Citation Nr: 1324950 Decision Date: 08/06/13 Archive Date: 08/13/13 DOCKET NO. 06-21 514A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a bilateral hearing loss disability. 2. Entitlement to service connection for a left eye disability. 3. Entitlement to service connection for pain and numbness in the legs (to include as a result of an undiagnosed illness). 4. Entitlement to service connection for hip pain (to include as a result of an undiagnosed illness). 5. Entitlement to service connection for a stomach disorder (to include as a result of an undiagnosed illness). 6. Entitlement to service connection for essential hypertension (to include as a result of an undiagnosed illness). 7. Entitlement to service connection for a heart disorder (to include as a result of an undiagnosed illness). 8. Entitlement to service connection for an allergic condition (to include as a result of an undiagnosed illness). 9. Entitlement to service connection for a sleep disorder (to include as a result of an undiagnosed illness). 10. Entitlement to service connection for a skin disorder on the bilateral arms (to include as a result of an undiagnosed illness). 11. Entitlement to service connection for a back disorder (to include as a result of an undiagnosed illness). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD H. Bunker, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1989 to January 1991. This case comes before the Board of Veterans' Appeals (Board) on appeal from September 2005 and August 2006 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified at a Board hearing at the RO in St. Petersburg, Florida in January 2009. This transcript has been associated with the file. The Veteran was notified in November 2011 that the Judge who held his hearing had retired from the Board. He was informed that he could have an additional hearing with a new Judge who would ultimately decide his appeal. He responded in January 2012 that he did not wish to have an additional hearing and that the Board should proceed based on the evidence of record. The case was brought before the Board in April 2009, at which time the claims were remanded to allow the Agency of Original Jurisdiction (AOJ) to further assist the Veteran in the development of his appeal. The case was again before the Board in June 2012 when it was remanded for additional development to include verifying the Veteran's service in the Persian Gulf, associating outstanding treatment records with the claims file, notifying him how to substantiate his claims, and affording him new VA examinations. The AOJ obtained confirmation that the Veteran served on the U.S.S. Independence in the Gulf of Oman, thus verifying service in the Persian Gulf. The Veteran's most recent VA treatment records were obtained and associated with the claims file. The Veteran was also notified in June and October 2012 how to substantiate his claims as due to undiagnosed illness. Following this remand the Veteran was also afforded VA examinations for his conditions. Therefore, the Board finds that there has been substantial compliance with its remand directives, as it pertains to the issues being decided in this decision. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). The issues of entitlement to service connection for a bilateral hearing loss disability, left eye disability, bilateral leg pain and numbness, stomach disorder, allergic condition, and skin disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's hip pain is not shown to be due to a disease or injury in-service or to any incident of his military service, to include service in the Gulf War, and degenerative arthritis of the hips did not manifest within one year of service. 2. The Veteran's hypertension is not shown to be due to a disease or injury in-service or to any incident of his military service, to include service in the Gulf War, and did not manifest within one year of service. 3. The Veteran's heart disorder is not shown to be due to a disease or injury in-service or to any incident of his military service, to include service in the Gulf War. 4. The Veteran's sleep disorder is not shown to be due to a disease or injury in-service or to any incident of his military service, to include service in the Gulf War. 5. The Veteran's back disorder is not shown to be due to a disease or injury in-service or to any incident of his military service, to include service in the Gulf War, and arthritis of the back did not manifest within one year of service. CONCLUSIONS OF LAW 1. The Veteran's hip pain was not incurred in or aggravated by military service and did not manifest within one year. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317 (2013). 2. The Veteran's hypertension was not incurred in or aggravated by military service and did not manifest within one year. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.317 (2013). 3. The Veteran's heart disorder was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317 (2013). 4. The Veteran's sleep disorder was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317 (2013). 5. The Veteran's back disorder was not incurred in or aggravated by military service and did not manifest within one year. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.317 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to review the entire record, the Board does not have to discuss each piece of evidence reviewed. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. Reasonable doubt is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). The notice requirements were met in this case by May 2005, June 2005, February 2006, June 2011, and October 2012 letters sent to the Veteran informing him how to substantiate his claims and of his and VA's respective obligations for obtaining specified types of evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b). He was also advised of how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the Veteran was not provided adequate 38 U.S.C.A. § 5103(a) notice prior to the adjudication of the claim in the September 2005 and August 2006 rating decisions, this notice problem does not constitute prejudicial error in this case because the record reflects that a reasonable person could be expected to understand what was needed to substantiate the claims after reading the above letters as well as the rating decision, statement of the case, and supplemental statements of the case. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Veteran has neither alleged nor proven that prejudice resulted from lack of proper VCAA notice, and therefore, the Board determines that none resulted. See Shinseki, supra. The Veteran has not alleged that VA failed to comply with the notice requirements of the VCAA, and he was afforded a meaningful opportunity to participate effectively in the processing of his claim, and has in fact provided additional arguments at every stage. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005). The Veteran's service treatment records and VA treatment records are in the file. VA has also obtained private treatment records and associated them with the claims file. The Veteran has not indicated that there are any additional outstanding records to be obtained. The duty to assist with obtaining medical records has been satisfied. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. The Veteran has been afforded numerous VA medical examinations, most recently in August and October 2012. These opinions were rendered by medical professionals following a thorough examination and interview of the Veteran and review of the claims file. The examiners obtained an accurate history. The examiners provided a detailed conclusion for the conclusions that were reached. Therefore, the Board finds that the examinations are adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran has been afforded a hearing before a Veterans Law Judge (VLJ) in which he presented oral argument in support of his service connection claims for hypertension, a back disorder, a disorder characterized as pain and numbness in the legs, hip pain, sleep apnea, and a heart murmur. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ or DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ addressed some of the elements that were lacking to substantiate the claims and specifically sought to identify any relevant outstanding treatment records. The Veteran also volunteered his treatment history and symptoms since service. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). In light of the foregoing, all relevant facts have been adequately developed to the extent possible; no further assistance to the Veteran in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The U.S. Court of Appeals for the Federal Circuit has recently held that for purposes of 3.303(b), where the veteran asserts entitlement to a chronic condition but there is insufficient evidence of a diagnosis in service, the veteran can establish service connection by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1337-39 (Fed. Cir. 2013), affirming Walker v. Shinseki, No. 10-2634, 2011 WL 2020827 (Vet. App. May 25, 2011). [emphasis added]. For disabilities that are not listed as chronic under 38 C.F.R. § 3.303(b), the only avenue for service connection is by showing in-service incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). Service connection may also be granted for a chronic disease, including arthritis and hypertension, when it is manifested to a compensable degree within one year of separation from service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). For VA rating purposes, "hypertension" means that diastolic blood pressure is predominately 90 millimeter (mm) or greater; "isolated systolic hypertension" means that the systolic blood pressure is predominately 160 mm or greater with a diastolic blood pressure of less than 90 mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For veterans who have served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317 (2012). Under that section, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1) (2012). For purposes of 38 C.F.R. § 3.317, there are two types of qualifying chronic disabilities: (1) an undiagnosed illness and (2) a medically unexplained chronic multi symptom illness such a chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to: (1) Fatigue, (2) Unexplained rashes or other dermatological signs or symptoms, (3) Headache, (4) Muscle pain, (5) Joint pain, (6) Neurological signs and symptoms, (7) Neuropsychological signs or symptoms, (8) Signs or symptoms involving the upper or lower respiratory system, (9) Sleep disturbances, (10) Gastrointestinal signs or symptoms, (11) Cardiovascular signs or symptoms, (12) Abnormal weight loss, and (13) Menstrual disorders. 38 C.F.R. § 3.317(b). Gulf War Illness The Veteran contends that his claimed conditions may be a result of his service in the Persian Gulf. Initially, the Board observes some of the Veteran's claimed disabilities have been attributed to known clinical diagnoses. The Veteran's right hip pain has been diagnosed as degenerative joint disease. See October 2012 VA examination report. The Veteran has also been diagnosed with hypertension, a heart murmur, and an enlarged heart. See November 2009 VA treatment record and October 2012 VA examination report. The Veteran also has sleep apnea. See October 2012 VA examination report. Finally, the Veteran's lumbar pain has been determined to stem from lumbar strain. See October 2012 VA examination report. In addition, none of these disabilities has been attributed to a medically unexplained chronic multi symptom illness, as will be shown by the medical evidence discussed in more detail in the direct service connection section. As there is no evidence that the Veteran is suffering from a chronic disability that cannot be attributed to any known clinical diagnosis or a medically unexplained chronic multi symptom illness, the provisions of 38 C.F.R. § 3.317 pertaining to undiagnosed illness do not apply. However, the Board will consider the Veteran's claims under the usual provisions pertaining to service connection. See 38 C.F.R. § 3.303. Presumptive Service Connection With regard to the presumption of service connection, the Veteran must be diagnosed with hypertension or arthritis which manifested to a degree of 10 percent or more within 1 year from service for the presumption to apply. 38 C.F.R. § 3.307 (a)(3). At his January 2009 Board hearing he testified that he was not diagnosed with hypertension until 1996 or 1997, more than 1 year after separation from service. The Veteran also was not diagnosed with degenerative changes of the right hip or lumbar spine until VA examinations more than one year after separation from service. As such, the presumption of service connection does not apply in the instant case, but the claims will also be considered under a theory of entitlement to direct service connection. 38 C.F.R. §§ 3.307, 3.309(a). Direct Service Connection The Veteran contends that he injured his back and hip in service during an accident where he fell on the flight deck. He further contends that his other conditions began while he was on active duty and should be service connected. See e.g., January 2009 Board hearing transcript. For the reasons discussed below, the Board finds service connection is not warranted. Heart Disorder Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment. 38 C.F.R. § 3.304(b). The presumption of soundness attaches only where there has been an induction examination during which the disorder about which the Veteran later complains was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). A pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows the increase in disability is due to the natural progression of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. The Veteran has testified that he entered service with a heart murmur which he believes was worsened by service. However, to the contrary, at his December 1988 entrance examination the Veteran specifically denied heart trouble and no condition was found on examination. In March 1989, one month after the Veteran was on active duty, he reported that he had a heart murmur as recently as 2 years prior. Although the Veteran contends that he entered service with a heart disorder, the Court has held that the regulation provides expressly that the term 'noted' denotes only such conditions as are recorded in examination reports, and that a mere history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions. 38 C.F.R. § 3.304(b)(1); Crowe v. Brown, 7 Vet. App. 238 (1994). In this case the Veteran specifically denied any heart trouble on entrance to service and none was found on examination during service. See March 1989 and December 1990 findings. The record also does not demonstrate clear and unmistakable evidence of a pre-existing heart disability, notwithstanding the normal clinical evaluation of the heart at entry into service. As discussed, the Veteran specifically denied heart trouble and no condition was found on his December 1988 examination. In March 1989 the Veteran reported that he had a heart murmur as recently as 2 years prior. On cardiac examination his findings were normal. In a November 1990 medical questionnaire the Veteran reported that he might have a heart murmur. At his December 1990 separation examination there were no heart defects noted and the Veteran specifically checked that he did not have palpations or pounding heart or heart trouble. See December 1990 Report of Medical History. Although the Veteran is now testifying and maintaining that he had a pre-existing heart murmur that just was not shown on clinical evaluation at entry into service, his comments do not constitute clear and unmistakable evidence of a pre-existing heart disability. Also, none of the medical evidence of record establishes clear and unmistakable evidence of a pre-existing heart disability. There is no other competent evidence of a heart murmur which pre-existed service. Accordingly, the Veteran is presumed sound on entrance to service, and the relevant inquiry in this case is whether any present heart disorder is related to his military service. An October 2005 VA treatment record indicated the Veteran had left ventricular hypertrophy. In a January 2007 VA treatment record the Veteran had a cardiology appointment where he denied heart murmurs, enlarged heart, rheumatic fever or leaky valves. The examiner noted the September 2005 echocardiogram which revealed a slight thickening of the left ventricular walls which he believed was due to longstanding hypertension. There was no murmur on examination. The Veteran had mild left ventricular hypertrophy on testing. This was related to his hypertension. In an undated statement from the Veteran's cardiologist the Veteran was noted to have hypertensive cardiovascular disease, left ventricular hypertrophy, and a systolic flow murmur. In a November 2009 VA treatment record it was noted that the Veteran had been diagnosed with an enlarged heart and was being followed by cardiology. In an August 2012 VA examination the Veteran was noted to have hypertensive heart disease. On examination there was no wall motion abnormality, but there is a statement relating to old inferior wall myocardial infarction. This appears nowhere else in the record. At the Veteran's October 2012 VA examination for a heart disorder he reported that he had a heart murmur which existed prior to entering the military. The examiner did not relate this condition to service as it was first noted 13 years after separation from service. The Veteran testified at his January 2009 Board hearing that he entered service with a heart murmur which was gone at his medical examination at entrance to service. He testified that he believed his heart condition was aggravated by service. Again the Board notes that the Veteran was presumed sound on entrance to service as there was no evidence of a heart disorder on his entrance examination and there is no clear and unmistakable evidence of a pre-existing heart disability. 38 C.F.R. § 3.304(b)(1); Crowe, supra. In light of all the evidence of record, the Board finds the evidence weighs against the Veteran's assertions that any heart disorder is related to service. The Board acknowledges that the Veteran is competent to report that he has experienced symptoms of a heart disorder since military service. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (holding that lay testimony is competent to establish the presence of observable symptomatology); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). However, he is not competent to report that the symptoms he has experienced are attributable to the current heart disorders he presently has. The most competent evidence of record suggests that the Veteran developed a heart disorder after separation from service. He was specifically evaluated in service and found to not have a heart disorder. See March 1989 record. The first post service reference to a heart disorder comes from an October 2005 treatment record, 14 years after separation from service. This examiner also linked the Veteran's condition to his longstanding hypertension, which, as discussed in the next section below, is also not related to military service. The October 2012 VA examiner did not relate the Veteran's heart murmur to service as it was first noted 13 years after separation from service. The Veteran's statements regarding the onset of a heart disability also are not credible as he has provided contradictory information concerning the onset of his heart disorder. While he currently maintains that he had a heart murmur prior to service that was aggravated by service, he denied any history of heart trouble on his December 1988 entrance examination. He also denied heart murmurs, enlarged heart, rheumatic fever or leaky valves on examination in January 2007. Given that the Veteran's statements regarding the onset of his heart disorder are contradictory the probative value of his assertions is undermined. Even if the Veteran's statements regarding the onset of a heart disorder were credible, it does not follow that any present heart condition is necessarily related to any demonstrated continuous symptomatology. The Board acknowledges that the Veteran believes he has a heart disorder which began in service or was worsened as a result of service. Although lay persons such as the Veteran are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the issue of diagnosing the etiology of a heart disorder, this falls outside the realm of common knowledge of a lay person. The Veteran's assertion has been investigated by competent medical opinion, and found to be without merit. See Jandreau, supra. The Board also finds it significant that a VA examiner in October 2012 found that after reviewing the claims file and pertinent medical history that a current heart disability was not related to service. The probative value of the examiner's opinion is high as the examiner was fully informed of the Veteran's medical history, provided a fully articulated rationale, and the opinion was supported by a reasoned analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-04 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for a heart disorder and the benefit of the doubt rule does not apply. See 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Hip Pain, Hypertension, Sleep Disorder, and Lumbar Spine Disorder As noted, the Veteran believes that the above listed conditions were caused by his active duty service and should therefore be service connected. For the reasons discussed below, the Board finds service connection is not warranted. At his entrance to service examination in December 1988 the Veteran denied swollen or painful joints, arthritis, or recurrent back pain and no defects were found on examination, except for moderate pes planus. His blood pressure was 124/70. In a March 1989 record his blood pressure was recorded as 155/71. In a March 1990 service treatment record the Veteran was seen for pain which began after falling on a shuttle on the flight deck. The Veteran reported no back, chest, or upper body pain. There was some evidence of guarding. He was diagnosed with a pelvic contusion. His blood pressure was recorded as 122/66. In a November 1990 medical questionnaire the Veteran denied hypertension, arthritis, or painful joints. At his December 1990 separation examination the examiner found no defects of the Veteran's spine, or lower extremities. The Veteran himself specifically denied swollen or painful joints, arthritis, recurrent or back pain. The lack of findings of chronic disorders in service weighs against the Veteran's claim that these conditions began in service and continued on thereafter. In his June 1994 Disability Report the Veteran reported that his lower back pain began in June 1994 after the car accident. The Veteran received treatment following the June 1, 1994 car accident. He reported lumbar spine pain that radiated down his legs. He was diagnosed with lumbar spine strain. See e.g., February 1996 private treatment record. In October 1994 the Veteran reported lower back pain. MRI evidence showed disc herniation central and to the left side at L5-S1. He was diagnosed with lumbar strain with incidental bulging disc. In a March 1997 private treatment record the Veteran reported that his back pain began following a car accident in June 1994. In a July 1997 private treatment record the Veteran complained of high blood pressure and dizziness. In a September 1997 general VA examination the Veteran reported lower back pain which began following the 1994 car accident. The Veteran's blood pressure was read as 176/100 and 160/88. His diagnoses included essential hypertension and partial sacralization of S1 and mild scoliosis concave to the right, as shown by x-ray. In a December 2001 private treatment record the Veteran reported lower back pain. In a January 2003 VA treatment record the Veteran reported lower back pain which had existed since 1990. In an August 2004 private treatment record the Veteran underwent a sleep study and was diagnosed with obstructive sleep apnea. See also October 2004 VA treatment record. In December 2005 the Veteran again reported that his back pain began in 1990 and was reinjured in 1994 when he was in a car accident. X-rays showed spinal stenosis with mild degenerative arthritis. An August 2008 VA treatment record also noted the Veteran was using a CPAP for his sleep apnea. The Veteran was afforded VA examinations for his spine and hips in November 2010. He reported that he was injured in service while working on the flight deck. He was also involved in the June 1994 car accident. The examiner noted the first reports of lower leg symptoms began post car accident in 1995, with left hip pain in 1996. The examiner also noted a normal EMG nerve study of the bilateral lower extremities done in September 1996. Spinal and right hip x-rays showed an essentially normal examination. The examiner opined that it was less likely than not that the Veteran's current lumbar spine strain with radiographic congenital narrowing was caused by military service. Her rationale was that the clinical history and evaluation was most consistent with the 1994 car accident. She also noted the in-service accident was a pelvic contusion which was not likely to result in the current spine condition. The November 2010 examiner also opined it was less likely than not that a right hip condition was related to service. Again she noted the evidence of record did not diagnose treatment for a right hip condition until after the 1994 car accident. The findings were consistent with early degenerative changes of the hips, which would not be seen on x-ray in the early stages. In a December 2010 VA treatment record the Veteran reported chronic lower back pain that was not completely relieved with over the counter medication. He also reported that his increased blood pressure was due to back pain. In a February 2011 VA treatment record the Veteran's blood pressure was adequately controlled. The Veteran was afforded a VA examination in July 2011 for his lumbar spine and hips where he reported that his lumbar spine and hips began bothering him following his injury in service. His pain was further aggravated in the 1994 car accident. The examiner noted no complaints of hip pain until following the 1994 car accident. The Veteran was diagnosed with bilateral hip strain, mild, and posttraumatic hip strain, residual hip contusion. He opined that it was less likely than not that the hip condition was related to service. His rationale was that following the injury in service the Veteran denied hip pain and x-rays showed no hip disorders. On subsequent visits the Veteran also denied hip pain. The examiner noted that the Veteran's current complaints are remote to the actual injury and although they could have been asymptomatic, abruptly increased severity of pain unprovoked was highly unlikely. He further opined it was a more reasonable relationship that the Veteran's hip pain was related to the 1994 car accident in that the pain was more prominent following this accident. The July 2011 VA examiner also did not relate the Veteran's lumbar spine condition to service. His rationale was that there was no evidence to support a finding that a pelvis contusion was related to current lumbar strain. At his October 2012 VA examination for hypertension the Veteran's blood pressure was recorded as 183/100, 215/119, and 184/106. He was taking medication to help control his symptoms. The examiner opined this was less likely than not related to service as hypertension was first noted in March 2003 and has many different causes. At his August 2012 VA examination it was noted his sleep apnea was first diagnosed in 2003 and that he was using a CPAP machine at night. He was afforded a VA examination for sleep apnea in October 2012. He reported that his current problems were falling asleep and being able to sleep more than 4 to 5 hours a night. He was using a CPAP machine. The examiner opined it was less likely than not that this condition was related to service as the Veteran was first noted to have it in 2003, years after separation from service. The Veteran was afforded a VA examination in October 2012 for his spine and hip pain. He reported that these conditions began with his injury in service and worsened following his 1994 car accident. The examiner did not relate any of these conditions to service. He noted the Veteran's service treatment records were silent for complaints of these conditions and that osteoarthritis of the hip was a normal result of aging. In deciding claims, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion). In light of all the evidence of record, the Board finds the evidence weighs against the Veteran's assertions that any of the claimed conditions are related to service. The Board acknowledges that the Veteran is competent to report that he has been diagnosed with these conditions. See Barr, supra; Jandreau, supra; Davidson, supra. A November 2005 buddy statement also indicated that the Veteran injured his lower back in service. The Veteran's sister also offered a statement that prior to service the Veteran did not have back or leg problems, or hypertension. See also statement of B.O. and K.G. At his January 2009 Board hearing the Veteran testified that he injured his back and hips in service when a 100 pound piece of machinery fell on him. He testified that this is where the back and hip pain began, however it was reinjured in the June 1994 car accident. He also believed his hypertension began on active duty. He also testified that he could not sleep in service for more than a couple hours at a time. He testified that a doctor had told him he had an old injury in his back, like a bulging and herniated disc, and that he reinjured it in the car accident. While the Veteran is competent to state what symptoms he has experienced over the years and since service, the Veteran has provided contradictory statements concerning the onset of his back pain, hip pain, hypertension, and sleep apnea. Even though the Veteran now reports that his back pain and hip pain started on active duty when he suffered injury to his pelvis in March 1990, the March 1990 service treatment record notes that the Veteran was seen for pain which began after falling on a shuttle on the flight deck and that he denied any no back pain radiating to the legs. In addition, in a November 1990 medical questionnaire the Veteran denied hypertension, arthritis, or painful joints. At his December 1990 separation examination the Veteran himself specifically denied swollen or painful joints, arthritis, recurrent or back pain. Again, after service a June 1994 Disability Report shows the Veteran reported that his lower back pain began in June 1994 after the car accident. He also reported on examination in March 1997 and again in September 1997 that his back pain began following a car accident in June 1994. None of the treatment records demonstrate any complaints of hip pain, sleep problems, or problems with his blood pressure. It was not until September 1997 that he was diagnosed with essential hypertension, and August 2004 that he was diagnosed with obstructive sleep apnea. Early degenerative changes of the hips also were not shown until November 2010. The probative value and credibility of the Veteran's statements concerning the onset of his symptoms attributed to his back, hips, hypertension, and sleep apnea is significantly undermined by his contradictory assertions regarding onset of his symptoms. The most credible evidence of record suggests that the Veteran's claimed conditions began after separation from service. The Veteran has been diagnosed with spinal stenosis, scoliosis, and hip arthritis. He has also been diagnosed with hypertension and sleep apnea. The November 2010 examiner did not relate the Veteran's leg, hip, and spine disabilities to service as the in service accident was a pelvic contusion. The hip arthritis was related to early degenerative changes, which was found to be a normal result of aging by the examiner in October 2012 and not related to service as there was no finding of a hip disorder in service. The July 2011 VA examiner also did not relate these conditions to service, as following the injury in service the Veteran denied hip pain and x-rays showed no hip disorders and he also denied hip pain on subsequent visits. The examiner found it was a more reasonable relationship that the Veteran's hip pain was related to the 1994 car accident in that the pain was more prominent following this accident. In addition the October 2012 examiner did not relate the Veteran's hypertension and sleep apnea to service as the first evidence of symptoms began 12 years after separation from active duty. Even if the Veteran's statements regarding the onset of the claimed conditions were credible, it does not follow that any currently diagnosed conditions are necessarily related to any demonstrated continuous symptomatology. The Board acknowledges that the Veteran believes he has multiple health disorders which began in service. Although lay persons such as the Veteran are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the issue of diagnosing the etiology of a numerous health disorders, including arthritis and sleep apnea, this falls outside the realm of common knowledge of a lay person. The Veteran's assertion has been investigated by competent medical opinion, and found to be without merit. See Jandreau, supra. The Board also finds it significant that multiple VA examiners have determined that the Veteran's claimed conditions are not related to service. See e.g., November 2010, July 2011, and October 2012 VA examination reports. There is no competent, credible evidence to the contrary. The probative value of the examiners' opinions is high as the examiners were fully informed of the Veteran's medical history, provided fully articulated rationales, and the opinions were supported by reasoned analyses. See Nieves-Rodriguez, supra; see also Stefl, supra. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for hip pain, hypertension, a sleep disorder, and a lumbar spine disorder and the benefit of the doubt rule does not apply. See 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). ORDER Entitlement to service connection for hip pain is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for a heart disorder is denied. Entitlement to service connection for a sleep disorder is denied. Entitlement to service connection for a back disorder is denied. REMAND Bilateral Hearing Loss Disability At the Veteran's August 2012 VA examination the examiner opined that the Veteran's March 2004 test results were called into question and he also stated hearing loss was not related to service as there was no evidence of hearing loss on separation. Evidence of in-service hearing loss is not required to show that current hearing loss is related to service. An addendum opinion should be obtained for further comment by the August 2012 VA examiner. Left Eye Disability At his August 2012 VA examination the examiner did not review the Veteran's claims file or address the fact that the Veteran alleges a left eye disability occurred as a result of being splashed in the face with chemicals. An addendum opinion should be obtained for a review of the claims file and opinion on a left eye disability as secondary to chemical exposure. Bilateral leg pain and numbness The Veteran was afforded a VA examination in October 2012 for his bilateral leg pain and numbness, spine, and hip pain. He reported that these conditions began with his injury in service and worsened following his 1994 car accident. The examiner did not relate any of these conditions to service. He noted the Veteran's service treatment records were silent for complaints of these conditions and that osteoarthritis of the hip was a normal result of aging. He opined the Veteran's peripheral neuropathy was related to his diabetes, but that it was at least as likely as not that it began in service. This opinion is contradictory in that the examiner also noted the Veteran was not diagnosed with diabetes until March 2007, after the Veteran had separated from service. As the Veteran was not diagnosed with diabetes until 16 years after separation from service, the Board is unclear how the October 2012 examiner related an onset of a subsequent symptom, peripheral neuropathy, to have begun in service. An addendum opinion should be provided to address whether the Veteran's peripheral neuropathy is related to his military service. Stomach Disorder, Skin Disorder, Allergic Condition The Veteran specifically denied stomach problems, to include ulcers, skin problems, and allergy problems while in service. However, in November 2011 he testified that he had constant blood in his stool when he was in service. At his August 2012 VA examination he was diagnosed with an ulcer which began in 1990, during service. At his October 2012 VA examination he reported frequent bowel movements in service. The examiner opined this was a side effect of his diabetes medication which had resolved. However, as early as April 2003, prior to his 2007 diabetes diagnosis, the Veteran reported bowel movements with bleeding. At his August 2012 VA examination the Veteran was diagnosed with dermatitis which began in 1991, possibly during service. However, an etiology opinion was not provided. At his October 2012 VA examination the Veteran was diagnosed with dry skin which began in 1990, while on active duty. However, the examiner determined that it was less likely than not that the Veteran's dry skin had its onset in service as there were many possible causes other than just the environment, which were difficult ot pinpoint. It was noted that thyroid disease, Hodgkin's disease, eczema, and diabetes all contributed to bothersome skin conditions. At his August 2012 VA examination the Veteran was diagnosed with allergic rhinitis which began in 1991, during service. At his October 2012 VA examination the Veteran was diagnosed with seasonal allergies. The examiner determined that it was less likely than not that the Veteran's seasonal allergies were related to service as the condition was first noted in July 2003. As there are conflicting opinions as to whether the Veteran has any of these disorders and if they are related to service, to include service in the Persian Gulf, new VA examinations should be scheduled. The RO should also take this opportunity to obtain recent VA outpatient treatment records and associate them with the claims file. Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's outstanding VA outpatient treatment records. Follow-up requests should be made if necessary and the VA Medical Center must provide a negative response if records are not available. 2. Ask the August 2012 VA examiner to provide an addendum opinion regarding the Veteran's bilateral hearing loss disability claim. a. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE), to include this Remand must be reviewed by the examiner in conjunction with the opinion. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner should indicate on the examination report that (s)he has reviewed the folder in conjunction with the examination. b. The examination report must reflect review of pertinent material in the claims folder. After reviewing the claims file, the examiner must state whether it is at least as likely as not (i.e., 50 percent probability or higher) that the Veteran's bilateral hearing loss disability is related to service. The examiner should note that evidence of in-service hearing loss is not required to show that current hearing loss is related to service. The Veteran's MOS in the Navy as an Airman Apprentice is similar to other aviation occupations where there was a high probability of noise exposure. See Duty MOS Noise Spreadsheets, Veterans Benefits Administration Fast Letter 10-35 (Dep't of Veterans Affairs, September 2, 2010). Accordingly, noise exposure is conceded. The examiner should also comment on the following: i. The change in thresholds, as shown in service treatment audiograms, over the Veteran's course of service. ii. His August 2012 statement that the March 2004 audiogram findings called into question the reliability of the Veteran's responses to testing. c. In all conclusions, the examiner must identify and explain the medical basis or bases, with identification of pertinent evidence of record. If the examiner is unable to render an opinion without resort to speculation, he or she must explain why and so state. Any necessary tests or studies must be conducted and all clinical findings should be reported in detail and correlated to a specific diagnosis. d. If further examination of the Veteran is necessary to provide the requested opinion, the Veteran should be scheduled for an additional examination. It is the Veteran's responsibility to report for any examination scheduled, and to cooperate in the development of the case; the consequences of failing to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158, 3.655 (2012). 3. Ask the August 2012 optometrist to provide an addendum opinion regarding the Veteran's left eye disability claim. a. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE), to include this Remand must be reviewed by the examiner in conjunction with the opinion. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner should indicate on the examination report that (s)he has reviewed the folder. b. The examination report must reflect review of pertinent material in the claims folder. After reviewing the claims file, the examiner must state whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's left eye disability is related to service. The examiner should comment on the Veteran's contention that he was splashed in the eye with chemicals while in service. See May 2005 statement. c. In all conclusions, the examiner must identify and explain the medical basis or bases, with identification of pertinent evidence of record. If the examiner is unable to render an opinion without resort to speculation, he or she must explain why and so state. Any necessary tests or studies must be conducted and all clinical findings should be reported in detail and correlated to a specific diagnosis. d. If further examination of the Veteran is necessary to provide the requested opinion, the Veteran should be scheduled for an additional examination. It is the Veteran's responsibility to report for any examination scheduled, and to cooperate in the development of the case; the consequences of failing to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158, 3.655 (2012). 4. Ask the October 2012 examiner to provide an addendum opinion regarding the Veteran's bilateral leg numbness and pain claim. a. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE), to include this Remand must be reviewed by the examiner in conjunction with the opinion. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner should indicate on the examination report that (s)he has reviewed the. b. The examination report must reflect review of pertinent material in the claims folder. After reviewing the claims file, the examiner must state whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's peripheral neuropathy is related to service. The examiner should comment on opinion provided in October 2012 that the Veteran has diabetic neuropathy related to service and reconcile this with the medical evidence demonstrating onset of diabetes in 2007. c. In all conclusions, the examiner must identify and explain the medical basis or bases, with identification of pertinent evidence of record. If the examiner is unable to render an opinion without resort to speculation, he or she must explain why and so state. Any necessary tests or studies must be conducted and all clinical findings should be reported in detail and correlated to a specific diagnosis. d. If further examination of the Veteran is necessary to provide the requested opinion, the Veteran should be scheduled for an additional examination. It is the Veteran's responsibility to report for any examination scheduled, and to cooperate in the development of the case; the consequences of failing to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158, 3.655 (2012). 5. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed stomach disorder. a. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE), to include this Remand must be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner should indicate on the examination report that (s)he has reviewed the folder in conjunction with the examination. b. The examination report must reflect review of pertinent material in the claims folder. After reviewing the claims file, the examiner must state: i) Whether the Veteran currently has a stomach disorder. If so, the examiner should state whether it is at least as likely as not (i.e., 50 percent probability or greater) related to service. ii) If the Veteran does not have a current stomach disorder, the examiner should review the Veteran's previous diagnoses and determine if it is at least as likely as not that his previous diagnoses were related to service. iii) )If necessary, the examiner should state whether it is at least as likely as not that the Veteran has a stomach disorder that cannot be attributed to a known clinical diagnosis. In this case the examiner should specify whether the Veteran's complaints correspond to objective symptoms, both in the sense of medical signs perceptible to a physician and other non-medical indicators that are capable of independent verification, of a chronic disorder. If a chronic disorder is determined not to be present, the examiner(s) should so state. c. In all conclusions, the examiner must identify and explain the medical basis or bases, with identification of pertinent evidence of record. If the examiner is unable to render an opinion without resort to speculation, he or she must explain why and so state. Any necessary tests or studies must be conducted and all clinical findings should be reported in detail and correlated to a specific diagnosis. 6. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed skin disorder. a. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE), to include this Remand must be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner should indicate on the examination report that (s)he has reviewed the folder in conjunction with the examination. b. The examination report must reflect review of pertinent material in the claims folder. After reviewing the claims file, the examiner must state: i) Whether the Veteran currently has a skin disorder. If so, the examiner should state whether it is at least as likely as not (i.e., 50 percent probability or greater) related to service. The examiner should specifically identify whether the Veteran has a skin condition, to include dry skin and dermatitis. The examiner should comment on whether these conditions are separate conditions, or if the Veteran's dermatitis encompasses dry skin. ii) If the Veteran does not have a current skin disorder, the examiner should review the Veteran's previous diagnoses, dermatitis and dry skin, and determine if it is at least as likely as not that his previous diagnoses were related to service. iii) If necessary, the examiner should state whether it is at least as likely as not that the Veteran has a skin disorder that cannot be attributed to a known clinical diagnosis. In this case the examiner should specify whether the Veteran's complaints correspond to objective symptoms, both in the sense of medical signs perceptible to a physician and other non-medical indicators that are capable of independent verification, of a chronic disorder. If a chronic disorder is determined not to be present, the examiner(s) should so state. c. In all conclusions, the examiner must identify and explain the medical basis or bases, with identification of pertinent evidence of record. If the examiner is unable to render an opinion without resort to speculation, he or she must explain why and so state. Any necessary tests or studies must be conducted and all clinical findings should be reported in detail and correlated to a specific diagnosis. 7. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed allergic condition. a. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE), to include this Remand must be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner should indicate on the examination report that (s)he has reviewed the folder in conjunction with the examination. b. The examination report must reflect review of pertinent material in the claims folder. After reviewing the claims file, the examiner must state: i) Whether the Veteran currently has an allergic condition. If so, the examiner should state whether it is at least as likely as not related to service. ii) If the Veteran does not have a current allergic condition, the examiner should review the Veteran's previous diagnoses, allergic rhinitis and seasonal allergies, and determine if it is at least as likely as not that his previous diagnoses were related to service. iii) If necessary, the examiner should state whether it is at least as likely as not that the Veteran has an allergic condition that cannot be attributed to a known clinical diagnosis. In this case the examiner should specify whether the Veteran's complaints correspond to objective symptoms, both in the sense of medical signs perceptible to a physician and other non-medical indicators that are capable of independent verification, of a chronic disorder. If a chronic disorder is determined not to be present, the examiner(s) should so state. c. In all conclusions, the examiner must identify and explain the medical basis or bases, with identification of pertinent evidence of record. If the examiner is unable to render an opinion without resort to speculation, he or she must explain why and so state. Any necessary tests or studies must be conducted and all clinical findings should be reported in detail and correlated to a specific diagnosis. 8. After the above has been completed, the RO must review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 9. After completing the above, and any other development deemed necessary, the RO should readjudicate the Veteran's claims. If the benefit sought on appeal is not granted, the Veteran and his representative should be furnished with a supplemental statement of the case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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. 2012). ____________________________________________ SARAH B. RICHMOND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs