Citation Nr: 0707360 Decision Date: 03/12/07 Archive Date: 03/20/07 DOCKET NO. 04-14 939 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in No. Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for left foot ulcer, to include as secondary to ionizing radiation. 2. Entitlement to service connection for stomach or digestive order, to include as secondary to exposure to ionizing radiation. 3. Entitlement to service connection for a scalp condition with hair loss, diagnosed as lichen simplex chronicus in the setting of alopecia androgenetica, to include as secondary to ionizing radiation. 4. Entitlement to a higher initial evaluation for post- traumatic stress disorder (PTSD), currently rated as 10 percent disabling. 5. Entitlement to a higher initial evaluation for left inguinal hernia status post operative repair, currently rated as 10 percent effective from August, 8, 2002. 6. Entitlement to a higher initial evaluation for right inguinal hernia status post operative repair, currently noncompensably rated. 7. Entitlement to a higher initial evaluation for onychomycosis and foot fungus, claimed as loss of toenails and foot fungus, currently noncompensably rated. WITNESSES AT HEARING ON APPEAL Appellant and Spouse. ATTORNEY FOR THE BOARD E. Ward, Counsel INTRODUCTION The veteran had active service from June 1965 to June 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in No. Little Rock, Arkansas. In February 2005, the veteran appeared at a Board video conference hearing before the undersigned. A transcript of that hearing is of record. The case was remanded in August 2005 for further development. In a July 2006 rating decision, the RO recharacterized the issues, and granted service connection for post-traumatic stress disorder inclusive of claims for fatigue, weakness, nightmares, sweat, and leg movements; left and right inguinal hernias; and onychomycosis and fungus of bilateral feet. Therefore, these issues are no longer in appellate status. See Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). Accordingly, the only issues remaining for the Board's consideration are those listed on the title page. Although the veteran's diagnosis included onychomycosis of the nails of the hand and feet, only the feet were service- connected by the RO. The Board will refer the fingernails condition for further development in this regard. In statements received at the Board in November 2006, the veteran expressed disagreement with the original ratings assigned to the service-connected disabilities. The Board deems this timely filed notice of disagreement with the July 2006 rating decision, and will remand the matter for appropriate action. The veteran also claims that he has been unemployed since September 2005. This matter is referred to the RO for appropriate action. After the case was forwarded to the Board, the veteran submitted additional statements. The Board has reviewed this evidence and finds it essentially duplicative of evidence already considered by the RO, thus it will be considered in the decision below. In an August 2005 remand, the Board referred the issues of skin disorder of the head, legs, and back for further development. However, the skin disorder of the scalp has been integrated by a March 2006 VA examination into the hair loss claim on appeal. The Board has recharacterized all issues to more accurately reflect the veteran's assertions and the procedural actions in this matter. FINDINGS OF FACT 1. The preponderance of the evidence does not show that the veteran was exposed to ionizing radiation in service or that he participated in a radiation-risk activity. 2. There is no objective medical evidence of current disability of a left foot ulcer. 3. There is no objective medical evidence of a current stomach or gastrointestinal disorder. 4. The veteran's scalp condition with hair loss, diagnosed as lichen simplex chronicus in the setting of androgenetica alopecia, is shown to have been first manifested many years after service and is not shown to be the result of ionizing radiation in service, radiation risk activity, or due to any event or incident of service. CONCLUSIONS OF LAW 1. The veteran has no current disability of left foot ulcer incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.303 (2006). 2. The veteran has no current stomach or gastrointestinal disability incurred in or aggravated by active military service, and such disability may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2006). 3. The veteran has no current hair loss and scalp disability incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2006); 38 C.F.R. § 3.303 (2006). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Duties to Assist and Notify Upon receipt of a complete or substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. This notice requires VA to indicate which portion of that information and evidence is to be provided by the claimant and which portion VA will attempt to obtain on the claimant's behalf. See 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. § 3.159 (2006). The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request or tell the claimant to provide any evidence in the claimant's possession that pertains to the claim, or something to the effect that the claimant should "give us everything you've got pertaining to your claim(s)." Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the RO sent VCAA notification letters in August 2002 and again in August 2005 to the veteran, pertinent to the claims. These letters appropriately notified the veteran what VA would do and what the veteran must do in furtherance of his claims, and together with other documents on file informed of evidence of record pertinent to the claims, as well as the need for his assistance in obtaining any further evidence in support of the claims. The letters requested that the veteran supply information on medical providers who examined him, notified of evidence still needed, and what he could do to assist with the claims, and what evidence he needed to substantiate the claims. The letters also informed the veteran that he should submit pertinent evidence in his possession that would further the claims. VA also informed that it was ultimately his responsibility to see that evidence was received in support of the claims, and he was notified to submit any additional evidence in support of the claims. Additionally, during the pendency of the appeal, on March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, herein Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between service and the disorder which is the basis of claim; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a claim for benefits, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if entitlement to benefits is awarded. Id. On review, the Board finds no prejudice to the veteran resulting from any failure to inform of all of the above- noted five crucial elements of disability claims. The veteran has been adequately informed by the VCAA letters of record, of the need for evidence of current disability and a medical nexus between the claimed disability and military service. In a February 2005 hearing before the undersigned, the veteran was again informed of the evidence required to substantiate his claims. Notifications of the degree of disability and effective dates for service connection are not relevant where, as here, the claims for service connection are denied. To the extent that there were any deficiencies in notice to the veteran, the Court has recently held in that regard, that an error is not prejudicial when the error does not affect the essential fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Additionally, the RO has obtained, or made reasonable efforts to obtain all records pertinent to the claim. The veteran's service medical records, post-service records of VA and private treatment are of record. He was afforded appropriate VA examinations and afforded a hearing before the undersigned by videoconference in February 2005. The veteran remains self-represented, and has been provided with adequate opportunity to submit evidence and argument in support of the claims, and has done so. The Board notes the veteran's assertions that records from some private physicians were not considered. However, the Board notes that the RO requested this evidence in September 2002 with negative results, and the veteran testified that one physician, Dr. M. is deceased and another's records are unavailable as he had moved away from the area. Thus the Board finds that the RO made sufficient attempts to obtain evidence or information that could be obtained to substantiate the claims, and that it was ultimately his obligation to provide the records, and the Board is unaware of any other outstanding evidence or information. The Board is satisfied that the RO has complied with the duty to assist provisions of the VCAA and the implementing regulations. Because of the lack of evidence of current disability pertinent to left foot ulcer and stomach/gastrointestinal disability, the Board will not reach the downstream questions of etiology or relationship to service. The veteran has had ample notice of what is required to substantiate the claims, and has provided no medical evidence showing current disability for the claimed conditions. The Board finds that no reasonable possibility exists that any further assistance would aid in substantiating the claims. 38 U.S.C.A. § 5103A. Therefore, a decision on the merits at this stage, without remand for any additional development, is not prejudicial to the veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). B. Factual Background The Board has reviewed all of the evidence of record submitted in support of the claims, including the service medical records, private and VA treatment records. Although the Board has an obligation to provide reasons and bases supporting this decision, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Accordingly, only the salient records will be discussed below. Service medical records form DD-214 reflect service assigned to B Btry 1st Bn (HERC) 60th Arty/ARADCOM, from June 1965 to June 1968. A 1968 separation examination reflects notation of foot trouble, athlete's foot of 2-3 months duration. In an August 2002 claim, VA Form 21-526, the veteran asserted exposure to radiation in service performed near Nike Hercules Missile Radars Range and nuclear warheads. In VA Form RRAIS Radiation Risk Activity Information Sheet dated in September 2002, he reported working as a range operator and switchboard operator and constant exposure to radiation and radar. Service personnel records and DA-20 file identify his unit of assignment as FC operator associated with a missile battalion. Post service records include private medical records dated from March 1987 to 1995 from a family treating physician shows treatment on two occasions for sore throat. Diagnosis was upper respiratory infection, pharyngitis sinusitis, treated with antibiotics. The RO requested records from all private physicians and Jefferson Regional Medical Center as identified by the veteran. Private medical records from 1995 through November 2004 reveal that requests to a private doctor who reportedly treated the veteran right after service for his left foot ulcer, were returned as undeliverable by the post office. The veteran later testified that this physician is deceased. VA outpatient treatment notes from 2002 through May 2006 have been obtained and associated with the claims folders. As regards the veteran's left foot ulcer claim, private medical records reveal examination showing a fungus type picture of nails and fingers and toes, with a circular type callous formation under the plantar surface of the left foot. In his February 2005 testimony before the undersigned, the veteran reported that he had a hard corn on his left foot which stayed sore all the time. On questioning he admitted he had no sore on his left foot in service. He acknowledged that the corn was better, but felt he had a virus in his bloodstream that might have something to do with it. He reported that he saw a private physician, Dr. Robinette, for it, and that it developed about four to five years prior. Private treatment notes dated from March 2003 to September 2003 from Dr. Robinette reflect evaluation of feet, with symptoms noted as severely mycolic thick disc, with hyperkeratotic areas, and diagnosis of neuropathy of the feet from a private neurophysiologist. Assessment was onychomycosis, with recommendation for new balance tennis shoes as current shoes were poorly supportive, nails to be aggressively debrided, and use of topical antifungals. Additional private treatment notes reveal impressions including onychomycosis and tinea versicolor. September 2003 private treatment notes reflect itching of feet, scalp, and back as doing better, with use of Lamisil, Loprox cream, ATS solution 2%, and Atarax. In a November 2003 statement the veteran expressed his belief that he was exposed to radiation in having to walk near the radar to get to his duty station in service. He reiterated numerous symptoms including leg pains with prolonged standing, loss of finger nails and toe nails which turned black and fell off, hair loss, fatigue, weakness, tenderness, trouble concentrating, depression, pains and stiffness in legs and hand, sleep disturbances, psychological distress and no desire for a good relationship with his wife. Private treatment records dated from February 2003 to November 2004 reflect reports of hair loss, itching in between fingers and toes, groin and scalp. The dermatologist noted there were five separate problems: 1) dark papulae in the scalp, itching, and bumps with hair loss several months prior; 2) dark areas of the back pruritic and itching; 3) scaly pruritic eruptions on the right hand and both feet; 4) onychomycosis in all nails of the right hand and both feet; 5) pruritic rash in both upper medial thighs treated with Lamisil and Loprox cream, ATS solution, and Atarax 10 mg, and rash on fingers and hands. A December 2004 VA outpatient MD clinic note shows follow-up for history of onychomycosis and lichen simplex chronicus (LSC) change on the top of the scalp. History was of past treatment with Loprox for feet and Nizoral Shampoo for scalp. Physical examination revealed a patch on the vertex scalp on the posterior left side consistent with some areas of LSC, otherwise no suspicious lesions. There was a well-defined asymmetrical well-bordered hyperpigmented verrucous plaque on the back of the right leg consistent with seborrheic keratosis. Assessment was onychomycosis, tinea pedis, and LSC. The examiner noted that they were able to reassure the veteran that the LSC was benign in nature treated with Westcort cream and Lac-Hydrin, and there were no active lesions at that time. An August 2005 VA outpatient treatment note shows improved area on top of head with lactic acid lotion, and noted past medical history of LSC. On March 2006 VA general medical examination with noted review of the C-File by the examiner, the veteran denied the presence of a current left foot ulcer, and indicated that the claim for foot ulcer was actually associated with the claim of fungus on his feet. Regarding the claim for a stomach/gastrointestinal (GI) condition, he indicated that several years ago his wife noted a foul odor from his breath which he attributed to problems with his GI tract. No workup was done at the time and the symptoms resolved several years ago by treating the underlying stress condition. He denied current pyrosis, nausea, vomiting, abdominal pain, diarrhea, reflux, gastritis, GI bleed, or sinus related symptoms, or symptoms related to his remote complaint, and was not on any medication for a GI condition. Physical examination revealed the veteran to be alert and pleasant. Abdominal examination was soft, non-tender, without masses or tenderness. Neurological examination was normal. Skin of both feet were normal without callus formation or ulcers. Legs were normal with good muscle tone and normal strength without deficit. Diagnostic impression was of remote mild odors in breath resolved, and insufficient medical evidence to render a specific diagnosis at this time; nocturnal leg cramps; fatigue/weakness, episodic and felt secondary to poor sleep. The examiner opined that based on history and review of the C file, he did not find that the veteran was exposed to radiation, and the veteran denied any history of left foot ulcer. On March 2006 dermatology examination with C-file review, assessment was of onychomycosis leading to toenail separation and loss. As regards hairloss, the examiner noted that the veteran had two processes on the scalp: Androgenetica alopecia starting 10 to 15 years prior with receding hairline, and a lichenified plaque on the vertex of the scalp which started approximately 6 to 7 years ago. The veteran reported being seen by a private dermatologist and being diagnosed with LSC, treated unsuccessfully with topical steroids and topical proteolytics, with continued itching. Diagnosis was LSC in the setting of androgenetica alopecia. Onset of LSC was noted as 6-7 years prior, and alopecia as 15 years prior, both conditions chronic. Rogaine had been tried for hairloss without success. For LSC he used Lac-Hydrin and Westcort Cream unsuccessfully over the last few years. The examiner noted that acne and chloracne were not involved, scar was not involved, and clinical tests were not conducted or photos taken. The examiner opined that it is not likely with less than 50% probability that hairloss and LSC are related to the veteran's military service. Also of record are internet research articles showing descriptions of various nuclear missiles and warheads and detailing their specifications. None of the articles address radiation exposure to personnel working around such missiles. Additional VA outpatient treatment notes from 2002 to 2005 reflect continuing treatment for various disabilities, including those claimed. In various statements, the veteran maintains that the claimed conditions are the result of exposure to ionizing radiation in service, and service connection is warranted. C. Analysis Under 38 C.F.R. § 3.309(d)(3)(i), the term radiation exposed veteran means, in pertinent part, a veteran who while serving on active duty participated in a radiation-risk activity. Under 38 C.F.R. § 3.309(d)(3)(ii)(A), the term radiation-risk activity means onsite participation in a test involving the atmospheric detonation of a nuclear device; the occupation of Hiroshima, Japan or Nagasaki, Japan by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946; or internment as a prisoner of war (or service on active duty in Japan immediately following such internment) during World War II which resulted in an opportunity for exposure to ionizing radiation comparable to that of the United States occupational forces in Hiroshima or Nagasaki during the period from August 6, 1945 through July 1, 1946. 38 C.F.R. § 3.309(d). Onsite participation, in turn, includes both presence at the test site during the official operational period of an atmospheric nuclear test or performance of official military duties in connection with ships, aircraft, or other equipment used in direct support of the nuclear test. See 38 C.F.R. § 3.309(d)(3)(iv)(A). Occupation of Hiroshima or Nagasaki, Japan, by United States forces means official military duties within 10 miles of the city limits of either city which were required to perform or support military occupation functions such as occupation of territory, control of the population, stabilization of the government, demilitarization of the Japanese military, rehabilitation of the infrastructure or deactivation and conversion of war plants or materials. 38 C.F.R. § 3.309(d) (3)(vi). Diseases subject to presumptive service connection based on participation in a "radiation-risk activity" are the following: (i) leukemia (other than chronic lymphocytic leukemia); (ii) cancer of the thyroid; (iii) cancer of the breast; (iv) cancer of the pharynx; (v) cancer of the esophagus; (vi) cancer of the stomach; (vii) cancer of the small intestine; (viii) cancer of the pancreas; (ix) multiple myeloma; (x) lymphomas (except Hodgkin's disease); (xi) cancer of the bile ducts; (xii) cancer of the gall bladder; (xiii) primary liver cancer (except if cirrhosis or hepatitis B is indicated); (xiv) cancer of the salivary gland; (xv) cancer of the urinary tract; (xvi) Bronchiolo-alveolar carcinoma; (xvii) Cancer of the bone; (xviii) Cancer of the brain; (xix) Cancer of the colon; (xx) Cancer of the lung; and (xxi) Cancer of the ovary. 38 C.F.R. § 3.309(d)(2). 38 C.F.R. § 3.311 provides instruction on the development of claims based on exposure to ionizing radiation. Pursuant to 38 C.F.R. § 3.311, "radiogenic disease" is defined as a disease that may be induced by ionizing radiation, and specifically includes the following: thyroid cancer, breast cancer, bone cancer, liver cancer, skin cancer, esophageal cancer, stomach cancer, colon cancer, pancreatic cancer, kidney cancer, urinary bladder cancer, salivary gland cancer, multiple myeloma, posterior subcapsular cataracts, non- malignant thyroid nodular disease, ovarian cancer, parathyroid adenoma, tumors of the brain and central nervous system, cancer of the rectum, lymphomas other than Hodgkin's disease, prostate cancer, and any other cancer. 38 C.F.R. § 3.311(b)(2)(i)-(xxiv) (2006). Notwithstanding the above, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994), reversing in part Combee v. Principi, 4 Vet. App. 78 (1993). Thus, the Board must not only determine whether the veteran had a disability which is recognized by VA as being etiologically related to exposure to ionizing radiation, but must also determine whether his disability was otherwise the result of active service. In other words, the fact that the veteran may not meet the requirements for service connection on a presumptive basis does not in and of itself preclude the establishment of service connection, as entitlement may alternatively be established on a direct basis. Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. The disease entity for which service connection is sought must be "chronic" as opposed to merely "acute and transitory" in nature. For a showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as opposed to merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service (or during any applicable presumptive period) is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without medical evidence of a current disability, medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table)]. 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.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 1. Service connection for a left foot ulcer and Stomach /GI Disorder. The veteran asserts that these disorders are related to service or secondary to exposure to ionizing radiation. Service medical records and 1968 separation examination are devoid of any evidence of a left foot ulcer, or stomach or gastrointestinal disorder. More recent VA outpatient treatment notes through May 2006, including March 2006 VA examination, reveal no current disability or treatment for these conditions. The salient point to be made is that service medical records do not establish the presence of either condition. Although a callous and bad breath were reported some years ago, there is no current evidence of disability for either condition. In the absence of competent evidence of current disability, there is no basis for a grant of service connection in either case. In reaching this conclusion, the Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). 2. Service connection for LSC in the setting of alopecia androgenetica Service medical records reflect no hair loss on 1968 separation examination. Post-service private and VA outpatient treatment notes reflect a diagnosis of androgenetica alopecia and lichen simplex chronicus (LSC) of the scalp. In March 2006 VA examination, the veteran reported onset of androgenetica alopecia as 15 years prior, and of LSC as 6-7 years prior. Thus both disorders have remote onset over 35 years after military service, and incurrence in service is not shown. Service connection for disability that is claimed to be attributable to exposure to ionizing radiation during service can be demonstrated by three different methods as laid out above. Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 71 (1997). First, there are certain diseases that are presumptively service connected specific to radiation-exposed veterans. 38 U.S.C.A. § 1112(c); 38 C.F.R. § 3.309(d). However, androgenetica alopecia and lichen simplex chronicus are not among them. Second, "radiogenic diseases" may be service connected pursuant to 38 C.F.R. § 3.311, however, androgenetica alopecia and lichen simplex chronicus are not among the list of diseases identified as potentially radiogenic in the regulations. Additionally, no competent authority has identified either as a radiogenic disease. 38 C.F.R. § 3.311(b)(4). Third, service connection may be granted under 38 C.F.R. § 3.303(d) when it is established that the disease diagnosed after discharge is the result of exposure to ionizing radiation during active service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). However, a recent March 2006 VA examiner opined that there was no evidence that the veteran was exposed to radiation during service. and that these conditions were less than 50 percent likely to be related to the veteran's military service. Thus no link to service has been shown by the competent medical evidence of record. The Board recognizes the veteran's belief that these disabilities are related to military service. While the veteran is competent as a layperson to describe the symptoms he experiences, he is not competent to provide medical opinion (which by its very nature requires specialized education, training, and experience) as to the etiology of any of his diagnosed disorders. Espiritu v. Derwinski, 2 Vet. App. 492 (1992); 38 C.F.R. § 3.159(a)(1). As the preponderance of the evidence is against the veteran's claim, the benefit of the doubt doctrine is therefore inapplicable. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a left foot ulcer, to include as secondary to ionizing radiation, is denied. Entitlement to service connection for stomach condition/gastro-intestinal disability, to include as secondary to ionizing radiation, is denied. Entitlement to service connection for scalp condition with hair loss, diagnosed as lichen simplex chronicus in the setting of alopecia androgenetica, is denied. REMAND In statements received in November 2006, the veteran expressed disagreement with the initial ratings assigned in the July 2006 rating action. The RO has not had an opportunity to issue a statement of the case in response to this notice of disagreement. As the filing of a notice of disagreement places a claim in appellate status, the United States Court of Veterans Appeals (Court) has held that the RO's failure to issue a Statement of the Case is a procedural defect requiring remand. See Manlicon v. West, 12 Vet. App. 238 (1999); Godfrey v. Brown, 5 Vet. App. 127, 132 (1993); see also Archibold v. Brown, 9 Vet. App. 124, 130 (1996). Accordingly, the case is REMANDED for the following action: 1. The veteran should be provided a statement of the case (SOC) in response to his notice of disagreement with the initial ratings. The veteran should also be informed of the requirements to perfect an appeal with respect to these issues. If a substantive appeal is not submitted, there is no jurisdiction of these issues to the Board. 2. If a substantive appeal is submitted, the case should be returned to the Board for further appellate action, if otherwise in order. No action is required of the appellant until he is otherwise notified but he has the right to submit additional evidence and argument on the matter the Board has remanded to the RO. See Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2005). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs