Citation Nr: 1409959 Decision Date: 03/11/14 Archive Date: 03/20/14 DOCKET NO. 10-06 536 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for coronary artery disease. 2. Entitlement to service connection for high blood pressure secondary to nerve gas exposure. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for flash burns of both eyes. 5. Entitlement to service connection for bilateral lower extremities problems secondary to lower back disorder. 6. Entitlement to service connection for bilateral hand numbness secondary to nerve gas. 7. Entitlement to service connection for joint pain secondary to nerve gas and Agent Orange. 8. Entitlement to service connection for obstructive pulmonary disease secondary to asbestos and nerve gas. 9. Entitlement to service connection for pneumonia in both lungs. 10. Entitlement to service connection for a gastrointestinal disorder, to include ulcers. 11. Entitlement to service connection for rash on the body. 12. Entitlement to service connection for cracking feet. 13. Entitlement to service connection for low back disorder. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Tahirih S. Samadani, Counsel INTRODUCTION The Veteran served on active duty from June 1971 to August 1971, with immediate reenlistment in August 1971 to August 1974. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In February 2010, the Veteran requested a hearing before the Board. The Veteran subsequently withdrew his request in May 2010. 38 C.F.R. § 20.704(e). In December 2010, the Veteran testified before a Decision Review Officer at the RO. A transcript of the proceeding is of record. When this case was before the Board in April 2013, it was decided in part and remanded in part. It is now before the Board for further appellate action. In an August 2013 decision, the Appeals Management Center (AMC) granted service connection for an anxiety disorder not otherwise specified (also claimed as posttraumatic stress disorder), prostate cancer, sleep apnea, erectile dysfunction, and special monthly compensation based on loss of use of a creative organ. This AMC decision represents a full and final determination of the issues of an acquired psychiatric disability, prostate cancer, and sleep disorder, and therefore these issues are not before the Board at this time. The issue of entitlement service connection for diabetes mellitus, type II, has been raised by the record in a July 2011 statement, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issue of entitlement a total disability evaluation based on unemployability (TDIU) was raised in a September 2007 claim, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issue of entitlement to service connection for a low back disability, a respiratory disabilities, bilateral hearing loss, bilateral lower extremities problems secondary to lower back disorder, and flash burns of both eyes are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC, in Washington, DC. FINDINGS OF FACT 1. The Veteran was exposed to various chemicals while stationed at the Dugway Proving Ground; however, he was not exposed to agent orange. 2. Coronary artery disease was not manifest in service or within one year of separation, and is unrelated to service. 3. Hypertension was not manifest in service or within one year of separation, and is unrelated to service. 4. Bilateral hand numbness was not manifest in service and is unrelated to service. 5. Joint pain was not manifest in service and is unrelated to service. 6. Gastrointestinal disorder, to include ulcers, was not manifest in service and is unrelated to service. 7. Rash on the body was not manifest in service and is unrelated to service. 8. Cracking feet was not manifest in service and is unrelated to service. CONCLUSIONS OF LAW 1. Entitlement to service connection for coronary artery disease is not warranted. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.655 (2013). 2. Entitlement to service connection for hypertension is not warranted. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.655 (2013). 3. Entitlement to service connection for bilateral hand numbness is not warranted. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303 (2013). 4. Entitlement to service connection for joint pain is not warranted. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303 (2013). 5. Entitlement to service connection for gastrointestinal disorder, to include ulcers, is not warranted. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303 (2013). 6. Entitlement to service connection for rash on body is not warranted. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303 (2013). 7. Entitlement to service connection for cracking feet is not warranted. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist In correspondence dated in November 2007 and September 2008, the agency of original jurisdiction (AOJ) satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2013). Specifically, the letters informed the Veteran of information and evidence necessary to substantiate his claims and of the relative burdens of VA and the Veteran, relating the information and evidence that VA would seek to provide and that which he was expected to provide. The subsequent notice informed the Veteran of information and evidence that governs the initial assignment of a disability evaluation and the regulations regarding the effective date of the establishment of service connection. In the letters, the Veteran was further notified of information and evidence that governs the initial assignment of a disability evaluation and the regulations regarding the effective date of the establishment of service connection. VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2013). Service treatment records and personnel records have been associated with the claims file. All identified and available post-service treatment records have been secured, including records from the Social Security Administration. The Veteran has been medically evaluated in conjunction with his claims, and medical opinions have been sought. The Board has reviewed the resultant reports and finds that the examinations and opinions of record are adequate for rating purposes. Specifically, they were conducted based on a review of the pertinent information in the claims file and a complete examination of the Veteran. The opinions offered were accompanied by reasonable rationales that are supported by the clinical evidence. Thus, the Board finds that the duty to assist has been fulfilled. Stegall In April 2013, the Board remanded the Veteran's case. In the remand, the Board requested that any available in-patient hospital treatment records for the Veteran at Letterman Army Hospital in San Francisco, dated from June 1971 to September 1971, be obtained. The AMC obtained service treatment records in May 2013 which included hospital discharge summary from the Letterman General Hospital. Attached to the newly received treatment record was a response indicating that service treatment record were furnished to WACO 349. An AMC officer contacted WACO 349 requesting these records. WACO 349 responded that a claims file for this Veteran was not at that location. The AMC officer responded that service treatment records were being requested and not the claims file. There was no response from WACO 349. The AMC informed the Veteran and drafted an formal finding of unavailability. As indicated above, service treatment records were associated with the claims file in May 2013 which includes a summary of treatment at the Letterman Army Hospital for the Veteran's back disability. For these reasons, the Board finds that the AMC substantially complied with the Board's April 2013 directive to obtain treatment records from the Letterman Army Hospital. Exposure to Chemicals During Service For most of his service connection claims, the Veteran alleges that they are secondary to exposure to various chemicals as a result of his duties during Project SHAD at the Dugway Proving Ground in Utah. See December 2010 RO hearing. Project SHAD is an acronym for Shipboard Hazard and Defense. It was part of a joint service chemical and biological warfare test program. The Veteran claims that during Project SHAD, he fired rounds full of herbicides, chemicals, and nerve agents while he worked at as a gunner in Dugway, Utah. He explained that he also drove a forklift in the underground storage facilities there checking for leaking 55 gallon barrels. If they were leaking, the Veteran would move them with the forklift, sometimes using his hands, and put them in a containment area. He explains that they also sprayed nerve gas in Dugway, Utah. He also reported loading Agent Orange and other chemicals on planes headed for Vietnam. In a February 2009 statement, the Veteran reported that during the military, he would wear different protective suits to see how they would hold up while being sprayed by different chemicals. The Veteran's personnel records confirm that he was stationed at the Dugway Proving Ground from December 1971 to August 1974, with the military occupational specialty of gunner. The Department of Defense has released several Fact Sheets with respect to specific tests conducted, to include the date and location of the test, the chemicals used, and the potential associated health risks. Five of these fact sheets address tests that were conducted at Dugway during the time the Veteran was stationed there. The Board finds this evidence highly probative of the Veteran's contentions regarding his exposure to specific chemicals. The Veteran was afforded several VA examinations for his claimed disorder and opinions were obtained as to whether such exposure is related to his current disabilities. The Veteran also submitted an article which discussed radiation testing at Dugway Proving Ground, but these occurred in the 1940's and 1950's, well before the Veteran was stationed at Dugway. The Veteran also does not appear to be claiming radiation exposure as his contention is that he was exposed to Agent Orange and chemical and biological warfare. Exposure to Agent Orange: A Veteran who "served in the Republic of Vietnam" between January 9, 1962, and May 7, 1975, is presumed to have been exposed during such service to Agent Orange. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). If a Veteran was exposed to an herbicide agent during active military service, ischemic heart disease will be presumed to have been incurred in service if manifest to a compensable degree within specified periods, even if there is no record of such disease during service. 38 U.S.C.A. § 1116(a)(2); 38 C.F.R. §§ 3.307(a)(6), 3.309(e). VA has validly interpreted the "service in Vietnam" language of the statute and regulation as requiring that a Veteran must have actually been present at some point on the landmass or the inland waters of Vietnam during the Vietnam conflict. See Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008). The RO submitted a PIES requested in February 2010 requesting documentation of exposure to herbicide. The response noted no records of exposure to herbicides. A review of the DD 214, service treatment records and personnel file shows no evidence of Vietnam service. A response from the National Personnel Records Center also found no service in Vietnam. During the December 2010 hearing with the Decision Review Officer, the Veteran recanted his statement that he served in Vietnam. The Veteran now contends that he was exposed Agent Orange while stationed at Dugway Utah Proving Ground. The Board acknowledges that the Veteran received an Agent Orange examination in July 2011 but having this examination does not confirm exposure to Agent Orange. Although the Veteran has submitted documentation showing storage of certain chemicals at Dugway Proving Ground, there is no documentation showing that Agent Orange was stored there. Furthermore, information from the Department of Defense (DoD) on projects to test, dispose of, or store herbicides does not include Dugway Proving Ground. See U.S. Department of Veterans Affairs, Public Health, Herbicide Tests and Storage in the U.S., http://www.publichealth.va.gov/exposures/agentorange /locations/tests-storage/usa.asp (last visited February 27, 2013). The Veteran is competent to report potential herbicide exposure, however, his reports must be weighed against the objective evidence and their credibility must be assessed. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). The Board also questions the Veteran's credibility regarding his testimony of Agent Orange exposure as he originally claimed Agent Orange exposure in Vietnam (and thus would have been afforded the presumptive benefit) when, in fact, he had no service in Vietnam. For these reasons and due to lack of evidence showing Agent Orange exposure, the Board finds that the Veteran was not exposed to Agent Orange. Legal criteria In general, service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303. Notwithstanding the above, service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred or aggravated in service. 38 C.F.R. § 3.303(d) (2013). To establish a right to compensation for a present disability, a Veteran must show: "(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." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For certain chronic disorders, including hypertensive vascular disease and ischemic heart disease, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C.A. §§ 1101, 1131, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2013). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (the Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Entitlement to service connection for coronary artery disease and high blood pressure secondary to nerve gas exposure. In essence, the Veteran claims that he his heart disorders and high blood pressure are due to exposure to nerve gas during his military service. As noted above, in order to establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus or relationship between the two. See Shedden, 381 F.3d at 1167. Service treatment records do not show treatment or complaints for coronary artery disease or hypertension. For the reasons expressed above, however, the Board finds that he was exposed to chemicals in service. The Veteran received a VA examination for his coronary artery disease in June 2013. The claims file was reviewed. The Veteran was diagnosed with acute, subacute, or old myocardial infarction (1993), atherosclerotic cardiovascular disease (1993), congestive heart failure (2009), heart block (2009), implanted cardiac pace maker, implanted cardiac pacemaker (2009), implanted automatic implatable cardioverter defibrillator (2009). A December 2012 VA treatment record notes that a cardiac stent placed in 2008 and a pacemaker surgical procedure occurred in 2009. The examiner opined that it was less likely than not that the current heart disease was related to any chemical exposure or other events of service, because the Veteran had multiple cardiac risk factors which combine to cause his current condition, including cigarette smoking, hypertension, hyperlipidemia and a strong genetic predisposition (father died at age 43 due to myocardial infarction). The Veteran also received a VA examination for hypertension in June 2013. The claims file was reviewed. The Veteran was diagnosed with essential hypertension that was controlled on medication. He was diagnosed with hypertension about 15 years earlier. The examiner opined that it was less likely than not that hypertension was related to chemical exposure during service. The examiner found that the Veteran's hypertension was related to genetic factors and obesity. The grant of service connection requires competent evidence to establish a diagnosis and relate the diagnosis to the Veteran's service. While the record reflects that the Veteran has a several heart disorders and hypertension, it does not show that these claimed disabilities were either caused or aggravated by any incident of service, to include chemical exposure. There is no competent evidence linking these two claimed disabilities to service. Instead, the June 2013 examiner found that it was less likely than not that the claimed disabilities were related to service. In reaching its conclusion, the Board has considered the Veteran's statements and testimony in regard to the cause of his heart disorders and hypertension. The Veteran is certainly competent to report the onset of symptoms and the circumstances surrounding such. However, the Board finds that he is not competent to offer an opinion on a complex medical matter, to include opining as to whether his disabilities were caused by chemical exposure. See Jandreau, 492 F.3d at 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). The Board finds that the etiology of these claimed disabilities is ultimately a medical question far too complex to lend itself to the opinion of a layperson. No medical opinion of record is contrary to the findings of the June 2013 VA examiner. The Veteran has been accorded ample opportunity to furnish medical and other evidence in support of his service-connection claims, and against the reasoned conclusions of the VA examiner; he has not done so. See 38 U.S.C.A. § 5107(a) [it is a claimant's responsibility to support a claim for VA benefits]. As noted above, for certain chronic disorders, including hypertensive vascular disease and ischemic heart disease, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. Here, there is no evidence showing that the Veteran's heart disorders or hypertension manifested to compensable degree within one year of discharge. The June 2013 examination instead noted that the Veteran's heart disorder began at the earliest in 1993, several years after discharge. Also, his hypertension was only diagnosed 15 years prior to the June 2013 VA examination. Therefore, service connection is also not warranted on a presumptive basis. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a); hypertension and heart disease are qualifying chronic diseases. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Here there is no showing of continuity of symptomatology for either disease since service. As noted above, he was diagnosed with these disabilities for the first time several years after discharge. As noted above, the Board does not find that the Veteran was exposed to Agent Orange and therefore, service connection for ischemic heart disease is not warranted on presumptive basis. 38 C.F.R. § 3.309(e) (2013). The preponderance of the evidence is against the Veteran's claim. Consequently, the doctrine of reasonable doubt is not applicable to the instant appeal. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54 (1990). Service connection is not warranted for coronary artery disease or hypertension. Entitlement to joint pain and numbness to the hands due to nerve gas The Veteran claims that he has joint pain and numbness in his hands due to exposure to nerve gas during service. As discussed above, the Board finds the evidence of record is highly probative of the Veteran's contentions regarding his exposure to specific chemicals, including nerve agents and mustard gas. The question then becomes whether such exposure is related to his current disabilities. To answer this question, the Veteran was afforded a VA examination in June 2013. The Veteran's claims file was not available for review. The examiner found that the Veteran had no finger or hand disorder. The examiner acknowledged that the Veteran reported intermittent joint pain affecting hands, wrists, feet, elbows and shoulders. The Veteran also reported that he had never been evaluated or diagnosed with a symmetric or systemic arthritis or a specific wrist or hand disorder. The Veteran also denied having any wrist or hand disorder while on active duty. The Veteran instead claims that his joint pain and bilateral hand numbness are based on symptoms the Veteran believed may be attributable to chemical exposures while stationed at Dugway Proving Ground in Utah. The examiner noted that the Veteran denied acute exposure symptoms to the chemicals he believed were in use at the time; nerve agents, vesicants, blood agents. The examiner also noted that the Veteran did not have VA or DOD confirmation or endorsement of any specific chemical, biological or nerve agents at this time. The Veteran reported that his joint pains in his wrists and hands are intermittent and random although his wrists will hurt with repetitive activity like working on his car with tools so he avoids that activity now. He denied any history of trauma, surgery or invasive procedure. The pain in his hands/wrist is usually dull but will get sharp with activity. Upon examination, he denied numbness and tingling. The Veteran was also provided a VA examination in June 2013 for his knee and lower leg conditions. The claims file was not available for review. The examiner found no knee or lower leg condition. The Veteran denied any knee or lower leg disorder. The Veteran instead reported intermittent radicular pain and numbness from his back to his lower extremities which was discussed in the back examination report. The Veteran noted intermittent joint pain affecting hands, wrists, feet, elbows, and shoulders. He also noted that his knees will hurt with prolonged standing. He denied any history of trauma, surgery or invasive procedure. The Veteran had never been evaluated or diagnosed with a symmetric or systemic arthritis. He has never been diagnosed with a specific knee or lower leg disorder. He denied having any knee or leg disorder while on active duty. Instead, the Veteran claims joint pain due to chemical exposure while stationed at Dugway Proving Ground in Utah. The Veteran also was provided a foot examination in June 2013. The claims file was not available for review. He was diagnosed with mild plantar fasciitis, diagnosed in 2013. The pain in his feet was dull and situated around the arches and heel. After the examiner reviewed the claims file, he provided an addendum opinion in September 2013. He found that it was less likely than not the Veteran's generalized joint pain of the hand, fingers, knees and feet were incurred in or caused by the clamed in-service injury, event, or illness. The examiner explained that the June 2013 examination showed that there had been no generalized joint disorder identified. Degenerative joint changes seen were due to aging and physical activity and not due a systemic process or exposure. The Board acknowledges that the examiner also noted that there was no documentation or evidence that the Veteran was exposed to any toxic chemicals above occupational exposure levels or without appropriate personal protective equipment. Despite this, the examiner maintained that if the Veteran had been exposed to the chemicals he was claiming (including nerve, biological warfare agents) much more acute health effects would be expected to have manifested at the time of exposure or shortly thereafter. The examiner noted that the Veteran's discharge examination only noted a low back disorder, and the Veteran reported that he otherwise was in good health at that time. The examiner concluded that there has been no identified systemic joint disorder and there is no evidence of a chemical exposure that would have led to the health effects that the Veteran is claiming. The grant of service connection requires competent evidence to establish a diagnosis and relate the diagnosis to the Veteran's service. The examination showed that the Veteran does not have any kind of systemic disease and in addition, the examiner found that the Veteran had no current diagnosis due to exposure to chemicals during service. The evidence does not show that these claimed disabilities were either caused or aggravated by any incident of service, to include chemical exposure. There is no competent evidence linking any joint pain or numbness to service. Instead, the examiner who provided the September 2013 addendum found that it was less likely than not that the claimed disabilities were related to service. In reaching its conclusion, the Board has considered the Veteran's statements and testimony in regard to his joint pain and numbness in hands. The Veteran is certainly competent to report the onset of symptoms and the circumstances surrounding such. However, the Board finds that he is not competent to offer an opinion on a complex medical matter, to include opining as to whether his current symptoms were caused by chemical exposure. See Jandreau, 492 F.3d at 1376 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). The Board finds that the etiology of these claimed symptoms are ultimately a medical question far too complex to lend itself to the opinion of a layperson. No medical opinion of record is contrary to the findings of the September 2013 Addendum. The Veteran has been accorded ample opportunity to furnish medical and other evidence in support of his service-connection claims, and against the reasoned conclusions of the VA examiner; he has not done so. See 38 U.S.C.A. § 5107(a) [it is a claimant's responsibility to support a claim for VA benefits]. The preponderance of the evidence is against the Veteran's claim. Consequently, the doctrine of reasonable doubt is not applicable to the Veteran's claim for entitlement to service connection for joint pain and numbness to the hands. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54 (1990). Service connection for joint pain and numbness to the hands due to nerve gas is not warranted. Entitlement to service connection for gastrointestinal disorder, to include ulcers. In essence, the Veteran claims that he had ulcers during service but did not seek treatment for the ulcers until after he was discharged. A November 2008 VA examination notes a diagnosis for gastroesophageal reflux disease (GERD), but the examiner did not provide an opinion as to whether it was related to service. The Veteran received a VA examination in June 2013. The claims file was reviewed. The examiner diagnosed the Veteran with GERD, which was diagnosed 20 to 30 years earlier. The examiner noted that no gastrointestinal (GI) disorder was noted on the discharge examination. The Veteran reported being diagnosed with ulcers after service but that he currently did not have ulcers. The Veteran's current gastrointestinal condition was GERD which was well controlled by medication. The examiner concluded that it was less likely than not that GERD was related to service because service treatment records had no mention of any gastrointestinal complaint. Furthermore, GERD was diagnosed several years after service. The grant of service connection requires competent evidence to establish a diagnosis and relate the diagnosis to the Veteran's service. While the record reflects a current diagnosis of GERD and ulcer (March 2011 VA treatment record), it does not show that these disorder was caused or aggravated by any incident of service, to include chemical exposure. There is no competent evidence linking this disorder to service. Instead, the June 2013 examiner found that it was less likely than not that GERD were related to service. In reaching its conclusion, the Board has considered the Veteran's statements and testimony in regard to when his GERD began. Despite this, there appears to be no treatment for GERD until the last 15 years. After weighing the Veteran's statements with the medical examiner's findings and the VA treatment records, the Board finds the examiner's opinion to be of greater probative value. Diagnosing GERD and ulcers is a medical determination and the Board finds that the Veteran is not competent to diagnosis these disorders. See Jandreau, 492 F.3d at1372 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). No medical opinion of record is contrary to the findings of the June 2013 VA examiner. The Veteran has been accorded ample opportunity to furnish medical and other evidence in support of his service-connection claims, and against the reasoned conclusions of the VA examiner; he has not done so. See 38 U.S.C.A. § 5107(a) [it is a claimant's responsibility to support a claim for VA benefits]. The preponderance of the evidence is against the Veteran's claim. Consequently, the doctrine of reasonable doubt is not applicable to issue of entitlement to service connection for GERD and ulcers. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54 (1990). Service connection for gastrointestinal disorder, to include ulcers, is not warranted. Entitlement to service connection for rash on the body and cracking feet. The Veteran was afforded a VA examination in June 2013. The claims file was reviewed. The examiner diagnosed the Veteran with xerosis of both feet. The Veteran reported that he had a long history of skin cracking and bleeding on his feet. The only treatment was lotion. He had a rash on his back which was pruritus and occurred about 2 times per year and lasted about one month. The examiner noted that his back had normal skin without rash or pigment change. His feet had dry skin with superficial cracking on plantar surfaces. The examiner opined that it was less likely than not that current skin conditions were related to any chemical exposure in service because the conditions began years after service and the Veteran wore socks and boots while on duty and there was no evidence of any chemical exposure to his feet. The grant of service connection requires competent evidence to establish a diagnosis and relate the diagnosis to the Veteran's service. The evidence does not show that these claimed disabilities were either caused or aggravated by any incident of service, to include chemical exposure. In reaching its conclusion, the Board has considered the Veteran's statements and testimony in regard to his skin problems. The Veteran is certainly competent to report the onset of symptoms and the circumstances surrounding such. However, the Board finds that he is not competent to offer an opinion on a complex medical matter, to include opining as to whether his current skin problems were caused by chemical exposure. See Jandreau, 492 F.3d at 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). The Board finds that the etiology of these claimed symptoms are ultimately a medical question far too complex to lend itself to the opinion of a layperson. No medical opinion of record is contrary to the findings of the June 2013 VA examination. The Veteran has been accorded ample opportunity to furnish medical and other evidence in support of his service-connection claims, and against the reasoned conclusions of the VA examiner; he has not done so. See 38 U.S.C.A. § 5107(a) [it is a claimant's responsibility to support a claim for VA benefits]. The preponderance of the evidence is against the Veteran's claim. Consequently, the doctrine of reasonable doubt is not applicable to the Veteran's claim for entitlement to service connection for skin disorders, including rash and cracking feet. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54 (1990). Service connection for rash on the body and cracking feet is not warranted. ORDER Entitlement to service connection for coronary artery disease is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for bilateral hand numbness secondary to nerve gas is denied. Entitlement to service connection for joint pain secondary to nerve gas and Agent Orange is denied. Entitlement to service connection for a gastrointestinal disorder, to include ulcers, is denied. Entitlement to service connection for a rash on the body is denied. Entitlement to service connection for cracking feet is denied. (CONTINUED ON NEXT PAGE) REMAND Entitlement to service connection for Bilateral Hearing Loss The Veteran claims that his current hearing loss is due to noise exposure during service which included working as a gunner. He reports having fired cannons daily with no hearing protection. A November 1974 service treatment record notes audiogram results revealing the puretone thresholds for 500, 1000, 2000, 3000, 4000, 6000 Hertz to be 10, 15, 15, 15, 15, and 30 for the right ear and 5, 5, 5, 20, 10, and 10 for the left ear. The treatment record notes that the Veteran was educated as to the importance of wearing protective hearing devices and ear plugs were fitted. The claims file includes two opinions regarding the Veteran's hearing loss. One opinion was provided in November 2008 and another was provided in August 2013. Neither the November 2008 examiner nor the August 2013 AMC Medical Officer considered the November 1974 service treatment record. The Board finds that this treatment record is highly probative as to whether he sustained permanent hearing loss during or shortly after service. For this reason, the Board finds that an opinion should be obtained from the June 2013 VA examiner who originally did not provide an opinion as to whether the Veteran's hearing loss was due to his military service. Entitlement to service connection for flash burns to the eye. The Veteran claims to have loss of vision in the left eye due to a flash burn injury during service. Neither the August 2013 VA examiner or the AMC Medical Officer addressed specifically whether his loss of vision in the left eye is at least as likely as not related to his injury in service. Although the examiner noted that his best corrected vision was 20/25 in both eyes, the Veteran's uncorrected distance was 20/100 in the left eye which appears to be significantly worse than his right eye. An addendum opinion is needed to clarify whether his loss of vision of the left eye is at least as likely as not due to his injury in service. Entitlement to service connection for a low back disability and lower extremity problems The Veteran was afforded a VA examination for his back disability in June 2013. The examiner was not provided with the claims file. The examiner also noted that x-rays and labs were pending, but that an addendum would be added to the file once the claims file and tests were available. In a September 2013 opinion regarding other disabilities, the examiner noted that he had previously recommended service connection be awarded for the Veteran's back disability. The examiner appears to have provided a positive opinion regarding whether the Veteran's back disability was related to the Veteran's military service. This addendum with the positive opinion is not included in the claims file or in Virtual VA. The case must be remanded so that this opinion can be associated with the claims file, and the claim readjudicated. The Board also finds that the August 2013 AMC Medical Officer's opinion to be inadequate. The AMC Medical Officer noted that the Veteran separated from the military without complaint of lower back conditions, and the active duty and presumptive period medical notes were silent for a lower back condition. The Board does not find this to be accurate. The service treatment records show hospitalization for a back injury during service and his discharge examination noted a history of a back injury. The AMC Medical Officer appears to have failed to consider this highly relevant evidence. During the June 2013 VA examination for the back, the examiner noted that the Veteran had signs or symptoms of radiculopathy. The Veteran is claiming bilateral lower extremities problems secondary to lower back disorder. For these reasons, the Board finds that the issue of service connection for the back disability is inextricably intertwined with the issue bilateral lower extremity problems. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered). Because the issues are inextricably intertwined, the Board is unable to review the issue of problems with the lower extremities at this time. Id. Entitlement to service connection for obstructive pulmonary disease secondary to asbestos and never gas and service connection for pneumonia in both lungs The Veteran claims that his obstructive pulmonary disease is due to asbestos and nerve gas. The Veteran also claims that his recent diagnosis of pneumonia is due service. A July 2010 VA treatment record notes a diagnosis of pneumonia. The Veteran also reported being diagnosed with pneumonia during service. The Veteran was afforded a VA examination in June 2013 for a respiratory disorder. The claims file was available for review. The examiner diagnosed the Veteran with chronic obstructive pulmonary disease (COPD). The examiner noted that the Veteran had a 20 years cigarette smoking history and quit in 1991. The examiner acknowledged that the Veteran had pneumonia in service but noted that it resolved with treatment. Current complaint was shortness of breath with minimal exertion. He had known cardiovascular disease and congestive heart failure. The chest x-ray showed mild cardiac enlargement and no evidence of asbestosis. The examiner opined that the Veteran's current respiratory condition was less likely than not related to any chemical exposure. The examiner noted that his current shortness of breath was due to COPD and cardiac condition. The Board finds that this examination and opinion are inadequate because the examiner did not provide an opinion as to whether his pneumonia, diagnosed in July 2010, was related to his military service. The rationale provided was also inadequate as it provided a reason for shortness of breath and not a reason why his respiratory disorder was not related to service. For these reasons, the Board finds that an addendum opinion should be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain any recent VA treatment records and associate them with the claims file. 2. Obtain an addendum opinion from the June 2013 examiner who conducted the VA audio examination. The claims folder should be forwarded to the examiner for review. Following review of the claims folder, the examiner should provide an opinion regarding whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the current bilateral hearing loss disability began in service or is related to any disease or injury in service. Specifically, the examiner should review the November 1974 service treatment record and consider whether the Veteran's hearing had worsened shortly after his discharge. The examiner should also consider the Veteran's credible reports of noise exposure during service. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Obtain an addendum opinion from the August 2013 VA examiner who conducted the VA Eye Conditions examination. Following review of the claims folder, the examiner should provide an opinion regarding whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the Veteran's loss of vision of the left eye is due to his injury in service. The examiner should review the claims file, including all documentation in the service treatment records relating to his eye injury. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Locate the addendum opinion by D.H., Physician Assistant, who conducted the June 2013 back examination. D.H. reports that he provided a positive opinion as to the relationship between the Veteran's back disability and his military service. 5. If the addendum opinion cannot be located, the case should be returned to the D.H., Physician Assistant, to provide an addendum opinion. Following review of the claims folder, the examiner should provide an opinion regarding whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the Veteran's current back disability is related to the injury he sustained during his military service. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 6. Obtain an addendum opinion from the June 2013 examiner who conducted the respiratory VA examination. The claims folder should be forwarded to the examiner for review. Following review of the claims folder, the examiner should provide an opinion regarding the following: a. whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the recent diagnosis of pneumonia is related to the Veteran's military service. b. whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the COPD (as differentiated from the Veteran's shortness of breath) is related to the Veteran's military service. Specifically the examiner should review both sets of service treatment records. The examiner's attention is directed to the April 1972 treatment record which notes a report of wheezing. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 7. If service connection is granted for the Veteran's back disability, a peripheral neuropathy examination should be conducted for the Veteran's claimed lower extremity problems to determine a current diagnosis. 8. Then, readjudicate the claims on appeal, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. The appellant has the right to submit additional evidence and argument on the 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. 2013). ______________________________________________ Bethany L. Buck Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs