Citation Nr: 1217691 Decision Date: 05/17/12 Archive Date: 05/24/12 DOCKET NO. 07-31 221 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a bilateral ankle disability, claimed as arthritis of the ankles. 2. Entitlement to service connection for arthritis of the feet and toes, to include as due to exposure to asbestos, jet fuel and/or lead paint. 3. Entitlement to service connection for a skin disability, to include as due to exposure to asbestos, jet fuel and/or lead paint. 4. Entitlement to a compensable disability rating for a deviated nasal septum. 5. Entitlement to service connection for depression and anxiety, to include as due to exposure to asbestos, jet fuel and/or lead paint. 6. Entitlement to service connection for gastroesophageal reflux disease with epigastric distress, regurgitation, and dysphagia, to include as due to exposure to asbestos, jet fuel and/or lead paint. 7. Entitlement to service connection for an epididymal cyst, to include as due to exposure to asbestos, jet fuel and/or lead paint. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD M. Moore, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1963 to May 1967. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, which granted service connection for bilateral hearing loss, assigning a noncompensable evaluation effective February 28, 2006, tinnitus, assigning a 10 percent evaluation effective February 28, 2006, and repair of a deviated nasal septum, assigning a noncompensable evaluation effective February 28, 2006; and denied service connection for a pulmonary condition and cough with breathing problems, depression and anxiety, gastroesophageal reflux disease (GERD) with epigastric distress, regurgitation, and dysphagia, irritable bowel syndrome with diarrhea, constipation, and nausea, arthritis/osteoarthritis of the feet, toes, and ankles, a liver condition, biapical pleural thickening, skin lesions, right shoulder disorder, migraines, a collapsed left lung, tendonitis, and an epididymal cyst; and a February 2008 rating decision from the Muskogee RO which continued noncompensable evaluations for bilateral hearing loss and a deviated nasal septum; and confirmed and continued the prior denial of service connection for a pulmonary disability. In November 2006, the Veteran submitted a notice of disagreement (NOD) with the denials of service connection for depression and anxiety, arthritis, GERD, skin lesions, and an epididymal cysts and subsequently perfected these appeals in August 2007. In February 2009, he filed an NOD with the noncompensable ratings assigned for his hearing loss and deviated nasal septum and perfected only the deviated nasal septum appeal in July 2009. In December 2009, the Veteran presented sworn testimony during a video conference hearing in Muskogee, Oklahoma, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's claims file. In March 2010, the Board remanded all of the Veteran's claims on appeal to the Appeals Management Center (AMC) for further evidentiary development, including obtaining updated VA treatment records and providing the Veteran with VA examinations for each of his claimed disabilities. The Board is obligated by law to ensure that the AMC complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. See Stegall v. West, 11 Vet. App. 268 (1998). A review of the record shows that the AMC obtained updated VA treatment records and afforded the Veteran VA examinations in March 2010 and April 2010. Accordingly, all remand instructions issued by the Board have been complied with and these matters are once again before the Board. The claims for service connection for depression and anxiety, GERD, and an epididymal cyst are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC in Washington, DC. VA will notify the Veteran if further action on his part is required. FINDINGS OF FACT 1. The competent evidence of record does not establish that the Veteran currently has a diagnosed bilateral ankle disorder. 2. The preponderance of the evidence is against a finding that arthritis of the feet and toes is the result of a disease or injury in active duty service, to include in-service exposure to asbestos, jet fuel and/or lead paint. 3. The preponderance of the evidence is against a finding that a skin disability is the result of a disease or injury in active duty service, to include in-service exposure to asbestos, jet fuel and/or lead paint. 4. The Veteran's service-connected deviated nasal septum is manifested by no obstruction of the nasal passage on either side. CONCLUSIONS OF LAW 1. A bilateral ankle disability was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2011). 2. Arthritis of the feet and toes was not incurred in or aggravated by service and may not be presumed to be. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2011). 3. A skin disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2011). 4. The criteria for a compensable disability rating for a deviated nasal septum have not been met. 38 U.S.C.A. §§ 1155 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.321, 4.97, Diagnostic Code 6502 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. 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 claims. The Veteran 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) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). 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 Veteran. 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, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Veterans Claims Assistance Act of 2000 (VCAA) With regard to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2011). 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. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2011); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), 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. Prior to the initial adjudication of the Veteran's claims, letters dated in May 2006 and November 2007 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2011); Quartuccio at 187. Additionally, the May 2006 and November 2007 letters informed the Veteran of how VA determines the appropriate disability rating or effective date to be assigned when a claim is granted, consistent with the holding in Dingess/Hartman v. Nicholson. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records, VA treatment records, and VA examination reports are in the file. The Veteran has at no time referenced any private or other outstanding treatment records that he wanted VA to obtain or that he felt were relevant to the claims. With respect to claims for service connection, 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. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when there is (1) evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. The record indicates that the Veteran underwent a VA general medical examination in March 2010 to address his arthritis and skin claims. The results from that examination have been included in the claims file for review. The examination involved a review of the claims file, a thorough examination of the Veteran, and an opinion that was supported by sufficient rationale. Therefore, the Board finds that the March 2010 examination is adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2011). The RO provided the Veteran with a VA examination that addressed his deviated nasal septum most recently in March 2010. The examiner reviewed the claims file and provided a thorough physical examination. Thus, the Board finds that the March 2010 examination is adequate for determining the disability rating for the Veteran's service-connected deviated nasal septum. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Additionally, there is no evidence indicating that there has been a material change in the severity of the Veteran's service-connected deviated nasal septum since he was last examined. See 38 C.F.R. § 3.327(a) (2011). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. See VAOPGCPREC 11-95. Thus, the Board finds that a new VA examination is not necessary at this time. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of these claims, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Merits of the Claims A. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002). However, that an injury or disease occurred in service is not enough; there must also be a chronic disability resulting from that injury or disease. If there is no showing of the chronic disability during service, then a showing of continuous symptoms after service is required to support a finding of chronicity. See 38 C.F.R. § 3.303(b) (2011). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. See 38 C.F.R. § 3.303(d) (2011). Where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and certain diseases, such as arthritis, become manifest to a degree of 10 percent or more within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.307, 3.309 (2010). In order to establish service connection for a disability, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). With regard to his arthritis and skin claims, the Veteran has asserted multiple theories of entitlement to service connection, including that these disabilities were caused by exposure to asbestos, jet fuel, and/or lead paint in service. With regard to asbestos-related claims, the Board notes that there is no specific statutory guidance, nor has the Secretary of VA promulgated any regulations in regard to these 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 DVB circular was subsumed verbatim as § 7.21 of Adjudication Procedure Manual, M21-1, Part VI. (This has now been reclassified in a revision to the Manual at M21- 1MR, Part IV, Subpart ii, Chapter 2, Section C.) See also VAOPGCPREC 4-00 (Apr. 13, 2000). The adjudication of a claim for service connection for a disability resulting from asbestos exposure should include a determination as to whether or not: (1) service records demonstrate the veteran was exposed to asbestos during service; (2) development has been accomplished sufficient to determine whether or not the veteran was exposed to asbestos either before or after service; and (3) a relationship exists between exposure to asbestos and the claimed disease in light of the latency and exposure factors. See M21-1MR, Part IV, Subpart ii, Chapter 2, Section C, Subsection (h). In this regard, the M21-1 MR provides the following non-exclusive list of asbestos-related diseases/abnormalities: asbestosis, interstitial pulmonary fibrosis, tumors, effusions and fibrosis, pleural plaques, mesotheliomas of pleura and peritoneum, lung cancer, bronchial cancer, cancer of the larynx, cancer of the pharynx, cancer of the urogenital system (except the prostate), and cancers of the gastrointestinal tract. See M21-1 MR, part VI, Subpart ii, Chapter 2, Section C, 9 (b). The M21-1 MR also provides the following non-exclusive list of occupations that have higher incidents of asbestos exposure: 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, and manufacture and installation of roofing and flooring materials, asbestos cement sheet and pipe products, and military equipment. See M21-1 MR, part VI, Subpart ii, Chapter 2, Section C, 9 (f). In Dyment v. West, 13 Vet. App. 141, 145 (1999), the Court found that provisions in former paragraph 7.68 (predecessor to paragraph 7.21) of former VBA Manual M21-1, Part VI, did not create a presumption of exposure to asbestos. Medical nexus evidence is required in claims for asbestos-related disease related to alleged asbestos exposure in service. See VAOPGCPREC 04-00. Bilateral Ankle Disability A review of the medical evidence of record does not reflect that the Veteran has a currently diagnosed right or left ankle disability. At the above-referenced March 2010 VA examination, the examiner found no objective abnormalities of either ankle. The only subjective abnormalities were pain, weakness, stiffness, fatigability, and lack of endurance. Although the Veteran complained of swelling, heat, redness, instability, and loss of motion, there was no objective confirmation of these complaints. The Veteran exhibited full range of motion of the right and left ankles and x-rays were unremarkable. The examiner concluded that the Veteran experienced bilateral ankle pain, but no diagnosable disorder. He explained that the x-rays did not show arthritis. Neurologic function, vascular status, and range of motion were normal, and there was no joint instability. Although VA and private treatment records show diagnoses of foot and toe arthritis, none of these treatment records indicate that the Veteran has been diagnosed with arthritis or any other disability in either ankle. As the VA examiner concluded that the Veteran does not have a current right or left ankle disability and there is no other evidence showing such a diagnosis, the Board must conclude that the Veteran does not have a currently diagnosed bilateral ankle disability. The Board also notes that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Thus, the Board finds that the Veteran's complaints of bilateral ankle pain do not constitute a current bilateral ankle disability. Without medical evidence of a current disability, the Veteran does not meet the first requirement set forth in Hickson, and the claim fails on this basis. See Hickson, supra. Thus, service connection for bilateral ankle pain may not be granted. See Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists); Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). As the Veteran has failed to satisfy the first element of Hickson, the Board finds the remaining questions of in-service disease or injury or other service-connected disability and medical nexus to be irrelevant. Accordingly, the Board finds that the claim of entitlement to service connection for a bilateral ankle disability 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 Veteran's claim of entitlement to service connection, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2011); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Arthritis of the Feet and Toes With respect to the first element of Hickson, VA and private treatment records show that the Veteran has been treated for and diagnosed with arthritis of the feet and toes. Additionally, the March 2010 VA examiner diagnosed the Veteran with severe osteoarthritis of the first metatarsophalangeal joint with elongated first metatarsals bilaterally. As such, the first element of Hickson is met for this claim. With respect to the second element of Hickson, the Veteran's service treatment records are negative for any complaints of arthritis symptoms or pain in the feet or toes, nor does the Veteran claim that he experienced arthritis in service or until many years thereafter. Therefore, the evidence does not support a grant of service connection for arthritis of the feet and toes on a direct or presumptive basis. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.307, 3.309 (2011). The Veteran asserts that he was exposed to asbestos, jet fuel, and lead paint during service, which resulted in arthritis. These reports of in-service exposures were supported by multiple statements from fellow service members. Moreover, the Veteran's DD-214 shows a military occupational specialty of marine oiler, consistent with his claimed exposures. There is no evidence to contradict the Veteran and his fellow service member's claims of such in-service exposures. As such, these exposures can arguably be conceded and the second element of Hickson is met for this claim. Although in-service exposures and current disability have been established, as noted above, this is not sufficient to warrant service connection. There still must be competent medical evidence of a nexus between the Veteran's conceded in-service asbestos, jet fuel, and/or lead paint exposure and his currently diagnosed arthritis of the feet and toes. See Hickson, supra. As referenced above, the Veteran was afforded a VA examination in March 2010. At that time, the examiner diagnosed the Veteran with arthritis affecting the feet and toes and concluded that his arthritis was not caused or aggravated by his military service, including in-service exposure to asbestos, jet fuel, and lead paint. He indicated that there was no medical literature that associated osteoarthritis with asbestos, jet fuel, or lead paint exposure. Further, he opined that the Veteran's bilateral foot and toe arthritis was at least as likely as not the result of post-service activities, including many years of employment in physically demanding jobs. In light of the lack of medical literature to support a link between osteoarthritis and asbestos, jet fuel, and/or lead paint exposure and the Veteran's post-service employment, the examiner was unable to connect his current bilateral foot and toe disability to service. The Veteran has submitted two letters from his private physician, Dr. M. K., that he claims support his claim for service connection for arthritis of the feet and toes. The first letter, dated in May 2006, states that the Veteran "has developed degenerative joint disease with generalized joint aches, pains and stiffness," as well as anxiety and depression and GERD, and that it "seems reasonable to consider that some of [the Veteran's] problems could be related to his exposures during his time in the Navy." This letter fails to indicate which of the Veteran's listed diagnoses are related to exposure in service, stating only that "some" of his problems "could be" related to his in-service exposures. It is unclear whether the Veteran's arthritis of the feet and toes is included in this assertion. The second letter from Dr. M. K., dated in October 2006, concluded that it was as likely as not that the Veteran's degenerative joint disease could be related to lead paint exposure in service. He states, without any citations, that "there is good scientific data" that lead contamination can lead to joint and muscle pain. However, this rationale does not address the Veteran's diagnosis - degenerative joint disease. While Dr. M. K.'s rationale links lead contamination to joint and muscle pain, it does not link lead exposure to degenerative changes, as the Veteran has been diagnosed with. As Dr. M. K.'s first opinion fails to specifically address the Veteran's arthritis of the feet and toes and his second opinion is not supported by a sufficient rationale, the Board finds both opinions to be less probative than the March 2010 VA examiner's opinion. The Board is free to favor one medical opinion over another as long as it provides an adequate basis for doing so. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Here, the Board finds Dr. M. K.'s opinions to be less probative than the March 2010 VA examiner's opinion. The private medical opinions fail to provide a sufficient rationale or any supporting research citations to link the Veteran's arthritis of the feet and toes to in-service exposures. As such, they are insufficient to grant service connection for arthritis of the feet and toes. The Board notes that the Veteran has also submitted internet research regarding petroleum product exposure, contaminated air in commercial airlines, and oil fire pollutants. These articles discuss the possible health effects of such exposures, including joint pain and skin problems. The Veteran contends that these articles provide a sufficient medical nexus between his arthritis of the feet and toes and his time in service. However, the Board finds that the articles are not probative evidence as they do not specifically relate to the Veteran's particular case. Indeed, the articles do not contain any analysis regarding the Veteran's conceded exposure to asbestos, jet fuel, and/or lead paint and the possible relationship to his current condition, including consideration of other factors such as his family history of arthritis. Moreover, it is not clear that these articles are addressing the same substances that the Veteran is claiming to have been exposed to in service. Medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38 C.F.R. § 3.159(a)(1) (2011) [competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses]. However, the Court has held that medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Unlike the highly probative March 2010 VA examiner's opinion, the internet research submitted by the Veteran is both inconclusive and general. As such, these articles are not sufficient to warrant a grant of service connection for arthritis of feet and toes. The only remaining evidence which purports to relate the Veteran's arthritis of the feet and toes to his in-service asbestos, jet fuel, and/or lead paint exposure consists of his own statements and those of his representative. However, laypersons, such as the Veteran and his representative, are not competent to determine the etiology of a particular diagnosis. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992); see also 38 C.F.R. § 3.159 (a)(1) (2011). Without medical training, the Veteran and his representative are simply not competent to opine on the etiology of his currently diagnosed arthritis of the feet and toes. Thus, there is no competent and probative medical evidence to provide a nexus between the Veteran's service and his current arthritis of the feet and toes. The Board is aware of the provisions of 38 C.F.R. § 3.303(b), referenced above, relating to chronicity and continuity of symptomatology. While the Board notes the Veteran's present contentions of continuous foot and toe pain since service, the March 2010 VA examiner considered these contentions and still found that the Veteran's arthritis of the feet and toes was not related to his military service. Moreover, the Board notes in passing that the Veteran's contentions of continuous symptoms since service, made now in conjunction with his current claim for monetary benefits, are directly contradicted by the history of foot and toe pain since the 1990s given to his physicians when seeking treatment. See private treatment records, March 1996, May 2001; VA treatment record, July 2009; see also Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the Veteran); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence). As such, the medical nexus element of Hickson cannot be met via continuity of symptomatology. As explained above, the competent medical evidence of record does not demonstrate that there is a relationship between the Veteran's active duty service, including any exposure to asbestos, jet fuel, and/or lead paint and his currently diagnosed arthritis of the feet and toes. Although the Board notes the Veteran's current disability and in-service exposures, without evidence of a medical nexus, service connection cannot be granted. Accordingly, the Board finds that the claim of entitlement to service connection for arthritis of the feet and toes, to include as due to exposure to asbestos, jet fuel and/or lead paint, 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 Veteran's claim of entitlement to service connection, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2011); see also Ortiz, supra. Skin With respect to the first element of Hickson, the Veteran has been diagnosed with multiple skin conditions, including skin tags and keratoses. Additionally, the March 2010 VA examiner diagnosed him with a history of seborrheic keratosis, nevus, minimal psoriasis of the left elbow and left eyebrow, and a right lumbar nevus. See VA general medical examination report, March 2010. Thus, the first element of Hickson is met. With respect to the second element of Hickson, the Veteran's service treatment records include a notation of a rash on the back and neck in January 1964. Additionally, as discussed above, in-service exposure to asbestos, jet fuel, and lead paint has been arguably conceded. As such, the second element of Hickson is met for this claim. Although in-service exposure and rash and current disability have been established, as noted above, this is not sufficient to warrant service connection. There still must be competent medical evidence of a nexus between the Veteran's conceded in-service asbestos, jet fuel, and/or lead paint exposure or January 1964 rash on the neck and his currently diagnosed skin disorder(s). See Hickson, supra. The Veteran was afforded a VA examination to determine the etiology of his skin complaints in March 2010. At that time, the examiner diagnosed the Veteran with a history of seborrheic keratosis, nevus, minimal psoriasis of the left elbow and left eyebrow, and a right lumbar nevus. He concluded that the Veteran's skin disorders were less likely than not related to service, including exposure to asbestos, jet fuel, and/or lead paint. He explained that the medical literature did not support a link between any of these exposures and any of the Veteran's diagnosed skin disorders. Rather, the examiner determined that the Veteran's skin disorders were intermittent and isolated skin conditions associated with sun exposure and/or the normal aging process. The Board notes that the Veteran was afforded a previous VA examination to address his skin disability in December 2007. Although that examiner found that the Veteran did not have a current skin disorder and thus did not provide an opinion on etiology, he did note that the Veteran's complaints of dry skin were not likely due to exposure to petroleum products in service. The only medical evidence to support the Veteran's claim for service connection for a skin disability are the above-referenced May and October 2006 letters from his private physician, Dr. M. K. Although the May 2006 letter indicates that some of the Veteran's medical problems may be related to in-service exposures, the letter does not reference any skin disorders. As such, it is not probative evidence as to the etiology of the Veteran's skin disorder(s). In his October 2006 letter, Dr. M. K. notes that the Veteran has experienced chronic dermatitis on his hands and the back of his forearms. He concluded that the Veteran's skin disorder is as likely as not related to exposure to petroleum products in service. He bases his conclusion on an article discussing the dermatological effects of exposure to crude oil in Operation Desert Storm, stating that there was "no doubt" that the Veteran was exposed to some of the same petroleum products as soldiers in Operation Desert Storm. The Board finds this rationale unconvincing. There is no evidence that the Veteran was exposed to the same products during his service in the 1960s, nor is there any evidence that the conclusions made in the Operation Desert Storm article are generally applicable to exposures on ships decades earlier. The article is not specific to the Veteran and is not relevant to the Veteran's period or location of service. As Dr. M. K.'s opinion is based on an article discussing circumstances, locations, and dates of service dramatically different than the Veteran's, the Board finds it is less probative than the March 2010 VA examiner's opinion, which is based on the actual circumstances of the Veteran's service. As discussed above, the Board is free to favor one medical opinion over another as long as it provides an adequate basis for doing so. See Evans, supra; Owens, supra. Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens, supra. Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean, supra. Here, the Board finds Dr. M. K.'s May 2006 opinion is not probative as to the Veteran's skin disability claim, as it does not discuss this disability. Further, the Board finds his October 2006 letter to be less probative than the March 2010 VA examiner's opinion. Dr. M. K.'s rationale is insufficient and based on general conclusions not applicable to the Veteran's particular case. As such, the Board finds Dr. M. K.'s opinions to be less probative than the March 2010 VA examiner's opinion and insufficient to grant service connection for a skin disability. As discussed in detail above, the Veteran has submitted internet research regarding petroleum product exposure, contaminated air in commercial airlines, and oil fire pollutants and the possible health effects thereof, including skin problems. He claims that these articles are sufficient to grant service connection for a skin disability. However, the Board finds that the articles are not probative evidence as they do not specifically relate to the Veteran's particular case. Indeed, the articles do not contain any analysis regarding the Veteran's conceded exposure to asbestos, jet fuel, and/or lead paint and the possible relationship to his current condition, including consideration of other factors such as sun exposure and the natural aging process. Medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin, supra. However, the Court has held that medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. See Obert, supra; see also Beausoleil, supra; Libertine, supra. Unlike the highly probative March 2010 VA examiner's opinion, the internet research submitted by the Veteran is both inconclusive and general. As such, these articles are not sufficient to warrant a grant of service connection for a skin disability. The only remaining evidence which purports to relate the Veteran's skin complaints to his in-service asbestos, jet fuel, and/or lead paint exposure consists of his own statements and those of his representative. However, laypersons, such as the Veteran and his representative, are not competent to determine the etiology of a particular diagnosis. See Espiritu, supra; see also 38 C.F.R. § 3.159 (a)(1) (2011). Without medical training, the Veteran and his representative are simply not competent to opine on the etiology of his currently diagnosed skin lesions. Thus, there is no competent and probative medical evidence to provide a nexus between the Veteran's service and his current skin disorder(s). The Board is aware of the provisions of 38 C.F.R. § 3.303(b), referenced above, relating to chronicity and continuity of symptomatology. However, the Veteran has not claimed that he has experienced skin symptoms since service. Rather, at his March 2010 VA examination, he failed to provide a date of onset of symptoms and only stated that his first skin evaluation was in the 1980s, over a decade after separation from service. As such, the medical nexus element of Hickson cannot be met via continuity of symptomatology. As explained above, the competent medical evidence of record does not demonstrate that there is a relationship between the Veteran's active duty service, including any exposure to asbestos, jet fuel, and/or lead paint and his currently diagnosed skin disorder. Although the Board notes the Veteran's current disability and in-service exposures, without evidence of a medical nexus, service connection cannot be granted. Accordingly, the Board finds that the claim of entitlement to service connection for a skin disability, to include as due to exposure to asbestos, jet fuel and/or lead paint, 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 Veteran's claim of entitlement to service connection, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2011); see also Ortiz, supra. B. Increased rating The Veteran's service-connected deviated nasal septum has been evaluated as noncompensable disabling under Diagnostic Code 6502. He seeks a higher rating. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2011). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2011). Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2011). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R. § 4.31 (2011). The veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2011). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. See 38 C.F.R. § 4.14 (2011). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Under Diagnostic Code 6502, a 10 percent evaluation is assigned for traumatic deviation of the nasal septum with 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. See 38 C.F.R. § 4.97, Diagnostic Code 6502 (2010). The Veteran was afforded VA/VA-QTC examinations for his deviated nasal septum in December 2007 and March 2010. At the time of the December 2007 VA-QTC examination, the Veteran complained of constant sinus problems with difficulty breathing, but without incapacitating episodes. He reported that the sinusitis caused headaches, hoarseness, and pain, interfered with breathing through the nose, and necessitated the use of antibiotics for 4 to 6 weeks per year. He also indicated that he had surgery in 1964 with good results. Despite the Veteran's complaints, the examiner did not observe any sinusitis, rhinitis, nasal obstruction, loss of part of the nose, loss of part of the ala, scar, obvious disfigurement, or nasal polyps. The examination of the nose showed only a deviated nasal septum on the right. The examiner reported symmetric breath sounds with no rhonchi or rales and an expiratory phase within normal limits. X-rays of the nasal bone were also normal. The examiner diagnosed the Veteran with status post deviated nasal septum based on the Veteran's subjective reports nasal discharge and the objective abnormal findings outlined above. At the time of the March 2010 VA examination, the examiner observed no evidence of sinus disease, nasal obstruction, nasal polyps, septal deviation, permanent hypertrophy of turbinates from bacterial rhinitis, rhinoscleroma, or residuals of an injury to the pharynx or nasopharynx. The examiner did observe mild deformity of the right nares and minimal deformity of the nasal spine. The examiner tested both nares with nasal inhalation and exhalation and found both to be patent. He diagnosed the Veteran with minimal nasal deformity related to congenital cleft lip with repair and concluded that the Veteran's nasal deformity did not have any effects on his usual daily activities. The medical evidence of record does not establish that the Veteran's service-connected deviated nasal septum warrants a compensable disability rating under Diagnostic Code 6502 at any point throughout the appeals period. Although the Veteran has claimed that he experiences difficulty breathing and nasal obstruction, this is contradicted by the objective medical evidence. Notably, two examiners have concluded that the Veteran does not have nasal obstruction. There is simply no objective competent evidence of obstruction of the nasal passage at any point throughout the appeals period. Without such evidence, a compensable rating cannot be granted under Diagnostic Code 6502. With regard to a higher evaluation under other diagnostic codes, the Board has reviewed the remaining diagnostic codes relating to nasal disabilities and finds that they are not applicable. The Veteran has been specifically service connected for a deviated nasal septum. There is no evidence that his service-connected disability is manifested by loss of part of the nose or scars or sinusitis. Again, the Board notes the Veteran's lay contentions of constant sinusitis. However, this claim is not supported by the medical evidence. The Veteran's VA treatment records have been included in the claims file and are negative for diagnoses of one or two incapacitating or three to six non-incapacitating episodes of sinusitis per year. Moreover, there is no evidence that any sinusitis is a manifestation of his service-connected deviated nasal septum. Thus, an increased rating cannot be assigned under Diagnostic Codes 6504-6514. See 38 C.F.R. § 4.97, Diagnostic Codes 6504-6524 (2011). Further, there is no indication in the medical evidence of record that the Veteran's deviated nasal septum warranted other than the currently assigned noncompensable disability rating throughout the appeal period. As such, assignment of staged ratings is not warranted. See Hart, supra. Accordingly, the Veteran's claim of entitlement to a compensable disability rating for a deviated nasal septum 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 Veteran's claim of entitlement to an increased rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2011); see also Ortiz, supra. The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2011); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court set forth a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. The evidence of record does not reflect that the Veteran's disability picture is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The rating criteria for the Veteran's currently assigned noncompensable disability rating contemplate his symptoms. Additionally, the Board considered any other applicable disability codes relating to the nose. Thus, the Board finds that the Veteran's disability picture is adequately contemplated by the rating schedule. As such, the threshold issue under Thun is not met for the Veteran's deviated nasal septum, and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. In short, the evidence does not support the proposition that the Veteran's service-connected deviated nasal septum presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2011). Thus, referral of this issue to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. ORDER Entitlement to service connection for a bilateral ankle disability is denied. Entitlement to service connection for arthritis of the feet and toes is denied. Entitlement to service connection for a skin disability is denied. Entitlement to a compensable disability rating for a deviated nasal septum is denied. REMAND After a thorough review of the Veteran's claims file, the Board has determined that additional evidentiary development is necessary prior to the adjudication of the Veteran's claims of entitlement to service connection for depression and anxiety, GERD, and an epididymal cyst, all to include as due to exposure to asbestos, jet fuel and/or lead paint. With regard to the Veteran's claim for service connection for depression and anxiety, the Veteran was afforded a VA mental disorders examination in April 2010. The examiner diagnosed the Veteran with depressive disorder not otherwise specified (NOS) and concluded that "not being able to work, which appears to be from exposure to toxic substances during service, has more likely than not contributed significantly to his depression." She provided no further clarification or opinion on the etiology of the Veteran's psychiatric disorder. As it is unclear from the examiner's statement whether the Veteran's psychiatric disorder is the result of his military service, including exposure to asbestos, jet fuel, and/or lead paint, the issue must be remanded for an addendum opinion. See Barr, supra. With regard to the Veteran's claim for service connection for GERD, the Veteran was afforded a VA general medical examination in March 2010. At that time, the examiner concluded that the Veteran's GERD was not related to his in-service asbestos, jet fuel, or lead paint exposure. However, the examiner failed to provide an opinion on whether the Veteran's GERD was incurred in service, based on his reports of antacid use and heartburn symptoms in service, as corroborated by a July 2009 buddy statement from R. O. D. In light of this deficiency, this issue must also be remanded for an addendum opinion. See Barr, supra. With regard to the Veteran's claim for service connection for an epididymal cyst, the Veteran was afforded a VA general medical examination in March 2010, as noted above. The March 2010 examination report indicates that the Veteran denied having an "epipymal" cyst or a claim for such and declined a genitourinary examination. Accordingly, the examiner failed to provide an opinion on the etiology of the Veteran's previously diagnosed epididymal cyst. Rather, he provided an opinion on the etiology of the Veteran's epidermal cysts. Although the examiner was unable to diagnose an epididymal cyst on examination, the treatment records reflect such a diagnosis. As such, the issue must be remanded for the VA examiner to provide an addendum opinion based on the medical evidence of record. As the Court explained in Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991), the Board may consider only independent medical evidence to support its medical findings. The Court went on to say that, if the medical evidence of record is insufficient, the Board is free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. See Colvin at 175. For the reasons described above, the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, must be remanded for addendum opinions. Accordingly, the case is REMANDED for the following actions: 1. The claims file should be returned to the March 2010 VA examiner for clarification of his opinion on the etiology of the Veteran's claimed GERD and epididymal cyst. The Veteran may be recalled for examination if deemed necessary. With regard to the Veteran's claimed GERD, the examiner should state whether the Veteran's currently diagnosed GERD was incurred or aggravated in service, in light of his assertions of antacid use and heartburn symptoms in service. With regard to the Veteran's claimed epididymal cyst, the examiner should state whether the Veteran's diagnosed epididymal cyst was caused or aggravated by his military service, to include exposure to asbestos, jet fuel and/or lead paint, based on the medical evidence of record. If the March 2010 examiner is unavailable, the Veteran must be scheduled for a VA examination(s) with an appropriate examiner(s) to determine the nature and etiology of his claimed GERD and epididymal cyst, with consideration of the March 2010 examination report and the Veteran's contentions of antacid use and heartburn in service. The examiner(s) must review pertinent documents in the Veteran's claims file in conjunction with the examination. This must be noted in the examination report. The examiner(s) must state whether it is at least as likely as not that the Veteran's GERD and epididymal cyst were caused or aggravated by his active duty service, to include exposure to asbestos, jet fuel, and/or lead paint. It would be helpful if the examiner(s) would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner(s) should provide a complete rationale for any opinion provided. 2. The claims file should be returned to the April 2010 VA psychiatric examiner for clarification of her opinion. Specifically, the examiner must state whether the Veteran's currently diagnosed depressive disorder NOS was caused or aggravated by his military service, to include exposure to asbestos, jet fuel and/or lead paint. The Veteran may be recalled for examination if deemed necessary. If the April 2010 VA examiner is unavailable, the Veteran must be scheduled for a VA mental disorders examination with an appropriate examiner to determine the nature and etiology of any psychiatric disorder(s). The examiner must review pertinent documents in the Veteran's claims file in conjunction with the examination, including the Veteran's contentions of depression since service. That such a review was conducted must be noted in the examination report. The examiner must state whether it is at least as likely as not that any current acquired psychiatric disorder(s) was caused by his active duty service, including exposure to asbestos, jet fuel, and/or lead paint. The examiner should also comment on the April 2010 VA psychiatric examination. If the examiner diagnoses the Veteran with a personality disorder, s/he must state whether the Veteran also has an acquired psychiatric disorder that is superimposed upon the personality disorder. It would be helpful if the examiner would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner should provide a complete rationale for any opinion provided. 3. After completing the above actions and any other development that may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims of entitlement to service connection for depression and anxiety, GERD, and an epididymal cyst, all to include as due to asbestos, jet fuel, and/lead paint exposure, should be readjudicated. If any of the claims remains denied, a supplemental statement of the case should be provided to the Veteran and his representative. After they have had an adequate opportunity to respond, all issues properly on appeal should be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claims, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. See 38 C.F.R. § 3.655 (2011). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2011). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs