substances while serving at Fort McClellan. Accordingly, the Board finds that the March 2023 VA opinions are inadequate, and a remand is required to obtain supplemental VA opinions to determine the nature and etiology of the Veteran's kidney stones, epilepsy, breast cancer, gallbladder disability, hypothyroidism, and rheumatoid arthritis. See Stegall v. West, 11 Vet. App. 268 (1998); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board emphasizes that it is not determining whether or not the Veteran's statements that her herpes, kidney stones, epilepsy, breast cancer, gallbladder disability, hypothyroidism, and rheumatoid arthritis were caused by her active duty service and/or a service-connected disability are credible at this time, as the additional development set forth in the directives below could impact that determination. Although the Board is requesting medical opinions regarding her lay contentions, this is for thoroughness and not based on a finding that these contentions are credible. The matters are REMANDED for the following actions: 1. Arrange for an addendum opinion by an appropriately qualified clinician to determine the nature and etiology of the Veteran's herpes. The examiner should respond to the following: (a.) Opine whether the Veteran's herpes had its onset during service or was etiologically related to her active duty service, to include her conceded sexual assault in service. (b.) Opine whether the Veteran's herpes was caused by her service-connected acquired psychiatric disorder. (c.) Opine whether the Veteran's herpes was aggravated by her service-connected psychiatric disorder. In providing the above opinions, the examiner should consider the Veteran's complete and relevant medical history, including service treatment records documenting treatment for a vaginal infection in February 1973 and a post-service February 1977 note from her private physician indicating treatment for chronic cervicitis with polyp formation, and whether these conditions were indicative of herpes. The examiner should also address the Veteran's December 2019 Board hearing testimony where she indicated that her "anxiety disorder it will bring on a breakout of the herpes." The examiner should note that secondary causation exists when, but for the service-connected disability, the non-service-connected was caused by a service-connected disability either in a direct, etiological way or via multiple steps in a causal chain. Additionally, secondary aggravation exists when the non-service-connected disability not caused by a service-connected disability would be less severe were it not for a service-connected disability. The examiner must address the Veteran's lay reports describing the onset and continuity of her herpes symptoms. The examiner must not rely solely on the lack of medical documentation as the basis for a negative opinion. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 2. Arrange for addendum opinions by appropriately qualified clinicians to determine the nature and etiology of the Veteran's kidney stones, epilepsy, breast cancer, gallbladder disability, hypothyroidism, and rheumatoid arthritis. The examiner should respond to the following: (a.) Opine whether the Veteran's kidney stones had their onset during active duty service or were otherwise etiologically related to service. (b.) Opine whether the Veteran's epilepsy had its onset during active duty service or was otherwise etiologically related to service. (c.) Opine whether the Veteran's breast cancer had its onset during active duty service or was otherwise etiologically related to service. (d.) Opine whether the Veteran's gallbladder disability had its onset during active duty service or was otherwise etiologically related to service. (e.) Opine whether the Veteran's hypothyroidism had its onset during active duty service or was otherwise etiologically related to service. (f.) Opine whether the Veteran's rheumatoid arthritis had its onset during active duty service or was otherwise etiologically related to service. The examiner must specifically address the Veteran's assertion that each of these disabilities developed due to her in-service exposure to toxic substances at Fort McClellan, which included radioactive compounds, chemical warfare agents and airborne polychlorinated biphenyls. The examiner cannot rely on the finding that VA has not presumed any adverse health effects for service at Fort McClellan and must address whether the Veteran's specific health conditions were directly caused by her in-service exposure to toxic substances at Fort McClellan. To the extent that the examiner finds that the Veteran has other risk factors for developing her specific disabilities, the examiner must identify the specific risk factor and explain whether those risk factors were more likely to have caused her specific health condition than her exposure to toxic substances at Fort McClellan. The examiner must consider the Veteran's complete and relevant medical history, including her assertion that she did not have any of these disabilities prior to her active duty service. See December 2019 Board hearing testimony. The examiner must address the Veteran's lay reports described the onset and continuity of her kidney stones, epilepsy, breast cancer, gallbladder disability, hypothyroidism, and rheumatoid arthritis symptoms. The examiner must not rely solely on the lack of medical documentation as the basis for a negative opinion. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. (Continued on the next page) ? 3. Thereafter, review the requested VA medical opinion reports to ensure responsiveness and compliance with the directives of this remand; implement corrective procedures as needed. Compliance with the Board's remand instructions is neither optional nor discretionary. Stegall v. West, 11 Vet. App. 268 (1998). 4. After ensuring the above development has been completed, readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran's satisfaction, send the Veteran and her representative a supplemental statement of the case and provide an opportunity to respond. Then, return the case to the Board for further appellate review. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Journet Shaw, 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.