Citation Nr: 1325775 Decision Date: 08/14/13 Archive Date: 08/16/13 DOCKET NO. 07-18 118 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected hypertension, lumbar disc disease, arthritis of the neck, dysthymia, and headaches. 2. Entitlement to service connection for gastritis, to include as secondary to service-connected hypertension, lumbar disc disease, arthritis of the neck, dysthymia, and headaches. 3. Entitlement to an effective date earlier than August 2, 2005 for the grant of service connection for obstructive sleep apnea. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran was initially found to have active service from October 1972 to October 1995; however, a VA 215 Form, correction to DD Form 214 shows that the Veteran entered service in October 1986.. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2008 and March 2013 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The January 2008 rating decision declined to reopen the Veteran's claim for service connection for gastritis and denied his claim for service connection for GERD. The March 2013 rating decision granted service connection for obstructive sleep apnea and assigned a 50 percent rating, effective August 2, 2005. The Veteran originally requested a travel board hearing in his May 2007 substantive appeal. However, in an April 2008 statement, the Veteran withdrew his request for a Board hearing. The hearing request is therefore deemed withdrawn. 38 C.F.R. § 20.704(e) (2012). In September 2012, the Veteran submitted additional evidence in support of his claims on appeal with a waiver of initial RO consideration of the evidence. See 38 C.F.R. § 20.1304 (2012). Therefore, the Board may properly consider such newly received evidence. In September 2012, the Board reopened the Veteran's claim for service connection for gastritis, and then remanded the claims for service connection for gastritis and GERD for additional development. As will be explained in further detail below, the Veteran's claims were remanded, in part, for the RO/AMC to issue a supplemental statement of the case in which it considered the relevant VA medical records dated from March 1998 to March 2012 in Virtual VA pertaining to the claim for service connection for GERD. In a May 2013 supplemental statement of the case, the RO/AMC only listed VA treatment records dated from March 2007 to May 2013 as part of its review of the evidence. The VA medical records in Virtual VA that are dated from March 1998 to March 2007 were not listed as having been part of the RO/AMC's evidence review. However, these medical records are not relevant to the issues that are being decided below. Thus, the Board finds that another remand for such consideration with respect to the issues that are being decided below is unnecessary. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in such file reveals that certain documents, including VA medical records dated from April 2010 to March 2013, are potentially relevant to the issue of service connection for GERD that is on appeal. Thus, the Board has considered these electronic records in its adjudication of the Veteran's case. The Board notes that these records were also considered by the agency of original jurisdiction. The issues of entitlement to a rating in excess of 20 percent for lumbar disc disease, entitlement to a rating in excess of 10 percent for arthritis of the neck, entitlement to a rating in excess of 10 percent for headaches, and entitlement to a compensable rating for hearing loss have been raised by the record, but still have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are again referred to the AOJ for appropriate action. The issue of an effective date earlier than August 2, 2005 for the grant of service connection for obstructive sleep apnea is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Chronic GERD was not shown in service, and the most probative evidence fails to link the Veteran's current GERD to service or to a service-connected disability. 2. Chronic gastritis was not shown in service or within one year after discharge from service, and the most probative evidence fails to link the Veteran's current gastritis to service or to a service-connected disability. CONCLUSIONS OF LAW 1. The requirements for establishing service connection for GERD have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. The requirements for establishing service connection for gastritis have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. In this case, in an October 2007 letter issued prior to the decision on appeal, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claims for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The October 2007 letter also advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. A February 2013 letter also provided notice regarding what information and evidence is needed to substantiate his claims for service connection on a secondary basis. The case was last readjudicated in May 2013. Although the February 2013 notification regarding secondary service connection was issued after the adjudication on appeal, the Veteran's case was subsequently readjudicated in the May 2013 supplemental statement of the case. The Veteran also had the opportunity to submit additional argument and evidence. Therefore, the content timing error did not affect the essential fairness of the adjudication of the claims. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA medical reports, VA examination reports, and the Veteran's statements. Additionally, the prior remand instructions were substantially complied with. Instructions pertinent to the claims being decided included obtaining updated VA medical records, issuing a VCAA notice regarding secondary service connection, obtaining VA examinations and opinions regarding direct and secondary service connection theories of entitlement, and issuing a supplemental statement of the case in which the VA medical records in Virtual VA that pertained to GERD were considered. In response, the RO/AMC obtained all updated VA medical records and sent the Veteran a February 2013 letter which provided VCAA notice regarding secondary service connection. The RO/AMC also scheduled the Veteran for May 2013 VA examinations in which opinions were made regarding both direct and secondary service connection theories of entitlement. With respect to consideration of the March 1998 to March 2012 VA medical records pertaining to GERD in Virtual VA, the Board acknowledges that in a May 2013 supplemental statement of the case, the RO/AMC only listed VA treatment records dated from March 2007 to May 2013 as part of its review of the evidence. The VA medical records in Virtual VA that are dated from March 1998 to March 2007 were not listed as having been part of the RO/AMC's evidence review. However, a review of the medical records dated from March 1998 to March 2007 reveals that they are not relevant to the issues that are being decided below. Indeed, the only relevant records in Virtual VA are VA medical records dated from April 2010 to March 2013, which reflect treatment for GERD, and were listed as being part of the RO/AMC's evidence review. The RO/AMC essentially considered these relevant medical records in the May 2013 supplemental statement of the case by indicating that the records showed that the Veteran had GERD, but did not show a link to service or a service-connected disability. Therefore, another remand to have the RO/AMC consider VA medical records that are not relevant to the issues being decided below is unnecessary. See Soyini v. Principi, 1 Vet. App. 540, 546 (1991) (concluding that remand is unnecessary where it "would result in this Court's unnecessarily imposing additional burdens on the [Board] with no benefit flowing to the veteran"). Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by providing evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that 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, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and gastric ulcers become manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Service connection may also be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2012). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service treatment records show that on March 22, 1995, the Veteran complained of diarrhea, chills, and belly pain. He was found to have increased bowel sounds and tenderness to palpation in the upper left and right quadrants of the abdomen. There was no rebound tenderness. He was given a diagnosis of "gastro." In a March 23, 1995 treatment record, the Veteran reported that he had experienced a loose bowel movement earlier that morning. He indicated that he still felt gassy and bloated and that he occasionally had cramping. He was given a diagnosis of "gastro - improving." On VA examination in January 2008, the examiner thoroughly reviewed the claims file. He noted that the Veteran's hypertension was treated with Felodipine, which was a medication that did not have side effects that would cause GERD or gastritis. The examiner found that there was no objective evidence that the Veteran had esophagitis or gastritis because he had not had an upper endoscopy or upper GI series. He explained that any symptoms of either of those conditions would be subjective, and not objective, findings. Further review of the claims file revealed that the Veteran's medication list did not include non-steroidal anti-inflammatory drugs (NSAIDs). The examiner indicated that the mechanical etiology of GERD was not caused by NSAIDs anyway. He noted that the Veteran's lumbar disc disease and arthritis of the neck were treated with Baclofen, which was a skeletal muscle relaxer, and not an NSAID, and therefore would not contribute to symptoms of GERD or gastritis. The record did not show that the Veteran was being treated for his dysthymia with any medication, and therefore, the examiner found that medications for dysthymia would not cause or aggravate the Veteran's GERD or gastritis. The record also did not indicate that the Veteran was being treated for his headaches, except possibly with Amlodipine or Gabapentin, which were sometimes given as preventive measures. He explained that autohypertensive drugs, including Amlodipine, did not cause GERD or gastritis. He also reported that neither Amlodipine nor Gabapentin were known to aggravate GERD or gastritis. He therefore found that the Veteran was not shown to be treated for headaches with medication that could cause or aggravate GERD or gastritis. The examiner also found no objective evidence of anemia or malnutrition as a result of GERD or gastritis. He concluded that there was no evidence that the Veteran's medications for his service-connected hypertension, lumbar disc disease, arthritis of the neck, dysthymia, or headaches aggravated the Veteran's GERD or gastritis. VA medical records dated from April 2009 to March 2013 show that the Veteran received intermittent treatment for GERD. On VA stomach and duodenal examination in May 2013 for conditions not including GERD or esophageal disorders, the examiner noted that she had reviewed the entire claims file and performed an in-person examination on the Veteran. The Veteran complained that he burped frequently and was flatulent, but maintained that he did not know he had been diagnosed as having gastritis. He denied weight loss or an inability to eat. He reported that he had previously smoked 1 pack of cigarettes per day for many years, but he currently smoked 6 cigarettes a day. He stated that he did not remember when his acid reflux began or being informed of having a hiatal hernia in 2009. He indicated that he had never been treated for gastritis and that he never knew he had had this condition. The examiner noted a December 2009 VA medical report in which the Veteran was shown to be using Tylenol to get relief for chronic neck and back pain. He used Tramadol when he had to work because it did not make him drowsy. The examiner noted that the Veteran currently took Pantoprazole for his stomach condition. The Veteran's other current medications were listed as Amlodipine Besylate and Atenolol for high blood pressure, Aspirin to reduce the risk of stroke or heart attack, Metformin for blood sugar, and Cholecalciferol for supplementation of Vitamin D. The examiner noted that the medications that the Veteran had taken from 2004 to 2009 included Atenolol Beclofen, Felodipine, Gabapentin, Simvastatin, and Trazodone. The medical records also indicated that the Veteran had nicotine abuse during that period of time. A February 2009 CT scan of the abdomen revealed left base scarring, mild fatty changes in the liver, nonspecific bilateral adrenal thickening and small adenoma, small hiatal hernia, and narrowing of distal small bowel loops. At that time, the Veteran was noted to have been diagnosed with GERD and hiatal hernia per the imaging study. The examiner diagnosed the Veteran with gastric ulcer and noted the date of diagnosis as being in 2009. She opined that the Veteran's gastritis was not caused by any active duty diagnosed condition or by any medications that he was taking due to his service-connected disabilities, and that his gastritis was also not aggravated by any of the service-connected disabilities or medications. The examiner explained that the Veteran's prescribed medications in the past or present did not contain any warning against acid reflux or gastritis. Although the Veteran had reported taking Ibuprofen several years ago for his degenerative joint disabilities, the record revealed that he had not been on Ibuprofen for the last several years and during his diagnosis of gastritis per imaging. The examiner acknowledged that the Veteran had been diagnosed with "gastro" with loose bowel movement in 1995 during service, but she explained that his condition had already been improving in 1995 according to the records. She commented that at this time, it was uncertain whether the Veteran still had gastritis or not because that had not been addressed by the Veteran to his primary physician. Nevertheless, she concluded that the Veteran's 2009 gastritis was not associated with his service-connected medication of Ibuprofen/Etodolac since he was not on those medications during that time period. At a May 2013 VA esophageal conditions examination which included GERD and hiatal hernia, the examiner noted that she had reviewed the entire claims file and performed an in-person examination on the Veteran. The Veteran maintained that he had developed GERD because he had been taking medication such as Ibuprofen for his service-connected disabilities. However, the examiner noted that the Veteran had not been on Ibuprofen for the last few years. The Veteran complained that he burped frequently, had acid reflux, and regurgitated food particles at times, but he indicated that he had not told that to his physician at this time. He reported that the Pantoprazole helped his symptoms, but stated that he was flatulent. He denied weight loss or an inability to eat. He reported that he had previously smoked 1 pack of cigarettes per day for many years, but he currently smoked 6 cigarettes a day. He stated that he did not remember when his acid reflux began or being informed of having a hiatal hernia in 2009. He maintained that because VA placed him on medication for GERD, he felt he was entitled to service connection for this disability. The examiner noted a December 2009 VA medical report in which the Veteran was shown to be using Tylenol to get relief for chronic neck and back pain. He used Tramadol when he had to work because it did not make him drowsy. The examiner noted that the Veteran currently took Pantoprazole for his stomach condition. The Veteran's other current medications were listed as Amlodipine Besylate and Atenolol for high blood pressure, Aspirin to reduce the risk of stroke or heart attack, Metformin for blood sugar, and Cholecalciferol for supplementation of Vitamin D. The examiner noted that the medications that the Veteran had taken from 2004 to 2009 included Atenolol Beclofen, Felodipine, Gabapentin, Simvastatin, and Trazodone. The medical records also indicated that the Veteran had nicotine abuse during that period of time. The examiner noted that in 2005, the Veteran's other medications included Omeprazole for his stomach, Sildenafil Citrate to take before intercourse, Felodipine, and Etodolac for pain or inflammation. A February 2009 CT scan of the abdomen revealed left base scarring, mild fatty changes in the liver, nonspecific bilateral adrenal thickening and small adenoma, small hiatal hernia, and narrowing of distal small bowel loops. At that time, the Veteran was noted to have been diagnosed with GERD and hiatal hernia per the imaging study. The examiner diagnosed the Veteran with GERD and hiatal hernia. She noted the date of diagnosis of GERD as being in 2005 while the date of diagnosis of hiatal hernia was in 2009. She opined that the Veteran's GERD/hiatal hernia was not caused by any active duty diagnosed condition or by any medications that he was taking due to his service-connected disabilities, and that his GERD/hiatal hernia was also not aggravated by any of the service-connected disabilities or medications. The examiner explained that the Veteran's prescribed medications in the past or present did not contain any warning against acid reflux or gastritis except for the Etodolac that he was placed on in 2005. She noted that this medication could cause symptoms of heartburn and nausea while the Veteran was on it. Although the Veteran had reported taking Ibuprofen several years ago for his degenerative joint disabilities, the record revealed that he had not been on Ibuprofen or Etodolac for the last several years and during his diagnosis of GERD. The examiner also explained that the Veteran's GERD was associated with hiatal hernia, which was more of a mechanical problem of the diaphragmatic sphincter, and that the sphincter tone loss was more likely associated with his nicotine abuse than medications which had no association with GERD. With regard to service connection for GERD on a direct basis, the Board reiterates that the Veteran's service treatment records only show one incident of "gastro" with loose bowels in March 1995. Additionally, at no time did any of the Veteran's treating providers find that his GERD was due to any period of service. The May 2013 VA examiner reviewed the claims file, interviewed and examined the Veteran, and provided adequate reasoning and bases for the opinion that it was less likely than not that the Veteran's GERD was caused by his service. The examiner found that the Veteran's GERD was associated with hiatal hernia, which was more of a mechanical problem of the diaphragmatic sphincter, and that the sphincter tone loss was more likely associated with his nicotine abuse. For these reasons, the May 2013 opinion by the May 2013 VA examiner is afforded great probative value. With regard to service connection for gastritis on a direct basis, the Board reiterates that the Veteran's service treatment records only show one incident of "gastro" with loose bowels in March 1995. Additionally, at no time did any of the Veteran's treating providers find that his gastritis was due to any period of service. The May 2013 VA examiner reviewed the claims file, interviewed and examined the Veteran, and provided adequate reasoning and bases for the opinion that it was less likely than not that the Veteran's gastritis was caused by his service. The examiner found that although the Veteran had been diagnosed with "gastro" with loose bowel movement in 1995 during service, this condition had already been improving in 1995 according to the records. For these reasons, the May 2013 opinion by the May 2013 VA examiner is afforded great probative value. With regard to service connection for GERD and gastritis on a secondary basis, the Board notes that at no time did any of the Veteran's treating providers find that his GERD or gastritis were due to or aggravated by his service-connected disabilities. The January 2008 VA examiner who provided the January 2008 opinion reviewed the claims file and provided adequate reasoning and bases for the opinions that it was less likely than not that the Veteran's GERD or gastritis were caused by his service-connected disabilities, and that it was less likely than not that the Veteran's GERD or gastritis had been aggravated by his service-connected disabilities. Similarly, the May 2013 VA examiner who performed the May 2013 VA examinations and provided the May 2013 opinions reviewed the claims file, interviewed and examined the Veteran, and provided adequate reasoning and bases for the opinions that it was less likely than not that the Veteran's GERD or gastritis were caused by his service-connected disabilities, and that it was less likely than not that the Veteran's GERD or gastritis had been aggravated by his service-connected disabilities. Specifically, the January 2008 VA examiner found that the Veteran's hypertension was treated with Felodipine, which was a medication that did not have side effects that would cause GERD or gastritis. He noted that the Veteran's lumbar disc disease and arthritis of the neck were treated with Baclofen, which was a skeletal muscle relaxer, and not an NSAID, and therefore would not contribute to symptoms of GERD or gastritis. The record did not show that the Veteran was being treated for his dysthymia or headaches with any medication. Regarding Amlodipine or Gabapentin, which were sometimes given as preventive measures, the examiner explained that neither Amlodipine nor Gabapentin were known to aggravate GERD or gastritis. He concluded that there was no evidence that the Veteran's medications for his service-connected hypertension, lumbar disc disease, arthritis of the neck, dysthymia, or headaches aggravated his GERD or gastritis. Additionally, the May 2013 VA examiner explained that the Veteran's prescribed medications in the past or present did not contain any warning against acid reflux or gastritis except for the Etodolac that he was placed on in 2005. She noted that this medication could cause symptoms of heartburn and nausea while the Veteran was on it. Although the Veteran had reported taking Ibuprofen several years ago for his degenerative joint disabilities, the record revealed that he had not been on Ibuprofen or Etodolac for the last several years and during his diagnoses of GERD and gastritis. The examiner also explained that the Veteran's GERD was associated with hiatal hernia, which was more of a mechanical problem of the diaphragmatic sphincter, and that the sphincter tone loss was more likely associated with his nicotine abuse than medications which had no association with GERD. For these reasons, the Board finds that the January 2008 and May 2013 VA opinions, taken together, are afforded great probative value regarding whether the Veteran's GERD and gastritis are due to or aggravated by his service-connected disabilities. The Board notes that the Veteran has been diagnosed with gastric ulcer, which is a condition explicitly recognized as chronic under 38 C.F.R. § 3.309(a) (2012). Service connection based on a continuity of symptomatology can be warranted under 38 C.F.R. § 3.303(b) (2012) for chronic diseases. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, in this case, the Veteran has not asserted having a gastric ulcer in service, nor has he asserted a continuity of symptomatology after discharge. Indeed the Veteran reported at his May 2013 VA examination that he did not know he had been diagnosed as having gastritis, that he had never been treated for gastritis, and that he never knew he had had this condition. Moreover, the objective evidence of record does not show that the Veteran has continuously had a gastric ulcer since discharge from service. Therefore, the Board finds that service connection for gastritis based on a theory of continuity of symptomatology is not warranted. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, GERD and gastritis fall outside the realm of common knowledge of a lay person. In this regard, while the Veteran can competently report the onset and symptoms of abdominal distress or heartburn, any actual diagnoses of GERD or gastritis require objective testing to diagnose, and can have many causes. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Moreover, whether symptoms the Veteran experienced in service or following service are in any way related to any current GERD or gastritis requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). To the extent that the Veteran himself believes that he has current GERD and gastritis that are due to service or a service-connected disability, as a lay person, he is not shown to possess any specialized training in the medical field. The Veteran's opinions as to the etiology of his current GERD and gastritis are not competent medical evidence, as such questions require medical expertise to determine. Id. In any event, the Board concludes that the medical evidence, which reveals that GERD and gastritis are not due to service or a service-connected disability, is of greater probative value than the lay contentions of the Veteran. In sum, the Board finds that the probative and persuasive evidence establishes that the Veteran did not have chronic GERD or gastritis in service, and there is no competent and credible evidence indicating he had a gastric ulcer manifested to a compensable degree within a year following discharge from service. Likewise, the weight of the competent and probative evidence does not show the Veteran's current GERD and gastritis are related to his period of service, or that his current GERD and gastritis are due to or aggravated by his service-connected disabilities. Accordingly, service connection for GERD and gastritis is not warranted on any basis. In reaching the conclusions above, the Board has considered the applicability of 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); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to service connection for GERD, to include as secondary to service-connected hypertension, lumbar disc disease, arthritis of the neck, dysthymia, and headaches, is denied. Entitlement to service connection for gastritis, to include as secondary to service-connected hypertension, lumbar disc disease, arthritis of the neck, dysthymia, and headaches, is denied. REMAND Following the March 2013 rating decision effectuating the September 2012 Board decision by granting service connection for obstructive sleep apnea, the Veteran expressed his disagreement with the assigned effective date in a May 2013 statement. The Veteran was not issued a statement of the case concerning this issue. Accordingly, the Board is required to remand this issue to the RO/AMC for the issuance of a statement of the case. 38 U.S.C.A. § 7105(d)(1) (West 2002 & Supp. 2012); 38 C.F.R. §§ 19.26, 19.29, 19.30 (2012); Manlincon v. West, 12 Vet. App. 238 (1999). After the RO/AMC has issued the statement of the case, the issue should be returned to the Board only if the Veteran perfects an appeal in a timely manner. See Smallwood v. Brown, 10 Vet. App. 93, 97 (1997). Accordingly, the case is REMANDED for the following action: Issue a statement of the case pertaining to the issue of entitlement to an effective date earlier than August 2, 2005 for the grant of service connection for obstructive sleep apnea. The statement of the case must contain the information required by 38 U.S.C.A. § 7105(d)(1) and 38 C.F.R. § 19.29, as well as notification that the issue should only be returned to the Board if a timely substantive appeal is filed. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim 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. 2012). ______________________________________________ K. OSBORNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs