Citation Nr: 1123351 Decision Date: 06/20/11 Archive Date: 06/28/11 DOCKET NO. 10-05 834 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for skin cancer. 4. Entitlement to service connection for coronary artery disease. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD K. Neilson, Counsel INTRODUCTION The Veteran served on active duty from August 1966 to May 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. FINDINGS OF FACT 1. The Veteran does not have hearing loss or tinnitus that is attributable to his active military service. 2. The Veteran's diagnosed squamous cell carcinoma is not attributable to active military service; it was not manifested within a year of separation from service. 3. The Veteran had service in Vietnam from January 1967 to February 1968; he has a current diagnosis of coronary artery disease. CONCLUSIONS OF LAW 1. The Veteran does not have hearing loss that is the result of disease or injury incurred in or aggravated by active military service; sensorineural hearing loss may not be presumed to have been incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385 (2010). 2. The Veteran does not have tinnitus that is the result of disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2010). 3. The Veteran does not have skin cancer that is the result of disease or injury incurred in or aggravated by active military service; nor may it be presumed to have been incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1101, 1110, 1113, 1116, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2010). 4. The Veteran has coronary artery disease that is presumed to have been the result of disease or injury incurred in service. 38 U.S.C.A. §§ 1110, 1116, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2010); 75 Fed. Reg. 53,202 (Aug. 31, 2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2010). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) 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. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). In addition, certain chronic diseases, including malignant tumors or organic disease of the nervous system such as sensorineural hearing loss, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.307, 3.309 (2010). The law further provides that there are certain diseases that are associated with exposure to "herbicide agents" during active military, naval, or air service, and are thus presumed to have been incurred in or aggravated during active military service if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of the disease during service, provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. 38 U.S.C.A. § 1116(a) (West 2002 & Supp. 2010); 38 C.F.R. § 3.309(e) (2010). (In this context, the term "herbicide agent" is defined as a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975, specifically: 2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram. 38 C.F.R. § 3.307(a)(6)(i).). A. Hearing Loss The Veteran asserts that he suffers from bilateral hearing loss as a result of his military service. The report of a June 1966 enlistment examination included the results of an audiogram that recorded the Veteran's pure tone auditory thresholds as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -10 (5) -10 (0) -10 (0) N/A -10 (-5) LEFT -10 (5) -10 (0) -5 (0) N/A -5 (0) (Service department audiometric testing conducted before November 1967 generally applied ASA standards. Thereafter, an ISO standard has been applied. The numbers in parentheses reflects a conversion to ISO standard for comparison purposes.) It does not appear that the Veteran was given a hearing test during his May 1968 separation examination as the report of such does not include the results of an audiogram or whispered/spoken voice test. The Veteran's service treatment records (STRs) are silent for complaints or treatment related to the Veteran's ears or hearing. Post-service medical records dated from July 2005 to March 2009 contain no reference to the Veteran's hearing. In August 2008, the Veteran submitted a claim for VA disability compensation, seeking service connection for, among other things, hearing loss. He did not indicate the date of onset of his hearing loss. In January 2009, the Veteran underwent a VA audiology examination. The Veteran reported noise exposure in service, but did not provide any specific details regarding that exposure. He denied occupational and recreational noise exposure. He stated that he had noticed a loss of hearing during the past 10 to 15 years. The results of audiometric testing were, in relevant part, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 5 5 40 60 LEFT 0 5 15 55 60 The Veteran's speech recognition scores were 96 percent bilaterally. His hearing was noted to be within normal limits at 250 to 2000 hertz. He was diagnosed as having moderate sensorineural hearing loss at 3000 and 4000 hertz. The VA audiologist noted that it was commonly accepted in audiology that when a person is removed from a noisy environment, hearing acuity should not change. The noted exceptions were recorded as: the aging process; further noise exposure; medications; and illnesses. The VA audiologist further stated that it was also commonly accepted that hearing loss and/or tinnitus will occur at the time of noise exposure, or soon thereafter, but not years later. He then opined that the Veteran's present hearing loss was not caused by, or the result of, the Veteran's active military service, as the Veteran had reported the onset of his hearing loss to be 10 to 15 years prior. At the outset, the Board notes that the evidence of record demonstrates that the Veteran has a current hearing loss disability for VA purposes. See 38 C.F.R. § 3.385. Further, as the Veteran's military occupational specialty was that of a mortarman, the Board concedes that he was exposed to noise in service. Thus, the question is one of nexus. In this case, the Veteran has stated his lay opinion as to why he believes that his hearing loss is related to service - his noise exposure during service. However, the VA audiologist, after weighing the evidence of record concluded that the Veteran's hearing loss was not related to service. The VA audiologist noted that the Veteran was not afforded a formal or informal hearing test at separation. He also acknowledged the Veteran's assertion that his only noise exposure was in service. The audiologist concluded, however, that the Veteran's hearing loss was not related to his military service. In so doing, the VA audiologist relied upon commonly accepted audiological principles regarding hearing loss and the fact that the Veteran's self-reported onset of hearing loss was more than 25 years after service. The Board notes that the United States Court of Appeals for Veterans Claims has held that 38 C.F.R. § 3.385 does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service if there is sufficient evidence to demonstrate a medical relationship between the Veteran's in-service exposure to loud noise and a current disability. Hensley v. Brown, 5 Vet. App. 155 (1993). Here, however, as the evidence fails to demonstrate a relationship between the Veteran's hearing loss and service, service connection is not warranted. In this regard, the Board finds probative the VA audiologist's negative nexus opinion. The Board also finds significant that the Veteran did not indicate the extent of his noise exposure in service. Further, the Veteran's post-service treatment records contain no complaints of hearing loss, despite the Veteran stating that he had noticed a decrease in hearing over the previous 10 to 15 years. Although the Veteran believes that his hearing loss is due to noise exposure in service, the Board notes that etiology of dysfunctions and disorders is generally a medical determination. See Jandreau v. Nicholson, 492 F.3d 1372, 1374-75 (Fed. Cir 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Here, the Veteran, as a lay person without the appropriate medical training and expertise, is not competent to make such an etiological conclusion, especially in light of the Veteran's own admission that his hearing loss did not begin until more than 25 years after service. See Jandreau, supra; Espiritu v. Derwinski, 2 Vet. App. 492 (1992); see also Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability that still exists currently). Thus, although the Veteran believes his hearing loss to be related to his military service, the Board finds the medical evidence of record to be more probative on the issue of nexus. The VA examiner provided a medical explanation for why the Veteran's theory of the case should be rejected. The Board is persuaded by the examiner's explanation because of his expertise and because the record is consistent with the explanation. Accordingly, because the preponderance of the evidence is against the Veteran's claim, his claim of service connection for hearing loss must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 53- 56 (1990); 38 C.F.R. § 3.102 (2010). B. Tinnitus In August 2008, the Veteran claimed service connection for tinnitus. He did not indicate the date of onset of his tinnitus nor provide any information regarding his symptoms of tinnitus or frequency or duration thereof. The Veteran's STRs are silent for complaints of tinnitus or related symptoms. His separation examination report indicated that his ears were clinically evaluated as normal. His post-service treatment records are similarly silent for complaints of tinnitus or related symptoms. As noted previously, the Veteran was afforded a VA audiology examination in January 2009. The examination request indicated that if the Veteran complained of tinnitus, the VA audiologist should render an opinion as to etiology. The examination report specifically noted that the Veteran did not report tinnitus. The Board notes that Congress has specifically limited entitlement to service connection to instances where disease or injury has resulted in a disability. See 38 U.S.C.A. §§ 1110, 1131. As such, an essential element of a service connection claim is the establishment of a current disability. After review of the record, the Board finds that service connection for tinnitus is not warranted. In this regard, the Board notes that service and post-service medical records are silent for complaints or treatment related to tinnitus. Similarly, the medical evidence of record fails to disclose a current diagnosis of tinnitus. On VA examination in January 2009, the Veteran denied tinnitus. Although in his informal hearing presentation, the Veteran's representative argued that the denial of tinnitus on examination did not preclude a finding of service connection, the Board notes that in none of the filings on appeal, to include the notice of disagreement and substantive appeal, has the Veteran argued that he in fact suffers from tinnitus. He has disagreed with the denial by the RO, but he has not affirmatively stated that he in fact experiences the disability or explained why he did not say that he had tinnitus when questioned by the VA examiner. In essence, the evidence does not show that the Veteran experiences this disability. The United States Court of Appeals for Veterans Claims (Court) has consistently held that service connection cannot be awarded in the absence of "competent evidence of current disability." Caluza v. Brown, 7 Vet. App. 498, 506 (1995) (citing Brammer v. Derwinski, 3 Vet. App. 223 (1992), and Rabideau v. Derwinski, 2 Vet. App. 141 (1992)) aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). In this regard, the Board is cognizant of the fact that lay evidence can be competent and sufficient to establish a diagnosis of a condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (stating the "[l]ay testimony is competent . . . to establish the presence of observable symptomatology and 'may provide sufficient support for a claim of service connection'" (quoting Layno v. Brown, 6 Vet. App. 465, 469 (1994))); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (noting that a veteran is competent to testify as to ringing in the ears). However, as stated previously, the Veteran has not proffered any lay evidence of a current diagnosis. Accordingly, without evidence of a current diagnosis, the Board finds that the claim of service connection for tinnitus must be denied. See Brammer, supra. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); Gilbert, supra; 38 C.F.R. § 3.102 (2010). C. Skin Cancer The Veteran asserts that he has skin cancer as a result of his exposure to Agent Orange in service. The Veteran's VA treatment records show that a skin biopsy of the left cheek done in June 2007 resulted in a diagnosis of squamous cell carcinoma. A biopsy performed in November 2008 showed a squamous cell carcinoma on the right forearm. A review of the Veteran's service personnel records shows that he served in the Republic of Vietnam from January 1967 to February 1968. A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975, is presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(a)(6)(iii). As the Veteran's service personnel records show service in Vietnam during the requisite time period, the Veteran is presumed to have been exposed to an herbicide agent. In accordance with 38 C.F.R. § 3.309(e), presumptive service connection on the basis of herbicide exposure is available for the following diseases: AL amyloidosis, chloracne and 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, and certain soft tissue sarcomas. 38 C.F.R. § 3.309(e). Initially, the Board notes that skin cancer is not one of the enumerated disabilities listed under 38 C.F.R. § 3.309(e). Further, under the authority granted by Congress in the Agent Orange Act of 1991 and the Veterans Education and Benefits Expansion Act of 2001, the Secretary has specifically determined that a presumption of service connection is not warranted based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era for skins cancers (melanoma, basal, and squamous cell). See 72 Fed. Reg. 32395, 32397- 32398 (June 12, 2007). Thus, although the Veteran served in the Republic of Vietnam during the requite time period, because he has not been diagnosed with a disability for which the Secretary has specifically determined that a presumption of service connection should apply based on herbicide exposure, the provisions of 38 C.F.R. §§ 3.307(a)(6) and 3.309(e) are not for application. Regardless of whether a claimed disability is recognized under 38 C.F.R. § 3.309(e), a veteran is not precluded from presenting evidence that a claimed disability was due to or the result of herbicide exposure. See Combee v. Brown, 34 F.3d 1039, 1044-45 (Fed. Cir. 1994). On the issue of direct service connection, the Board notes that the Veteran's STRs are silent for complaints or treatment related to his skin. His May 1968 separation examination report documented that his skin was clinically evaluated as normal at that time. The Veteran's post-service medical records show that in June 2007 he presented at a VA dermatology clinic for a skin check. He reported no history of skin cancer at that time. The Veteran indicated that he spent a large amount of time outdoors, as his work involved swimming pools. He stated that he did wear sunscreen and a hat. As stated above, a cheek biopsy revealed a squamous cell carcinoma. Here, the Board finds that service connection for skin cancer must be denied. The record contains no nexus evidence linking squamous cell carcinoma to the Veteran's active military service, to include his presumed exposure to herbicides. Further, the Veteran has not asserted that he suffered from any skin-related disorder in service. Indeed, the first evidence of skin cancer was in 2007. In view of the evidence, only a current disability is shown. An in-service event, injury, or disease, has not been shown. Additionally, the Veteran's skin cancer was not diagnosed until 39 years after service and there is an absence of symptomatology during the intervening period. (The one-year presumption for malignant tumors under 38 C.F.R. §§ 3.307, 3.309 is therefore not helpful.) Moreover, medical nexus evidence linking the current disability to military service, or specifically to herbicide exposure, is not shown. Consequently, service connection is not warranted for skin cancer on a direct basis, including as a result of exposure to herbicides. See Davidson, supra (service connection requires evidence of in-service incurrence or aggravation of a disease or injury and a nexus between the claimed in-service disease or injury and the present disability); see also Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability that still exists currently). Further, although the Veteran believes that his skin cancer is due to herbicide exposure, the Board notes that etiology of dysfunctions and disorders is generally a medical determination. See Jandreau and Colantonio, both supra. Here, the Veteran, as a lay person without the appropriate medical training and expertise, is not competent to make such an etiological conclusion, especially in light of the fact that the evidence fails to demonstrate the onset of skin cancer disability in service. See Jandreau and Espiritu, both supra. (The Veteran has not indicated that he experienced symptoms since service or that a medical practitioner has told him that skin cancer is traceable to his period of military service.) The Board notes that the Veteran was not afforded a VA examination for the purpose of determining whether there is a medical nexus between his military service and his currently diagnosed skin cancer. However, as will be discussed in further detail below, because there is no evidence that suggests a link between the Veteran's skin cancer and his military service or his in-service exposure to herbicides, VA's duty to provide him with a medical examination in this case was not triggered. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). In finding that service connection for skin cancer is not warranted, the Board has considered the benefit-of-the-doubt doctrine, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Board is unable to identify a basis for granting service connection. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert, supra; 38 C.F.R. § 3.102 (2010). D. Coronary Artery Disease The Veteran asserts that he has coronary artery disease as a result of his military service. The Veteran's post-service VA and private treatment records show that in July 2005, he suffered an acute anterior myocardial infarction. A cardiac catheterization and stent placement were completed. The Veteran was placed on Toprol and Plavix (clopidrogel). A diagnosis of coronary artery disease, status post myocardial infarction and angioplasty and stenting was rendered. In June 2007, it was noted that the Veteran's coronary artery disease was clinically doing well, with good adenosine stress test results. The Veteran was encouraged at that point to discuss with his private physician whether or not he should continue on Plavix. A November 2007 VA primary care note indicated that the Veteran's private physician stated that the Veteran would need to be in Plavix indefinitely. VA treatment records dated in March 2009 show that the Veteran was seen for a scheduled visit regarding the management of his coronary artery disease. It was noted that the Veteran's private cardiologist informed VA that due to the nature of the Veteran's disease and the stent used, he should be prescribed Plavix (clopidrogel) indefinitely. As noted above, VA has determined that there are certain diseases that are associated with exposure to herbicides in service, and are thus presumed to have been incurred in or aggravated during active military service if the requirements of 38 C.F.R. § 3.307(a)(6) are met. See 38 U.S.C.A. § 1116(a); 38 C.F.R. § 3.309(e). With respect to the Veteran's diagnosis of coronary artery disease, the Board notes that ischemic heart disease, including atherosclerotic cardiovascular disease, such as coronary artery disease, is a disease for which presumptive service connection is warranted based upon herbicide exposure. See 75 Fed. Reg. 53,202 (Aug. 31, 2010). Here, because the Veteran served in Vietnam during the requisite time period, he is presumed to have been exposed during such service to an herbicide agent. 38 C.F.R. § 3.307(a)(6)(iii). Further, as VA has amended 38 C.F.R. § 3.309(e) to include ischemic heart disease as a disease associated with herbicide exposure and the record demonstrates a diagnosis of coronary artery disease, managed indefinitely with the use of Plavix, the Board finds that under the newly amended regulation, the Veteran is entitled to service connection for coronary artery disease on a presumptive basis as due to herbicide exposure. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307(a)(6); 3.309(e); 75 Fed. Reg. 53,202. II. Notice and Assistance The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp 2010)), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2010), provides that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. (The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008. See 73 Fed. Reg. 23353-56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the veteran to provide any evidence in the veteran's possession that pertains to the claim. See 38 C.F.R. § 3.159(b)(1).) The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO received the Veteran's claims for service connection in August 2008. In October 2008, the RO sent to him a letter notifying him of the evidence required to substantiate his claims for service connection. The letter advised the Veteran of the information already in VA's possession and the evidence that VA would obtain on his behalf, as well as of the evidence that he was responsible for providing to VA, to include any records not in the possession of a Federal agency. The RO further advised the Veteran on the types of evidence he could submit that would support his claims for service connection, such as the dates of medical treatment during service, evidence of medical treatment since service, employment physical examination reports, and statements by persons who knew of the Veteran's disability. The letter also notified him of the specific evidence necessary to substantiate a claim based on herbicide exposure. It further included the notice elements required by Dingess for how VA determines disability ratings and effective dates. The Veteran has not disputed the contents of the VCAA notice in this case. Further, the Board finds that the October 2008 notice letter complies with the requirements of 38 U.S.C.A. § 5103(a), and afforded the Veteran a meaningful opportunity to participate in the development of his claims. Thus, the Board is satisfied that the duty-to-notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were satisfied. Regarding the duty to assist, the Board also finds that VA has fulfilled its obligation to assist the Veteran. All available evidence pertaining to the Veteran's claims has been obtained. The evidence includes his STRs, service personnel records, VA outpatient treatment records and examination reports, and private medical evidence. The Veteran elected to not have a hearing in his case. Further, in January 2009, the Veteran was afforded a VA audiology examination. The VA audiologist reviewed the Veteran's claims folder, conducted the appropriate hearing tests, and provided an opinion as to the etiology of the Veteran's hearing loss that is supported by an adequate rationale. The Board notes that the Veteran's representative has asserted that the VA audiology examination was inadequate because the examiner did not offer an opinion as to the etiology of the Veteran's tinnitus. However, the examiner was requested to offer such an opinion only if the Veteran complained of tinnitus on examination. As the Veteran made no such complaint, the VA examiner was under no obligation to render an etiology opinion. The Board has considered whether VA examinations were required in connection with the Veteran's claims of service connection for tinnitus and skin cancer under the duty-to-assist provisions codified at 38 U.S.C.A § 5103A(d) and by regulation found at 38 C.F.R. § 3.159(c)(4). In accordance with those provisions, a medical opinion or examination is required if the information and evidence of record does not contain sufficiently competent medical evidence to decide the claim, but there is-- (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability. McLendon, supra. The evidence of record is such that the duty to obtain medical examinations was not triggered in this case. With regard to the Veteran's claim of service connection for skin cancer, although the record demonstrates that the Veteran has a current diagnosis of that condition and he is presumed to have been exposed to herbicides in service, there is no indication that that disability may be associated with service, to include his herbicide exposure. The first evidence of skin cancer was not until 2007. It was noted that the Veteran's job required him to spend prolonged periods of time outdoors. None of the evidence of record has related the Veteran's skin cancer to service. Thus, the Board finds that there is no requirement to obtain a VA medical examination in connection with the Veteran's claim of service connection for skin cancer. See McLendon, 20 Vet. App. at 85-86; see also Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (rejecting appellant's argument that his "conclusory generalized statement that his service illness caused his present medical problems was enough to entitle him to a medical examination under the standard of [38 U.S.C.A. § 5103A(d)(2)(B).]"). The Board therefore finds that VA has complied, to the extent required, with the duty-to-assist requirements found at 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c)-(e). ORDER Service connection for hearing loss is denied. Service connection for tinnitus is denied. Service connection for skin cancer is denied. Service connection for coronary artery disease is granted. _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs