Citation Nr: 1126541 Decision Date: 07/14/11 Archive Date: 07/21/11 DOCKET NO. 09-08 469 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a heart disorder, to include coronary artery disease. 2. Entitlement to service connection for a skin disorder, to include as secondary to exposure to ionizing radiation. 3. Entitlement to service connection for a disability manifested by dizziness. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant, R.M. ATTORNEY FOR THE BOARD K. Marenna, Associate Counsel INTRODUCTION The appellant had active service from September 1943 to May 1946. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In September 2010, the appellant testified at a personal hearing before the undersigned, sitting at the RO. A transcript of the hearing is associated with the claims file. This case was previously before the Board in November 2010. In the November 2010 decision, the Board reopened the appellant's claim for entitlement to service connection for a heart disorder and remanded the claims for additional development. For the reasons discussed below, the Board finds that there has been substantial compliance with the November 2010 remand and will proceed to adjudicate the appeal. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The issue of entitlement to service connection for a disability manifested by dizziness 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. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. There has been no demonstration by competent medical or competent and credible lay evidence that the appellant has a heart disorder, to include coronary artery disease, that is related to or proximately due to service. 2. There has been no demonstration by competent medical or competent and credible lay evidence that the appellant has a skin disorder, to include as secondary to exposure to ionizing radiation, that is related to or proximately due to service. CONCLUSIONS OF LAW 1. A heart disorder, to include coronary artery disease, was not incurred in, or aggravated by, active service and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2010). 2. A skin disorder was not incurred in, or aggravated by, active service, to include as due to exposure to ionizing radiation. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the appellant's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Veterans Claims Assistance Act (VCAA) VA has met all statutory and regulatory notice and duty to assist provisions as to the appellant's claims. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2010). Duty to Notify Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2010). The United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Court observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490 (2006); see also 38 U.S.C. § 5103(a) (West 2002). Compliance with the first Quartuccio element requires notice of these five elements. See id. Prior to initial adjudication of the appellant's claims, letters dated in December 2006 and April 2007 fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2010); Quartuccio, 16 Vet. App. at 187; Dingess/Hartman, 19 Vet. App. at 490. Duty to Assist The Board concludes VA's duty to assist has been satisfied. The appellant's service treatment records and VA medical records are in the file. Private medical records identified by the appellant have been obtained, to the extent possible. As requested in the November 2010 remand, the VA Appeals Management Center (AMC) sent the appellant a letter in November 2010 requesting that the appellant identify all private providers of treatment received that is relevant to his claims. In a December 2010 statement, the appellant responded that he had nothing to add to the file. Consequently, the Board finds that the AMC complied with the November 2010 remand. See Dyment, 13 Vet. App. at 146-147; Stegall, 11 Vet. App. at 271. The appellant has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. VA must provide an examination when there is evidence of (1) a current disability, (2) an in-service event, injury, or disease, (3) some indication that the claimed disability may be associated with the established event, injury, or disease, and (4) insufficient competent evidence of record for VA to make a decision. McLendon v. Nicholson, 20 Vet. App. 79 (2006). If VA provides a claimant with an examination in accordance with the duty to assist, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The appellant was afforded medical examinations in February 2009 and December 2010 to obtain an opinion as to whether any heart disorder found in the examination was the result of service. The opinions were rendered by a medical professional following a thorough examination and interview of the appellant. The examiner obtained an accurate history and listened to the appellant's assertions. The claims file was reviewed. The Board notes that the February 2009 VA examiner incorrectly stated that the appellant was diagnosed with a heart condition while in active service in 1947. A review of the claims file reflects that he was diagnosed with a heart condition following active service. Therefore, as the February 2009 VA examination report is based on an inaccurate interpretation of the facts, the Board finds that it is inadequate. However, the December 2010 VA examination is adequate. The examiner laid a factual foundation for the conclusions that were reached. Therefore, the Board finds that the examination is adequate. See Nieves-Rodriguez, 22 Vet. App. at 304. As the AMC provided the appellant with a VA examination in December 2010, as requested in the November 2010 remand, the Board finds that there was substantial compliance with the remand. See Dyment, 13 Vet. App. at 146-147; Stegall, 11 Vet. App. at 271. In regard to the appellant's claim for entitlement to service connection for a skin disorder, to include as secondary to exposure to ionizing radiation, the evidence reflects that the appellant has seborrheic dermatitis of the scalp, xerosis and contact irritant dermatitis. The appellant contends that the skin disorders are due to his exposure to ionizing radiation during service. However, there is no indication that the skin disorders are related to the appellant's service. Additionally, the appellant has asserted that he has had the skin conditions since service. As there is no evidence of an in-service event, injury, or disease or some indication that the claimed disability may be associated with an established event, injury, or disease, an examination is not required. See McLendon, 20 Vet. App. at 81. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). II. Legal Criteria Service connection is warranted if it is shown that a veteran has a disability resulting from an injury incurred or a disease contracted in active service or for aggravation of a pre-existing injury or disease in active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2010). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2010). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in- service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may be also granted for disability which is proximately due to, the result of, or aggravated by, a service connected disease or injury. 38 C.F.R. § 3.310 (2010). Briefly, the threshold legal requirements for a successful secondary service connection claim are: (1) Evidence of a current disability for which secondary service connection is sought; (2) a disability for which service connection has been established; and (3) competent evidence of a nexus between the two. See Wallin v. West, 11 Vet. App. 509. 512 (1998). Certain chronic disabilities, including cardiovascular disabilities, if manifest to a degree of 10 percent within one year after separation from active duty, may be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2010). However, this presumption does not apply as discussed below. Heart Disorder, to include Coronary Artery Disease The appellant contends that he is entitled to service connection for a heart disorder, to include coronary artery disease. For the reasons that follow, the Board concludes that service connection is not warranted. A February 2009 VA examination report indicates that the appellant has a diagnosis of coronary artery disease. A December 2010 VA examination report also reflects that the appellant has a diagnosis of stable coronary artery disease, post coronary artery bypass. The report reflects that the appellant has also had an aortic valve replacement. Thus, the appellant has a current disability. The appellant's service treatment records do not reflect that he had any complaints related to his heart. A May 1946 discharge examination report reflects that the appellant's heart and cardiovascular system were normal. In March 1948, the appellant filed a claim for entitlement to service connection for a heart condition. He reported that he had pains in his left chest in December 1945. A July 1948 letter reflects that the appellant was examined at Firmin Desloge Hospital, Student Health Service in March 1947 and a sharp clicking first wound at the base of the heart was noted by the examiner. A cardiology report indicated that the rhythm of the heart was irregular and varied with respiration. He was diagnosed with sinus arrhythmia and sinus tachycardia. He was not treated for any heart ailment. An October 1948 VA examination report indicates that the appellant reported that in 1944, while in the Marine Corps at Camp Pendleton, California, he went on a 20 mile hike. That night, the appellant reported that he had dyspnea while in bed, associated with chest pain, both of which lasted 1/2 hour. He reported that he did not go to sick call. He stated that while overseas, he would note transient chest pain which still occurred. He reported that it seemed to occur while sitting down or moving. On examination, there was a respiratory arrhythmia. A systolic murmur and accentuated pulmonic second heart sound were heard at the pulmonary area. There was a short murmur at the mitro area, difficult to time, but probably presystolic. The impression was heart disease of undetermined etiology, manifested by tachycardia and murmurs (probably active rheumatic heart disease). A February 1949 Special Cardiac Examination report reflects that on physical examination, there was considerable sinus arrhythmia. There was no sign of cardiac decompensation; 50 hops were tolerated well; and there was no dyspnea, cyanosis or chest pain. There was no enlarged thyroid, exophthalmos, or objective signs of hyperthyroidism. No constant murmur was found. A grade I transient systolic murmur was occasionally heard in the precordium. The pulmonic second heart sound equaled the aortic second heart sound. A chest X-ray of the chest showed the heart and aorta to be within normal limits in size and configuration. No organic heart disease was found. The February 2009 VA examination report noted that the appellant reported that he had a history of coronary artery disease, a coronary artery bypass graft, and an aortic valve replacement. The VA examiner opined that it is less likely than not that the chest pain the appellant the appellant experienced in service is related to his subsequent coronary artery disease. The examiner stated that this is evidenced by his ability to remain free of the need for coronary intervention for over thirty years, and that it would also be exceedingly unlikely (although not impossible) to have clinically relevant coronary artery disease at that age. The VA examiner noted that his symptoms of chest pain while in service, as noted by Dr. K., were likely related to active rheumatic heart disease. This may have caused damage to the aortic valve requiring premature replacement. As noted above, the February 2009 VA examination report is inadequate because the VA examiner incorrectly stated that the appellant was diagnosed with a heart condition while in service in 1947. The appellant was discharged from service in May 1946. Consequently, the Board finds that the February 2009 VA examination report is not probative. A March 2009 VA treatment record reflects that the appellant reported that he had a noted shortness of breath on exertion with biking on a static bicycle or climbing a flight of stairs. He did not report orthopnea, paroxysmal nocturnal dyspnea, or palpitations. After a physical examination, the examining physician's impression was that there was evidence of 50 to 79 percent stenosis of both internal carotid arteries, by velocity. The record also reflects that the appellant's aortic valve replacement was functioning normally, per a recent echo in December 2008. Left ventricle size and left ventricular ejection fraction were normal. The appellant's coronary artery disease was stable and asymptomatic. The examining physician suspected volume overload and diastolic dysfunction with high-cholesterol fructose as the cause of his shortness of breath. A May 2009 VA treatment record reflects that the appellant reported that he was feeling better. He denied any chest pain and noted a decrease of swelling and shortness of breath since trying to limit sodium. He denied palpitations. The appellant was evaluated in a VA examination in December 2010. The VA examination report reflects that the appellant reported that he had a heart condition since his active duty period when he went on the 20 mile road march with a full pack. The appellant reported that over the years he has been bothered with chronic, sharp, nonradiating, stabling quality, left sternal chest pains. The VA examiner noted that the appellant persistently said that he had heart trouble ever since then and that these pains are secondary to his heart. Following the road march, the appellant reported that he was involved in heavy combat in Iwo Jima and then stationed in Nagasaki after the war. The VA examiner noted that any type of heart condition that he may or may not have had certainly did not preclude the heavy exertion of combat. The VA examiner noted that the appellant's discharge physical indicated that his cardiovascular examination was completely normal. The appellant reported that he began seeing a Dr. C.J. following service, who told him that he had a heart condition because of his persistent, recurrent, stabbing chest pains. He stated that he also went to local hospitals, including Deaconess Hospital and Christian Hospital over the years for various tests, but the records are not available. The appellant reported that he never saw a cardiologist and that he did not have a history of rheumatic fever. In 1982, the appellant sustained an acute myocardial infarction and underwent a one-vessel, coronary artery bypass graft along with aortic valve replacement. The appellant sustained a second myocardial infarction in 1995 and underwent a second bypass grafting procedure. The appellant reported that he had no coronary interventions since that time and began being following by the Cardiology Clinic in 2008. The appellant reported that he had a smoking history of one pack per day for approximately 40 years, but he quit smoking in 1982 when he had his first heart attack. The appellant also had a long standing history of hypertension and a history of hyperlipidemia. The appellant described current symptoms of sharp, stabbing, left sternal, nonradiating chest pains occurring about one time per week. He also had some heartburn type of pain with reflux. The VA examiner noted that the symptoms sound compatible with gastroesophageal reflux disease (GERD), for which he is being treated with ranitidine. He stated that occasionally he will get a type of squeezing pain with exertion, which happens one time per month and is usually relived by taking nitroglycerin. On physical examination, the appellant was an alert, very pleasant, cooperative gentleman with no stigma of acute or chronic illness. He walked with a normal gait for his age of 85 years. His heart rate was of regular sinus rhythm with no audible murmurs. He had a mechanical sound to his aortic prosthetic valve. His lungs were clear to auscultation in all fields with no rales, rhonchi or wheezes present. He had mild pretibial edema bilaterally in the lower extremities. His heart rate was of regular sinus rhythm with no audible murmurs. He had a mechanical sound to his aortic prosthetic valve. His lungs were clear to auscultation in all fields with no rales, rhonchi, or wheezes present. He had mild pretibial edema bilaterally in the lower extremities. The diagnoses were stable coronary artery disease, post-coronary artery bypass, and aortic valve replacement. The VA examiner noted that based upon his history; the appellant's report that he does light household chores such as swelling, dusting and vacuuming; and the fact that the appellant is also able to climb a flight of stairs without difficulty, he would estimate his maximum MET level at approximately 4. The December 2010 VA examiner opined that it is less likely than not that the appellant's organic heart disease, that is coronary artery disease, as well as aortic valve pathology requiring replacement, is related to any subjective chest pains that he may have felt during active duty and is less likely than not related to anything for which he was seen within one year of discharge from active duty. The VA examiner noted that the appellant may still have chronic non-cardiac chest wall pains, but that would not be related to his heart. The VA examiner opined that the etiology of the appellant's coronary artery disease is more likely than not due to his longstanding hypertension along with hyperlipidemia and significant past smoking history. The examiner also found that it is less likely than not that the appellant's current cardiac condition is related to the first degree atrioventricular block and sinus tachycardia noted by the St. Louis University Student Health Center doctor. The VA examiner had earlier noted that an atrioventricular block and sinus tachycardia are not definitive for any organic heart disease. The VA examiner also noted that the cardiac evaluation dated in February 1949, signed by R.C., M.D., A.C., M.D. and H.S., M.D., indicated that the appellant had no organic heart disease found upon their evaluation. As the VA examiner provided a rationale for his opinions and based his opinion on a full review of the evidence, the Board finds that the VA examination is adequate. Based on a review of the above evidence, the Board finds that a preponderance of the evidence is against the appellant's claim for entitlement to service connection for a heart disorder, to include coronary artery disease. Although the appellant has a diagnosis of coronary artery disease, the evidence does not reflect that it is related to service. The appellant is competent to report that he experienced chest pains in service. However, the December 2010 VA examiner found that it is less likely than not that the appellant's organic heart disease, that is coronary artery disease, as well as aortic valve pathology requiring replacement, is related to any subjective chest pains that he may have felt during active duty and is less likely than not related to anything for which he was seen within 1 years of discharge from active duty. The VA examiner stated that the etiology of the appellant's coronary artery disease is more likely than not due to his longstanding hypertension along with hyperlipidemia and significant past smoking history. The examiner also found that it is less likely than not that his current cardiac condition is related to the first degree atrioventricular block and sinus tachycardia noted by the St. Louis University Student Health Center doctor. The appellant's VA treatment records do not reflect that there is a nexus between the appellant's heart disorder and service. The Board finds the VA opinion to be highly probative, as it is based on a thorough review of the appellant's medical records and physical evaluation of the appellant. The opinion is also consistent with the other evidence of record and is supported by a detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion.) Furthermore, the opinion was obtained from a licensed medical professional rather than a lay person. The appellant has submitted no competent medical nexus evidence contrary to the opinion cited above. The appellant has been accorded ample opportunity to furnish medical and other evidence in support of his claim; he has not done so. See 38 U.S.C.A. § 5107(a) (2010) (noting it is a claimant's responsibility to support a claim for VA benefits). Lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, in this case, assertions as to the etiology of the appellant's heart disability is an etiological question unlike testimony as to a separated shoulder, varicose veins, or flat feet, which are capable of direct observation. See Jandreau, 492 F.3d at 1376 (noting that lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 308-09 (2007) (finding that lay testimony is competent to establish the presence of varicose veins); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (discussing that unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Falzone v. Brown, 8 Vet. App. at 405 (finding that a lay person is competent to testify to pain and visible flatness of his feet). There is nothing in the record to suggest that the appellant has the appropriate training, experience, or expertise to render a medical opinion regarding the etiology of his current heart disability. See 38 C.F.R. § 3.159 (a)(1) (2010) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the appellant is competent to report what he experienced during service (i.e. chest pains), he is not competent to ascertain the etiology of his current heart disability, as the causative factors for such is not readily subject to lay observation. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); Layno v. Brown, 6 Vet. App. 465 (1994). Even if the appellant were competent to provide an opinion as to the etiology of a disorder which is typically confirmed by medical tests, the Board finds that the probative value of any such opinion is outweighed by that of the December 2010 VA examiner. There is no evidence of record showing that the appellant has the specialized medical education, training, and experience necessary to render a competent medical opinion as to diagnosis and etiology of a disability. In contrast, the December 2010 VA examiner has education, training and experience in evaluating the etiology of a heart disorder. The December 2010 VA examiner reviewed the appellant's claims folder and opined that it is less likely than not that the appellant's organic heart disease is related to any subjective chest pains that he may have felt during active duty and is less likely than not related to anything for which he was seen within one year of discharge from active duty. Service connection may also be granted upon a showing of continuity of symptomatology. The appellant has asserted that he has had symptoms of chest pain since service. (See December 2010 VA treatment record). The appellant is competent to report symptoms capable of lay observation. Layno v. Brown, 6 Vet. App. 465 (1994). However, the appellant is not competent to provide an opinion as to the cause of the symptoms or that he has had a diagnosis of a heart disorder since service. The appellant's discharge examination report reflects that the appellant's heart and cardiovascular system were normal. Service treatment records do not show that the appellant reported having chest pains while in service. However, as noted in the October 1948 examination the appellant indicated that he felt chest pain in service and has had such symptoms since then, the Board finds that the appellant's assertion that he has had chest pain since service is credible. Although the appellant contends that he has had chest pains since service, the evidence reflects that the appellant's chest pains are not related to his heart disability. The February 1949 VA examiner noted that neither the pressure pain nor sticking pain described by the appellant is characteristic of angina pectoris. The December 2010 VA examiner opined that the appellant's current complaint of symptoms of sharp, stabbing, left sternal, nonradiating chest pains occurring about one time per week were compatible with his GERD. The VA examiner also noted that the appellant may still have chronic non-cardiac chest wall pains, but that would not be related to his heart. Although service connection may be granted upon a showing of continuity of symptomatology, the evidence does not reflect that the appellant's chest pain symptoms are related to his heart disorders. As a lay person, the appellant is not competent to provide an opinion as to the etiology of his symptoms of chest pain. Thus, the evidence does not reflect that the appellant has had continuous symptoms of a heart disability, to include coronary artery disease, since service. The Board finds that a preponderance of the evidence is against the appellant's claim. Although the appellant has a current diagnosis of coronary artery disease, the evidence does not support a finding that it is related to service. The December 2010 VA examiner found that the appellant's organic heart disease, that is coronary artery disease, as well as aortic valve pathology requiring replacement, is not related to any subjective chest pains that he may have felt during active duty and is less likely than not related to anything for which he was seen within one year of discharge from active duty. Although the appellant has asserted that he has had chest pain since service, the December 2010 VA examiner opined that the appellant's chest pain is compatible with GERD and not related to his heart. There is no evidence that the appellant's chest pains are related to his coronary artery disease. The appellant has asserted that his heart disability is related to service. However, for the reasons discussed above, the Board finds the December 2010 VA examination report to be more probative. Accordingly, the Board finds that the preponderance of the evidence is against the appellant's claim. Consequently, the benefit-of-the-doubt rule is not applicable, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Skin Disorder The appellant contends that he has a skin disorder as a result of service. For the reasons that follow, the Board concludes that service connection is not warranted. Legal Criteria- Radiation Exposure Service connection for a disability which is claimed to be attributable to radiation exposure during service can be accomplished in three different ways. See Ramey v. Brown, 9 Vet. App. 40, 44 (1996), affirmed at 120 F.3d 1239 (Fed. Cir. 1997). First, there are specific diseases which may be presumptively service-connected if manifest in a radiation-exposed veteran. A 'radiation-exposed veteran' is defined by 38 C.F.R. § 3.309(d)(3) as a veteran who, while serving on active duty or on active duty for training or inactive duty training, participated in a radiation-risk activity. 'Radiation-risk activity' is defined to mean onsite participation in a test involving the atmospheric detonation of a nuclear device; the occupation of Hiroshima, Japan or Nagasaki, Japan by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946; internment as a prisoner of war (or service on active duty in Japan immediately following such internment) during World War II which resulted in an opportunity for exposure to ionizing radiation comparable to that of the United States occupational forces in Hiroshima or Nagasaki during the period from August 6, 1945 through July 1, 1946; or the Veteran's presence at certain specified additional locations. See 38 C.F.R. § 3.309(d)(3) (2010). In applying this statutory presumption, there is no requirement for documenting the level of radiation exposure. The presumptively service-connected diseases specific to radiation-exposed veterans are the following: leukemia (other than chronic lymphocytic leukemia), cancer of the thyroid, cancer of the breast, cancer of the pharynx, cancer of the esophagus, cancer of the stomach, cancer of the small intestine, cancer of the pancreas, multiple myeloma, lymphomas (except Hodgkin's disease), cancer of the bile ducts, cancer of the gall bladder, primary liver cancer (except if cirrhosis or hepatitis B is indicated), cancer of the salivary gland, cancer of the urinary tract, bronchio-alveolar carcinoma, cancer of the bone, cancer of the brain, cancer of the colon, cancer of the lung, and cancer of the ovary. 38 C.F.R. § 3.309(d)(2) (2010). The second avenue of recovery is found under 38 C.F.R. § 3.311(b)(2). This provision provides that certain listed 'radiogenic' diseases found 5 years or more after service in an ionizing-radiation-exposed veteran may be service connected if the VA Undersecretary for Benefits determines that they are related to ionizing radiation exposure while in service or if they are otherwise linked medically to ionizing radiation exposure while in service. When it has been determined that: (1) a veteran has been exposed to ionizing radiation as a result of participation in the atmospheric testing of nuclear weapons, the occupation of Hiroshima or Nagasaki, Japan, from September 1945 until July 1946, or other activities as claimed; (2) the veteran subsequently develops a specified radiogenic disease; and (3) the disease first becomes manifest in the period specified, the claim will be referred to the VA Under Secretary for Benefits for further consideration in accordance with 38 C.F.R. § 3.311(c). When such a claim is forwarded for review, the VA Undersecretary for Benefits shall consider the claim with reference to 38 C.F.R. § 3.311(e) and may request an advisory medical opinion from the VA Undersecretary of Health. 38 C.F.R. § 3.311(b), (c)(1) (2010). The medical adviser must determine whether sound scientific and medical evidence supports a conclusion that it is at least as likely as not that the disease resulted from in-service radiation exposure or whether there is no reasonable possibility that the disease resulted from in-service radiation exposure. 38 C.F.R. § 3.311(c)(1) (2010). Pursuant to 38 C.F.R. § 3.311(b)(2), radiogenic diseases include the following: all forms of leukemia except chronic lymphatic (lymphocytic) leukemia, thyroid cancer, breast cancer, lung cancer, bone cancer, liver cancer, skin cancer, esophageal cancer, stomach cancer, colon cancer, pancreatic cancer, kidney cancer, urinary bladder cancer, salivary gland cancer, multiple myeloma, posterior subcapsular cataracts, non-malignant thyroid nodular disease, ovarian cancer, parathyroid adenoma, tumors of the brain and central nervous system, cancer of the rectum, lymphomas other than Hodgkin's disease, prostate cancer, and any other cancer. 38 C.F.R. § 3.311(b)(2) (2010). A disease is also considered a radiogenic disease where competent scientific or medical evidence that the claimed condition is a radiogenic disease is received. See 38 C.F.R. § 3.311(b)(4) (2010). Finally, there is a third avenue of recovery in this case. The United States Court of Appeals for the Federal Circuit has determined that the Veterans' Dioxin and Radiation Exposure Compensation Standards Act, Pub. L. No. 98-542, § 5, 98 Stat. 2724, 2727- 29 (1984), does not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Analysis The appellant contends that he has a skin disorder due to exposure to radiation in service. The appellant has stated that he was stationed at Nagasaki between August 1945 and July 1946. (See September 2010 Board Hearing Transcript (Tr.) at p. 28). A February 2006 VA treatment record reflects that the appellant had complaints of a scaly scalp and itchy skin on his arms, back and body. On examination, the scalp, arms, and legs had diffuse scale. The lower back had ill-defined pink, mildly scaly plaques. The appellant was diagnosed with seborrheic dermatitis of the scalp. He was prescribed an over the counter treatment of selenium sulfide or zinc pyrithione shampoo. The appellant was also diagnosed with xerosis and contact irritant dermatitis. Thus, the appellant has a current skin disorder. However, the appellant has not been diagnosed with any disability for which service connection on a presumptive basis due to ionizing radiation can be granted, nor has he been diagnosed with a radiogenic disease. Additionally, none of the appellant's VA treatment records indicate the etiology of his skin disorder. Based on a review of the evidence, the Board finds that service connection or a skin disorder is not warranted. Although the appellant has been diagnosed with seborrheic dermatitis of the scalp, xerosis and contact irritant dermatitis, the Board does not find that the evidence supports a finding that an in-service incurrence or aggravation of an injury or disease actually occurred. In reaching this conclusion, the Board observes that the appellant has not reported any other in-service injury or disease, aside from claiming the skin disorder is due to exposure to radiation. At the September 2010 hearing, the appellant specifically denied having been diagnosed with skin cancer. (See Tr. at p. 10). As noted above, the appellant has not been diagnosed with any diseases presumptively related to ionizing radiation exposure, nor has he been diagnosed with a radiogenic disease. Regardless of whether the appellant was exposed to ionizing radiation, without a diagnosis of a disease presumptively related to ionizing radiation exposure or a diagnosis of radiogenic disease, the only way to establish service connection is on a direct-incurrence basis. The appellant has not contended that his skin disorders are related to his military service, other than through exposure to ionizing radiation. The service treatment records do not show that any skin disorder diagnosed post-service had its onset in service. The appellant's May 1946 separation examination report reflects that the appellant was treated for fungus of the feet in 1944 and cellulitis of the left foot in 1944. The appellant has not asserted that he has a current skin disorder of his feet and there is no evidence that he has been diagnosed with a skin disorder of the feet. The examination report reflects that the appellant's skin, hair, and glands were normal. The Board finds that the onset of any post-service skin disorders did not occur in service. The Board's finding is further supported by the lack of post-service evidence showing skin complaints until 2006, more than sixty years after his discharge from service. The Court has indicated that normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service is probative evidence against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board where it found that veteran failed to account for the lengthy time period after service for which there was no clinical documentation of low back condition); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (noting that a prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability). Thus, the lack of any evidence of skin complaints, symptoms, or findings until nearly sixty years after the period of active service and his first skin complaint is itself evidence which tends to show that any skin disorders did not have its onset in service or for years thereafter. The appellant has contended that his skin disorders are related to service. Although lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology, in this case, assertions as to the etiology of the appellant's skin disorder are etiological questions unlike testimony as to a separated shoulder, varicose veins, or flat feet, which are capable of direct observation. See Jandreau, 492 F.3d at 1376; Barr v. Nicholson, 21 Vet. App. 308-09 (2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). There is no evidence of record showing that the appellant has the specialized medical education, training, and experience necessary to render competent medical opinion as to the diagnosis and etiology of a disability. Consequently, the appellant's assertions regarding the etiology of any current skin disorders are not competent or probative. Service connection may be granted upon a showing of continuity of symptoms since service. Although the appellant is competent to report that he has had symptoms of a skin disorder since service, the Board finds that these assertions are not credible. Significantly, there are no documented complaints related to the skin until 60 years after service discharge. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (noting that it was proper to consider the veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised). The appellant's assertions are outweighed by the objective medical evidence. Therefore, the appellant is not credible with regard to his symptoms and onset thereof. In sum, the Board finds that a preponderance of the evidence is against the appellant's claim for service connection for a skin disorder, diagnosed as seborrheic dermatitis of the scalp, xerosis and contact irritant dermatitis, to include due to in-service exposure to radiation. Accordingly, the Board finds that the preponderance of the evidence is against the appellant's claim. Consequently, the benefit-of-the-doubt rule is not applicable, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to service connection for a heart disorder, to include coronary artery disease, is denied. Entitlement to service connection for a skin disorder, to include as secondary to exposure to ionizing radiation, is denied. REMAND VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion only when it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); 38 C.F.R. § 3.159(c)(4) (2010). See also Robinette v. Brown, 8 Vet. App. 69, 76 (1995). The appellant seeks service connection for a disability manifested by dizziness. Specifically, in a November 2006 letter, the appellant stated that he has had occasional spells of dizziness, and associated the symptom with his hearing loss and tinnitus. The evidence of record includes a May 2007 letter from C.E., M.D., reflects that the appellant has had problems with balance dysfunction and dizziness, which have persisted to the present time. Dr. C.E. stated that on examination in May 2007, the appellant's ear canals and eardrums looked normal. He noted that they elected to do electronystagmography, a complex test of balance function which is an objective way of measuring abnormalities in the balance function generally originating from the inner ear. The test revealed a dysfunction in the right inner ear with a 36% reduction in function compared to the left ear. There were also some elements in the test suggesting trouble in the inner ear, based on other parameters done during the test. Dr. C.E. opined that he believed that this type of finding could well have resulted from his exposure to weapons fire and the usual conditions found during war time. Dr. C.E. states that the appellant reported that his balance issue had been present since his time in the service and his duty in Japan after detonation of the bomb. Additionally, a December 2007 VA treatment record reflects that the appellant reported occasional dizziness and vertigo when he turns his head quickly or rises from being bent forward. He said that he has become sick to his stomach. He explained that when this occurs, he is usually able to sit down or grasp onto something until the dizziness subsides. He denied falling. He reported that he has been experiencing this for 10 years, once or twice a month. Symptoms of dizziness/vertigo were not reproduced at the examination, but he was instructed to perform slow rolling daily to reduce the incidences of dizziness. It is unclear from the available medical records what diagnosis is associated with the Veteran's subjective complaints of dizziness. The Board notes that the appellant is competent to report symptoms of dizziness because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 at n.4 (Fed. Cir. 2007). As the appellant is competent to report that he suffers from dizziness, the Board finds that a medical examination is necessary to determine the diagnosis associated with this symptomatology and an opinion is necessary to determine whether any such dizziness disorder is related to his service-connected hearing loss and/or service-connected tinnitus, or to his service. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). Expedited handling is requested.) 1. Schedule the appellant for an examination to determine the nature and etiology of any disability manifested by dizziness. Any necessary testing should be conducted. The claims file must be reviewed in conjunction with such examination, and the examiner must indicate that such review occurred. The examiner should render an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any dizziness disorder(s) diagnosed was caused by, or aggravated by, the appellant's service-connected hearing loss and/or tinnitus, or is at least as likely as not (a 50 percent probability or greater) that the disability had its onset in service or is otherwise related to service. The term "aggravated" in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. If aggravation is present, the examiner should identify the percentage of disability which is attributable to the aggravation. See 38 C.F.R. § 3.310(a) (2010); Allen v. Brown, 7 Vet. App. 439 (1995). 2. Notify the appellant that it is his responsibility to report for the scheduled VA examination, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2010). In the event that the appellant does not report for a scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. Copies of all documentation notifying the appellant of any scheduled VA examination must be placed in the appellant's claims file. 3. Readjudicate the appellant's claim, to include as secondary to service-connected disabilities. If the benefit sought on appeal remains denied, the appellant and his representative should be provided with a Supplemental Statement of the Case. The appellant has the right to submit additional evidence and argument on the matter 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. 2010). ______________________________________________ LANA K. JENG Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs