Citation Nr: 1307013 Decision Date: 03/01/13 Archive Date: 03/11/13 DOCKET NO. 09-32 042 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for tremors of the feet. 2. Entitlement to service connection for tremors of the hands. 3. Entitlement to service connection for migraine headaches. 4. Entitlement to service connection for diabetes mellitus. 5. Entitlement to service connection for a left adrenal gland disability. 6. Entitlement to service connection for a renal disability. 7. Entitlement to service connection for hypertension. 8. Entitlement to service connection for heart disease. 9. Entitlement to service connection for lung cancer. 10. Entitlement to service connection for asbestos exposure. 11. Entitlement to service connection for tinnitus. 12. Entitlement to service connection for bilateral hearing loss. 13. Entitlement to service connection for pes planus. 14. Entitlement to service connection for a left hand/thumb disability. 15. Entitlement to service connection for ingrown toenails. 16. Entitlement to service connection for gastroesophageal reflux disease (GERD). 17. Entitlement to service connection for a hiatal hernia. REPRESENTATION Appellant (the Veteran) is represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from July 1960 to June 1964. This appeal comes before the Board of Veterans' Appeals (Board) from a February 2007 rating decision of the RO in Huntington, West Virginia. Although the Veteran requested a local hearing with a Decision Review Officer with his August 2009 substantive appeal, he withdrew the request in correspondence received in November 2009. In reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. The issues of entitlement to service connection for ingrown toenails, hearing loss, tinnitus, GERD, and hiatal hernia are addressed in the REMAND below and are therein REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the issues decided herein has been accomplished. 2. The Veteran did not engage in combat with the enemy. 3. Tremors of the feet, tremors of the hands, migraine headaches, a left adrenal gland disability, lung cancer, and pes planus are not chronic diseases under 38 C.F.R. § 3.309(a) (2012). 4. Diabetes mellitus, renal disability, hypertension, and heart disease are chronic diseases under 38 C.F.R. § 3.309(a). 5. Symptoms of diabetes mellitus, a renal disability, hypertension, and heart disease were not chronic in service. 6. Symptoms of diabetes mellitus, a renal disability, hypertension, and heart disease have not been continuous since service separation. 7. There is no current disability of asbestos exposure; the Veteran does not have a current left thumb/hand disability, or pes planus. 8. The Veteran's current tremors of the feet, tremors of the hands, migraine headaches, diabetes mellitus, a left adrenal gland disability, a renal disability, hypertension, heart disease, lung cancer, and pes planus are not related to service. CONCLUSIONS OF LAW 1. Tremors of the feet were not incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. Tremors of the hands were not incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 3. Migraine headaches were not incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 4. Diabetes mellitus was not incurred in service and is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 5. A left adrenal gland disability was not incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 6. A renal disability was not incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 7. Hypertension was not incurred in service and is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 8. Heart disease was not incurred in service; cardiovascular/renal disease is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 9. Lung cancer was not incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 10. The claim for service connection for asbestos exposure lacks legal merit. 38 U.S.C.A. §§ 1110, 1131, 7104 (West 2002); 38 C.F.R. § 3.303 (2012). 11. Pes planus was not incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 12. A left hand/thumb disability was not incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection - Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (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 present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (CAVC) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Certain specific conditions are considered chronic diseases under VA Law. These include the following: Anemia, primary; Arteriosclerosis; Arthritis; Atrophy, progressive muscular; Brain hemorrhage; Brain thrombosis; Bronchiectasis; Calculi of the kidney, bladder, or gallbladder; Cardiovascular-renal disease, including hypertension (This term applies to combination involvement of the type of arteriosclerosis, nephritis, and organic heart disease, and since hypertension is an early symptom long preceding the development of those diseases in their more obvious forms, a disabling hypertension within the 1-year period will be given the same benefit of service connection as any of the chronic diseases listed); Cirrhosis of the liver; Coccidioidomycosis; Diabetes mellitus; Encephalitis lethargica residuals; Endocarditis (This term covers all forms of valvular heart disease); Endocrinopathies; Epilepsies; Hansen's disease; Hodgkin's disease; Leukemia; Lupus erythematosus, systemic; Myasthenia gravis; Myelitis; Myocarditis; Nephritis; Other organic diseases of the nervous system; Osteitis deformans (Paget's disease); Osteomalacia; Palsy, bulbar; Paralysis agitans; Psychoses; Purpura idiopathic, hemorrhagic; Raynaud's disease; Sarcoidosis; Scleroderma; Sclerosis, amyotrophic lateral; Sclerosis, multiple; Syringomyelia; Thromboangiitis obliterans (Buerger's disease); Tuberculosis, active; Tumors, malignant, or of the brain or spinal cord or peripheral nerves; Ulcers, peptic (gastric or duodenal)(A proper diagnosis of gastric or duodenal ulcer (peptic ulcer) is to be considered established if it represents a medically sound interpretation of sufficient clinical findings warranting such diagnosis and provides an adequate basis for a differential diagnosis from other conditions with like symptomatology; in short, where the preponderance of evidence indicates gastric or duodenal ulcer (peptic ulcer). Whenever possible, of course, laboratory findings should be used in corroboration of the clinical data. 38 C.F.R. § 3.309(a). Where one of the above chronic diseases is shown to be chronic in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). 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, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Where a veteran served 90 days or more during a period of war or after December 31, 1946, and any of the chronic diseases listed above becomes manifest to a degree of 10 percent 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. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The CAVC has emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303(2007); Davidson v. Shinseki, 581 F.3d 1313(Fed. Cir. Sept. 14, 2009). Combat Rule In the case of a veteran who engaged in combat with the enemy in a period of war, lay evidence of in-service incurrence or aggravation of a disease or injury shall be accepted if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the lack of official record of such incurrence or aggravation. See 38 U.S.C.A. § 1154(b); Libertine v. Brown, 9 Vet. App. 521, 524 (1996); Collette v. Brown, 82 F.3d 389, 392-94 (Fed. Cir. 1996). The standard used to determine whether a veteran engaged in combat with the enemy is reasonable doubt, which is to be resolved in a veteran's favor. See VAOPGCPREC 12-99. The provisions of 38 U.S.C.A. § 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See Libertine, 9 Vet. App. at 522-23. The provisions of 38 U.S.C.A. § 1154(b) do not establish service connection for a combat veteran; it aids him by relaxing the adjudicative evidentiary requirements for determining what happened in service. Clyburn v. West, 12 Vet. App. 296, 303 (1999). Although the Veteran served during a period of war, the evidence does not suggest, and the Veteran does not contend, that he engaged in combat with the enemy, or that his claimed disabilities are related to combat. As such, the combat rule is not applicable. 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(d) (2012). Analysis of Service Connection for Asbestos exposure Although the RO adjudicated the issue of service connection for asbestos exposure, the Veteran simply noted on his claim form that he was exposed to asbestos, and he related lung cancer to such exposure. The issue by its very nature is a theory of causation for lung cancer, and is not an independent claim. The issue of service connection for lung cancer is addressed below, and the matter of whether additional development is necessary to determine asbestos exposure is addressed in the context of the duty to assist, also below. Congress has specifically limited entitlement to service-connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. § 1110. Hence, where the issue does not entail a current disability, but simply alleges exposure, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As established by the CAVC, the definition comports with the everyday understanding of disability, which is defined as an "inability to pursue an occupation because of physical or mental impairment." Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991). Where the law is dispositive, the claim must be denied due to a lack of legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001); Mason v. Principi, 16 Vet. App. 129 (2002). Analysis of Service Connection for Diabetes Mellitus Diabetes mellitus is a chronic disease listed under 38 C.F.R. § 3.309(a); therefore the presumption of service connection under 38 C.F.R. § 3.307 and the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) must be addressed. See Walker v. Shinseki, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb 21, 2013). In addition, certain diseases are deemed associated with herbicide exposure, under VA law, and these include Type 2 diabetes, 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, acute and subacute peripheral neuropathy, and respiratory cancers (cancer of the lung, bronchus, larynx, or trachea). The term acute and subacute peripheral neuropathy means transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of the date of onset. 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. 38 C.F.R. § 3.309(e). 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, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii). In this case, the RO has confirmed that the Veteran did not service in Vietnam, and the Veteran does not contend that he was present in Vietnam. Therefore, there is no presumption of service connection for any disability under these provisions. The Veteran does contend that he was exposed to Agent Orange, as he noted on his claim form; however, he does not contend that such exposure occurred in Vietnam. He specified that he was exposed to Agent Orange in the States. The RO requested any records concerning herbicide exposure from the National Personnel Records Center (NPRC), and received confirmation that there was no record of herbicide exposure. The Veteran was asked specifically to provide evidence or information regarding his alleged herbicide exposure in a April 2006 letter sent to him by the RO; however, while he responded to the letter, he provided no additional information or evidence regarding herbicide exposure. While the Department of Defense has confirmed the operational use, testing, and disposal of Agent Orange and other herbicides outside of Vietnam, including specific sites within the United States, such exposure is not presumed for any veteran. The Veteran here has provided no more than his bare assertion that he was exposed to Agent Orange. He has not provided the date and location of his alleged exposure. Despite a specific request for details of this exposure, he has provided none. The CAVC has held that VA's duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). It is the responsibility of veterans to cooperate with VA. See Caffrey v. Brown, 6 Vet. App. 377, 383 (1994); Olson v. Principi, 3 Vet. App. 480, 483 (1992). The Veteran's bare assertion that he was exposed to Agent Orange is not presumed to be either competent evidence or credible evidence. Without some description of the details of the exposure such as would allow the Board determine whether exposure was even possible, the Board must find that the Veteran was not exposed to Agent Orange or other herbicides in service. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that symptoms of diabetes mellitus were not chronic in service; symptoms of diabetes mellitus were not continuous after service; and the current diabetes mellitus is not related to service. Service treatment records reflect no treatment of diabetes mellitus in service. When examined for service separation, the endocrine system was found to be clinically normal. The Veteran has not described symptoms of or treatment for diabetes mellitus during service. Thus, symptoms of diabetes mellitus were not chronic in service. After service, the first reference to diabetes mellitus comes in VA outpatient records in 2004. At that time, it was noted that the Veteran had a history of diabetes mellitus. While the date of onset of diabetes mellitus is not established by the record, there is no evidence, including assertions, that diabetes mellitus became manifest to a compensable degree within a year of service separation. Moreover, there is no clinical evidence or assertion on the part of the Veteran that there was continuous symptomatology after service. The Veteran's principal assertion appears to be that his diabetes mellitus resulted from exposure to Agent Orange, an assertion which the Board has found to be false. There is no medical opinion that purports to relate current diabetes mellitus to service. While the Veteran believes his diabetes mellitus is related to service, he has not explained the basis of this belief outside of his assertion that he was exposed to Agent Orange at some unidentified location in the U.S. Again, the Board has found this assertion to be false. Therefore, based on the lack of any credible evidence relating current diabetes mellitus to service, the Board finds that service connection for diabetes mellitus is not warranted. 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); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Analysis of Service Connection for Tremors of the Feet and Hands Tremors of the feet and hands are not included among the chronic diseases listed under 38 C.F.R. § 3.309(a); therefore the presumption of service connection under 38 C.F.R. § 3.307 does not apply, and the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) do not apply. See Walker, No. 2011-7184. 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). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that tremors of the hands and feet are not related to service. On his claim form, the Veteran simply reported that he now has tremors in legs and hands. He has not asserted that he had such symptoms in service. Service treatment records reflect no injury or disease resulting in tremors of the feet and hands. When examined for service separation in June 1964, the lower extremities and neurological system were clinically normal. Thus, the weight of the evidence demonstrates that the Veteran did not have a disability manifested by tremors of the hands and feet at service separation. The first evidence of tremors of the hands and feet comes in the context of the current claim, more than 40 years after service separation. The Board acknowledges a VA outpatient record in June 2004 in which the Veteran reported that his feet and left arm became intermittently numb. These symptoms were not attributed to any specific diagnosis, and they appear facially different than the asserted tremors. There is no medical opinion that purports to relate current tremors of the hand or feet to service. While the Veteran believes they are related, he has not explained the basis of this belief. Accordingly, the Board concludes that his assertion is based on speculation. To the extent that he asserts a relationship to diabetes mellitus, or to herbicide exposure, the Board has found that service connection is not warranted for diabetes mellitus, and that the Veteran was not exposed to herbicides. Based on the lack of any conclusive evidence relating current tremors of the hands or feet to service, the Board finds that service connection for tremors of the hands or feet is not warranted. 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); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Analysis of Service Connection for Migraine Headaches Migraine headaches are not among the chronic diseases listed under 38 C.F.R. § 3.309(a); therefore the presumption of service connection under 38 C.F.R. § 3.307 does not apply, and the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) do not apply. See Walker, No. 2011-7184. 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). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that migraine headaches are not related to service. While the Veteran's VA outpatient records reflect that he has a current diagnosis of chronic headaches, service treatment records reflect no treatment for headaches of any type; and, when examined for service separation, the Veteran's head and neurological system were clinically normal. Thus, the weight of the evidence demonstrates that the Veteran did not have a headache disability at service separation. The first reference to chronic headaches comes in approximately 2003, almost 40 years after service separation. VA outpatient records reflect that the Veteran began seeking treatment for headaches in 2003. In a June 2004 pre-op history and physical, the Veteran reported that he had been experiencing headaches for the past 25 to 30 years, but for the past six months had been experiencing headaches all of the time. Thus, by the Veteran's report, headaches had onset at the earliest 30 years ago, in 1974, a decade after service separation. There is no medical opinion that purports to relate current migraine headaches to service. A January 2007 VA neurology consult reveals a possible link to sleep apnea, which is not a service-connected disability. While the Veteran believes that his headaches are related to service, he has not explained the basis of this belief. Accordingly, the Board concludes that his assertion is based on speculation. To the extent that he asserts a relationship to asbestos and/or herbicide exposure, the Board has found that the Veteran was not exposed to asbestos or herbicides in service. Based on the lack of any conclusive evidence relating current headaches to service, the Board finds that service connection for headaches is not warranted. 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); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Analysis of Service Connection for a Left Adrenal Gland Disability Diseases of the adrenal gland are not among the chronic diseases listed under 38 C.F.R. § 3.309(a); therefore the presumption of service connection under 38 C.F.R. § 3.307 does not apply, and the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) do not apply. See Walker, No. 2011-7184. 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). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that an adrenal gland disability is not related to service. On his claim form, the Veteran reported that he had the left adrenal gland removed in 1999 due to a non-cancerous tumor. He also reported that, in 2001, he had hernia repair surgery where his adrenal gland ruptured. He now has a large knot in left side which causes pain and discomfort. Service treatment records reflect no treatment for disease or injury of the adrenal gland. When examined for service separation, the endocrine system findings were clinically normal. After service, private treatment records from Logan General Hospital in October 1997 reflect that a biopsy was conducted, but that no metastatic tumor was found. Imaging in March 1998 revealed a left adrenal mass measuring 3.5cm by 3.5cm by 4.2cm. Thus, based on the Veteran's own assertion, the adrenal gland disability had onset several decades after service separation. Moreover, there is no medical opinion that purports to relate an adrenal gland disability to service. While the Veteran believes an adrenal gland disability is related to service, he has not explained the basis of this belief outside of an assertion that he was exposed to Agent Orange, an assertion which the Board has found to be false. Based on the lack of any credible evidence relating a current adrenal gland disability to service, the Board finds that service connection for an adrenal gland disability is not warranted. 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); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Analysis of Service Connection for a Renal Disability Nephritis and cardiovascular-renal disease are chronic diseases listed under 38 C.F.R. § 3.309(a); therefore the presumption of service connection under 38 C.F.R. § 3.307 and the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) must be addressed. See Walker, No. 2011-7184. Service connection may also 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). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that a renal disability was not chronic in service; a renal disability was not continuous after service; and current renal disability is related to service. Service treatment records reflect no injury or disease of the kidneys. When examined for service separation, the urinary system was clinically normal. Thus, symptoms of renal disability were not chronic in service. After service, the first reference to a kidney disability comes in the context of the current claim. Imaging in May 2005 revealed an enlarged left kidney. There is no clinical evidence or assertion on the part of the Veteran that there was continuous symptomatology after service, or that nephritis or renal disease became manifest within a year of service. There is no medical opinion that purports to relate a renal disability to service. While the Veteran believes it is related to service, he has not explained the basis of this belief. Accordingly, the Board concludes that his assertion is based on speculation. Based on the lack of any conclusive evidence relating current renal disability to service, the Board finds that service connection for the claimed renal disability is not warranted. 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); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Analysis of Service Connection for Hypertension Hypertension is a chronic disease listed under 38 C.F.R. § 3.309(a); therefore the presumption of service connection under 38 C.F.R. § 3.307 and the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) must be addressed. See Walker, No. 2011-7184. Service connection may also 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). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that symptoms of hypertension were not chronic in service; symptoms of hypertension were not continuous after service separation; and the current hypertension is not related to service. On his claim form, the Veteran simply reported that he now has high blood pressure and takes medication. Service treatment records reflect no treatment for hypertension in service. When examined for service separation, the Veteran's blood pressure was 116/70. The vascular system was clinically normal. Thus, symptoms of hypertensions were not chronic in service. After service, the first reference to hypertension comes in VA outpatient records in 2004. At that time, it was noted that the Veteran had a history of hypertension; however, there is no clinical evidence or assertion on the part of the Veteran that hypertension became manifest to a compensable degree within a year of service separation, or that symptoms of hypertension were continuous after service. There is also no medical opinion that purports to relate current hypertension to service. While the Veteran believes hypertension is related to service, he has not explained the basis of this belief outside of an assertion that he was exposed to Agent Orange, an assertion which the Board has found to be false. To the extent that the Veteran asserts that hypertension is proximately due to or a result of diabetes mellitus, the Board has found that diabetes mellitus is not service-connected. Based on the lack of any credible evidence relating current hypertension to service, the Board finds that service connection for hypertension is not warranted. 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); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Analysis of Service Connection for Heart Disease Cardiovascular-renal disease is a chronic disease listed under 38 C.F.R. § 3.309(a); therefore the presumption of service connection under 38 C.F.R. § 3.307 and the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) must be addressed. See Walker, No. 2011-7184. Service connection may also 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). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that symptoms of heart disease were not chronic in service; symptoms of heart disease were not continuous after service separation; and the current heart disease is not related to service. Service treatment records reflect no disease or injury to the heart. When examined for service separation, the heart and chest were clinically normal. Thus, symptoms of hypertensions were not chronic in service. After service, the first reference to heart disease comes in VA outpatient records in 2004. At that time, it was noted that the Veteran had a history of coronary artery disease and myocardial infarction and a stent. Records also show procedures in August 1999, July 2005, October 2009, February 2010, and September 2011. There is no clinical evidence or assertion on the part of the Veteran that heart disease became manifest to a compensable degree within a year of service separation, or that symptoms of heart disease were continuous after service. On his claim form, the Veteran reported that he had a heart catheterization in August 1999 followed by implant of stents at Charleston Area Medical Center. There is no medical opinion that purports to relate heart disease to service. While the Veteran believes his heart disease is related to service, he has not explained the basis of this belief outside of an assertion that he was exposed to Agent Orange, an assertion which the Board has found to be false. To the extent that the Veteran asserts that heart disease is proximately due to or a result of diabetes mellitus, the Board has found that diabetes mellitus is not service-connected. Based on the lack of any credible evidence relating current heart disease to service, the Board finds that service connection for a heart disability is not warranted. 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); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Analysis of Service Connection for Lung Cancer Lung cancer is not among the chronic diseases listed under 38 C.F.R. § 3.309(a); therefore the presumption of service connection under 38 C.F.R. § 3.307 does not apply, and the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) do not apply. See Walker, No. 2011-7184. Service connection may also 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). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that the Veteran's lung cancer is not related to service. Service treatment records reveal no injury or disease of the lungs. When examined for service separation, lungs and chest were clinically normal. After service, private treatment records from Logan General Hospital in August 1997 reflect that a non-small cell carcinoma was excised. Thus, the first reference to lung cancer comes more than 30 years after service separation. There is also no medical opinion that purports to relate lung cancer to service. While the Veteran believes lung cancer is related to service, he has not explained the basis of this belief outside of an assertion that he was exposed to asbestos, an assertion which the Board has found to be unverified in the record. Based on the lack of any credible evidence relating a current lung cancer to service, the Board finds that service connection for lung cancer is not warranted. 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); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Analysis of Service Connection for Pes planus Pes planus is not among the chronic diseases listed under 38 C.F.R. § 3.309(a); therefore the presumption of service connection under 38 C.F.R. § 3.307 does not apply, and the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) do not apply. See Walker, No. 2011-7184. Service connection may also 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). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that the Veteran does not have pes planus. When examined at service separation, the Veteran's feet were clinically normal. He was assigned a physical profile (PULHES) score of L-1. PULHES is the six categories into which a physical profile is divided. The P stands for physical capacity or stamina; the U for upper extremities; the L for lower extremities; the H for hearing and ear; the E for eyes; and the S stands for psychiatric). The number 1 indicates that an individual possesses a high level of medical fitness and, consequently, is medically fit for any military assignment. Odiorne v. Principi, 3 Vet. App. 456, 457 (1992). After service, the first reference to pes planus comes in the context of the current claim, more than 40 years after service separation. However, there is no clinical diagnosis of pes planus. A March 2011 podiatry clinic note reveals that the Veteran's feet were examined and that the only diagnoses were diabetic toes, onychomycosis, and tinea pedis. The Veteran has not asserted any of these diagnoses are related to service, and service connection is not in effect for diabetes mellitus. Congress has specifically limited entitlement to service-connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. § 1110. Hence, where there is no current disability, there can be no valid claim for service connection. See Gilpin, 155 F.3d 1353; Brammer, 3 Vet. App. at 225. As the Veteran does not have a current diagnosis of pes planus, the Board finds that service connection for pes planus is not warranted. 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); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Analysis of Service Connection for a Left Hand/Thumb Disability Arthritis is a chronic disease listed under 38 C.F.R. § 3.309(a); therefore the presumption of service connection under 38 C.F.R. § 3.307 and the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) must be addressed. See Walker, No. 2011-7184. Service connection may also 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). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that the Veteran does not have a current left thumb/hand disability. The Veteran has not identified the nature or origin of his claimed left hand/thumb disability. The Veteran was treated in service for an injury to the right thumb, and service connection has been granted for that disability. Service treatment records reflect no injury or disease of the left hand or thumb. With the exception of the right thumb disability, the examination for service separation reflects no disability of the upper extremities. Congress has specifically limited entitlement to service-connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. § 1110. Hence, where there is no current disability, there can be no valid claim for service connection. See Gilpin, 155 F.3d 1353; Brammer, 3 Vet. App. at 225. Accordingly, the Board finds that service connection for a left thumb/hand disability is not warranted. 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); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (CAVC) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (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. In this case, the Veteran submitted his claim for service connection in March 2006. He was sent letters in April 2006 and December 2006, which advised him of the information and evidence necessary to substantiate his claims. Those letters also advised him as to how disability ratings and effective dates were assigned in the event of a successful claim seeking service connection. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Since the letters were sent to the Veteran prior to the initial adjudication of the claim in February 2007, there exists no error in the timing of this notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). In short, VA has complied with its duty to notify the Veteran in this case. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records, private records submitted by the Veteran, and the Veteran's written assertions regarding his claims. The Board finds that a VA examination is not necessary regarding the claims decided here. 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. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the CAVC 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). The Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service would not suffice to meet the standard of subsection (B), as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Here, the record as to each of the claims decided establishes no disease or injury in service and normal clinical findings at service separation. The only evidence that the Veteran's claimed disabilities are related to his military service is his own conclusory generalized lay statements, which are unsupported by even speculative medical evidence. Accordingly, the Board finds that referral for a VA medical examination is not warranted for any of the issues decided. In the January 2013 informal hearing, the Veteran's representative referred to a statement attached to the original application for benefits which refers to SHAD/Project 112. The representative notes that VA has not fully developed this contention by the Veteran, and that the appellant should be scheduled for a VA examination to determine whether he has any disabilities that have been attributed to SHAD tests. SHAD is an acronym for Shipboard Hazard and Defense, that was part of a larger effort called Project 112. This was a comprehensive program initiated in 1962, by the Department of Defense to protect and defend against potential chemical and biological warfare threats. See http://www.publichealth.va.gov/exposures/ shad/index.asp. Project 112 tests involved tests conducted on land rather than aboard ships. Project SHAD involved service members from the Navy and Army and may have involved a small number of personnel from the Marine Corps and Air Force. Service members were not test subjects, but rather were involved in conducting the tests. In this case, the Veteran has never suggested that he was involved in Project SHAD/112. More importantly, he has never provided any details regarding his involvement, such as where he was stationed and what his role might have been. Indeed, the only reference to project SHAD/112 in the claims file, aside from the reference in the informal hearing, comes from an unsigned note attached to the Veteran's claim, which is apparently not written by the Veteran, as it addresses him by name. Under the heading for renal problems, it states, "address possible exposure to SHAD and Project 112." In response, the RO sent a letter to the Veteran in April 2006 referring to Project SHAD and asking him to provide the name of the test in which he participated, identify the date and location of the test, identify the name of the ship he was on during the test, and identify the specific disabilities he was claiming as a result of participation in SHAD. The Veteran never provided this information. The Board finds that there is no reasonable possibility that further development would substantiate the unspecified claim based on participation in Project Shad/112. The reference to this project appears to be mere speculation from an individual counseling the Veteran on his claims. The Board reiterates that the Veteran has never mentioned Project SHAD and has never provided the information requested of him by the RO. The Veteran returned a copy of the April 2006 letter in June 2006 with hand-written notes regarding questions pertaining to asbestos exposure; however, he made no notation on the questions pertaining to participation in Project SHAD/112. The duty to assist is not a license for a fishing expedition to determine if there might be some unspecified information which could possibly support a claim. See Counts v. Brown, 6 Vet. App. 473, 478-9 (1994), Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992). In this case, the Board finds that there is no reasonable possibility that further development would benefit the Veteran. See Soyini v. Derwinski, 1 Vet. App. 541 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis, 6 Vet. App. at 430 (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). Regarding the Veteran's assertion that he was exposed to asbestos in the service, and that his lung cancer resulted from such exposure, the information provided regarding actual exposure consists of the Veteran having checked a box on the claim form indicating that he was exposed to asbestos. When asked by the RO for details regarding his exposure, he replied that he lived in barracks with steam heat. To the extent that the Veteran contends that he was exposed to asbestos by some unspecified instrumentality of steam heating, the Board finds that this evidence is not competent. While the Veteran is competent to relate events that come to him through his senses, and conceivably possess the competence to identify asbestos or to relate information conveyed to him through official sources as to the asbestos content of certain materials, the Veteran has not described any particular training or specialized knowledge that would allow him to personally identify the asbestos content of steam heating apparatus. He has also not described or provided any official notice that was provided to him regarding these matters. That the buildings he worked in were heated by steam is not competent evidence of asbestos exposure. While it may have been common knowledge among those in the buildings that there was asbestos in the building, this is also not competent evidence of exposure. These assertions amount to mere speculation on the Veteran's part. Accordingly, no additional development is warranted on the basis of the claimed asbestos exposure. While not adjudicated as an issue on appeal, the Veteran has noted that his service involved repair of radar equipment. The Board simply notes that the CAVC has taken judicial notice that radar equipment emits microwave-type non-ionizing radiation which is not subject to review under the ionizing radiation law and regulations. Rucker v. Brown, 10 Vet. App. 67 (1997) citing The Microwave Problem, Scientific American, September 1986; Effects upon Health of Occupational Exposure to Microwave Radiation (RADAR), American Journal of Epidemiology, Vol. 112, 1980; and Biological Effects of Radiofrequency Radiation, United States Environmental Protection Agency, September 1984. Therefore, to the extent that the Veteran asserts that any disability was a result of exposure to emissions from a radar set, there are no presumptive provisions regarding this assertion, and no additional development is necessary. ORDER Service connection for tremors of the feet is denied. Service connection for tremors of the hands is denied. Service connection for migraine headaches is denied. Service connection for diabetes mellitus is denied. Service connection for a left adrenal gland disability is denied. Service connection for renal disability is denied. Service connection for hypertension is denied. Service connection for heart disease is denied. Service connection for lung cancer is denied. Service connection for asbestos exposure is denied. Service connection for pes planus is denied. Service connection for a left hand/thumb disability is denied. REMAND A remand is required to ensure that there is a complete record upon which to decide the issues of entitlement to service connection for bilateral hearing loss, tinnitus, ingrown toenails, GERD, and hiatal hernia. VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) (West 2002 & Supp. 2011); 38 C.F.R. § 3.159(c), (d) (2012). In order to establish service connection for a claimed disorder, generally, 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran maintains that he was treated for heartburn in service, and that he has current disability related symptoms noted in service. On his claim form, the Veteran reported that he underwent surgery for hiatal hernia in 1977 at Man Appalachian hospital, and again in 1978 at Charleston Area Medical Center. He now gets sick but cannot throw up. He reports that he had this when he got out of service. Service treatment records note treatment for heartburn on April 13. 1962. He was prescribed sodium bicarb tablets. When examined at service separation, his abdomen and viscera were clinically normal. On his claim form, the Veteran also reported that he was issued two different size boots when he entered the service -- size 7 and 7-1/2 -- and because of this, he had trouble with ingrown toenails on both feet. He reported that he underwent surgery to remove nail beds in 1966 at Stevens Clinic Hospital in Welch, West Virginia, when he was in the Reserves. Service treatment records show treatment for ingrown toenails in 1963. On March 18, 1963, ingrown toenails were cleaned and the top of the toenails were scraped. On March 22, 1963, the ingrown toenails were cleaned and dressed. On March 27, 1963, the ingrown toenails were cleaned and bandaged. A March 2011 VA podiatry consultation reveals nail and skin changes with notation of nail spicules on the medial 1st nails, bilaterally, since removal of nails in 1966. The assessment was onychomycosis and tinea pedis. A February 2012 podiatry clinic note reveals diagnoses of onychomycosis and onychocryptosis. Regarding hearing loss and tinnitus, service treatment records reflect that ears and drums were clinically normal at service separation. Whispered voice audiometric results were 15/15. The Veteran was assigned a physical profile score (PULHES) of H-1. While the record does not contain audiometric findings establishing a hearing loss disability for VA purposes, or any audiometric findings for that matter, the VA records show that the Veteran has been given hearing aids, and he does have a diagnosis of tinnitus. The Veteran is competent to describe symptoms of hearing loss and tinnitus as well as exposure to loud sounds in service. With respect to continuity of symptomatology, certain types of hearing loss (sensorineural) are subject to the provisions under 38 C.F.R. § 3.303(b). This case presents certain medical questions which cannot be answered by the Board. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (the Board is prohibited from exercising its own independent judgment to resolve medical questions). These questions concern the relationship, if any, between the Veteran's diagnosed GERD and hiatal hernia and his heartburn treatment in service. These questions must be addressed by an appropriately qualified medical professional. See Charles v. Principi, 16 Vet. App. 370 (2002); see also 38 C.F.R. § 3.159(c)(4) (2012) (a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim). In disability compensation (service connection) claims, VA must provide a medical examination and medical opinion when 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, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). With respect to the factor of relationship of current disability to service, the CAVC has indicated 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 a 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, 20 Vet. App. at 83; see also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service). Given the competent evidence of treatment for ingrown toenails in service, and the current diagnoses related to the toenails, given the competent evidence of treatment for heartburn in service and the current diagnoses of GERD and hiatal hernia, and given the competent evidence of noise exposure in service, and the Veteran's current diagnosis of tinnitus and his requirement of hearing aids, the Board finds that a VA examination with medical nexus opinion is required to determine whether the current toenail conditions, hearing loss, tinnitus, GERD, and hiatal hernia are causally related to service. Accordingly, the issues of entitlement to service connection for ingrown toenails, hearing loss, tinnitus, GERD, and hiatal hernia are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA evaluation(s) to determine the nature and etiology of his toenail conditions, GERD, and hiatal hernia. The relevant documents in the claims file should be made available to the VA examiner. The examiner is directed to consider the Veteran's treatment for ingrown toenails and heartburn in service and his post-service surgery for removal of toenails in 1966, and for hiatal hernia in 1977. For the purposes of the examination, the Veteran's service treatment records document treatment for ingrown toenails in March 1963, and for heartburn in April 1962. Service records show that the feet, abdomen, and viscera were clinically normal at service separation. The VA examiner is requested to offer an opinion as to whether it is at least as likely as not (i.e., to at least a 50-50 degree of probability) that any current disorder of the toenails is causally or etiologically related to the Veteran's active service. The VA examiner is requested to offer an opinion as to whether it is at least as likely as not (i.e., to at least a 50-50 degree of probability) that GERD and/or hiatal hernia are causally or etiologically related to the Veteran's active service. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but that the medical evidence for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. All opinions are to be accompanied by a rationale consistent with the evidence of record. If the requested medical opinion cannot be given, the examiner should state the reason(s) why. 2. Schedule the Veteran for a VA evaluation to determine the nature and etiology of his bilateral hearing loss and tinnitus. Audiometric testing should be conducted. The relevant documents in the claims file should be made available to the VA examiner. The VA examiner is requested to identify the type of hearing loss, if any, and confirm whether the Veteran has tinnitus. The examiner is also requested to offer an opinion as to whether it is at least as likely as not (i.e., to at least a 50-50 degree of probability) that bilateral hearing loss and/or tinnitus is causally or etiologically related to the Veteran's active service. All opinions are to be accompanied by a rationale consistent with the evidence of record. If the requested medical opinion cannot be given, the examiner should state the reason(s) why. 3. Readjudicate the remanded claims for service connection for ingrown toenails, bilateral hearing loss, tinnitus, GERD, and hiatal hernia. If any benefit sought on appeal is not granted, the Veteran and his representative should be provided a supplemental statement of the case and an appropriate time period for response. The case should then be returned to the Board for further consideration, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These issues 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. 2012). ______________________________________________ T. D. JONES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs