1A

Medical evidence taken into consideration

A Not SC N0 Complaints
***You will use this as a template when there are no complaints
THE CLAIMED Lumbosacral Strain CONDITION WAS LESS LIKELY THAN NOT (LIKELIHOOD
IS LESS THAN APPROXIMATELY BALANCED OR NEARLY EQUAL) INCURRED IN OR
CAUSED BY THE CLAIMED IN-SERVICE INJURY, EVENT, OR ILLNESS. I reviewed the 492
page e-file and cited specific records of interest. I found no record of chronic or recurrent BACK
problems beginning in the service. No BACK pain is noted in the STRs or immediate post-
separation period.

A nexus for service connection cannot be made at this time due to the missing elements of
origin and chronicity of the current condition as found in the C&P exam. A disability which
began in service or was caused by some event in service must be considered "chronic" before a
nexus for service connection can be established. No permanent residual or chronic disability is
shown by the service medical records or demonstrated by evidence immediately following
discharge from the service. Therefore, a nexus for service connection for the LUMBOSACRAL
STRAIN condition cannot be made.

A Not SC 1 complaint
*** You will use this as a template for not service connection case with 1 complaint

THE CLAIMED Lumbosacral Strain CONDITION WAS LESS LIKELY THAN NOT (LIKELIHOOD
IS LESS THAN APPROXIMATELY BALANCED OR NEARLY EQUAL) INCURRED IN OR
CAUSED BY THE CLAIMED IN-SERVICE INJURY, EVENT, OR ILLNESS. I reviewed the 492
page e-file and cited specific records of interest. I found no record of chronic or recurrent BACK
problems beginning in the service. BACK pain is noted in the 12/12/2012 STR however not
chronically thereafter in the STRs or immediate post-separation period.

A nexus for service connection cannot be made at this time due to the missing elements of
origin and chronicity of the current condition as found in the C&P exam. A disability which
began in service or was caused by some event in service must be considered "chronic" before a
nexus for service connection can be established. Although an acute BACK condition is noted in
the STR, no permanent residual or chronic disability is shown by the service medical records or
demonstrated by evidence immediately following discharge from the service. Therefore, a nexus
for service connection for the Lumbosacral Strain condition cannot be made.

Aggravation
*** You will use this at end of answer when they ask if a pre-existed condition is
aggravated by another Service connected condition.

There is no evidence in the entire efile of any "aggravation", nor any evidence "aggravation" has
ever been objectively verified. Nor is there any evidence to attribute "aggravation" of the OSA
to PTSD. Determination of aggravation is not objectively supported.

Article Submitted
*** You will use this when they ask you to take into consideration an article that the
Veteran has submitted for review. Ex: ED is linked to HTN.

I reviewed the resources the veterans have provided extensively however the articles only
demonstrate a correlative link not a causal one. Correlation is not causation. Although
hypertension can be a potential risk factor for ED, there is no evidence in the entire 7643 page
efile that the Hypertension caused the ED.

Baseline
*** You will use this when they ask for the baseline when you are doing an aggravation
case.

Medical evidence in the efile is insufficient to establish a baseline. I cannot determine a baseline
for aggravation without objective evidence.

Death
***You will use this at the end of a death case. If they ask if SC condition is cause of
death, you remove “TERA exposure” and replace with SC conditions

There is no evidence that the TERA exposure resulted in debilitating effects and general
impairment of health to an extent that would render the person materially less capable of
resisting the effects of other disease or injury primarily causing death or that the condition
contributed substantially or materially to death, or that the conditions aided or lent assistance to
the production of death.
Far Outweigh TERA
***You will use this when the risk factors far outweigh the TERA risk Factor.

The risk factors outside of the military service far outweigh the factors identified in the TERA.

If 1st tab is approved

*** You will use if another Direct Service Connection has already been established and
they are asking for secondary connection for the same condition

I performed a full search of the efile and found no evidence of a secondary connection. As
previously discussed, the condition is directly service connected.

If 1st tab approved, and 2nd is TERA

*** You will use if another Direct Service Connection has already been established and
they are asking for TERA connection for the same condition

No TERA decision rendered as the claimed condition is already service connected.

Lay Statement Does Not Match Evidence

*** You will use this if QTC says that you cannot take a lack of evidence to deny a case as
the Veteran’s lay statement is credible. (BE SURE to put in the evidence with dates
towards the end of their service or after service that they denied such a condition. VERY
IMPORTANT)

I have reviewed and acknowledge the veteran's lay statements. However, multiple
questionnaires and objective evidence from the period of service clearly and unmistakably show
the vet categorically denied having knee pain. I cannot overlook such indisputable and clear
objective evidence in favor of his subjective statements made decades after separation in order
to establish a nexus for service connection.

Nausea
*** You will use this when you click no pathology because the diagnosis given is a
symptom and not a diagnosable condition.
The Veteran claims he experiences occasional nausea due to his gastrointestinal issues. The
Veteran should have been diagnosed with IBS as he complains of chronic diarrhea, nausea,
and abdominal pain. Nausea and abdominal pain are a symptom to his IBS. I cannot give an
opinion on a symptom.

Not Aggravated Beyond its natural progression

*** You will use this as a generic not aggravated template.

THE CLAIMED L/S strain CONDITION, WHICH CLEARLY AND UNMISTAKABLY EXISTED
PRIOR TO SERVICE, WAS CLEARLY AND UNMISTAKABLY NOT AGGRAVATED BEYOND
ITS NATURAL PROGRESSION BY AN IN-SERVICE INJURY, EVENT, OR ILLNESS. I
reviewed the 4112 page efile and cited specific records of interest. I found no record of an injury
or event representing unnatural aggravation of the vet's pre-existing BACK condition in the
service. Symptoms or complaints during the service represent flare ups of the pre-existing
condition. Determination of aggravation is not objectively supported.

Not Due to TERA

*** You will use this at the end of the TERA opinion.

I found no evidence in the job aids or in medical literature linking his HTN to his exposure during
the service.

Obesity
***You will use this when they ask if the Vet is Obese due to another SC condition

THE CLAIMED obesity CONDITION IS LESS LIKELY THAN NOT (less than 50 percent
probability) PROXIMATELY DUE TO OR THE RESULT OF THE VETERAN'S SERVICE
CONNECTED CONDITIONS. I have reviewed the entire e-file. It is not possible to determine
why the veteran gained weight. The leading causes of obesity include diet, lack of
activity/exercise, lifestyle, genetic, hormonal, medication etc. There is no way to predict why the
veteran gained weight without mere speculation and assuming the vet gained weight due to
inactivity from the service connected disabilities or simply due to the service connected
disabilities is entirely speculative and does not fit even the standard of 50% probability. In a
case like this accepting the vet's testimony as fact, ignores and overlooks his daily diet/caloric
intake, his genetic predisposition, daily habits, personal desire to perform non weight bearing
exercises etc. I cannot correlate his weight gain to any factor with any semblance of certainty.
Obesity 2
*** You will use this when they ask if another condition would have developed if not for
the Veteran’s obesity in next tab. (ex: is OSA due to obesity)

This question cannot be answered as correlation of the vet's obesity to his SC conditions is
completely speculative.

OSA Not due to PTSD

*** You will use this when they ask if OSA is due to any condition

THE CLAIMED OSA CONDITION IS LESS LIKELY THAN NOT (less than 50 percent
probability) PROXIMATELY DUE TO OR THE RESULT OF THE VETERAN'S SERVICE
CONNECTED posttraumatic stress disorder CONDITION.

The polysomnography report found OSA, not central apnea which would be due to central
nervous system issues such as would happen in advanced/severe PTSD. The veteran was
diagnosed with obesity. His BMI has been over 30 which is in the "obese" range.

According to the Mayo Clinic the "leading risk factor of OSA is Excess weight, Obesity."
[Link]

He has also been noted to have a Mallampati score of 4. The Mallampati score has been used
for many years to identify patients at risk for difficult tracheal intubation. The classification
provides a score of 1-4 based on the anatomic features of the airway seen when the patient
opens his or her mouth and protrudes the tongue. A 2006 study showed that for each 1-unit
increase in the Mallampati score, the odds ratio of having OSA (defined by an apnea-hypopnea
index [AHI] >5) increased by 2.5. In addition, the AHI increased by 5 events per hour.

[Link]

His neck circumference of 18 inches is past the point of being a risk factor for obstruction.

The vet's has an extensive smoking history which has caused lower respiratory tract and upper
respiratory tract obstruction as well as respiratory depression
The vet's advanced age of 63 puts him at increased risk for upper airway obstruction due to
age-related loosening and progressive laxity of the pharyngeal walls and the throat muscles
causing blockage of air movement as he sleeps.

It is much more likely that the condition is due to the obesity, smoking, very small nasopharynx,
very large neck and age-related contraction of the throat causing obstruction. In this case the
most obvious and likely causes are anatomic. This is further supported by the fact that the vet's
symptoms are relieved with CPAP use since the positive airway pressure is mitigating the
obstruction. If the condition was psychiatric in nature it would be highly unlikely that CPAP would
alleviate the problem.

OSA Not Due to TERA

*** You will use this when they ask if OSA is due to TERA

The claimed OSA condition was less likely than not (likelihood is less than approximately
balanced or nearly equal) caused by the indicated toxic exposure risk activity(ies), after
considering the total potential exposure through all applicable military deployments of the
veteran and the synergistic, combined effect of all toxic exposure risk activities of the veteran to
include burn pits, particulate matter and environmental hazard exposure in SW Asia / Herbicide
in Vietnam / Perchloroethylene (PCE), trichloroethylene (TCE), vinyl chloride, and benzene in
Camp Lejeune water.

The TERA memorandum, ILER report and Job Aids were reviewed.

The polysomnography report found OSA, not Central Apnea which would be due to central
nervous system issues resulting from possible exposure.

The veteran was diagnosed with obesity. His BMI has been over 32 which is in the "obese"
range. According to the Mayo Clinic the "leading risk factor of OSA is Excess weight, Obesity."
[Link]

He has also been noted to have a Mallampati score of 3. The Mallampati score has been used
for many years to identify patients at risk for difficult tracheal intubation. The classification
provides a score of 1-4 based on the anatomic features of the airway seen when the patient
opens his or her mouth and protrudes the tongue. A 2006 study showed that for each 1-unit
increase in the Mallampati score, the odds ratio of having OSA (defined by an apnea-hypopnea
index [AHI] >5) increased by 2.5. In addition, the AHI increased by 5 events per hour.
[Link]

His neck circumference of 18 inches is past the point of being a risk factor for obstruction.

The vet has an extensive smoking history which has caused lower respiratory tract and upper
respiratory tract obstruction as well as respiratory depression.

The vet's advanced age of 76 puts him at increased risk for upper airway obstruction due to
age-related loosening and progressive laxity of the pharyngeal walls and the throat muscles
causing blockage of air movement as he sleeps.

It is much more likely that the condition is due to the obesity, smoking, very small oropharynx,
very large neck and age-related contraction of the throat causing obstruction. In this case the
most obvious and likely causes are anatomic.

I found no evidence of respiratory obstruction or central apnea that could be attributed to any
toxic exposure while in the service. The risk factors outside of the military service far outweigh
the factors identified in the TERA. The literature, TERA memo and Job Aids do not support any
such connection.

Pes Planus Aggravated and PF

*** You will use this when the Vet comes in with Pes Planus and they have Pes Planus,
Plantar Fasciitis, or any other foot condition such as Hammer Toes, Calcaneal spurs,
hammer toes, etc…

THE CLAIMED PES PLANUS CONDITION, WHICH CLEARLY AND UNMISTAKABLY

EXISTED PRIOR TO SERVICE, WAS CLEARLY AND UNMISTAKABLY NOT AGGRAVATED
BEYOND ITS NATURAL PROGRESSION BY AN IN-SERVICE INJURY, EVENT, OR ILLNESS.
As found in the 2/14/14 Report of Medical Exam for enlistment the vet entered the service with
pes planus, a condition which is usually chronic and progressive in nature. Due to effects of
gravity, weight, activities etc the longitudinal arch is expected to collapse/sag further causing
worsening flattening. There is no documented measurement or radiologic evidence to show that
the arches collapsed any further than or more aggressively than expected. More specific
evidence, namely objective measurement, is needed to show abnormal progression beyond the
vet's expected worsening. The vet's exam on 04/24/2022 shows similar findings of pes planus
without signs of unnatural aggravation.
Reports of foot pain during the service would represent flare ups of a pre-existing condition. As
a result of this lack of evidence, no findings suggest unnatural aggravation or progression.

The veteran's plantar fasciitis is due to the pre-existing pes planus condition. As a result of
chronic decrease longitudinal arch the plantar fascia was pulled/stretched and accentuated
force of weight bearing on this fascia led to the development of plantar fasciitis. The plantar
fasciitis which occurs in most people with chronic pes planus, would likely have occurred in this
case with or without the service activity and represents a natural progression of the condition.

SC
*** You will use this as template to connect when 2 or more complaints

THE CLAIMED L/S Strain CONDITION WAS AT LEAST AS LIKELY AS NOT (50 percent or
greater probability) INCURRED IN OR CAUSED BY THE CLAIMED INSERVICE INJURY,
EVENT, OR ILLNESS. I reviewed the 471 page e-file and cited specific records of interest. The
vet's enlistment exam makes no mention of a chronic LOW BACK condition. However, multiple
STRs show recurrent and chronic BACK problems which began in the service.

STR - back pain 8/2021 also had back pain 4/2022.

Post service seen for back pain - 1/31/2023

The condition continues to be symptomatic as per the 4/11/2023 C&P Exam. Since origin and
chronicity are verified, a nexus for service connection can be established.

SOB
*** You will use this when they diagnose Shortness of Breath. ((make sure to adjust
template based off of C&P exam)

The Veteran claims he experiences occasional shortness of breath when exerting himself during
exercise but has no chronic or daily symptoms. He does not use any medication for this
condition. He denies recent studies or imaging or intervention for this. His PFT scores were
also within normal limits. SOB with exertion is a symptom, not a diagnosis. I cannot give an
opinion on a symptom.
TERA Job Aid
*** You will use this when submitting TERA memo evidence into evidence box

Toxic Exposure Risk Activity (TERA) Memorandum Dated:

TERA Job Aids Reviewed:

• [Link]
• [Link]
• [Link]
• [Link]

•[Link]
• [Link]
Exposures/

•[Link]

•[Link]
•[Link]
• [Link]
[Link]

Unemployability
***You will use this as template when asked about their employability as a clarification
question.

I reviewed the vet's entire e-file to include his most recent Hip C&P exam performed
02/23/2024 for the diagnosis of " right hip osteoarthritis". At the time, the vet complained of pain
and functional loss. He demonstrated loss of ROM and pain on the exam.
The veteran's service connected disability of right hip osteoarthritis is less than likely as not to
render him unable to secure and maintain substantially gainful employment. His disabilities may
cause limitations:

Alternate sitting and standing so that neither is performed more than 10 minutes at a time.
Limited climbing, no walking more than 1/2 a mile at a time
Limited squatting, crawling, kneeling

I found no evidence to support any claim of permanent or total unemployability/disability, nor

any evidence to suggest he cannot maintain sedentary/limited labor.

Z3
*** You will use this when explaining a condition that is (3) a diagnosable chronic multi-
symptom illness with a partially explained etiology.

Erectile dysfunction is a diagnosable chronic multi-symptom illness with a partially explained

etiology. The underlying pathophysiological mechanism of this disease is understood and there
are multiple known risk factors and potential causes for this condition.

Z4
*** You will use this when explaining a condition that is(4) a disease with a clear and
specific etiology and diagnosis.

The Veteran's disability pattern of knee strain is a disease with a clear and specific etiology and
diagnosis. The underlying pathophysiological mechanism of this disease is well understood and
there are known risk factors for this condition.