Citation Nr: 1117827 Decision Date: 05/10/11 Archive Date: 05/17/11 DOCKET NO. 05-26 601 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for tuberculosis exposure. 2. Entitlement to service connection for residuals of an eye injury. 3. Entitlement to service connection for renal insufficiency. 4. Entitlement to service connection for a skin disorder to include as secondary to herbicide exposure. 5. Entitlement to service connection for dizziness to include as secondary to herbicide exposure. 6. Entitlement to service connection for left ear hearing loss. 7. Entitlement to service connection for right ear hearing loss. 8. Entitlement to service connection for tinnitus, to include as due to herbicide exposure. 9. Entitlement to service connection for a respiratory disorder to include as secondary to asbestos and herbicide exposure. 10. Entitlement to service connection for a low back disorder. 11. Entitlement to service connection for sterility to include as secondary to lead and mercury exposure. 12. Entitlement to service connection for hypertension to include as secondary to a psychiatric disorder. 13. Entitlement to service connection for an acquired psychiatric disorder to include depression. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL Veteran and spouse ATTORNEY FOR THE BOARD S. Grabia, Counsel INTRODUCTION The Veteran served on active duty from June 1962 to August 1966. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which denied the claims at issue. By rating action in June 2004 service connection for a skin disorder was denied. By rating action in June 2005 service connection for hypertension, an eye disorder, depression, non-Hodgkin's lymphoma, and dizziness was denied, in part. By rating action in September 2006 service connection for a right ear and a left ear hearing loss; tinnitus, a respiratory disorder; back injury; and sterility was denied, The Veteran testified at a January 2011 Board hearing at the Waco RO before the undersigned. He also offered testimony before a decision review officer in December 2005. Transcripts of both hearings have been associated with the claims file. The Veteran has multiple claims pending in various stages of development. The issues shown on the title page are the only issues which are currently perfected for adjudication by the Board. The appeals as to service connection for a respiratory disorder; low back disorder; hypertension; and an acquired psychiatric disorder are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. FINDINGS OF FACT 1. The Veteran has withdrawn his claim of entitlement to service connection for tuberculosis exposure. 2. The Veteran has withdrawn his claim of entitlement to service connection for residuals of an eye injury. 3. The Veteran has withdrawn his claim of entitlement to service connection for renal insufficiency. 4. The Veteran, who is presumed to have been exposed to herbicides during active service, manifests a skin disorder, described as mycosis fungoides which is a form of non-Hodgkin's lymphoma, which is subject to presumptive service connection as an herbicide related disease. 5. The Veteran's dizziness is a symptom, and is not a disability for VA benefit purposes. 6. The competent medical evidence of record does not reflect the Veteran has any current left ear hearing loss disability. 7. The Veteran's current right ear hearing loss disorder first shown years after service, is not etiologically related to active service. 8. The Veteran's current tinnitus first shown years after service, is not etiologically related to active service. 9. The competent medical evidence of record does not reflect the Veteran has any current diagnosis of sterility, to include as secondary to lead and mercury exposure from dental fillings. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal have been met with regard to the claim of entitlement to service connection for tuberculosis exposure. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2010); 38 C.F.R. §§ 20.202, 20.204 (2010). 2. The criteria for withdrawal of a substantive appeal have been met with regard to the claim of entitlement to service connection for residuals of an eye injury. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2010); 38 C.F.R. §§ 20.202, 20.204 (2010). 3. The criteria for withdrawal of a substantive appeal have been met with regard to the claim of entitlement to service connection for renal insufficiency. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2010); 38 C.F.R. §§ 20.202, 20.204 (2010). 4. Service connection for a skin disorder, described as mycosis fungoides, a form of non-Hodgkin's lymphoma is warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1133, 1137, 5103, 5103A, 5107, 5017 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309(e) (2010); 75 Fed. Reg. 53,202-01 (Aug. 31, 2010). 5. Service connection is not warranted for dizziness. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.303 (2010). 6. Right ear hearing loss was not incurred by active service, and a right ear sensorineural hearing loss may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1133, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.385 (2010). 7. A left ear hearing loss was not incurred by active service, and a left ear sensorineural hearing loss may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 1112, 1131, 1133, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.385 (2010). 8. Tinnitus was not incurred by active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.303 (2010). 9. Sterility was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.303 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified at 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010)), imposes obligations on VA in terms of its duties to notify and assist claimants. In letters dated in December 2003, June 2005, and April 2006, prior to the adjudication of the claims, the RO notified the appellant of the information necessary to substantiate the claims on appeal, and of his and VA's respective obligations for obtaining specified different types of evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). He was told that the evidence must show a relationship between his current disability and an injury, disease or event in military service. He was advised of various types of lay, medical, and employment evidence that could substantiate his service connection claims. The letters also provided information regarding assigned ratings and effective dates. Hence, the VCAA notice requirements have been satisfied. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159. The Board finds that all necessary notification and development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Finally, with regard to the Veteran's claims for dizziness and sterility, the Board finds that VA examination is not warranted because there is no indication that the Veteran has ever been diagnosed with sterility and his alleged dizziness is a symptom and not a disability for which service connection may be awarded. His allegations alone and without any other evidence suggesting any relationship to service, are not sufficient to trigger VA's duty to provide a VA examination. See Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (holding that a claimant's "conclusory generalized statement that his service illness caused his present medical problems" was not sufficient to entitle him to a VA examination). In this regard, the Veteran himself, as a lay person, does not have the medical training or experience to offer a competent opinion that his alleged sterility and dizziness may be related to any in-service injury or event as this is a determination that is medical in nature and therefore requires medical expertise. See Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno, 6 Vet. App. at 469-70; Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992); see also Savage v. Gober, 10 Vet. App. 488, 494 (1997) (holding that a lay person is not competent to provide a medical opinion relating his present arthritis to a fall in service). Accordingly, the Board finds that the provision of a VA examination is not necessary to decide these claims. See McLendon, 20 Vet. App. at 83. II. Decision A. Withdrawn Claims At the January 2011 Board hearing, the Veteran requested to withdraw his appeal of the denial of service connection for tuberculosis exposure, residuals of an eye injury, and renal insufficiency pending before the Board. The Veteran's wish to withdraw this appeal has been reduced to writing in the form of a hearing transcript, as well as a January 2011 personal statement. VA regulation provides for the withdrawal of an appeal to the Board by the submission of a written request to that effect at any time before the Board issues a final decision on the matter in question. See 38 C.F.R. § 20.204(b); Hanson v. Brown, 9 Vet. App. 29, 31 (1996) (holding that when a claim is withdrawn by an appellant, it ceases to exist; it is no longer pending, and is not viable). After an appeal is transferred to the Board, an appeal withdrawal is effective the date it is received by the Board. 38 C.F.R. § 20.204(b). Appeal withdrawals must be in writing and must include the name of the appellant, the applicable claim number, and a statement that the appeal is withdrawn. Id. When pending appeals are withdrawn, there is no longer an allegation of error of fact or law with respect to the determinations that had been previously appealed. See 38 U.S.C.A. § 7105(d)(5) (West 2002). Consequently, in such an instance, dismissal of the pending appeal is warranted. Accordingly, further action by the Board on these claims is not appropriate and the appeals are dismissed. B. Applicable Rules and Regulations Pertaining to Remaining Claims Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, service connection for a psychosis, hypertension, sensorineural hearing loss, and arthritis may be established on a presumptive basis by showing that these diseases manifested themselves to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1133, 1137; 38 C.F.R. §§ 3.307; 3.309(a). This presumption is rebuttable by affirmative evidence to the contrary. 38 C.F.R. § 3.307(d). Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. §§ 1110, 1131; Brammer v. Derwinski, 3 Vet. App. 223 (1992). In Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997), it was observed that 38 U.S.C.A § 1131, as well as other relevant statutes, only permitted payment for disabilities existing on and after the date of application for such disorders. The Federal Circuit observed that the structure of these statutes "provided strong evidence of congressional intent to restrict compensation to only presently existing conditions," and VA's interpretation of the law requiring a present disability for a grant of service connection was consistent with the statutory scheme. Degmetich, 104 F.3d at 1332; and see Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (holding VA's interpretation of the provisions of 38 U.S.C.A § 1110 to require evidence of a present disability to be consistent with congressional intent); Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (the law limits entitlement for service-related diseases and injuries to cases where the underlying in-service incident has resulted in a disability). Simply put, in the absence of proof of present disability there can be no valid claim. Herbicide Exposure A Veteran who during active military, naval, or air service served in the Republic of Vietnam during the period beginning January 9, 1962 and ending on May 7, 1975 shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence establishing that the Veteran was not exposed to any such agent. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307. Here, the Veteran's service personnel records establish that the Veteran had service in Vietnam. Therefore, he is presumed to have been exposed to an herbicide agent such as Agent Orange. See id. In order to benefit from the presumption of service connection for diseases associated with herbicide exposure, the Veteran must have one of the diseases enumerated in section 3.309(e). The diseases presumed to be caused by herbicide exposure are AL amyloidosis, chloracne or other acneform disease consistent with chloracne, Type 2 diabetes (also known as Type II diabetes mellitus or adult- onset diabetes), Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). Effective August 31, 2010, section 3.309(e) was amended to add certain diseases to the list of diseases associated with exposure to herbicide agents. 75 Fed. Reg. 53, 202 (August 31, 2010). The amendment, in pertinent part, removes "chronic lymphocytic leukemia" and replaces it with "all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia);" adds "Parkinson's disease" immediately preceding "Acute and subacute peripheral neuropathy"; and adds "ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina)" immediately following "Hodgkin's disease." Id. The amendment also adds a new Note 3 at the end of § 3.309(e) which reads as follows: "For purposes of this section, the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease." Id. Asbestos exposure There is no specific statutory guidance with regard to asbestos related claims, nor has the VA Secretary promulgated any regulations in regard to such claims. However, VA has issued a circular on asbestos-related diseases. DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988) provides guidelines for considering compensation claims based on exposure to asbestos. The information and instructions from the DVB Circular were included in the VA Adjudication Procedure Manual, M21-1 (M21-1), Part VI, § 7.21. In December 2005, M21-1, Part VI was rescinded and replaced with a new manual, M21-1MR, which contains the same asbestos-related information as M21-1, Part VI. The Court of Veterans Appeals (now the Court of Appeals for Veterans Claims and hereinafter the Court) has held that VA must analyze an appellant's claim to entitlement to service connection for asbestosis or asbestos-related disabilities under the administrative protocols under the DVB Circular guidelines. See Ennis v. Brown, 4 Vet. App. 523 (1993); McGinty v. Brown, 4 Vet. App. 428 (1993). Subpart ii of M21-1MR Part IV, lists some of the major occupations involving exposure to asbestos including mining, milling, work in shipyards, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, manufacture and installation of roofing and flooring materials, asbestos cement and pipe products, and military equipment. High exposure to respirable asbestos and a high prevalence of disease have been noted in insulation and shipyard workers, and this is significant considering that, during World War II, U.S. Navy veterans were exposed to chrysotile, amosite, and crocidolite that were used extensively in military ship construction. Furthermore, it was revealed that many of these shipyard workers had only recently come to medical attention because the latent period for asbestos-related diseases varies from 10 to 45 or more years between first exposure and development of disease. M21-1MR, Part IV Subpart ii, Chapter 2, Section C, Topic 9, see also M21-1MR Part IV, Subpart ii, Chapter 1, Section H, Topic 29. VA's Manual 21-1MR, Part IV, subpart ii, Chapter 2, Section C in essence acknowledges that inhalation of asbestos fibers can result in fibrosis and tumors, and produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of the pleura and peritoneum, and cancer of the lung, gastrointestinal tract, larynx, pharynx and urogenital system (except the prostate), with the most common resulting disease being interstitial pulmonary fibrosis (asbestosis). With respect to claims involving asbestos exposure, VA must determine whether or not military records demonstrate evidence of asbestos exposure during service, develop whether or not there was pre-service and/or post-service occupational or other asbestos exposure, and determine whether there is a relationship between asbestos exposure and the claimed disease. M21-1MR, Part IV, Subpart ii, Chapter 1, Section H, Topic 29; DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988). The pertinent parts of the manual guidelines on service connection in asbestos-related cases are not substantive rules, and there is no presumption that a veteran was exposed to asbestos in service by reason of having served aboard a ship. Dyment v. West, 13 Vet. App. 141 (1999), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002); VAOPGPREC 4-2000. For many asbestos related diseases, the latency period varies from ten to forty-five or more years between first exposure and development of disease. M21-1MR at IV.ii.2.C.9.d. In order to establish service connection on a direct basis, there must be competent evidence of (1) a current disability; (2) in- service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Although the Board has an obligation to provide adequate reasons and bases supporting these decisions, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). C. Analysis Skin Disorder The Veteran claims entitlement to service connection for a skin disability to include as due to herbicide exposure. At his January 2011 Board hearing, he initially claimed the skin disorder primarily affects his feet. However as the hearing progressed, he testified that the disorder spreads to his entire body, and he was now receiving ultraviolet light treatment through his local VA dermatology clinic. The disorder was diagnosed as mycosis fungoides. A review of the Veteran's VA outpatient dermatology clinic records reveals that the Veteran had indeed been treated and diagnosed with mycosis fungoides (MF). The Board notes that MF is a chronic or rapidly progressing form of cutaneous T-cell lymphoma (formerly thought to be of fungal origin) and a type of non-Hodgkin's lymphoma. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1088, 1962 (28th ed. 1994). On review of the entire record, the Board finds that over the years the Veteran has filed numerous claims including claims for service connection for skin disease, skin cancer, T-cell lymphoma, and non-Hodgkin's lymphoma. These have been denied for various reasons including that he had no recognized service in Vietnam. In an April 2010 rating action the RO conceded that the Veteran had stepped foot on the land mass of Vietnam. The Veteran is therefore presumed to have been exposed to an herbicide agent. 38 C.F.R. § 3.307(a)(6)(iii). Thus, presumptive service connection for MF, a non-Hodgkin's lymphoma is warranted. Therefore, the claim of service connection for a skin disorder to include mycosis fungoides is granted subject to the provisions which govern monetary awards. See generally 38 U.S.C.A. § 5110. Dizziness At the January 2011 hearing, the Veteran and his representative testified that he suffered from dizziness which coincided with his hypertension. The Board finds that service connection for dizziness is not warranted. Although the Board sympathizes with the Veteran's complaints of dizziness, it notes that dizziness alone, without a diagnosed or identifiable underlying condition, does not constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). While the Veteran testified that his dizziness was associated with his hypertension, service connection is not established for hypertension at this time. In the absence of competent proof of a present disability, there can be no valid claim, and the appeal must be denied. Brammer, supra. The Board has considered the statements of the Veteran, but notes that he is not competent to provide medical opinions. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Grover v. West, 12 Vet. App. 109, 112 (1999). The Veteran is competent to report symptoms; however, he is not competent to diagnose a disorder, which is required here. The evidence is therefore against a finding of any current disability due to service. Absent proof of the existence of the disability being claimed, there can be no valid claim. See Gilpin, supra; Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Accordingly, the claim is denied. Left Ear Hearing Loss, Right Ear Hearing loss, and Ttinnitus VA defines a hearing loss disability, for compensation purposes, as when "auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent." 38 C.F.R. § 3.385. Frequencies above 4000 Hertz are not considered. During service the Veteran was exposed to excessive noise onboard ship, as his duties as an electrician's mate would entail. The Veteran's service treatment records however, are entirely silent as to any complaints, treatment, or diagnoses of any hearing disorder or tinnitus. The June 1962 enlistment examination was normal and a whisper test on the August 1966 separation examination revealed 15/15 hearing acuity and no evidence of tinnitus. In a September 2006 VA audiometric examination, the examiner noted the Veteran reported a high pitched pinging sound beginning in service after a water immersion exercise. He also reported working as an electrician and being exposed to engine room and artillery noise in service. Subsequent to service he worked many years as an air conditioning systems repairman. The examiner noted the Veteran's hearing was normal at enlistment, but a formal audio evaluation was not performed upon separation. A whisper test was done indicating normal hearing. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 20 20 20 45 LEFT 10 15 15 25 20 Average pure tone thresholds, in decibels (dB), were 26 dB for the right ear and 19 dB for the left ear. Speech audiometry revealed 100 percent speech discrimination skills bilaterally. It was noted that the Veteran had normal hearing in the right ear dropping to a moderate sensorineural hearing loss at 4000 to 8000 Hz; and normal hearing in the left ear. The examiner opined that as no formal hearing evaluation was performed at separation from service any opinion regarding hearing loss due to service would be speculative. Regarding tinnitus the examiner opined that since there was no documentation of tinnitus in service and as there was a history of post service noise exposure, it was the examiner's opinion that any tinnitus was less likely than not related to military service. The Board finds that there is a preponderance of evidence against the claims of service connection for a left and right ear hearing loss disorder and for tinnitus for the following reasons. In regards to the Veteran's claimed left ear hearing loss, while the Veteran is competent to report he endured noise exposure during service, and currently has hearing loss in the left ear, the Board assigns more probative weight to the audiometric test results of record, which do not meet the criteria for a hearing loss disability under 38 C.F.R. § 3.385. There is no competent evidence to show that the veteran has a current left hearing loss disorder by VA standards. Id. As such, the veteran has not brought forth competent evidence from a medical professional of a "disability" and service connection cannot be granted for left ear hearing loss. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (Court stated "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability," and held "[i]n the absence of proof of a present disability[,] there can be no valid claim"); Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Turning to the Veteran's right ear hearing loss and tinnitus, there are no medical records in service which reveal any treatment or diagnosis of hearing loss or tinnitus; and there is no evidence of a bilateral hearing loss or tinnitus within the first year after service; and, of greatest significance, there is no post service evidence of any contemporaneous objective evidence of hearing loss or tinnitus prior to approximately September 2006, when a right ear hearing loss was first observed by VA examination. Such lapses of time are factors for consideration in deciding service connection claims. See Maxson, 230 F.3d 1330 (Fed. Cir. 2000). The September 2006 VA examiner gave a detailed rationale for his conclusions based on an accurate characterization of the evidence; the examiner's opinion is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). Of course, in addition to the medical evidence, the Board must consider lay evidence, including the Veteran's statements and testimony See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing 38 U.S.C.A. 1154(a) (West 2002)) (VA required to "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits). The Veteran testified in January 2011 that he was exposed to a lot of acoustic trauma in service as a result of his duties as an electrician's mate and not having proper hearing protection. He also testified that he was exposed to extensive acoustic trauma post service while working for the post office as an air conditioning chiller repairman. However he was provided with hearing protection in this job. To the extent that the Veteran has indicated generally that he experienced continuity of symptomatology, this testimony must be considered in conjunction with the absence of any complaints, treatment, or diagnoses of any right ear hearing loss or tinnitus for many years after service. The initial claim for benefits was made many decades after service. The Board also notes that, to the extent that the Veteran has been diagnosed with right ear hearing loss, such diagnosis was not within the one-year period during which the manifestation of a chronic disease such as sensorineural hearing loss warrants service connection on a presumptive basis. 38 U.S.C.A. §§ 1101, 1112, 1133, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). In sum, the preponderance of the evidence is against the claims. The benefit-of-the-doubt doctrine is therefore not for application, and the claims for service connection for bilateral hearing loss and tinnitus must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Sterility After having carefully reviewed the evidence of record, the Board finds that the preponderance of the credible evidence on file is against the grant of service connection for the Veteran's claimed sterility. At his January 2011 Board hearing the Veteran testified that he believed that he was sterile as a result of lead and mercury used as fillings in his teeth during service. He acknowledged that he has never seen a doctor for sterility, nor has he ever been diagnosed with sterility as a result of dental fillings or otherwise. He based his claim on the fact that he had not fathered any children subsequent to service. He did some personal online research and read that the amalgam used by dentists may cause sterility. He submitted the online treatise as evidence. As previously noted the existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110, 1131; Degmetich, Supra. Evidence must show that the veteran currently has the disability for which benefits are being claimed. In the absence of proof of present disability, there can be no valid claim. Brammer, Supra. The Board notes that the Veteran is currently service connected for erectile dysfunction and is receiving compensation on account of the loss of use of a creative organ. However his claim appears to be related not to his service connected erectile dysfunction but to sterility allegedly caused by lead/mercury poisoning in his dental fillings. However, the records do not reveal that he has ever been diagnosed with sterility. Because the Veteran has no current sterility disability, service connection must be denied. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Holton v. Shinseki, 557 F.3d 1362 (2009); Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006). As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C.A. § 5107(b), Gilbert. ORDER The appeal of entitlement to service connection for tuberculosis exposure is dismissed. The appeal of entitlement to service connection for residuals of an eye injury is dismissed. The appeal of entitlement to service connection for renal insufficiency is dismissed. Entitlement to service connection for a skin disorder to include mycosis fungoides is granted. Entitlement to service connection for dizziness is denied. Entitlement to service connection for left ear hearing loss disorder is denied. Entitlement to service connection for right ear hearing loss disorder is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for sterility is denied. REMAND Unfortunately, a remand is required in this case as to the remaining claims on appeal. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. Respiratory Disorder The Veteran contends that his current respiratory disorder is the result of exposure to asbestos during his service aboard ship in the Navy as an electrician's mate. In the alternative he contends that the disorder is either the result of exposure to herbicides or other toxic chemicals while serving in Vietnam. The Veteran's service personnel records indicate that he served in the Navy, and that his military occupational specialty was that of an electrician's mate. His records further indicate that he likely served in the engine room of Navy ships. Thus, the Board concedes exposure to asbestos in service. Regarding exposure to herbicides, the Veteran's exposure to herbicides during service has previously been conceded by the RO. In a May 2006 VA outpatient treatment records note that the Veteran came to the clinic with concerns about COPD. He noticed shortness of breath (SOB) with exertion and believed that it may be caused by lung cancer. He denied SOB with ordinary physical activities. A computerized tomography (CT) scan in March 2006 noted tiny pulmonary nodules and old granulomatous disease. The Veteran had been followed by a private pulmonologist, Dr. Howard Mintz. A pulmonary function test (PFT) in February 2006 revealed severe obstructive lung disease, diffuse normal. As the evidence demonstrates current diagnoses of granulomatous disorder and chronic obstructive pulmonary disease, as well as exposure to asbestos and herbicides in service, the Veteran should be afforded an examination by an appropriate VA physician. The physician is requested to provide an opinion addressing whether the current diagnoses are either due to Agent Orange or asbestos exposure during service. See 38 U.S.C.A. § 5103A(d) (West 2002); 38 C.F.R. § 3.159 (c)(4) (2010). Low Back Disorder At his January 2011 Board hearing, the Veteran testified that he injured his back in service in 1963 while moving drums of "some liquid," in a warehouse. He was treated in sick bay, given some pills, and taken off duty for 3 or 4 days. He did not seek any additional treatment during the remainder of service for his back condition. He did not seek post service treatment for his back until he was approximately 29 years old. Since that time, he has treated his back disorder with pills and some shots in the back. His spouse noted that in 1969, he had undergone some form of shock treatment for approximately 11/2 years. Service treatment records dated in June 1964 note the Veteran was treated for complaints of back pain for 4 to 5 days. He reported no history of any injuries or strain. Range of motion of the back was normal. He had slight tenderness of the left flank. January 2006 VA outpatient treatment records reveal that the Veteran has been diagnosed with chronic degenerative/partial fusion to L4-5. He reported injuring the lower back during heavy lifting in a Navy warehouse in service. The Veteran was afforded a VA examination in September 2006. The examiner noted that a CT scan of his spine revealed chronic degenerative/partial fusion of L4-5 with secondary degenerative osteophytes. The Veteran reported injuring the lower back during heavy lifting in a Navy warehouse in service. Unfortunately the claims file was not available to the examiner at that time. The Board finds that a remand is necessary in order to afford the Veteran a current and comprehensive VA examination so as to determine whether his low back disorder is caused by his in service back injury. A remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Acquired Psychiatric Disorder and Hypertension At his January 2011 Board hearing, the Veteran testified that he experienced psychiatric symptoms and hypertension as a result of his several health issues including his service connected prostate cancer. A review of the available VA outpatient treatment records reveal that the Veteran has been diagnosed and treated for anxiety as well as hypertension. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record 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). With respect to the third factor above, the Court has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, there are diagnoses of anxiety and hypertension of record. The first McLendon element is therefore met. Turning to the second McLendon element, the Veteran has testified that he believes he had high blood pressure during active duty, a symptom which he is competent to report. Arguably, McLendon element two is met. As to McLendon element three, the Veteran provided testimony as to his current symptoms and his belief that he has an acquired psychiatric disability as a result of his service connected disability and hypertension either as a result of service or secondary to his service connected conditions. Thus, arguably, McLendon element three is met. Despite this and other evidence of record, there remains a question as to the current nature, extent, and etiology of the claimed acquired psychiatric disability and hypertension. Accordingly, a VA examination and opinion are required. Additionally, as relevant to all remanded claims, the Veteran should be requested to identify any outstanding treatment records, to include any current treatment records not already in the claims file, and, thereafter, all identified records should be obtained for consideration in his appeal. Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran identify any outstanding treatment records relevant to his respiratory disorder, low back disorder, acquired psychiatric disorder, and hypertension. After securing any necessary authorization from him, obtain all identified treatment records not already in the claims file. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. The Veteran should be accorded an examination by an appropriate pulmonary specialist to determine the current nature and likely etiology of his respiratory disorder. The RO should inform the examiner that asbestos exposure and herbicide exposure in service has been conceded. The Veteran's claims folder and a copy of this REMAND must be provided to the examiner for review prior to completion of the examination. Moreover, a notation to the effect that this record review took place must be included in the examination report. Based on review of the record, the examiner should answer the following questions: Is it at least as likely as not that the Veteran's respiratory disorder is related to any incident of service, to include asbestos exposure, and/or herbicide exposure? A complete rationale is requested for any opinion expressed. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 3. The Veteran should be accorded an examination by an orthopedic specialist to determine the current nature and extent of his low back disorder. Any and all back disorders that may be present should be diagnosed. The Veteran's claims folder and a copy of this REMAND must be provided to the examiner for review prior to completion of the examination. Moreover, a notation to the effect that this record review took place must be included in the examination report. All indicated studies, tests, and evaluations, particularly orthopedic and neurological testing, should be performed. All pertinent symptomatology and findings should be reported in detail. Following evaluation of the Veteran, the examiner must express an opinion as to whether it is at least as likely as not (50 percent or greater likelihood) that any low back disorder was caused by; or, was otherwise related to the back injury that the Veteran has indicated that he sustained while on active duty. A complete rationale must be provided for any opinion(s) offered. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why such an opinion cannot be provided without speculation. 4. The Veteran should be scheduled for a VA psychiatric examination to determine the nature and etiology of any psychiatric disability diagnosed. The Veteran's claims folder and a copy of this REMAND must be provided to the examiner for review prior to completion of the examination. Moreover, a notation to the effect that this record review took place must be included in the examination report. All indicated studies, tests, and evaluations should be performed. All pertinent symptomatology and findings should be reported in detail. Based on the review of the file and the psychiatric examination, the examiner is asked to render an opinion as to the appropriate diagnosis or diagnoses for this Veteran. Further, the examiner is asked to opine on the following: Is it at least as likely as not (50 percent or greater probability) that the Veteran's current psychiatric disability is causally related to his period of active service, or any incident thereof? Is it as least as likely as not (50 percent or greater probability) that psychoses manifested to a compensable degree within one year of discharge from active duty, or by August 1967? Is it at least as likely as not (50 percent or greater probability) that the Veteran's psychiatric disability is causally related to his service-connected disorders, including prostate cancer? The examiner must set forth all examination findings, along with the complete rationale for the conclusions reached in the examination report. Furthermore, if the examiner cannot provide an etiology opinion without resorting to speculation, the examiner must so state, and provide a rationale for why he or she cannot opine without speculating. 5. The appellant should be afforded a VA cardiology examination for the purpose of identifying the nature and etiology of his current hypertension. The Veteran's claims folder and a copy of this REMAND must be provided to the examiner for review prior to completion of the examination. Moreover, a notation to the effect that this record review took place must be included in the examination report. All indicated studies, tests, and evaluations should be performed. All pertinent symptomatology and findings should be reported in detail. After examining the appellant and reviewing the claims folder, the examiner should provide an opinion, with supporting rationale, as to the whether it is at least as likely as not that the appellant's current hypertension is causally related to the appellant's active service or any incident therein. Alternatively, the examiner should state whether the Veteran's current hypertension is causally related to or aggravated by his service-connected prostate cancer. 6. The Veteran should be notified that it is his responsibility to report for the examinations and to cooperate in the development of the claims. 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 Veteran does not report for the aforementioned examinations, documentation should be obtained which shows that notice scheduling the examinations was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 7. Thereafter, the RO/AMC must review the claims folder and ensure that the foregoing development actions, as well as any other development that may be in order, have been conducted and completed in full. The RO should review the examination report to ensure that it is in complete compliance with the directives of this REMAND. If the report is deficient in any manner, the RO must implement corrective procedures at once. 8. Following any other indicated development, the RO/AMC should readjudicate the claims. If any benefit is not granted, the Veteran and his representative should be furnished with a supplemental statement of the case and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ____________________________________________ KRISTI L. GUNN Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2009). Department of Veterans Affairs