Citation Nr: 0813472 Decision Date: 04/24/08 Archive Date: 05/01/08 DOCKET NO. 05-08 866 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for PTSD. 3. Entitlement to service connection for tinnitus. 4. Entitlement to service connection for respiratory disorder, including bronchitis, secondary to presumed exposure to herbicides. 5. Entitlement to service connection for epidural inclusion cyst (claimed as fibrotic tumor) secondary to presumed exposure to herbicides. 6. Entitlement to service connection for a skin disorder secondary to presumed exposure to herbicide. 7. Entitlement to service connection for an immune system disorder secondary to presumed exposure to herbicide. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD W.T. Snyder, Counsel INTRODUCTION The veteran had active service from January 1969 to February 1971. This appeal to the Board of Veterans' Appeals (Board) arose from a May 2004 rating decision of the Regional Office (RO) of the Department of Veterans Affairs (VA) in Cleveland, Ohio. The veteran appeared at a formal hearing in April 2006 before an RO Decision Review Officer. A transcript of the hearing testimony is associated with the claims file. The veteran also indicated on his substantive appeal (VA Form 9) that he desired a Board Hearing at the local RO, which a December 2007 RO letter informed him was scheduled for February 19, 2008. He failed to appear for his scheduled hearing, and there is no evidence of him having requested that the hearing be rescheduled. Thus, the hearing request is deemed withdrawn. See 38 C.F.R. § 20.702 (2007). The veteran applied for service connection for delayed stress syndrome in July 1981. A rating action in September 1981 denied the claim for delayed stress syndrome. The decision was timely appealed. A September 1983 Board decision denied service connection for an acquired mental disorder, claimed as delayed stress syndrome. The RO adjudicated the veteran's current PTSD claim on a de novo basis, rather than as a petition to reopen a claim on the basis of new and material evidence. Nonetheless, as discussed below, the Board conducts a new and material evidence analysis, as delayed stress syndrome and PTSD are in fact the same disorder. Cf. Boggs v. Peake, No. 2007-7137 (Fed. Cir. Mar. 26, 2008) (a claim for one diagnosed disease or injury cannot be prejudiced by a prior claim for a different diagnosed disease or injury, even if the symptomatology of the two are the same). FINDINGS OF FACT 1. A September 1983 Board decision denied service connection for an acquired mental disorder, including delayed stress syndrome. The decision was final. 2. The evidence submitted since the September 1983 Board decision, by itself, or when considered with the previous evidence of record, does relate to an unestablished fact necessary to substantiate the claim for entitlement to service connection for PTSD and raises a reasonable possibility of substantiating the claim. 3. The veteran does not have PTSD attributable to an independently verifiable in-service stressor. 4. The preponderance of the probative evidence indicates that tinnitus is not related to an in-service disease or injury. 5. The preponderance of the probative evidence indicates that a respiratory disorder, including bronchitis is not related to an in-service disease or injury nor is it the result of exposure to herbicides in service. 6. The preponderance of the probative evidence indicates that an epidural inclusion cyst is not related to an in- service disease or injury nor is it the result of exposure to herbicides in service. 7. The preponderance of the probative evidence indicates that a skin disorder is not related to an in-service disease or injury nor is it the result of exposure to herbicides in service. 8. The preponderance of the probative evidence indicates that an immune disorder is not related to an in-service disease or injury nor is it the result of exposure to herbicides in service. CONCLUSIONS OF LAW 1. The September 1983 Board decision is final. New and material evidence has been received to reopen the claim for service connection for PTSD. 38 U.S.C.A. §§ 5103A, 5108, 7104 (West 2002 and Supp. 2007); 38 C.F.R. §§ 3.156(a) (2007). 2. PTSD was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1154, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f). 3. Tinnitus was not incurred in or aggravated by active service, nor may it be presumed to have been incurred in or aggravated by active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309(a). 4. A respiratory disorder, including bronchitis, was not incurred in or aggravated by active service, nor may it be presumed to have been incurred as a result of exposure to certain herbicide agents. 38 U.S.C.A. §§ 1110, 1116, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309(e). 5. An epidural inclusion cyst was not incurred in or aggravated by active service, nor may it be presumed to have been incurred as a result of exposure to certain herbicide agents 38 U.S.C.A. §§ 1110, 1116, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309(e). 6. A skin disorder was not incurred in or aggravated by active service, nor may it be presumed to have been incurred as a result of exposure to certain herbicide agents. 38 U.S.C.A. §§ 1110, 1116, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309(e). 7. An immune disorder was not incurred in or aggravated by active service, nor may it be presumed to have been incurred as a result of exposure to certain herbicide agents. 38 U.S.C.A. §§ 1110, 1116, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309(e). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The requirements of the 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, have been met. There is no issue as to providing an appropriate application form or completeness of the application. In a November 2003 letter, VA notified the veteran of the information and evidence needed to reopen a prior claim, see Kent v. Nicholson, 20 Vet. App. 1 (2006), as well as the information or evidence needed to substantiate a current claim, including PTSD, to include notice of what part of that evidence is to be provided by the claimant, and notice of what part VA will attempt to obtain. A March 2006 letter provided adequate notice of how disability ratings and effective dates are assigned in the event service connection is granted. VA has fulfilled its duty to assist the veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. While the veteran may not have received full notice prior to the initial decision, after notice was provided, he was afforded a meaningful opportunity to participate in the adjudication of the claims, and the claims were readjudicated, as shown in March 2007 Supplemental Statement of the Case. The veteran was provided the opportunity to present pertinent evidence and testimony. In sum, there is no evidence of any VA error in notifying or assisting the appellant that reasonably affects the fairness of this adjudication. New and Material Evidence Once a decision becomes final, absent submission of new and material evidence, a claim may not thereafter be reopened or readjudicated by VA. 38 U.S.C.A. §§ 5108, 7104; 38 C.F.R. § 3.156(a); Suttman v. Brown, 5 Vet. App. 127, 135 (1993). "New" evidence means more than evidence that has not previously been included in the claims folder. 38 C.F.R. § 3.156. See Evans v. Brown, 9 Vet. App. 273, 284 (1996), wherein the Court held that the question of what constitutes new and material evidence requires referral only to the most recent final disallowance of a claim. The evidence, even if new, must be material, in that it is evidence not previously of record that relates to an unestablished fact necessary to establish the claim, and which by itself or in connection with evidence previously assembled raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a); Prillaman v. Principi, 346 F.3d 1362 (Fed. Cir. 2003). Moreover, if it is determined that new and material evidence has been submitted, the claim must be reopened and considered on the merits. See generally Elkins v. West, 12 Vet. App. 209 (1999). Both the May 2004 rating decision and the Statement of the Case suggest the RO adjudicated the PTSD claim on the merits. Nonetheless, if so, the Board still has the jurisdictional responsibility to consider whether it was proper to reopen the claim. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed Cir. 2001). Thus, the Board will determine whether new and material evidence has been received and, if so, consider entitlement to service connection on the merits. Analysis The Board will be brief. The veteran applied for service connection for delayed stress syndrome in July 1981. The examiner at the August 1981VA examination diagnosed the veteran with dysthymic disorder and alcohol dependence in remission. A September 1981 rating decision denied service connection for delayed stress syndrome, as the disorder was not diagnosed and there was no evidence of the claimed acquired stressor. Service connection for dysthymic disorder was denied as due to his own misconduct, as a private report noted the veteran's symptoms started after his experimentation with illicit drugs. A September 1983 Board decision denied service connection for an acquired mental disorder, and that decision is final. The evidence added to the record since the September 1983 Board decision includes a private August 2001 report that the veteran was treated for "post-traumatic stress issues" and a private March 2002 report by a license social worker that notes the veteran was diagnosed with PTSD. Such evidence is presumed credible for purposes of new and material evidence, and it raises a reasonable possibility of proving the claim. Thus, the veteran submitted new and material evidence, and his claim is reopened. 38 C.F.R. § 3.156(a). The Board further finds, as noted above, the RO fully developed the claim, so the Board may address the merits of the claim without prejudicing the veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service Connection 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; 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). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status do not constitute competent medical evidence. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Post-Traumatic Stress Disorder The veteran asserts that he has PTSD related to stressors he experienced during his brief tour in Vietnam, which included intense combat during his participation in illegal operations conducted in Cambodia. Governing Law and Regulation In addition to the legal standards for service connection discussed above, service connection for PTSD requires medical evidence diagnosing the condition in accordance with the applicable regulatory criteria, which is: a link, established by medical evidence, between current symptoms and an in- service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128 (1997). Section 4.125(a) of 38 C.F.R. incorporates the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS-IV (DSM-IV) as the governing criteria for diagnosing PTSD. There must be competent evidence that the veteran personally joined in battle with the enemy to have engaged in combat. Merely serving in a theater of combat operations is insufficient to meet the standard. VAOPGCPREC No. 12-99, pp. 2-3 (October 18, 1999), 65 Fed. Reg. 6,257(2000). This factual determination is made by the Board on a case-by-case basis. Id., at 4; Gaines v. West, 11 Vet. App. 353 (1998). If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). If, however, the veteran did not serve in combat, or if the claimed stressor is not related to combat, there must be independent evidence to corroborate the veteran's statement as to the occurrence of the claimed stressor. See Doran v. Brown, 6 Vet. App. 283, 288-89 (1994). The veteran's testimony alone cannot, as a matter of law, establish the occurrence of a non-combat stressor. See Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Furthermore, an opinion by a medical health professional based on post-service examination of the veteran cannot be used to establish the occurrence of a stressor. See Moreau v. Brown, 9 Vet. App. 389, 395-96 (1996). Analysis The veteran asserts that, while assigned to a U.S. Air Force civil engineering unit Prime Beef element in Vietnam, he was involved in illegal combat operations in Cambodia in support of and with U.S. Army units surveying and mining the Ho Chi Minh Trail. During these operations, he asserts, he encountered Viet Cong suicide attacks and engaged in hand-to- hand combat. His last incursion into Cambodia was around January 1971. April 2006 hearing transcript, pp. 5-8, 15-16, 20-22. As noted above, the first element in showing service connection for PTSD is a valid diagnosis of the disorder. The August 1981 VA examination report notes the veteran's service and that he told the examiner that he some brief combat in Vietnam, and that he first started experiencing anxiety symptoms in 1975. Although he reported having experienced nightmares about Vietnam, the primary symptom he reported was anxiety. The examiner diagnosed dysthymic disorder and did not specifically link the veteran's symptoms with his active service. In a private September 1981 report of R.M.K., Ph.D., clinical psychologist, he related having treated the veteran for debilitating anxiety while he was a student at Kent State University. The veteran told him his symptoms started two years earlier after he experimented with psychoactive drugs. Dr. K. noted the veteran's childhood was marked by poverty, an ailing father, delinquency, and a general lack of enforcement of his own self-worth. He opined the veteran manifested an agitated form of depression which was related to his multiple life struggles and losses. The veteran spontaneously terminated his therapy after only three sessions. In an August 2001 statement, N.R.J., Ph.D., a psychologist recalled having treated the veteran approximately 20 years earlier for PTSD issues. The psychologist then indicated that he did not have a copy of the treatment records. VA outpatient records note the veteran's presentation in September 2003 with complaints that the Iraq war had intensified his PTSD symptoms. The VA social worker noted the veteran's report that a private provider had diagnosed PTSD. After noting the veteran's symptoms, the social worker noted Axis I diagnoses of depressive and anxiety disorders not otherwise specified and recommended PTSD be ruled out. A PTSD assessment, including a Minnesota Multiphasic Personality Inventory-2 (MMPI 2) was conducted on the veteran in October 2003. The evaluator noted that the veteran reported no traumatic incidents during his active service and, as a result, the Clinical Administered PTSD Scale was not administered (a specific trauma is required). The only specifics offered by the veteran was that the U.S. government lied about Vietnam. The MMPI2 was interpreted and the results indicated the veteran responded in a valid manner but with a tendency to overstate symptoms. The psychologist noted that the overall and subscale elevations were not at all typical of the elevations shown by veterans with a confirmed diagnosis of PTSD. Further, the veteran's subscale on the MMPI showed a raw score of 22, while the differential threshold for PTSD in Vietnam veterans is 28. Persons with similar results, noted the psychologist, are usually diagnosed as psychophysiologically with physical symptoms increasing under stress, and that they may be demanding and self-centered when somatic. The Board notes the veteran's March 2005 written submissions, wherein he asserted that he refused to open up and share his innermost hurt in an interview that lasted perhaps 10 minutes and to a person who, in the veteran's view, was unprofessional in presentation. Thus, the veteran asserts, the September/October 2003 testing result should not be held against him. Received in March 2005 was a statement from the veteran's former spouse which was to the effect that the veteran experienced "demons" during their marriage, causing him to have trouble socializing except when in a bar. She described that they lived separate lives as he became more agitated, nervous and angry. They eventually separated, attempted a reunion, and finally divorced. The veteran's wife also submitted a statement which was to the effect that she was a licensed psychologist and trauma- based psychotherapist. She indicated that the intent of the letter was to describe the veteran from the viewpoint of a wife, and not a clinician. She then described startle reaction in the veteran, exaggerated startle response, survivor guilt, depression, a lack of personal hygiene, and paranoia. She reported concentration problems, memory impairment, indicating that she had read a study describing similar problems in combat veterans with PTSD. In deciding this appeal, the Board must weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). The Board is also mindful that it cannot make its own independent medical determination, and that there must be plausible reasons for favoring one medical opinion over another. Evans at 31. The Board may favor the opinion of one competent medical expert over that of another, provided the reasons therefor are stated. Winsett v. West, 11 Vet. App. 420, 424-25 (1998). Further, in evaluating a veteran's claim, the opinion of a treating physician, or other provider, i.e., a mental health provider, is not entitled to greater weight solely because of the treating relationship- sometimes referred to as the "treating physician rule." See Van Slack v. Brown, 5 Vet. App. 499, 502 (1993). In light of the fact that, historically, neither private nor VA psychologists who personally interviewed the veteran in the 1980s diagnosed him with PTSD, and the veteran's October 2003 MMPI 2 results were interpreted as being inconsistent with those of Vietnam veterans with confirmed diagnoses of PTSD, the Board finds the preponderance of the evidence scale tips against the August 2001 "diagnosis" of the counselor and the veteran's current wife's tacit diagnosis. There also is the matter of the veteran's claimed stressors being unconfirmed. Either defect, standing alone, defeats a claim for service connection for PTSD. See 38 C.F.R. § 3.304(f). The essence of the veteran's claimed stressors are set forth above. He sought to preemptively resolve any doubt related to his claimed stressors by asserting in his March 2005 statement that none of the events he claims would be found in his records, as he was involved in clandestine and illegal operations. The Board is not required to accept this "explanation" and, in fact, does not accept it. First, service personnel records in fact confirm the veteran was assigned to Tan Son Nhut Air Base Vietnam from October 1970 to February 1971, when he was administratively separated for claimed dependency hardship. They also confirm that he was assigned to the 377th Civil Engineering Squadron as a carpenter. There is absolutely nothing in the veteran's service records that indicates he was ever personally involved in combat. The veteran asserts that his assignment to a Prime Beef element of the 377th placed him on patrols along the Cambodian border as well as inside Cambodia, where he came under heavy fire and engaged in hand-to-hand combat. April 2006 hearing transcript, pp. 5-6. He stated that he went on his first patrol shortly after Thanksgiving 1970. The contingent consisted of 30 or 40 troops which was commanded by a platoon or squad leader. Transcript, pp. 15-16. His last incursion into Cambodia was around January 1971, when he accompanied 65 to 70 troops. The equipment included personnel carriers and a couple of bulldozers. He asserts that they sustained casualties and it took one and one-half to two weeks to get out. Transcript, pp. 20-22. The RO Hearing Officer commented to the veteran that he was describing duties normally performed by Army combat engineers, rather than an Air Force civil engineering unit and asked if he was temporarily detailed from the 377th. The veteran responded that he was in fact detached as part of the Prime Beef element, but he still was a member of the 377th. Transcript, pp. 5-7. Most regrettably, the Board rejects these claims and finds them incredible. As a military member (versus a civilian employee) of an Air Force civil engineering unit, the veteran would in fact have been a member of the unit's Prime Beef element, as were all civil engineering airmen. Unlike the Green Berets, or other special operations elements, available information notes nothing otherwise unique to Air Force Prime Beef units. The Prime Beef designation simply denotes the military (vice civilian) elements of Air Force civil engineering units deployed to conduct operations such as runway construction and rapid runway repair for Air Force air operations. A brief excerpt of an unofficial history of Prime Beef notes: Three 25-man PRIME BEEF teams were organized from Air Training Command, Strategic Air Command, and Air Defense Command. Teams were deployed to Tan Son Nhut, Bien Hoa and Da Nang Air Bases (all in South Vietnam) to construct aircraft revetments and complete whatever work that was needed. During their 120-day deployments, the teams constructed over 12,000 linear feet of revetments, parking aprons, and several miles of roads. The revetments paid for themselves in saved aircraft in just the first six months. Soon other specialized teams were deployed to bases in Vietnam and Thailand to perform short-term construction projects. A PRIME BEEF team was sent to Tan Son Nhut to ensure the rapidly growing base had an adequate water supply. PRIME BEEF III sent teams to several other bases to build housing. The teams erected "hootches," framed tents, and constructed over 34,000 square feet of support facilities at six bases in South Vietnam. PRIME BEEF teams continued to perform critical repair and construction work in Southeast Asia. Between 1965 and 1972, nearly 2,000 PRIME BEEF team members were deployed to Southeast Asia to construct vital petroleum, oil, and lubricant (POL) pipelines and storage facilities; install jet engine exhaust blast deflectors; provide electrical power to buildings; and to erect small buildings. See www.redhorsehistory.com. The above excerpt clearly indicates that the deployed teams were used during the early phase of establishing the Vietnam bases from which the U.S. Air Force conducted its air operations. As of the time of the veteran's tour, 1970, Ton Son Nhut would have been in a maintaining, vice a construction, mode, for which the 377th's own, vice deployed, personnel would have been responsible. The veteran's Air Force Specialty of carpenter would be entirely consistent with such home base operations. There is nothing in the above excerpt to imply that Prime Beef elements ever accompanied Army or other U.S. service elements, especially in an active ground combat role, as the Prime Beef mission was, and is, to support air operations. After the Hearing Officer's comment and the veteran's reply, the veteran's representative suggested an alternative that may have helped corroborate the veteran's claims of having engaged in personal combat. He asked, or reminded, the veteran that he had mentioned the 555th Red Horse. Transcript, p. 7. Air Force Red Horse Squadrons were, and are, responsible for heavy construction and, unlike Prime Beef Teams, they included a combat capability that was frequently used in Vietnam. See www.redhorsehistory.com. The veteran responded that, while he worked with them, he was a member of the 377th Prime Beef. In addition to the veteran's claimed activities being contrary to Prime Beef's documented historical mission, there also is the matter that his assertions are directly contrary to known publicly reported information. Specifically, the U.S. made no attempt to survey or mine the Ho Chi Minh trail via use of U.S. ground forces. Instead, that mission was undertaken via electronic monitoring by use of The McNamara Line, named after then Secretary of Defense, Robert McNamara. See, i.e., www.cc.gatech.edu/~tpilsch/AirOps/McNamaraLine.html. Further, the U.S. Army and Joint Services Records Research Center informed the RO in October 2007 that there is no record of the veteran's claimed stressors. For the reasons set forth above, the Board finds the veteran's claimed stressors incredible as well as unconfirmed. Thus, even were the Board to accord the veteran the benefit of the doubt and find he is in fact diagnosed with PTSD, it is not medically linked with a confirmed military stressor. The benefit sought on appeal is denied. 38 C.F.R. § 3.304(f). Tinnitus The general service connection requirements set forth above prior to the PTSD discussion are incorporated here by reference. Further, 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 certain diseases of the central nervous system, such as tinnitus, becomes 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; 38 C.F.R. §§ 3.307, 3.309. The veteran is service connected for bilateral hearing loss secondary to acoustic trauma during his active service. At the hearing, however, he noted that he first experienced tinnitus in 1974 or 75, Transcript, p. 3, at least three years after his separation from active service. Service medical records of 1971 note a hearing loss, but are negative for any entries related to complaints, findings, or treatment, for tinnitus. The July 2005 VA audio examination report notes that, in light of the above, the examiner opined that it was less likely than so that the veteran's tinnitus was the result of any activity that occurred during his active service. Thus, the Board is constrained to find the preponderance of the evidence is against this claim on both a direct and presumptive basis. 38 C.F.R. § 3.303, 3.307, 3.309(a). Bronchitis The veteran asserts that the respiratory symptomatology he experienced during his active service prove that he has a current systemic disorder. The evidence, however, does not support his assertion. Service medical records note the veteran's treatment for various upper respiratory complaints. Entries of February 1969 note diagnoses of the common cold and viral upper respiratory infection. He was also treated for a viral upper respiratory infection in March 1970. Service medical records contain no evidence of any chronic residuals. The February 1971 separation physical examination was silent for any complaints or findings related to a respiratory disorder, and his lungs and chest were assessed as normal. His chest X-ray was read as normal. On the accompanying Report Of Medical History, the veteran denied any chronic problems related to his sinus or respiratory system. Thus, he was deemed physically fit for separation. Parenthetically, the Board notes, that the examination report is misdated as having occurred in 1970. It is evident from other documents, however, including the veteran's medical history report, that it occurred in 1971. Apparently, the veteran's respiratory symptoms became prominent around 1981. The August 1981 VA examination report notes a history of bronchitis and chronic allergies. The veteran's private provider, Dr. Dumm, in a July 1981 report, also noted the veteran had experienced almost-constant nasal and chest infections secondary to chronic respiratory allergies. In January 2001, the veteran was diagnosed with possible bronchitis, and in October 2003 VA outpatient treatment records, acute bronchitis/pharyngitis was diagnosed. Neither the VA examiner nor any private examiner indicated any causal link between the veteran's symptoms and those noted in the service medical records. Thus, the Board finds that the instances noted in the service medical records were acute and transitory events that resolved without any chronic residuals, and that the veteran's current symptoms did not manifest until several years after his separation from active service. The passage of many years between discharge from active service and the medical documentation of a claimed disability may be considered evidence against a claim of service connection. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Thus, service connection on a direct basis is denied. 38 C.F.R. § 3.303. Skin Disorder/ Epidural Inclusion Cyst (claimed as Fibrotic Tumor) Service treatment records, including the enlistment physical examination and the separation physical examination are silent for complaints or findings of any skin disorder or epidural inclusion cyst in service. Post service records reflect that in 1986, the veteran had an epidural inclusion cyst removed from his back at a private hospital. In October 2003, VA outpatient treatment records include a problem list noting fibrotic tumors. Physical examination revealed a scar on the back reportedly a residual from a previous resection of a fibroma. The etiology of the fibromas was not noted in either 1986 or 2003. No other skin disorder has been identified in the records. In order to prevail on the issue of service connection there must be: medical evidence of a current disability, medical evidence, or in some cases lay evidence, of in-service incurrence or aggravation of a disease or injury; and, medical evidence of a nexus between an in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); Pond v. West, 12 Vet. App. 341, 346 (1999). In the present case, two of the three requirements for service connection - an inservice diagnosis of skin disorders or fibrotic tumors, and a nexus opinion are absent in this case. Where a determinative issue involves medical causation or a medical diagnosis, competent medical evidence is required. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Although the appellant is competent to provide evidence of visible symptoms, he is not competent to provide evidence that requires medical knowledge. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). As there is a lack of the necessary evidence to award service connection on a direct basis, service connection is denied. Immune System Disorder Service treatment records, including the enlistment physical examination and the separation physical examination are silent for complaints or findings of any immune system disorder in service. Post service medical records likewise fail to note any immune system disorder. In order to prevail on the issue of service connection there must be: medical evidence of a current disability, medical evidence, or in some cases lay evidence, of in-service incurrence or aggravation of a disease or injury; and, medical evidence of a nexus between an in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); Pond v. West, 12 Vet. App. 341, 346 (1999). As none of the necessary requirements to award service connection have been met, service connection on a direct or presumptive basis is denied. Herbicide-Related Claims The veteran also asserts that his claimed skin disorder, respiratory disorder, and immune problems are secondary to his presumed exposure to herbicides during his service in Vietnam. The veteran's formal 2003 claim included a claim for "tumors and skin condition." At the hearing, the Hearing Officer clarified with the veteran that he was not claiming a general skin condition in addition to the one related to the tumor, as the veteran considered them as the same and no other part of his body was involved. The Hearing Officer advised him that he was combining the two into one claim based on herbicide exposure. Neither the veteran nor his representative objected or otherwise disagreed. Transcript, p. 11. Private records of March 1986 note the excision of a epidermal inclusion cyst on the veteran's back that had ruptured. The pathology report noted there was no evidence of malignancy. It was silent as to etiology. A lesion or mass was excised from his chest in 2000. A November 2000 entry notes the lesion was of uncertain etiology. There is no entry or indication that it was causally related to herbicide exposure. Law and Regulations A veteran who served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent (i.e., Agent Orange). 38 C.F.R. § 3.307(a)(6)(iii). Furthermore, the diseases listed at 38 C.F.R. § 3.309(e) shall, in turn, be presumptively service connected if this requirement is met, even though there is no record of such disease during service. The Secretary of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 72 Fed. Reg. 32395-407 (June 12, 2007). The only skin disorders deemed associated with herbicide exposure are chloracne and porphyria cutanea tarda. See 38 C.F.R. § 3.309(e). There is no evidence whatsoever, and neither does the veteran assert, that he manifests either skin disorder listed above. The Agent Orange Act of 1991 (PL 102-4) requires that the National Academy of Sciences (NAS) and the Secretary enter into an agreement for NAS to review, summarize, and make recommendations about diseases associated with exposure. The NAS is required to submit a report on its activities every two years and, based on the findings contained in the report, the Secretary has to make decisions about presumptive service connection with diseases studied. In light of the NAS update report issued March 4, 2005, the Secretary specifically determined that non-cancerous respiratory disorders are among those for which an association with Agent Orange exposure is not warranted. This is also the case for any immune or autoimmune disorder the veteran may have. Initially, the Board notes that, at the hearing, although he asserted he had a general breakdown of his immune system, the veteran specifically denied asserting that he had an autoimmune disorder. Transcript, p. 13. Further, the Secretary has specifically determined that immune system disorders are not associated with herbicide exposure and, as such, are not subject to service connection on a presumptive basis. See 68 Fed. Reg. 14,567 (March 26, 2003). The Board is mindful of the fact that the veteran was not afforded a VA examination in conjunction with the RO's adjudication of these claims. Under the VCAA, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d). The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). The threshold for the duty to conduct an examination is rather low. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Nonetheless, the low threshold notwithstanding, the probative evidence of record did not trigger the necessity of an examination. The only evidence tending to link the veteran's claimed disorders with his active service are his personal assertions, which go beyond his recount of his symptomatology. He also asserted an etiological linkage, which, in the absence of evidence that he has medical training, he is not competent to do. Further, the Board finds the medical evidence of record sufficient to decide the claim. Thus, the Board finds that the Duty To Assist with an examination was not triggered. See 38 C.F.R. § 3.159(c)(4). Thus, the preponderance of the probative evidence is against service connection secondary to presumed Agent Orange exposure. 38 C.F.R. § 3.309(e). In reaching this decision on the veteran's claims, the Board considered the doctrine of reasonable doubt. As the preponderance of the evidence is against the veteran's claims, however, the doctrine is not for application. Gilbert. ORDER New and material evidence having been received, the claim for service connection for PTSD is reopened and allowed. Entitlement to service connection for PTSD is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for respiratory disorder, including bronchitis, secondary to presumed exposure to herbicides is denied. Entitlement to service connection for epidural inclusion cyst (claimed as fibrotic tumor) secondary to presumed exposure to herbicides is denied. Entitlement to service connection for a skin disorder secondary to presumed exposure to herbicide is denied. Entitlement to service connection for an immune system disorder secondary to presumed exposure to herbicide is denied. ____________________________________________ RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs