Citation Nr: 1324460 Decision Date: 08/01/13 Archive Date: 08/13/13 DOCKET NO. 11-31 098 ) DATE ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Whether new and material evidence has been presented to reopen the claim of service connection for a skin rash. 2. Entitlement to service connection for a skin rash. 3. Entitlement to service connection for removal of the left ovary and fallopian tube. 4. Entitlement to service connection for migraine headaches with visual disturbance. 5. Entitlement to service connection for a gastrointestinal disability. 6. Entitlement to service connection for a back disability (formerly claimed as body and muscle aches). 7. Entitlement to service connection for a bilateral knee disability (formerly claimed as body and muscle aches). 8. Entitlement to an initial rating higher than 50 percent for service-connected posttraumatic stress disorder. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. Meawad, Counsel INTRODUCTION Pursuant to 38 C.F.R. § 20.900(c), the appeal has been advanced on the Board's docket. The Veteran, who is the appellant, served on active duty from September 1989 to December 1992, including service in the Southwest Asia Theater of operations during the Persian Gulf War. This matter is before the Board of Veterans' Appeals (Board) on appeal of rating decisions in June 2009, in July 2010, and in August 2012 of a Department of Veterans Affairs (VA) Regional Office (RO). In the rating decision in June 2009, the RO denied service connection for memory problems, and the Veteran did not initiated an appeal of the denial of service connection by filing a notice of disagreement and the claim is not before the Board for appellate review. While on appeal in a rating decision in August 2012, the RO increased the rating for posttraumatic stress disorder to 50 percent, effective from the date of the grant of service connection. The RO also denied the claim of service connection for a bilateral knee disability. In November 2012, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is the Veteran's file. At the hearing the Veteran expressed the desire to pursue the claim of service connection for a bilateral knee disability. The Veteran's hearing testimony reduced to a writing as evidenced by the transcript constitutes a timely notice of disagreement to the denial of service connection. As the RO has not had the opportunity to issue a statement of the case, the claim is remanded. Manlicon v. West, 12 Vet. App. 238, 240-41 (1999). The claims of service connection for migraine headache and visual impairment have been recharacterized as service connection for migraine headaches with visual disturbance. The claim of service connection for abdominal problems has been recharacterized as service connection for a gastrointestinal disorder. The claim of service connection for body and muscle aches has been recharacterized as separate claims of service connection for a back disability and for a bilateral knee disability. The recharacterization comports to the Veteran's reasonable expectations as expressed at the hearing in November 2012 and as argued by the Veteran's representative. The reopened claim of service connection for a skin rash, the claims of service connection for migraine headaches with visual disturbance, a gastrointestinal disorder, and a back disability, and the claim for increase for posttraumatic stress disorder are also REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. In a decision in December 1993, the RO denied the claim of service connection for an arm rash; after the Veteran was notified of the adverse determination and of his appellate rights, she did not appeal the rating decision and no new and material evidence was submitted within one year of the rating determination; and the rating decision became final on the evidence of record. 2. The additional evidence presented since the rating decision in December 1993 by the RO, pertaining to service connection for a skin rash, raises a reasonable possibility of substantiating the claim. 3. Cysts of the left ovary resulting in removal of the left ovary and fallopian tube were not affirmatively shown to have been present during service; cysts of the left ovary as a chronic disease were not manifested to a compensable degree within one year from the date of separation from service in December 1992; cysts of the left ovary resulting in removal of the left ovary and fallopian tube, first diagnosed after service beyond the one-year presumptive period for a chronic disease, is otherwise unrelated to an injury, disease, or event in service; cysts of the left ovary resulting in removal of the left ovary and fallopian tube were not caused by or made worse by the service-connected vaginal cysts. CONCLUSIONS OF LAW 1. The criteria for reopening a previously denied claim of service connection for a skin rash are met. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 2. The criteria for service connection for removal of the left ovary and fallopian tube on a direct basis and as secondary to service-connected vaginal cysts have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 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 v. Nicholson, 19 Vet. App. 473, 484-86 (2006). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). In a new and material evidence claim, the VCAA notice must include the evidence and information that is necessary to reopen the claim and the evidence and information that is necessary to establish the underlying claim for the benefits sought. Kent v. Nicholson, 20 Vet. App. 1 (2006). As the Board is reopening the claim of service connection for a skin rash, VCAA compliance as to this issue need not be further addressed. On the claim of service connection for removal of the left ovary and fallopian tube, the RO provided a pre-adjudication VCAA notice by letter dated in April 2010. As for the content and the timing of the VCAA notice, the document complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370, 374 (2002) (identifying the document that satisfies VCAA notice); Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004) (pre-adjudication VCAA notice); and of Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The RO has obtained service treatment records, VA records, and private medical records The Veteran was afforded VA examinations in November 2009 and in February 2010. As the reports of the VA examinations are based on a review of the Veteran's history and described the current findings in sufficient detail so that the Board's review is a fully informed one, the examinations reports are adequate to decide the claim. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). As there is no indication of the existence of additional evidence to substantiate the claim, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claim is required to comply with the duty to assist. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS New and Material Evidence Claim Procedural History and Evidence Previously Considered In a rating decision in December 1993, the RO denied service connection for an arm rash on grounds that a skin rash was not shown in service or since service. After the Veteran was notified of the determination and of her appellate rights, she did not appeal the adverse determination. As no new and material evidence pertinent to the claim was received by VA within one year from the date that the RO mailed notice of the adverse determination to the Veteran, the rating decision became final by operation of law on the evidence of record, except the claim may be reopened if new and material evidence is presented. 38 U.S.C.A. § 7105(c); 38 C.F.R. §§ 3.104, 3.156. The evidence previously considered consisted of the service treatment records, which contained no complaint, finding, history, treatment, or diagnosis of a skin rash. Current Claim to Reopen and Additional Evidence The current claim to reopen was received by VA in December 2008. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, 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. New and material evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(a). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The presumption of credibility is rebuttable when the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). In determining whether the evidence is new and material, the specified basis for the last final disallowance must be considered. Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). Current Claim to Reopen and Additional Evidence The additional evidence not previously considered by VA consists in part of VA records. VA records show that in July 2010 the Veteran was treated for a rash on her forearms described as a papular rash. In March 2011, the Veteran was again treated for dark papules and nodules on her legs. The hyperpigmented nodules on the skin were consistent with dermatofibromas. Analysis As the additional evidence relates to an unestablished fact necessary to substantiate the claim, namely, a current diagnosis of a rash, the lack of such evidence was in part the basis for the previous denial of the claim, the additional evidence is new and material under 38 C.F.R. § 3.156. For this reason, the claim of service connection for a skin rash is reopened, and the claim is remanded for further development. Service Connection Principles and Theories of Service Connection A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active military service or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active military service. 38 U.S.C.A. § 1110 (wartime service) and 38 U.S.C.A. § 1131 (peacetime service). Generally, to establish entitlement to compensation for a present disability, that is, service connection, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so called "nexus" requirement. All three elements must be proved. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for endocrinopathies, such as ovarian cysts, if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. § § 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Secondary service connection may be granted for a disability that is proximately due to or the result of (caused by) a service- connected disability. Secondary service connection also includes the theory of aggravation where a nonservice connected disability is aggravated (permanently made worse) by a service connected disability. 38 C.F.R. § 3.310(a). Evidentiary Standards VA must give due consideration to all pertinent lay and medical evidence in a case where a veteran is seeking service connection. 38 U.S.C.A. § 1154(a). As the Veteran was not in combat, the provisions of 38 U.S.C.A. § 1154(b) do not apply. Competency is a legal concept in determining whether lay or medical evidence may be considered, in other words, whether the evidence is admissible as distinguished from credibility and from the weight of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Competency is a question of fact, which is to be addressed by the Board. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). When the evidence is admissible, the Board must then determine whether the evidence is credible. "Credible evidence" is that which is plausible or capable of being believed. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (the determination of credibility is a finding of fact to be made by the Board in the first instance). If the evidence is credible, the Board, as fact finder, must determine the weight or probative value of the admissible evidence, that is, does the evidence tend to prove a material fact. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005). If the evidence is not credible, the evidence has no probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). Evidence The service treatment records show that the Veteran was diagnosed with vaginal cysts. In May 1990, the Veteran was treated for vaginitis. In May 1991, a pap smear showed mild dysplasia and inflammation. In March 1992, an examination of the uterus, including the ovaries, was normal. In April 1992, it was noted that three months previously the Veteran had delivered a child by cesarean section and she still had some bleeding from the surgery. In October 1992, the Veteran had a spontaneous miscarriage. On separation examination in October 1992, the Veteran was noted to be pregnant. After service, in a rating decision in December 1993, the RO granted service connection for vaginal cysts. Private medical records show that in March 2005 the Veteran gave birth by cesarean section and she elected to have permanent sterilization, which was done by a bilateral tubal ligation. In August 2008, the Veteran complained of abdominal and back pain. An ultrasound showed that the left ovary was adherent to the bowel. In November 2008, the Veteran complained of left lower abdominal pain of nine months'duration. History included a laparoscopic cystectomy in 1991, two spontaneous abortions, and three cesarean sections. The Veteran consented to a diagnostic laparoscopy. In November 2008, a diagnostic laparoscopy showed two cysts on the left ovary, pelvic adhesions in the left lower quadrant, and omental adhesions. The left ovary and left fallopian tube were removed. In November 2009 on VA examination, the VA examiner reviewed the Veteran's inservice and post-service medical history noting the vaginal cysts found during service, pregnancies and miscarriages during and following service, and the surgical procedure following service removing the left ovary and fallopian tube. The diagnosis was a Pfannenstiel scar of the lower abdomen. The VA examiner expressed the opinion that the removal of the left ovary and fallopian tube was less likely as not a result of the gynecological problems in service, including a bulky uterus, cervicitis, and cervical dysplasia. The VA examiner explained that the Veteran had a normal pelvic ultrasound of the fallopian tubes, uterus, and ovaries in March 1992. The VA examiner stated that although the Veteran was evaluated for abdominal pain, there was no objective evidence suggesting that the left ovary or fallopian tube were a source of the pain and the normal pregnancies were indicative that the fallopian tubes, uterus, and ovaries were functioning normally. In February 2010 on VA examination, it was noted that an ultrasound in January 2010 showed a small hemorrhagic right ovarian cyst, but was otherwise unremarkable. The VA examiner stated that the vaginal cysts were not related to the removal of the left ovary and fallopian tube as a vaginal cyst is not a progressive condition. The VA examiner noted that the ultrasound in 1992 was normal. The VA examiner stated that it was unlikely that a vaginal wall cyst would be connected in any way to an ovarian cyst and the Veteran had other sources of left lower quadrant pain, including postservice pelvic adhesions. On VA examination in December 2010, the Veteran stated that the vaginal cysts were surgically removed in the 1990s and the cysts had not recurred. Analysis In addition to vaginal cysts, the service treatment records show that the Veteran had other gynecological conditions, including abnormal Pap smears, a bulky uterus, vaginitis, cervicitis, and amenorrhea. In March 1992, on examination for separation because of hardship, an ultrasound was negative for left ovarian cysts. In October 1992, on examination for separation because of pregnancy, history included vaginal cysts. The examination was limited because the Veteran was in the 2nd trimester of her pregnancy. There was no history of ovarian cysts. On the basis of the service treatment records alone, left ovarian cysts, the underlying condition, resulting in the postservice removal of the left ovary and left fallopian tube in 2008, were not affirmatively shown to have had inception in service and service connection under 38 U.S.C.A. § § 1110 and 1131 and 38 C.F.R. § 3.303(a) (affirmatively showing inception in service) is not established. In addition to the gynecological problems documented in service, the Veteran is competent to describe gynecological problems since service, which is within the realm of the Veteran's personal experience. 38 C.F.R. § 3.159 (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); see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge, personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness). As there is evidence of gynecological conditions noted in service, the principles of service connection, pertaining to chronicity and continuity of symptomatology under 38 C.F.R. § 3.303(b) are addressed. Chronicity and continuity of symptomatology under 38 C.F.R. § 3.303(b) apply to ovarian cysts, because an endocrinopathy, which includes ovarian cysts, but not vaginal cysts, is a chronic disease listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013) (chronicity and continuity of symptomatology under 38 C.F.R. § 3.303(b) apply only to a disease listed in 38 C.F.R. § 3.309(a)). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Although there was evidence of gynecological conditions in service, in 1992, an ultrasound of the ovaries did not show cysts and there was no other finding of ovarian cysts. As the service treatment records lack the documentation of the combination of manifestations sufficient to identify ovarian cysts and insufficient observation to establish chronicity at the time, considering the service treatment records only, chronic ovarian cysts in service were not shown. As for continuity, the elements to establish continuity are: (1) that the condition was "noted" during service; (2) evidence of postservice continuity of the same symptomatology noted in service; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Barr v. Nicholson, 21 Vet. App. 303 and Savage v. Gober, 10 Vet. App. 488, 497 (1997), overruled in part by Walker v. Shinseki, 708 F.3d 1331, (Fed. Cir. 2013) (to extent that 38 C.F.R. § 3.303(b) was applied to diseases not listed in 38 C.F.R. § 3.309(a), but not disturbing the elements to establish continuity of symptomatology). As there is evidence of gynecological conditions noted in service and the Veteran is competent to describe postservice gynecological symptoms, which are within the realm of the Veteran's personal experience, the Veteran's lay statements and testimony are evidence of postservice continuity of symptomatology. The remaining element to establish continuity is evidence of a relationship or nexus between the present disability, removal of the left ovary and fallopian tube, and the postservice symptomatology. In statements and in testimony, the Veteran has asserted that there is a causal relationship or nexus between the present disability and continuity of symptoms. As the Veteran's statements and testimony are an inference based on facts, it is an opinion rather than a statement of fact. The question then is whether the Veteran as a lay person is competent to offer an opinion on the causal relationship or nexus between the present disability, removal of the left ovary and fallopian tube, and the postservice symptomatology. The Veteran as a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Veteran as lay person is also competent to identify a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Removal of the left ovary and fallopian tube due to ovarian cysts is not simple medical condition the Veteran is competent to identify, because the diagnosis falls outside the realm of common knowledge of a lay person, that is, the diagnosis cannot be made based on mere personal observation, which comes through sensory perception. And it is not argued or shown that the Veteran is otherwise qualified through specialized education, training, or experience to identify ovarian cysts, resulting in removal of the left ovary and fallopian tube. Also, ovarian cyst, resulting in removal of the left ovary and fallopian tube, are not the type of conditions under case law that has been found to be capable of lay observation. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfeet are capable of lay observation); see McCartt v. West, 12 Vet. App. 164, 167 (1999) (a skin condition is capable of lay observation; see Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus is capable of lay observation); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); and see Jandreau, at 1377, n. 4 (a lay witness is capable of diagnosing a dislocated shoulder or a simple medical condition, for example a broken leg, but not, for example, a form of cancer). Applying the guidance of current case law, ovarian cysts, resulting in removal of the left ovary and fallopian tube, are more analogous to an internal disease process such as rheumatic fever or a form of cancer rather than either flatfeet, a skin condition, tinnitus, varicose veins, a dislocated shoulder, or a broken leg. For this reason, the Board concludes that ovarian cysts, resulting in removal of the left ovary and fallopian tube, are not the type of conditions under case law that has been found to be capable of lay observation. As ovarian cysts, resulting in removal of the left ovary and fallopian tube, are not the type of conditions that can be identified based on personal observation either as a simple medical condition under Jandreau, or by case law, any inference based on what is not personally observable cannot be competent lay evidence. And no factual foundation has been established to show that the Veteran is otherwise qualified through specialized education, training, or experience to offer an opinion on the causal relationship or nexus between the ovarian cysts, resulting in removal of the left ovary and fallopian tube, and the continuity of symptoms that the Veteran avers. For these reasons, the Veteran lay opinion is not competent evidence on the third element of continuity, namely, a causal relationship or nexus between the present disability and the postservice symptomatology. Since the Veteran's lay opinion is not competent evidence, the lay opinion is excluded, that is, not admissible as evidence and cannot be considered as competent lay evidence favorable to claim based on continuity of symptomatology. As the evidence is not admissible, the Board need not reach the credibility of the evidence. Although service connection for the present disability is not established under either 38 C.F.R. § 3.303(a) or by chronicity or by continuity of symptomatology under 38 C.F.R. § 3.303(b), service connection may still be established based on an initial diagnosis after service, when all of the evidence, including that pertinent to service, shows that the disability was incurred in service. 38 C.F.R. § 3.303(d). Where, as here, there is a question of the presence or a diagnosis of a disability, which are not capable of lay observation, as previously explained, to the extent the Veteran's lay evidence is offered as proof of the presence of the disability in service and since service and before 2008, the Veteran's lay evidence is not competent evidence, and the lay evidence is not admissible as evidence and cannot be considered as competent evidence favorable to the claim. Except the Veteran as a lay person is competent to describe a contemporaneous medical diagnosis or symptoms that later support a diagnosis by a medical professional. Jandreau, at 1377. As for the Veteran reporting a contemporaneous medical diagnosis, no medical professional had diagnosed ovarian cysts before 2008, more than 15 years after separation from service in 1992, and well beyond the one year presumptive period for ovarian cysts as a chronic disease under 38 C.F.R. §§ 3.307 and 3.309. As for symptoms described by the Veteran that later support a diagnosis by a medical professional, on VA examination in November 2009, the VA examiner expressed the opinion that the removal of the left ovary and fallopian tube was less likely as not a result of the gynecological problems in service, including a bulky uterus, cervicitis, and cervical dysplasia. The VA examiner explained that the Veteran had a normal pelvic ultrasound of the fallopian tubes, uterus, and ovaries in March 1992. The VA examiner stated that although the Veteran was evaluated for abdominal pain, there was no objective evidence suggesting that the left ovary or fallopian tube were a source of the pain and the normal pregnancies were indicative that the fallopian tubes, uterus, and ovaries were functioning normally. In February 2010 on VA examination, the VA examiner stated that the vaginal cysts were not related to the removal of the left ovary and fallopian tube as a vaginal cyst is not a progressive condition. The VA examiner noted that the ultrasound in 1992 was normal. The VA examiner stated that it was unlikely that a vaginal wall cyst would be connected in any way to an ovarian cyst. On VA examination in December 2010, the Veteran stated that the vaginal cysts were surgically removed in the 1990s and the vaginal cysts had not recurred. Neither VA examiner related the removal of the left ovary or fallopian tube to the gynecological conditions in service or to the service-connected vaginal cysts based on causation. As for aggravation, the vaginal cysts without evidence of recurrence were removed in 1991 or 1992, 15 years before ovarian cysts by ultrasound were document in 2008. Therefore the vaginal cysts did not make the ovarian cysts permanently worse. 38 C.F.R. § 3.310. Also as previously explained, the Veteran as a lay person is not competent to offer an opinion on medical causation where the disability is not capable of lay observation either as a simple medical condition under Jandreau, or by case law, any inference or opinion based on what is not personally observable cannot be competent lay evidence. And no factual foundation has been established to show that the Veteran is otherwise qualified through specialized education, training, or experience to offer an opinion on the causal relationship or nexus between the ovarian cysts, resulting in removal of the left ovary and fallopian tube, and the gynecological conditions in service or to the service-connected vaginal cysts. As the only competent medical evidence of record, pertaining to causation or a nexus to service or to a service-connected disability consists of the reports of VA examinations, opposes rather than supports the claim, and as there is no medical evidence in favor of the claim, or competent lay evidence in favor of the claim on a material issue of fact, namely, a nexus to service or to a service-connected disability, the preponderance of the evidence is against the claim, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). ORDER The application to reopen the claim of service connection for a skin rash is granted and to this extent only the appeal is granted. Service connection for the removal of the left ovary and fallopian tube is denied. REMAND On the reopened claim of service connection for a skin rash and the claim of service connection for migraine headaches with visual disturbance, as the evidence of record is insufficient to decide the claims, further development under the duty to assist is needed. On the claims of service connection for a gastrointestinal disability and for a back disability, as the evidence of record is insufficient to decide the applicable theories of service connection, further development under the duty to assist is needed. On the claim of service connection for a bilateral knee disability, the Veteran's hearing testimony reduced to a writing as evidenced by the transcript constitutes a timely notice of disagreement to the denial of service connection. As the RO has not had the opportunity to issue a statement of the case, further procedural development is needed. On the claim for increase for posttraumatic stress disorder, since the Veteran was last examination in July 2012, the Veteran testified in November 2012 that her condition is worse. As there is a need to verify the current severity of the disability, a reexamination is warranted under 38 C.F.R. § 3.327. Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran a VA examination to determine: a). Does the Veteran have a skin disease, and, if so, b). Whether it is more likely than not (probability greater than 50 percent), at least as likely as not (probability of 50 percent), or less likely than not (probability less than 50 percent), that the current skin disease is related to the in-service arm rash as described by the Veteran or the development of a new and separate condition? The Veteran is competent to describe a skin rash, which is capable of lay observation in service and since service, although there is no contemporaneous record of the symptoms in service. If, however, after a review of the record, an opinion is not possible without resort to speculation, the VA examiner is asked to clarify that the opinion cannot be rendered because there are other potential causes for the current skin disease, please identify the other potential causes, when the skin symptoms the Veteran has described in service are not more likely than any other etiology related to the current skin disease and that an opinion is beyond what may be reasonably concluded based on the evidence of record and current medical knowledge. The Veteran's file must be provided to the VA examiner for review. 2. Afford the Veteran a VA examination to determine: a). Whether the Veteran has migraine headaches with visual disturbance, and, if so, b). Whether it is more likely than not (probability greater than 50 percent), at least as likely as not (probability of 50 percent), or less likely than not (probability less than 50 percent), that migraine headaches with visual disturbance are related to the history of frequent headaches, noted on separation examination in October 1992 or the development of a new and separate condition? The Veteran is competent to describe headaches in service, which are capable of lay observation, although there is no contemporaneous record of the symptoms in service. If, however, after a review of the record, an opinion is not possible without resort to speculation, the VA examiner is asked to clarify that the opinion cannot be rendered because there are other potential causes for the current headaches, please identify the other potential causes, when the headaches the Veteran has described in service are not more likely than any other etiology related to the current headaches and that an opinion is beyond what may be reasonably concluded based on the evidence of record and current medical knowledge. The Veteran's file must be provided to the VA examiner for review. 3. Afford the Veteran a VA examination to determine: Whether the Veteran has either a known gastrointestinal disease or a functional gastrointestinal disorder, characterized by chronic or recurrent symptoms that are unexplained by any structural, endoscopic, laboratory, or other objective signs of injury or disease, and apart from any abdominal pain sydrome associated with two diagnostic laparoscopies, three cesarean sections, removal of the left ovary and fallopian tube, lysis of pelvic and omental adhesions, and a Pfannenstiel scar. The Veteran's file must be provided to the VA examiner for review. 4. Afford the Veteran a VA examination to determine: Whether the Veteran has either a known back disability or medically unexplained back muscle and joint pains apart from any abdominal pain sydrome associated with two diagnostic laparoscopies, three cesarean sections, removal of the left ovary and fallopian tube, lysis of pelvic and omental adhesions, and a Pfannenstiel scar. The Veteran's file must be provided to the VA examiner for review. 5. Afford the Veteran a VA examination VA to determine: The current level of occupational and social impairment due to posttraumatic stress disorder. The VA examiner is asked to address: Whether the Veteran is still employed and how well she is doing with her current employment or if she is unemployed, because of service-connected posttraumatic stress disorder. The Veteran's file must be made available to the VA examiner for review. 6. Furnish the Veteran and her representative, a statement of the case on the claim of service connection for bilateral knee disability, including notice that the Veteran still must file a timely substantive appeal in order to perfect appellate review by the Board. 7. After the above development, adjudicate the reopened claim of service connection for a skin disease on the merits, the claim of service connection for migraine headaches with visual disturbance, the claims of service connection for a gastrointestinal disorder and a back disability, including under 38 C.F.R. § 3.317, and the claim for increase for posttraumatic stress disorder. If any benefit sought is denied, furnish the Veteran and her representative a supplemental statement of the case and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs