Citation Nr: 1313575 Decision Date: 04/23/13 Archive Date: 05/03/13 DOCKET NO. 08-11 945 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for arthralgia of the back and the right wrist and elbow, to include as due to an undiagnosed illness. REPRESENTATION Appellant represented by: National Association for Black Veterans, Inc. WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Nadine W. Benjamin, Counsel INTRODUCTION The Veteran served on active duty from December 1988 to November 1993. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a September 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, which denied the benefits sought on appeal. The Veteran appealed that decision to BVA, and the case was referred to the Board for appellate review. A hearing was held at the RO in July 2009, conducted by a Decision Review Officer (DRO). In May 2012, the Veteran also presented testimony at a hearing conducted by the use of video conferencing equipment at the Muskogee RO before Kathleen K. Gallagher, a Veterans Law Judge (VLJ) sitting in Washington, D.C. Transcripts of the hearings are in the claims file. In August 2012, the Board remanded this claim for additional development. The Board is satisfied that there was substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In this regard, the Veteran was examined and nexus opinions were obtained. The case has been returned to the Board and is ready for further review. FINDINGS OF FACT 1. The Veteran was exposed to acoustic trauma during active service. 2. The current hearing loss is not related to service. 3. The Veteran had active military service in the Southwest Asia Theater of operations during the Persian Gulf War. 4. The Veteran's low back disorder is attributed to degenerative joint disease, a disability of the right wrist is attributed to tendonitis and a disability of the right elbow is attributed to tendonitis, all of which are known clinical diagnoses and which were not manifested in service or within one year of discharge from active service and are not otherwise shown to be related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for hearing loss have not been met. 38 U.S.C.A. §§ 101(16), 1110, 1112, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2012). 2. Arthralgia of the low back, right wrist and right elbow, including as due to undiagnosed illness, was not incurred in or aggravated during active service nor may arthritis be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 1112, 1117, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 2004). 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. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, proper VCAA notice was provided to the Veteran in May 2006. The letter addressed all of the notice elements and was sent prior to the initial unfavorable decision by the RO in September 2006. The duty to assist was also met in this case. All pertinent service treatment records, service personnel records, VA treatment records, and private treatment records have been obtained and associated with the file. VA examinations with respect to the issues on appeal were obtained. 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are adequate, as they were predicated on a full reading of the private and VA medical records in the Veteran's claims file. The examiners considered all of the pertinent evidence of record and the statements of the appellant, and the examiners provided a complete rationale for opinions stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). The available records and medical evidence have been obtained in order to make adequate determinations as to this claim. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110. 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). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, 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. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain chronic diseases may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year (three years for active tuberculous disease and Hansen's disease; seven years for multiple sclerosis) from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term "chronic disease" refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C.A. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). Organic diseases of the nervous system are included among the diseases listed as chronic diseases under the law. 38 U.S.C.A. § 1101(3); 38 C.F.R. § 3.309(a). VA considers high frequency sensorineural hearing loss to be an organic disease of the nervous system. See Memorandum from Under Secretary of Health to Under Secretary for Benefits, Characterization of High Frequency Sensorineural Hearing Loss, October 4, 1995; but see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). (noting in a claim for service connection for bilateral hearing loss that the Veteran "seeks compensation for a condition that is not listed as a chronic disease in [section] 3.309(a)). Where a chronic disease under 3.309(a) is "shown as such in service" ("meaning clearly diagnosed beyond legitimate question" Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) , or in the presumptive period 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). In cases where a chronic disease is "shown as such in service", the Veteran is "relieved of the requirement to show a causal relationship between the condition in service and the condition for which service connected disability compensation is sought." " Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Instead, service connection may be granted for subsequent manifestations of the same chronic disease without any evidence of link or connection between the chronic disease shown in service and manifestations of the same disease at a later time. In other words, "there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. If evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not "shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned," i.e., "when the fact of chronicity in service is not adequately supported," then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. § 3.303(b). For claims for service connection for hearing loss or impairment, VA has specifically defined what is meant by a "disability" for the purposes of service connection. 38 C.F.R. § 3.385. "[I]mpaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent." 38 C.F.R. § 3.385. The threshold for normal hearing is from zero to 20 decibels, and higher threshold levels indicate some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Section 3.385 does not preclude service connection for a current hearing loss "disability" where hearing was within normal audiometric testing limits at separation from service. See Hensley, 5 Vet. App. at 159. When audiometric test results do not meet the regulatory requirements for establishing a "disability" at the time of the Veteran's separation, the Veteran may nevertheless establish service connection for a current hearing disability by submitting competent evidence that the current disability is the result of disease or injury in service. Id. at 160. 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. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. Under the provisions of specific legislation enacted to assist Veterans of the Persian Gulf War, service connection may be established for a qualifying chronic disability which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2011. 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317(a)(1)(i) (2012). The term "qualifying chronic disability" means a chronic disability resulting from an undiagnosed illness; a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined as a cluster of signs or symptoms; or, any diagnosed illness that VA determines in regulations warrants a presumption of service-connected. 38 U.S.C.A. § 1117(a)(2). Signs or symptoms that may be a manifestation of an undiagnosed illness or a chronic multisymptom illness include: (1) fatigue, (2) unexplained rashes or other dermatological signs or symptoms, (3) headache, (4) muscle pain, (5) joint pain, (6) neurological signs and symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the upper or lower respiratory system, (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, and (13) menstrual disorders. 38 U.S.C.A. § 1117(g). Among the requirements for service connection for a disability due to an undiagnosed illness is that such disability, by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). There must be no affirmative evidence that relates the undiagnosed illness to a cause other than being in the Southwest Asia Theater of operations during the Persian Gulf War. See 38 C.F.R. § 3.317(c). If signs or symptoms have been attributed to a known clinical diagnosis in the particular Veteran's case being considered, service connection may not be provided under the specific provisions pertaining to Persian Gulf Veterans. See VAOPGCPREC 8-98 at paras. 4-5 (Aug. 3, 1998). The term "Persian Gulf Veteran" means a Veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(d)(1). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(d)(2). There is evidence that the Veteran is a "Persian Gulf Veteran" and can avail himself of the provisions relating to undiagnosed illness pursuant to 38 C.F.R. § 3.317 . The identification of a diagnosis, per se, renders consideration of an "undiagnosed illness" under statute and regulation inappropriate. See VAOGCOP 8-98 (In addressing the question of whether VA may pay compensation under 38 U.S.C.A. § 1117 for disability manifested by symptoms that either elude diagnosis or are attributed to a poorly- defined disease such as chronic fatigue syndrome or fibromyalgia, it is held that section 1117(a) authorizes service connection on a presumptive basis only for disability arising in Persian Gulf Veterans due to "undiagnosed illness" and may not be construed to authorize presumptive service connection for any diagnosed illness, regardless of whether the diagnosis may be characterized as poorly defined.). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The Board is obligated under 38 U.S.C.A. § 7104(d) (West 2002) to analyze the credibility and probative value of all evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide reasons for its rejection of any material evidence favorable to the Veteran. See Eddy v. Brown, 9 Vet. App. 52 (1996); Meyer v. Brown, 9 Vet. App. 425 (1996); Gabrielson v. Brown, 7 Vet. App. 36 (1994). The Board has the authority to "discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Court has held that the Board may not reject medical opinions based on its own medical judgment. See Obert v. Brown, 5 Vet. App. 30 (1993). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider is weighed by such factors as its thoroughness and degree of detail, and whether there was review of the Veteran's claims file. Prejean v. West, 13 Vet. App. 444 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379 (1998). See also Claiborne v. Nicholson, 19 Vet. App. 181 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the Veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345 (1998). Hearing Loss The Evidence The Veteran claims that his exposure to noise in service caused his current hearing loss. He states that he served as a Fire Control Systems Repairman where he tested and repaired weapons. This is noted as his MOS on his DD Form 214. He also has claimed exposure to noise from combat vehicles while serving in South West Asia during the Gulf War. His DD Form 214 confirms service in South West Asia from October 1990 to April 1991. Thus exposure to acoustic trauma is conceded. The Veteran's service treatment records show at service entrance in November 1988, the Veteran denied a history of hearing loss and on audiometric testing pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 15 10 5 LEFT 0 0 5 10 5 His hearing profile was 1. During service, several audiograms were performed. No audiogram showed defective hearing. At separation in August 1993, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 5 15 15 25 LEFT 0 0 5 15 20 His hearing profile was 1. He denied having hearing loss. The Veteran was examined by VA in August 2006. The claims file was reviewed. It was noted that he served as a fire control systems repairman in service and worked on M1s, Bradleys, M16s and 60-caliber guns. He also stated he was in direct armed combat in the Gulf War, but never injured. On audiological evaluation pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 25 40 55 LEFT 30 20 20 35 50 Speech audiometry revealed speech recognition ability of 88 percent in both ears. The examiner found that the Veteran had mild to moderately severe sensorineural hearing loss 3000 to 8000 Hz. The examiner noted the audiograms during service, and stated that audiograms at entrance and separation were normal. She stated that therefore it is less likely than not that current threshold values are secondary to acoustic trauma during service. The Veteran was examined by VA in February 2008. His military history was documented. On audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 35 40 60 LEFT 25 25 20 40 45 Speech audiometry revealed speech recognition ability of 96 percent in both ears. The examiner stated that the claims file was reviewed and that at service entrance and exit, hearing was normal. The examiner stated that therefore it is less likely than not that current threshold values are secondary to acoustic trauma during service. In a private report dated in December 2010, it was stated that the Veteran reported that he had hearing loss due to noise exposure during service. It was noted that pure tone audiometry revealed normal to mild sensorineural hearing loss bilaterally. The examiner diagnosed binaural hearing loss. It was stated that after reviewing the history provided by the Veteran, it cannot be ruled out that his past history of acoustic trauma and exposure to hazardous noise while in the military are contributing factors to his current hearing threshold levels. The Veteran was examined by VA in September 2012. The claims file was reviewed. On audiological evaluation pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 15 30 55 LEFT 15 15 25 30 45 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 92 percent in the left ear. The examiner found that the hearing loss was not at least as likely as not caused by or a result of an event in military service. The examiner noted reviewing the audiometric examinations in the file including the examinations performed in service, the VA examinations and the private examiner's report. The examiner stated that the service records are noted to be absent of any consistent and significant shift or decrease in hearing sensitivity during service as well as his separation examination report on which he denies hearing loss for either ear. It was noted that on current examination there was a disabling degree of hearing loss bilaterally. The examiner stated that the file does not reveal significant evidence of an audiometric pattern consistent with acoustic trauma. The examiner reported that as to the private examiner's report, the opinion was provided without the benefit of a claims file review and is also somewhat in contrast to her audiometric findings that were neither consistent with a disabling degree of hearing loss for either ear according to VBA guidelines nor consistent with an audiometric pattern that was suggestive of or consistent with a pattern of hearing loss typically associated with a history of acoustic trauma. The examiner stated that thus, given hearing within normal limits for each ear at the time of discharge in 1983 and given the absence of any consistent significant decrease in hearing sensitivity during service, and given the absence of consistent or significant audiometric evidence suggestive of auditory damage due to acoustic trauma in review of the audiometric assessment, and in light of the absence of clinical or research evidence supportive of a delayed onset hearing loss attributable to noise exposure or acoustic trauma that occurs weeks, months or years after exposure, and given the Institute of Medicine's Report on "Noise and Military Service" that has concluded that there is currently no scientific evidence that supports delayed onset noise-induced hearing loss that occurs weeks, months, or years after the reported exposure event, it is less likely than not that the Veteran's current hearing loss is caused or the result of acoustic trauma encountered during military service. Analysis As noted, given the Veteran's Military Occupational Specialty and his service in South West Asia during the Gulf War, the Board concedes inservice exposure to acoustic trauma. There is no evidence of hearing loss during service or within the first year after separation from service. The Veteran asserts that his current hearing loss is due to noise exposure in the military. However his statements do not indicate that he had hearing loss, symptoms of decreased hearing, or difficulty hearing during service or within the first year after service. Thus, this is not a case where the chronic disease of sensorineural hearing loss under 3.309(a) (other organic diseases of the nervous system) was "shown as such in service," i.e., "meaning clearly diagnosed beyond legitimate question", or in the presumptive period so as to permit a finding of service connection, such that 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); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Therefore, in this case the Veteran is not "relieved of the requirement to show a causal relationship between a condition in service and the condition for which service connected disability compensation is sought," and this is not a case where service connection may be granted for subsequent manifestations of the same chronic disease without any evidence of link or connection between a chronic disease shown in service and manifestations of the same disease at a later time. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Moreover, this is not a case where evidence of a chronic condition was noted during service or during the presumptive period, but the chronic condition was not "shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned," i.e., "when the fact of chronicity in service is not adequately supported," so that then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. § 3.303(b). Instead, this is a case where the chronic condition of sensorineural hearing loss was not noted in service at all. Therefore, the provisions of section 3.303(b) do not apply here, and evidence of a nexus between current bilateral hearing loss and a disease or injury in service is required for service connection in this case. 38 C.F.R. § 3.303(a), (d). With regard to a link or nexus between current hearing loss and a disease or injury in service, including noise exposure, the Board notes that the earliest evidence of record demonstrating that the Veteran complained of or was treated for bilateral hearing loss was his May 2006 claim, which was dated several years after his service discharge. This nearly 13-year period without complaints or treatment for hearing loss may be considered, along with other factors, with regard to whether an injury or a disease in service resulted in any continuous or persistent disability. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (noting that a prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability). Moreover, during the pendency of this appeal, the Veteran has not specifically asserted that he experienced bilateral hearing loss during and continuously after his active duty service. The VA examiner in 2012 stated that evidence provided by the Veteran in conjunction with the review of the claims file clearly documents the onset of hearing loss following discharge from service. Lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno, 6 Vet. App. at 469-70. Lay evidence is competent and sufficient in certain instances related to medical matters. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Specifically, such instances include establishing a diagnosis of a condition when (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Id. at 1377. Similarly, when a disorder 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. Barr, 21 Vet. App. at 307. As the Veteran has not claimed that he had hearing loss in service which continued thereafter, a discussion on competency and credibility of lay evidence with regard to hearing loss is not necessary in this case. Rather, the issue in this case with whether a current bilateral hearing loss is the result of noise exposure in service. The Board concludes that this question is a matter requiring expert evidence for its support and resolution, rather than lay evidence, because it requires medical or audiological training to determine the specific etiology or likely cause of hearing loss in a given set of circumstances or an individual case. Before proceeding to this question, the Board notes first that the evidence of record demonstrates current a diagnosis of bilateral hearing loss. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim). Second, the Board has already conceded exposure to inservice acoustic trauma. Accordingly, as noted above, the salient issue with respect to the Veteran's claim is an etiological nexus between the current diagnosis and the inservice acoustic trauma(s). See Hickson, 12 Vet. App. at 253; see also Pond, 12 Vet App. at 346. The Board observes that there were four opinions of record addressing the etiological relationship between the Veteran's current bilateral hearing and his active duty service. The opinions were rendered by VA audiologists and a private audiologist. In deciding this appeal, the Board must weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). The Board is also mindful that it cannot make its own independent medical determination, and that there must be plausible reasons for favoring one medical opinion over another. Evans v. West, 12 Vet. App. 22, 31 (1998). The Board may favor the opinion of one competent medical expert over that of another provided the reasons therefore are stated. Winsett v. West, 11 Vet. App. 420, 424-25 (1998). Factors that may be considered in assessing the probative value of a medical opinion include a physician's access to the claims file or pertinent evidence, the thoroughness and detail of the opinion, the accuracy of the factual premise underlying the opinion, the scope of examination, the rationale for the opinion offered, the degree of certainty provided, and the qualifications and expertise of the examiner. See generally Prejean v. West, 13 Vet. App. 444, 448-89 (2000); Sklar v. Brown, 5 Vet. App. 140 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993); Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board is more persuaded by the opinion rendered by the September 2012 VA examiner than the opinion provided by the private examiner. Schoolman, 12 Vet. App. at 310-11; Winsett v. West, 11 Vet. App. at 424-25; Reonal, 5 Vet. App. at 460-61. With respect to the private examiner's statement, the audiologist did not have the claims file and based her opinion on the history of noise exposure in service provided by the Veteran. Although noise exposure in service has been conceded, the private audiologist's statement is less persuasive than the most recent VA examiner's opinion because the private examiner did not address the Veteran's normal audiogram results upon testing in service. Moreover, although she stated that acoustic trauma and hazardous noise in the military could not be ruled out as a contributing factor to his current hearing loss she did not state whether current hearing loss was at least as likely the result of those factors as it was the result of any other cause or factors involved in the development of sensorineural hearing loss. In short, she provided no explanation or reason for the conclusion she reached. Thus, the opinion is speculative and not supported by rationale. A medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. See Bloom v. West, 12 Vet. App. 185, 187 (1999), As to the August 2006 and February 2008 VA opinions, the Board also finds that they are inadequate and are of little probative value since they were based solely on a lack of inservice findings of hearing loss. However, the September 2012 VA examiner administered a thorough audiological evaluation, including measuring the Veteran's puretone thresholds; reviewed the Veteran's service treatment records; considered the Veteran's statements; considered other etiologies; and offered a detailed rationale. Therefore, the Board finds the September 2012 VA examiner's opinion to be highly probative. In sum, to the extent that the Veteran asserts that his current bilateral hearing loss is related to his active duty service, the Board finds that the matter of the determination of the origin of hearing loss, where the credible evidence first demonstrates such disorder many years after service, is more suited to the realm of medical, rather than lay expertise. The precise determination of one etiology when there are several potential origins is too complex for a layperson to proffer a competent opinion. The evidence of record does not demonstrate that the Veteran possesses the ability, knowledge, or experience to provide competent etiological opinions. Jandreau, 492 F.3d at 1377. Consequently, the Veteran's assertions do not constitute competent evidence of etiology in this case. Accordingly, service connection for bilateral hearing loss is not warranted as the most probative evidence shows that the Veteran's current bilateral hearing loss is not related to his military service, to include as due to noise exposure. In reaching this decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claims for service connection for bilateral hearing loss and tinnitus, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). Arthralgia of the Back, and Right Wrist and Elbow The Evidence The service treatment records show that at service entrance in November 1988, the Veteran had no history of back, right wrist, or right elbow problems, and no complaint, diagnosis or treatment for any of the disorders was documented at that time. There is no showing of treatment in service for a back disorder, a right wrist disorder or a right elbow disorder. At separation in August 1993, the Veteran was noted to have complaints of on and off back pain; back pain, no treatment sought, was among the findings. The Veteran was examined by VA in August 2006. He stated he injured his right hand in November 1989 after being involved in an altercation. He described the current pain to be in the right index finger. There was no diagnosis regarding the right wrist, the right elbow or the back. The examiner found claimed arthraligias present in joints where fractures are documented-this is not secondary to environmental exposures during the Gulf War but to previous fractures. During his hearing at the RO before a hearing officer in July 2009, the Veteran stated that is right wrist and right elbow disorders may have been injured when he fell in service and injured his left wrist and left elbow which are service connected. The Veteran was examined by VA in August 2009. The right elbow showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malialignment, drainage, subluxation or guarding of movement. Range of motion was full. The right wrist showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malialignment, drainage, subluxation or guarding of movement. Range of motion was full. The Veteran underwent a Gulf War Registry Examination in January 2010. He reported having joint pain. Athralgias was the diagnosis. The Veteran was examined by VA in May 2010. The claims file was reviewed. The Veteran reported having right elbow pain that started about 6 years prior. He stated that he did not remember a specific injury to the elbow. He stated that he fell and injured his right wrist in 1991 and that he has had problems with the wrist since. He said he has had back pain for 10 years with no remembrance of a specific injury. The Veteran was examined. Flexion of the back was to 90 degrees without pain and extension was 0 to 30 degrees. Left and right lateral flexion as well as left to right lateral rotation were to 30 degrees. Range of motion of the right elbow was from 0 to 145 degrees. The right wrist had some tenderness. Palmar flexion was to 80 degrees; dorsiflexion was to 70 degrees; radial deviation was to 20 degrees; and ulnar deviation was to 45 degrees. X-rays of the back, right wrist and right elbow were normal. The examiner diagnosed tendonitis of the right wrist, chronic musculoskeletal of the lumbar spine, and tendonitis of the right elbow. The examiner stated that the Veteran's disability pattern of chronic strain of the right wrist is a disease with a clear and specific etiology and diagnosis, as the Veteran reports an injury to the right wrist while on active duty. The examiner also stated that the Veteran's disability pattern of chronic strain of the lumbar spine and of tendonitis of the right elbow are diseases with a clear and specific etiology and diagnosis. The examiner noted that according to known medical facts, a chronic strain/tendonitis results from repetitive use of a joint, muscle or tendon and would be linked to such things as occupation, trauma, repetitive use, and insult to the joint, muscle or tendon over time. The examiner indicated that there is no literature available that links chronic muscle strain or tendonitis to exposure to smoke, pesticides from oil well fire, pesticides, insecticides, indigenous infectious diseases, solvents fuel flames, ingestion of pyridostigmine bromide tablets, a combined effect of multiple vaccines administered, inhalation of ultra-fine grain sand particles, or the exposure to smoke or particles from burn pit fires. She stated that therefore, it was her opinion that the chronic muscle strain, of the spine, tendonitis of the right elbow and tendonitis of the right wrist is less likely than not secondary to a specific exposure event experienced by the Veteran during service in Southwest Asia. The Veteran was examined by VA in September 2012. The claims file was reviewed. It was noted that the Veteran reported that his back pain started after service discharge and he denied any injury of the back in the military. He reported having right elbow pain in service and denied any inservice injury. He also reported that the pain started after service. He reported right wrist pain since service and he reported the pain began right after discharge. He denied any right wrist injury. The Veteran was examined. X-rays of the right wrist and right elbow were normal. X-rays of the lumbar spine showed arthritis. The examiner stated that the Veteran's arthralgia of the back is related to degenerative joint disease of the lumbar spine. It was reported that this is related to a diagnosed condition. The examiner also reported that the right wrist and right elbow conditions are also related to a diagnosed disability. The examiner stated that the service treatment records show evidence of on and off back pain in 1993, and recurrent back pain is noted at separation. The examiner noted that there is no documentation of injury, fracture or trauma in the military, and no evidence of a chronic back condition after service until 2007. It was indicated that there is about a 15 year gap in the medical records regarding a back condition. The examiner stated that therefore, it is less likely than not that the back disability began in service or is causally linked to any incident in service. The examiner found that the right elbow disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. It was stated that there is no evidence of treatment for a chronic elbow condition in the military and no evidence of trauma or fracture of the right elbow in service. The examiner stated that there is no evidence of treatment of a right elbow disorder after discharge. It was opined that therefore it is less likely than not that the right elbow condition began during service or is causally related to any incident in service. The examiner indicated that the right wrist disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. It was stated that there is no evidence of treatment for a right wrist condition in the military and no evidence of treatment of a right wrist disorder after discharge. It was opined that therefore it is less likely than not that the right wrist disorder began during service or is causally related to any incident in service. The examiner diagnosed degenerative joint disease of the lumbar spine, right elbow tendonitis, and right wrist strain. Analysis With respect to the claim for service connection for on a direct basis for a back disorder, a right wrist disorder and a right elbow disorder, the Board notes that there are current diagnoses. The service treatment records are negative for right wrist and right elbow complaints, and after service there is no indication of treatment or complaints until the 2000's, several years after the veteran's discharge in 1993. Back pain is noted at service separation; however no back disorder was diagnosed. 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. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Additionally, no back disorder was found until many years after service discharge. There are medical are opinions in the file regarding the etiology of the Veteran's complaints. As previously noted, factors that may be considered in assessing the probative value of a medical opinion include a physician's access to the claims file or pertinent evidence, the thoroughness and detail of the opinion, the accuracy of the factual premise underlying the opinion, the scope of examination, the rationale for the opinion offered, the degree of certainty provided, and the qualifications and expertise of the examiner. See generally Prejean v. West, 13 Vet. App. 444, 448-89 (2000); Sklar v. Brown, 5 Vet. App. 140 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993); Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board finds the May 2010 and September 2012 VA opinions against the claims to be of great probative value. The claims file was reviewed prior to the opinions, the Veteran was examined and the examiners offered clear rationale for the negative opinions. Further, the opinions stand uncontradicted in the record. Further, with regard to the Veteran's own statements, the Board acknowledges that the Veteran is competent to provide evidence of his own experiences; however, the fact that the Veteran's treatment records do not reflect a diagnosis of a back, right elbow, or right wrist problem until many years after service weighs heavily against the claims in this particular case. The Board is not holding that corroboration is required. Rather, the Board finds his assertions to be less credible than the negative contemporaneous records. In this regard, the Veteran has been unclear and inconsistent as to when his back, right elbow and right wrist problems began. For example, he stated in August 2006 that he injured his right hand in November 1989 in an altercation. During his RO hearing he stated that his right wrist and right elbow disorders may have been injured when he fell and injured his left wrist and elbow. In May 2010, he indicated that the right elbow pain began six years prior and that he did not remember any injury. He also said he fell and hurt his right wrist in 1991 and had pain for 10 years. In September 2012, he stated that the back pain started after service, that the right elbow pain started after service and that the right wrist pain began right after service. The inconsistent statements by the Veteran damage his credibility. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (providing that the credibility of a witness can be impeached by a showing of inconsistent statements). Thus, the Veteran has been inconsistent with regard to his symptomatology and the onset date of such, and therefore his statements are not persuasive as to the onset of these symptoms. With respect to claims based on an undiagnosed illness, it was concluded on VA examinations in May 2010 and in September 2012, that the Veteran had definite diagnoses for his back, right elbow and right wrist complaints. Because these disabilities are attributed to known diagnoses, service connection under undiagnosed illness presumptions cannot be granted. Under the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 that relate to Persian Gulf veterans' undiagnosed illness presumptions, the pertinent issue is whether the Veteran has signs and symptoms that are manifestations of an undiagnosed illness that are objective indications of qualifying chronic disability. Joint pain is specifically listed as a manifestation of an undiagnosed or medically unexplained chronic multisymptom illness for which service connection may be granted on the basis of Gulf War service. Thus, such symptoms are considered precipitating factors rather than a real clinical diagnosis within the meaning of VA regulations. However, in order for the Veteran to be eligible for service connection for undiagnosed illness based on his Gulf War service in this regard, the symptoms must be manifest to a degree of 10 percent. In this case, the weight of the evidence is against a finding of any objective indications of a qualifying chronic disability manifested by back, right wrist or right elbow joint complaints which has manifested to a degree of 10 percent or more by December 31, 2011. Concerning whether the record shows objective indications of a qualifying chronic disability, it is noted that arthritis of the lumbar spine was not diagnosed prior to December 31, 2011. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Further, the evidence shows that the motion of the back was not manifested to a compensable degree; that is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, Diagnostic Code 5237. As to the right wrist, dorsiflexion was not less than 15 degrees and palmar flexion was not limited in line with the forearm. 38 C.F.R. § 4.71a, Diagnostic Code 5215. As to the right elbow, flexion was not limited to 100 degrees (Diagnostic Code 5207); extension was not limited to 45 degrees (DC 5207); there was no malunion (DC 5211, 5212); and supination was not limited 30 degrees or less (DC 5213). The evidence shows that the Veteran's current report of joint pains in the elbow, spine, and wrist are attributed to known diagnoses. Therefore, service connection is not warranted under the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317. As the preponderance of the evidence is against the service connected claims at issue, the doctrine of reasonable doubt is not for application. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Service connection for bilateral hearing loss is denied. Service connection for arthralgia of the back and the right wrist and elbow, to include as due to an undiagnosed illness is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs