Citation Nr: 1313713 Decision Date: 04/24/13 Archive Date: 05/03/13 DOCKET NO. 07-04 563 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for tension and/or migraine headaches. 2. Entitlement to service connection for chronic obstructive pulmonary disease. 3. Entitlement to service connection for gastroesophageal reflux disease, to include as secondary to service-connected irritable bowel syndrome with duodenal ulcer and hiatal hernia. 4. Entitlement to service connection for chronic sinusitis. 5. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected posttraumatic stress disorder and/or medication therefor. 6. Entitlement to an increased rating for irritable bowel syndrome with duodenal ulcer and hiatal hernia, evaluated as 20 percent disabling prior to November 1, 2006, and as 10 percent disabling thereafter, to include restoration of the previously-assigned 20 percent evaluation effective from November 1, 2006. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARINGS ON APPEAL The appellant ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The Veteran had active duty from October 2, 1979 to January 26, 1980, in addition to other active duty service from January 3 to April 22, 1991, and July 7 to November 16, 1991. This case comes before the Board of Veterans Appeals (Board) on appeal of various decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In that regard, in March 2006, the RO determined that new and material evidence had not been presented to reopen a claim of entitlement to service connection for "headaches, tension and migraine," and denied claims for chronic obstructive pulmonary disease, gastroesophageal reflux disease, sinusitis, and erectile dysfunction. In August 2006, the RO reduced the Veteran's evaluation for his "duodenal ulcer with hiatal hernia" from 20 percent to 0 percent (i.e., noncompensable), with an effective date of November 1, 2006. The Veteran appealed all of the aforementioned decisions, to include the issue of restoration of the 20 percent evaluation. In May 2007, the RO granted service connection for irritable bowel syndrome, evaluated this disability together with the Veteran's duodenal ulcer with hiatal hernia, and assigned a 10 percent evaluation with an effective date of November 1, 2006. In rating decisions of September 1992, April 1995, September 1997, June 1999, and most recently, July 2004, the RO denied entitlement to service connection for tension and/or migraine headaches. The Veteran voiced no disagreement with, or failed to perfect his appeal regarding, all of the aforementioned decisions, which have now become final. Since the time of the most recent rating decision in July 2004, the Veteran has submitted additional evidence in an attempt to reopen his claim. The RO found such evidence neither new nor material, and the current appeal ensued. In a decision of March 2011, the Board indicated that the Veteran had withdrawn his appeal regarding the issue of service connection for an upper respiratory infection, and, accordingly, dismissed his appeal as to that issue. At that same time, the Board remanded for additional development all of the other issues now on appeal. The case is now, once more, before the Board for appellate review. Finally, for reasons which will become apparent, the appeal as to the issue of an evaluation in excess of 10 percent for service-connected irritable bowel syndrome with duodenal ulcer and hiatal hernia effective from November 1, 2006, to include restoration of the previously-assigned 20 percent evaluation, is being REMANDED to the RO via the Appeals Management Center (AMC) in Washington, D.C. VA will notify you if further action is required on your part. FINDINGS OF FACT 1. In rating decisions of September 1992, April 1995, September 1997, June 1999, and, most recently, July 2004, the RO denied entitlement to service connection for tension and/or migraine headaches. 2. Evidence submitted since the most recent rating decision in July 2004 denying entitlement to service connection for tension and/or migraine headaches is neither cumulative nor redundant, and, when considered with the previous evidence of record, relates to an unestablished fact necessary to substantiate the Veteran's claim. 3. The Veteran's headache disorder, variously diagnosed, as likely as not had its origin during, or is in some way the result of, his period or periods of active military service. 4. Chronic obstructive pulmonary disease, to the extent it currently exists, is not shown to have been present in service, or for many years thereafter, nor is it the result of any incident or incidents of the Veteran's periods of active military service. 5. Gastroesophageal reflux disease is not shown to have been present in service, or for many years thereafter, nor is it the result of any incident or incidents of the Veteran's periods of active military service, or in any way causally related to a service-connected disability or disabilities, including irritable bowel syndrome with duodenal ulcer and hiatal hernia. 6. Chronic sinusitis is not shown to have been present in service, or for many years thereafter, nor is it the result of any incident or incidents of the Veteran's periods of active military service. 7. Erectile dysfunction is not shown to have been present in service, or for many years thereafter, nor is it the result of any incident or incidents of the Veteran's periods of active military service, or in any way causally related to a service-connected disability or disabilities, including posttraumatic stress disorder or medication therefor. 8. Prior to the November 1, 2006, the Veteran's service-connected irritable bowel syndrome with duodenal ulcer and hiatal hernia was not characterized by moderately severe symptomatology, with impairment of health manifested by anemia and weight loss, recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year, or persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation accompanied by substernal or arm or shoulder pain productive of considerable impairment of health, or diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. CONCLUSIONS OF LAW 1. The rating decisions of September 1992, April 1995, September 1997, June 1999, and, most recently, July 2004 denying entitlement to service connection for tension and/or migraine headaches are final. 38 U.S.C.A. §§ 5103, 5103A, 7105 (West 2002); 38 C.F.R. § 20.1103 (2012). 2. Evidence received since the most recent rating decision in July 2004 denying entitlement to service connection for tension and/or migraine headaches is new and material, and sufficient to reopen the Veteran's previously-denied claim. 38 U.S.C.A. §§ 5103, 5103A, 5108 (West 2002); 38 C.F.R. § 3.156 (a) (2012). 3. With the resolution of all reasonable doubt in his favor, the Veteran's headache disorder, variously diagnosed, was incurred in active military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 4. Chronic obstructive pulmonary disease was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131, 5103, 5103A (West 2002); 38 C.F.R. § 3.303 (2012). 5. Gastroesophageal reflux disease was not incurred in or aggravated by active military service, nor is it in any way proximately due to, the result of, or aggravated by a service-connected disability or disabilities, including irritable bowel syndrome with duodenal ulcer and hiatal hernia. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 6. Chronic sinusitis was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131, 5103, 5103A (West 2002); 38 C.F.R. § 3.303 (2012). 7. Erectile dysfunction was not incurred in or aggravated by active military service, nor is it in any way proximately due to, the result of, or aggravated by a service-connected disability or disabilities, including posttraumatic stress disorder or medication therefor. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 8. The criteria for an evaluation in excess of 20 percent for service-connected irritable bowel syndrome with duodenal ulcer and hiatal hernia prior to November 1, 2006 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. § 4.114 and Part 4, Diagnostic Codes 7305, 7319, 7346 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) In the case at hand, the requirements of the Veteran's Claims Assistance of 2000 (VCAA) have been met. There is no issue as to whether the Veteran was provided an appropriate application form, or the completeness of his application. VA notified the Veteran in March, April, and October 2005, as well as in May 2008, and March and June 2011, of the information and evidence needed to substantiate and complete his claims, to include notice of what part of that evidence was to be provided by him, and what part VA would attempt to obtain. VA has also fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claims, and, as warranted by law, affording VA examinations. Currently, there is no evidence that additional records have yet to be requested, or that additional examinations are in order. Moreover, there is currently no error or issue which precludes the Board from addressing the merits of the Veteran's appeal. Finally, in reaching this determination, the Board has reviewed all the evidence in the Veteran's claims file, to include testimony presented at an RO hearing in October 2008, as well as at a hearing before the undersigned Acting Veterans Law Judge in October 2010, service treatment records, VA (including Virtual VA) and private treatment records and examination reports, various statements from the Veteran's friends and family members, and submitted articles. The October 2010 hearing focused on the elements necessary to substantiate the claims and the Veteran, through his testimony and questioning by his representative, demonstrated his actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that VA fully complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the Veteran's claims, and what the evidence in the claims file shows, or fails to show, with respect to those claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Pertinent Law and Regulations Service Connection The Veteran in this case seeks service connection for a chronic headache disorder (to include tension and/or migraine headaches), chronic obstructive pulmonary disease, gastroesophageal reflux disease, sinusitis, and erectile dysfunction. In pertinent part, it is contended that the Veteran's current headache disorder (to include migraine and/or tension headaches), as well as his chronic obstructive pulmonary disease and sinusitis, had their origin during his period or periods of active military service. Further contended is that the Veteran's gastroesophageal reflux disease had its origin in service, or is in some way causally related to his service-connected irritable bowel syndrome with duodenal ulcer and hiatal hernia. Finally, it is contended that the Veteran's erectile dysfunction is in some way causally related to service-connected posttraumatic stress disorder, or medication therefor. In that regard, service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Service connection may also be granted for any disability resulting from disease or injury incurred in or aggravated while performing active duty for training, or injury incurred or aggravated while performing inactive duty training. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131 (West 2002). Service connection may additionally be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (2012). In order to establish service connection for a claimed disability, there must be competent evidence of that disability; medical, or in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and competent evidence of a nexus between the claimed inservice disease or injury and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); see also Hickson v. West, 12 Vet. App. 247, 253 (1999). The Federal Circuit in Walker made it clear that service connection based upon a theory of continuity of symptomatolgoy is only available for a finite set of chronic diseases identified in §3.309(a). As the Veteran seeks to establish service connection for GERD, COPD, erectile dysfunction and sinusitis, diseases that are not listed as a chronic disease in §3.309(a), the provisions of §3.303 (b) are inapplicable to this case. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. The United States Court of Appeals for Veterans Claims (Court) has held that when aggravation of a Veteran's nonservice connected disability is proximately due to or the result of a service-connected disease or injury, it too shall be service connected to the extent of the aggravation. See Allen v. Brown, 7 Vet. App. 439, 446 (1995). Pursuant to law and regulation in effect prior to October 10, 2006, disabilities which are proximately due to or the result of a service-connected disease or injury are to be granted service connection. When service connection is thus established for a secondary condition, the secondary condition is to be considered a part of the original condition. See 38 C.F.R. § 3.310 (effective prior to October 10, 2006). Effective October 10, 2006, an increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, is to be service connected. In reaching a determination as to aggravation of a nonservice-connected disability, consideration is required as to what the competent evidence establishes as the baseline level of severity of the nonservice connected disease or injury (prior to the onset of aggravation by the service-connected condition) in comparison to the medical evidence establishing the current level of severity of the nonservice-connected disease or injury. These findings as to baseline and current levels of severity are to be based upon application of the corresponding criteria under the Schedule for Rating Disabilities (38 C.F.R. Part 4) for evaluating that particular nonservice-connected disorder. See 71 Fed. Reg. 52,744-47 (September 7, 2006). In the present case, the Veteran's claims for secondary service connection were received in 2005. Accordingly, his claims are controlled by the more liberal regulations governing awards of secondary service connection in effect prior to October 10, 2006. Notwithstanding the aforementioned, once entitlement to service connection for a given disorder has been denied in a rating decision, that decision, absent a timely perfected appeal, is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2012). Where a claim for entitlement to service connection has been previously denied, and that decision becomes final, the claim can be reopened and reconsidered only if new and material evidence has been presented with respect to that claim. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). Evidence is considered to be "new" if it was not previously submitted to agency decisionmakers. Evidence is "material" if, by itself, or when considered with previous evidence of record, it relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). In addition, new evidence may be found to be material if it provides a "more complete picture of the circumstances surrounding the origin of the Veteran's injury or disability, even where it will not eventually convince the Board of Veterans Appeals to alter its decision." See Hodge v. West, 155 F. 3d 1356 (Fed. Cir. 1998). In determining whether new and material evidence has been submitted, the evidence is generally presumed to be credible. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Service Connection for Tension and/or Migraine Headaches New and Material In the present case, at the time of the aforementioned rating decisions in September 1992, April 1995, September 1997, June 1999, and most recently, July 2004, it was essentially determined that the Veteran's headache disorder preexisted his periods of active military service, with no evidence of inservice aggravation. Those determinations have now become final. Evidence submitted since the time of the most recent rating decision in July 2004, consisting, for the most part, of VA and private treatment records and examination reports, transcripts of the Veteran's testimony at an October 2008 RO hearing and at a subsequent Travel Board hearing in October 2010, and statements from the Veteran's private physicians, are "new" and "material" as to the issue of service connection for a chronic headache disorder. In that regard, statements from the Veteran's private physicians raise the possibility that the Veteran's current headache disorder might have had its origin during, or is in some way the result of, his period or periods of active military service. Such evidence, at a minimum, provides a "more complete picture of the circumstances surrounding the origin of the Veteran's injury or disability," and, accordingly, is sufficient to reopen the Veteran's claim of entitlement to service connection for a chronic headache disorder. Having determined that new and material evidence has, in fact, been submitted sufficient to reopen the Veteran's previously-denied claim, the Board must now turn to de novo review of all pertinent evidence of record. In that regard, service treatment records covering the period from March to October 1991, which is to say, the Veteran's second and third periods of active military service, show treatment during that service for migraine and/or tension headaches. A review of these records reflects that the Veteran's headaches may have to some extent preexisted his periods of active military service. A Veteran is presumed in sound condition except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service. 38 U.S.C.A. § 1111 (West 2002); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The burden then falls on the Government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by service. Wagner, 370 F.3d at 1096; Bagby, 1 Vet. App. at 227. The U.S. Court of Appeals for Veterans Claims (Court) in Horn v. Shinseki, explained that even when there is clear and unmistakable evidence of preexistence, the claimant need not produce any evidence of aggravation in order to prevail under the aggravation prong of the presumption of soundness. Rather, the burden is on VA to establish by clear and unmistakable evidence that it did not or that any increase was due to the natural progress of the disease. 25 Vet. App. 231, 235 (2012). On the other hand, where a disorder is noted on service entrance or a Veteran is otherwise not presumed sound on entrance, 38 U.S.C.A. § 1153 applies. In such claims, the evidence of record must simply show that there was an increase in disability during service to trigger the presumption of aggravation. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). "If the presumption of aggravation under section 1153 arises, the burden then shifts to the government to show a lack of aggravation by establishing 'that the increase in disability is due to the natural progress of the disease.'" Wagner, 370 F.3d at 1096 (citing 38 U.S.C.A. § 1153 ). This requires the government show by clear and unmistakable evidence that any increase in disability was due to the natural progress of the condition. Cotant v. Principi, 17 Vet. App. 116, 130-32 (2003); Horn v. Shinseki, 25 Vet. App. at 235 (2012) ("Once the Veteran establishes worsening, the burden shifts to the Secretary to show by clear and unmistakable evidence that the worsening of the condition was due to the natural progress of the disease."); see also 38 C.F.R. § 3.306(b). Clear and unmistakable evidence means that the evidence "cannot be misinterpreted and misunderstood, i.e., it is undebatable." Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009) (quoting Yanerson v. West, 12 Vet. App. 254, 258-59 (1999)). The clear-and-unmistakable-evidence standard is an "onerous" one. Laposky v. Brown, 4 Vet. App. 331, 334 (1993) (citing Akins v. Derwinski, 1 Vet. App. 228, 232 (1991)); see also Yanerson, 12 Vet. App. at 263 (Nebeker, C.J., concurring in part and dissenting in part) ("[O]nly an inference that is iron clad and copper riveted can be 'unmistakable.'"). In the present case, although the August 1990 enlistment examination described the head as normal and noted no defects, other than bradycardia, there is clear and unmistakable evidence that the headaches existed prior to service. Specifically, a May 1986 service record reflected a complaint of a headache and diagnosed tonsillitis. The Veteran reported a history of frequent or severe headaches on a February 1987 report of medical history and explained he was on medication. A June 1987 record noted a complaint of headaches and assessed constant nosebleeds and headaches. Having found clear and unmistakable evidence the condition pre-existed service, the relevant question is whether there is clear and unmistakable evidence that the headaches were not aggravated during service. A review of the record reflects that as of the time of a VA medical examination in February 1992, shortly following the Veteran's third and final period of active service, it was noted that, while the Veteran's headaches had begun in 1990, prior to his going to Saudi Arabia, those headaches had become worse during that overseas service. Moreover, following a VA gastrointestinal examination in May 1995, it was the opinion of the examiner that the Veteran's headaches might well be the result of his service in the Persian Gulf. The Board notes that, in correspondence of April 2011, the Veteran's private physician wrote that, following a "careful review" of the Veteran's service and VA records, it was her opinion that the Veteran's headaches were "from his time served in the military." As a rationale for that opinion, the Veteran's physician cited to an examination in March 1991 showing "stress related headaches," as well as April 1999 records suggesting the presence of tension headaches. Further noted were medical records dated in October and November 1991 showing evidence of "probable migraine headaches." In other words, based on the aforementioned, and with the resolution of all reasonable doubt in the Veteran's favor, the Board is of the opinion that the Veteran's current headache disorder at least as likely as increased in severity or were aggravated during his period or periods of active military service. None of the evidence proves by clear and unmistakably shows that the increase was due to the natural progress of the disease. In other words, the Government has failed to rebut the presumption of soundness. As such, the Veteran is presumed to be in sound condition at entry into his second period of service. As discussed above, service records from that period reflect treatment for headaches and an April 2011 private medical opinion that indicated it is likely that the headaches had their onset during service. Accordingly, an award of service connection for a chronic headache disorder is in order. Service Connection for Chronic Obstructive Pulmonary Disease and Sinusitis Service treatment records, it should be noted, are negative for history, complaints, or abnormal findings indicative of the presence of chronic obstructive pulmonary disease or sinusitis. In point of fact, at the time of a service separation examination in November 1991, the Veteran's lungs and sinuses within normal limits, and no pertinent diagnoses were noted. The earliest clinical indication of the presence of sinusitis is revealed by VA outpatient treatment records dated in April 1997, almost six years following the Veteran's discharge from service, at which time the Veteran was seen for a recurring upper respiratory infection, with a sensation of "pressure," as well as swelling across the bridge of his nose. In like manner, the earliest clinical indication of chronic obstructive pulmonary disease is revealed by service medical facility treatment records dated in April 2000, almost nine years following the Veteran's discharge from service, at which time the Veteran received a diagnosis of "probable" chronic obstructive pulmonary disease. The Board observes that, following VA radiographic studies in August 2000, there was noted the presence of frontal and mild bilateral sinusitis. However, subsequent treatment records raise some question as to whether the Veteran does, in fact, suffer from "chronic" sinusitis, as opposed to an "intermittent" sinusitis related to allergic rhinitis. In like manner, while following a VA medical examination in January 2006, the Veteran received a diagnosis of chronic obstructive pulmonary disease, his lungs at that time were clear to both percussion and auscultation. Moreover, on subsequent VA examination in October 2006, both chest X-rays and pulmonary function tests were entirely within normal limits. Significantly, according to the examiner, at the time of examination, there was "no evidence of chronic obstructive pulmonary disease." Based on the aforementioned, there remains some question as to whether the Veteran currently suffers from chronic obstructive pulmonary disease and/or chronic sinusitis. Nonetheless, to the extent the Veteran does, in fact, suffer from one or both of those disabilities, there exists no evidence that such pathology had its origin during, or is in any way the result of, the Veteran's period or periods of active military service. Accordingly, service connection must be denied. Service Connection for Gastroesophageal Reflux Disease and Erectile Dysfunction As regards the Veteran's claimed gastroesophageal reflux disease and erectile dysfunction, the Board notes that service treatment records are entirely negative for any such pathology. In fact, at a time of a service separation examination in November 1991, the Veteran's abdomen and viscera, as well as his genitourinary system, were entirely within normal limits, and no pertinent diagnoses were noted. The earliest clinical indication of the presence of gastroesophageal reflux disease is revealed by a VA medical examination dated in July 1998, almost seven years following the Veteran's final discharge from service, while erectile dysfunction was first noted no earlier than May 2005, almost 14 years following service discharge. Significantly, while in that May 2005 private medical record, the Veteran's physician indicated that his diagnostic impressions included "erectile dysfunction probably secondary to depression and posttraumatic stress disorder," that conclusion appears to have been reached based primarily on history provided by the Veteran, inasmuch as there is no evidence that, at the time of the rendering of the opinion, the examiner had access to either the Veteran's claims folder or his service treatment records. Nor was any rationale offered for the examiner's opinion. See Leshore v. Brown, 8 Vet. App. 406, 409 (1995); see also Swann v. Brown, 5 Vet. App. 229, 233 (1993). The Board notes that, following a VA medical examination in October 2006, which examination, it should be noted, involved a full review of the Veteran's claims folder and medical records, it was the opinion of the examiner that the Veteran's gastroesophageal reflux disease was unrelated to his service-connected ulcer disease or his military service. Moreover, in an addendum to the aforementioned VA examination dated in February 2007, that same examiner indicated that it was "unlikely" that the Veteran's gastroesophageal reflux disease was related to or due to his "now service-connected" irritable bowel syndrome. Nor was there any relationship between the Veteran's duodenal ulcer disease and gastroesophageal reflux disease. Significantly, following a subsequent VA medical examination in November 2008, which examination, once again, involved a full review of the Veteran's claims folder and medical records, the same VA examiner who have provided the October 2006 and 2007 opinions indicated that the Veteran's gastroesophageal reflux disease ("esophageal symptoms") were separate from his duodenal ulcer disease, and "more likely than not" not caused by that duodenal ulcer disease. The Board observes that, following a VA examination in October 2007, which examination involved a full review of the Veteran's claims folder, the examiner indicated that, given the Veteran's low testosterone, smoking history, and the lack of significant evidence for erectile dysfunction from his psychotropic medications, it was less likely than not that the Veteran's erectile dysfunction was caused by his posttraumatic stress disorder. While it is true that, in a treatment record of September 2008, the Veteran's VA physician wrote that the Veteran had been on "several medications for depression and anxiety which could contribute to his erectile dysfunction," following a VA genitourinary examination in April 2011, it was the opinion of the examiner that the Veteran's erectile dysfunction was, in fact, unlikely to be related to medications utilized in the treatment of his posttraumatic stress disorder. Significantly, while that same examiner indicated that the Veteran's erectile dysfunction was "more likely" to be related to his posttraumatic stress disorder, that opinion was offered without access to the Veteran's claims folder, or any supporting rationale. Moreover, that same examiner, following a review of the Veteran's claims folder in June 2011, offered the opinion that the Veteran's erectile dysfunction was less likely than not related to his service-connected posttraumatic stress disorder, or aggravated by medication taken for that disorder. In fact, the examiner specifically stated that the Veteran's posttraumatic stress disorder medications "did not cause erectile dysfunction." Nor was his erectile dysfunction related to his period or periods of active military service. Significantly, in an addendum to the aforementioned April 2011 examination dated in October 2012, a different VA examiner, following a full review of the Veteran's claims folder, noted that erectile dysfunction was a "multifactorial process," the best predictors of which, according to the medical literature, were diabetes mellitus, hypertension, obesity, dyslipidemia, cardiovascular disease, smoking, and medication use. According to the examiner, the Veteran had multiple risk factors for the development of erectile dysfunction, including his age (51), dyslipidemia, cardiovascular disease, smoking, and medication use. Regarding the Veteran's posttraumatic stress disorder medications, it was noted that, while the Veteran had been taking Depakote and Elavil for his post-traumatic stress disorder, when these medications were stopped to determine if his erectile dysfunction would improve, no improvement was shown. Under the circumstances, the examiner was of the opinion that the Veteran's erectile dysfunction was unlikely related to his posttraumatic stress disorder medications, and more likely (at least in part) due to his cardiac medications, that is, Metoprolol and Lisinopril. In summary, the Veteran's service-connected conditions (posttraumatic stress disorder, ulcer disease, and bronchitis) were not recognized risk factors for the development of erectile dysfunction. Rather, the Veteran's erectile dysfunction was more likely related to age, dyslipidemia, cardiovascular disease, smoking, and cardiac medications. The Board finds the aforementioned opinions of VA physicians highly probative, because those opinions were based upon a review of the Veteran's entire claims folder, as well as other pertinent medical records, and full examinations, including both history and clinical findings. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). The VA physicians reviewed the Veteran's claims folder, discussed the Veteran's medical history, provided well-reasoned medical opinions, and alluded to the evidence which supported those opinions. See Hernandez-Toyens v. West, supra. Under the circumstances, the Board is of the opinion that the probative medical evidence of record fails to establish that the Veteran's gastroesophageal reflux disease or erectile dysfunction are in any way related to his period or periods of active military service. Nor is there persuasive evidence that the Veteran's gastroesophageal reflux disease is in any way related to his service-connected irritable bowel syndrome with duodenal ulcer and hiatal hernia, or that erectile dysfunction is in some way caused or aggravated by posttraumatic stress disorder, or medication for that disability. In evaluating the Veteran's claims, the Board has a duty to assess the credibility and weight to be given to the evidence of record. See Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). In that regard, the Veteran has attributed his current gastroesophageal reflux disease to service, or, in the alternative, service-connected irritable bowel syndrome with duodenal ulcer and hiatal hernia. In like manner, the Veteran has attributed his erectile dysfunction to service, or his service-connected posttraumatic stress disorder (or medication therefor). However, not until 2005, many years following his discharge from service, did the Veteran file a claim for service connection for either of those disabilities, both of which were first shown many years following service discharge. Significantly, the passage of many years between discharge from service and medical documentation of a claimed disability is a factor which tends to weigh against a claim for service connection. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). In the case at hand, there is no persuasive medical evidence suggesting a link between the Veteran's gastroesophageal reflux disease or erectile dysfunction and his period or periods of active military service. Nor has it been demonstrated that the Veteran's gastroesophageal reflux disease or erectile dysfunction are in some way proximately due to, the result of, or aggravated by a service-connected disability or disabilities, including the Veteran's service-connected gastrointestinal disorder and posttraumatic stress disorder. Under the circumstances, the Veteran's claims for service connection must be denied. The Board acknowledges the Veteran's testimony regarding the origin of the disabilities at issue. However, the Board rejects those assertions to the extent that they seek to etiologically relate the disabilities at issue to the Veteran's active military service, or, in the case of gastroesophageal reflux disease and erectile dysfunction, to a service-connected disability or disabilities. The Veteran's statements and history, when weighed against the objective evidence of record, are neither credible nor of particular probative value. Moreover, the Veteran, as a lay person, is not competent to create the requisite causal nexus for the disabilities at issue as in this case an opinion as to etiology is a complicated matter that requires consideration of things, such as, the many interrelated gastrointestinal symptoms and disabilities the Veteran currently has and knowledge as to the side effects and contraindications of various medications. Accordingly, as the Veteran has not demonstrated he has the medical knowledge skill, experience, training, or education, to provide an opinion in such complicated matters, he is not competent to provide an opinion as to the etiology of the erectile dysfunction and GERD. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran may be competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Based on the aforementioned, the Board is unable to reasonably associate the Veteran's chronic obstructive pulmonary disease, gastroesophageal reflux disease, sinusitis, or erectile dysfunction with any incident or incidents of his periods of active military service, or, in the case of gastroesophageal reflux disease and erectile dysfunction, with a service-connected disability or disabilities. Accordingly, his claims for service connection must be denied. Evaluation in Excess of 20 Percent for Irritable Bowel Syndrome with Duodenal Ulcer and Hiatal Hernia Prior to November 1, 2006 In addition to the above, the Veteran seeks entitlement to an increased rating for service-connected irritable bowel syndrome with duodenal ulcer and hiatal hernia. As noted above, the Veteran is currently in receipt of a 10 percent evaluation for that disability effective from November 1, 2006, an increased rating for which is the subject of the remand portion of this decision. The following discussion addresses the appropriate evaluation to be assigned for the Veteran's service-connected irritable bowel syndrome with duodenal ulcer and hiatal hernia prior to November 1, 2006. In that regard, disability evaluations, in general, are intended to compensate for the average impairment of earning capacity resulting from a service-connected disability. They are primarily determined by comparing objective clinical findings with the criteria set forth in the Rating Schedule. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Where there is a question as to which of two evaluations apply, the higher evaluation will be assigned where the disability picture more nearly approximates the criteria for the next higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). In order to evaluate the level of disability and any changes in the Veteran's condition, it is necessary to consider the Veteran's complete medical history. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of that disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Ratings shall be based as far as practicable upon the average impairment of earning capacity, with the additional proviso that the Secretary shall, from time to time, adjust the schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluation is found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in 38 C.F.R. § 3.321 an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as a marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2012). In the present case, during the course of VA outpatient treatment in July 2004, the Veteran complained of frequent diarrhea with some constipation. However, he denied any problems with fatigue or weakness. Physical examination revealed some mild right lower quadrant tenderness, with a negative Rovsing's/McBurney's. The Veteran's abdomen was nondistended, and there was no evidence of any masses or pulsations. Nor was there evidence of rebound or guarding. On subsequent VA gastrointestinal examination in January 2006, the Veteran indicated that it was difficult for him to eat certain types of cookies, spicy or greasy foods, and juices. While he occasionally experienced some problems with nausea, he denied any problems with vomiting. According to the Veteran, he occasionally experienced bouts of constipation with intermittent loose stools in conjunction with epigastric pain. However, he denied any melena or bright red blood in his stools. Noted at the time of examination was that the Veteran had undergone an upper gastrointestinal series in August of 2004, which showed a normal upper gastrointestinal tract. On physical examination, the Veteran's abdomen was slightly tender in the upper gastric area. However, no organomegaly or rebound tenderness was present, and bowel signs appeared active. At the time of evaluation, the Veteran's rectal examination was reported as "completely normal." The pertinent diagnosis noted was duodenal ulcer in the past, along with hiatal hernia, with a normal upper gastrointestinal series in August of 2004. During the course of VA outpatient treatment in February 2006, the Veteran's abdomen was soft and nontender, with no evidence of any masses. On subsequent VA examination in October 2006, the Veteran reported that, notwithstanding the fact that he continued to take medication, he experienced episodes of two to three loose stools three days a week associated with cramps. According to the Veteran, his stools were soft to runny, but not watery, and alternated with constipation. Further noted was that the Veteran's diet consisted of limiting caffeine and spicy foods. Significantly, the Veteran denied any problems with nausea or vomiting, and similarly denied any rectal bleeding, melena, or weight loss. On physical examination, the Veteran's abdomen was flat, soft, and nontender, with normal bowel sounds. Significantly, no hernias were noted in either the abdomen or inguinal regions. The pertinent diagnoses noted at the time of examination were irritable bowel syndrome, including symptoms of gastroesophageal reflux and episodic diarrhea and constipation; and past peptic ulcer disease. According to the examiner, there was no evidence of recurring or chronic peptic ulcer disease, inasmuch as followup upper gastrointestinal studies had been within normal limits. In an addendum to the aforementioned VA examination dated in February 2007, it was noted that the Veteran's record showed evidence of active peptic ulcer disease some years ago in the early 1990's. However, all studies since then had shown no evidence of peptic ulcer disease activity. Nor had the Veteran had any recent symptoms suggesting a duodenal ulcer. However, the Veteran had been taking acid-blocking medications on a regular basis. According to the record, in 1993, the Veteran had peptic ulcer disease. Moreover, in August 2000, he was diagnosed with irritable bowel syndrome. However, an upper gastrointestinal series conducted in August 2004 was within normal limits. According to the examiner, the Veteran had inactive duodenal ulcer disease. Moreover, at no time had the Veteran had evidence of a significant hiatal hernia on radiographic studies over the course of the past 12 to 14 years. Pursuant to applicable law and regulation, ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7548 inclusive are not to be combined with each other. Rather, a single evaluation is to be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such evaluation. 38 C.F.R. §§ 4.114 (2012). In that regard, a 20 percent evaluation is warranted for service-connected duodenal ulcer disease where there is evidence of moderate impairment, with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations. A 40 percent evaluation, under those same laws and regulations, requires evidence of moderately severe impairment, with impairment of health manifested by anemia and weight loss, or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. 38 C.F.R. Part 4, Diagnostic Code 7305 (2012). A 30 percent evaluation for service-connected hiatal hernia is warranted where there is evidence of persistently recurrent epigastric distress, with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 30 percent evaluation is, similarly, warranted where there is evidence of severe irritable colon (bowel) syndrome, with diarrhea or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. Part 4, Diagnostic Codes 7346, 7319 (2012). Based on the aforementioned, it is clear that no more than a 20 percent evaluation for the Veteran's service-connected irritable bowel syndrome with duodenal ulcer and hiatal hernia is warranted prior to November 1, 2006. More specifically, there is no indication that, for the period in question, the Veteran experienced either anemia or weight loss, or, for that matter, incapacitating episodes. Nor was there evidence of dysphagia, pyrosis, or regurgitation accompanied by substernal arm or shoulder pain productive of considerable impairment of health. To the extent that, for the period in question, the Veteran experienced some problem with diarrhea and/or constipation, such episodes were not severe, or characterized by constant abdominal distress. In point of fact, in an addendum to a previous VA gastrointestinal examination dated in February 2007, the Veteran's duodenal ulcer disease was described as inactive, and there was no evidence of any significant hiatal hernia. As noted above, no more than a 20 percent evaluation is warranted for the Veteran's service-connected irritable bowel syndrome with duodenal ulcer and hiatal hernia prior to November 1, 2006. In reaching this determination, the Board has considered the potential application of various other provisions, including 38 C.F.R. § 3.321(b)(1) governing those exceptional cases where a schedular evaluation is found to be inadequate. See Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009); see also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, in the case at hand, the Rating Schedule adequately contemplates the nature and extent of the appellant's pathology. Accordingly, referral for consideration of an extraschedular evaluation is not warranted. See Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). ORDER Service connection for a chronic headache disorder, variously diagnosed, is granted. Service connection for chronic obstructive pulmonary disease is denied. Service connection for gastroesophageal reflux disease, to include as secondary to service-connected irritable bowel syndrome with duodenal ulcer and hiatal hernia is denied. Service connection for chronic sinusitis is denied. Service connection for erectile dysfunction, to include as secondary to service-connected posttraumatic stress disorder or medication therefor, is denied. An evaluation in excess of 20 percent for irritable bowel syndrome with duodenal ulcer and hiatal hernia prior to November 1, 2006 is denied. REMAND In addition to the above, the Veteran seeks an evaluation in excess of 10 percent for irritable bowel syndrome with duodenal ulcer and hiatal hernia effective from November 1, 2006, to include restoration of a previous 20 percent evaluation. However, a review of the record raises some question as to the current severity of the Veteran's service-connected gastrointestinal disorder. In that regard, based on a review of the Veteran's file, it would appear that he last underwent a VA examination for the purpose of determining the severity of his service-connected gastrointestinal disorder in November 2008, at this point, more than four years ago. Moreover, the Veteran has consistently argued that his gastrointestinal symptomatology has not, in fact, improved, and that his 20 percent evaluation should not therefore have been reduced. Under the circumstances, the Board is of the opinion that an additional, more contemporaneous VA examination would be appropriate prior to a final adjudication of the Veteran's current claim. See Snuffer v. Gober, 10 Vet. App. 400 (1997); see also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994). Accordingly, in light of the aforementioned, the case is REMANDED to the RO/AMC for the following actions: 1. Any pertinent VA or other inpatient or outpatient treatment records, subsequent to November 2012, the date of the most recent evidence of record, should be obtained and incorporated in the claims folder. The Veteran should be requested to sign the necessary authorization for release of any private medical records to the VA. All attempts to procure such records should be documented in the file. If the RO/AMC cannot obtain records identified by the Veteran, a notation to that effect should be included in the claims file. In addition, the Veteran and his representative should be informed of any such problem. 2. The Veteran should then be afforded an additional VA gastrointestinal examination in order to more accurately determine the current severity of his service-connected irritable bowel syndrome with duodenal ulcer and hiatal hernia. The Veteran is to be notified that it is his responsibility to report for the examination, and to cooperate in the development of his claim. The Veteran is further to be advised that the consequences for failure to report for a VA examination without good cause may include denial of his claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for the aforementioned examination, documentation should be obtained which shows that notice scheduling the examination was sent to his last known address. It should also be indicated whether any notice sent was returned as undeliverable. Following completion of the examination, and in accordance with the latest AMIE worksheets for evaluating service-connected gastrointestinal disabilities, the examiner is to provide a detailed review of the Veteran's pertinent medical history and current complaints, as well as the nature and extent of his service-connected irritable bowel syndrome with duodenal ulcer and hiatal hernia. A complete rationale must be provided for any opinion offered, and all information and opinions, once obtained, must be made a part of the Veteran's claims folder. The claims folder and a separate copy of this REMAND must be made available to and reviewed by the examiner prior to completion of the examination. In addition, the examiner must specify in the report that the claims file and Virtual VA records have been reviewed. 3. The RO/AMC should then review the examination report to ensure that it is in complete compliance with the directives of this REMAND, and that the examiner has documented his consideration of all records contained in Virtual VA. If the report is deficient in any manner, the RO/AMC must implement corrective procedures. 4. The RO/AMC should then readjudicate the Veteran's claim for an evaluation in excess of 10 percent for irritable bowel syndrome with duodenal ulcer and hiatal hernia effective from November 1, 2006, to include restoration of the previously-assigned 20 percent evaluation. Should the benefit sought on appeal remain denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case (SSOC). The SSOC must contain notice of all relevant action taken on the claim for benefits since the issuance of the most recent SSOC in December 2012. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome in this case. The Veteran need take no action unless otherwise notified. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ HOLLY SEESEL, Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs