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In a claim for service-connected aggravation of a pre-existing disability, must the veteran show an increase in disability during service to trigger the presumption of aggravation?

No. A published General Counsel Opinion has now made clear that, under 38 C.F.R. § 3.306(b), a claimant is not required to show that the disease or injury in question increased in severity during service to trigger the presumption of aggravation, thus requiring the VA to rebut the presumption by clear and unmistakable evidence. See VAOPGCPREC 3-2003.