Citation Nr: 1326981 Decision Date: 08/22/13 Archive Date: 08/29/13 DOCKET NO. 02-11 043A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for hypertension as a result of exposure to lead-based paint. 2. Entitlement to service connection for a disorder manifested by muscle and joint pain as a result of exposure to lead-based paint. 3. Entitlement to service connection for a digestive disorder as a result of exposure to lead-based paint. 4. Entitlement to a disability rating in excess of 50 percent for the period from November 6, 2002, to March 7, 2012 for a disorder characterized as memory and concentration loss. 5. Entitlement to a total disability rating due to individual unemployability (TDIU). REPRESENTATION Appellant represented by: Michael A. Leonard, Attorney ATTORNEY FOR THE BOARD A.E.H. Gibson, Associate Counsel INTRODUCTION The Veteran had active duty service from April 1969 to January 1971. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which denied service connection for hypertension, a digestive disorder, memory and concentration problems, and muscle and joint pain, each claimed as a result of exposure to lead-based paint. The Veteran timely appealed the RO's February 2003 rating action to the Board. In an October 2004 decision, the Board denied the claims. The Veteran appealed that decision to the Court of Appeals for Veterans Claims (Court). In a May 2009 Memorandum Decision, the Court vacated the portion of the Board's October 2004 decision that denied the service connection claims based on exposure to lead-based paint, and remanded them to the Board for compliance with the Court's decision. In October 2009, the Board remanded the claims to provide the Veteran with VA examinations. In September 2010, the RO granted service connection for an anxiety disorder with memory and concentration loss as due to lead exposure and assigned a 50 percent disability rating effective November 6, 2002. The Veteran filed a notice of disagreement (NOD) in regard to the disability rating assigned, which was later raised in a June 2012 decision to 100 percent disabling effective March 8, 2012. The Veteran has not expressed satisfaction with this rating specifically as to the established effective date prior to March 8, 2012. Review of the Virtual VA paperless claims processing system does not reveal additional documents pertinent to these claims. The issues of entitlement to service connection for a digestive disorder as a result of lead-based paint, to a rating higher than 50 percent for the period from November 6, 2002, to March 8, 2012, and to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. Hypertension was not incurred or aggravated by exposure to lead-based paint or any other incident of active duty service. 2. A disability manifested by muscle and joint pain was not incurred or aggravated by exposure to lead-based paint or any other incident of active duty service. CONCLUSIONS OF LAW 1. The criteria to establish service connection for hypertension are not met or approximated. 38 U.S.C.A. §§ 1101, 1110, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. The criteria to establish service connection for a disability manifested by muscle and joint pain are not met or approximated. 38 U.S.C.A. §§ 1101, 1110, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. VA is to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. 38 U.S.C.A. § 1154(a) (West 2002). The Federal Circuit held that medical evidence is not always or categorically required in every instance to establish the required nexus or linkage between the claimed disability and the Veteran's military service. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); but see Waters v. Shinseki, 601 F.3d 1274 at 1278 (Fed. Cir. 2010) ("VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to"). Citing to its previous decisions in Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) and Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit stated in Davidson that it has previously and explicitly rejected the view that competent medical evidence is always required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. See id. at 1316. The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis; or, (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465 (1994). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The standard of proof to be applied in decisions on compensation claims is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet.App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet.App. 518 (1996). Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and, (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). A VCAA notice informing him of his and VA's respective duties for obtaining evidence was provided in January 2003, prior to adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran was not advised of the manner in which effective dates and disability ratings are assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Because the Veteran's claims to service connect hypertension and a disability manifested as muscle and joint pain are being denied, the issues of the effective date and disability rating will not arise, and the Veteran is not prejudiced by this omission VA also has a duty to assist in the development of the claim, which includes assisting in obtaining service treatment records (STRs) and post-service medical records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained his STRs and post-service VA and private treatment records. In a March 2012 communication, the Veteran requested VA obtain copies of his Social Security Administration (SSA) records; however, in a February 2012 communication, he had been informed that his SSA records were unavailable and further attempts to locate them would be futile. He was asked to submit any copies he had. To date, there has been no response to that request, and no further request that the records be obtained. There is no indication that there are any other outstanding records that the Veteran wanted VA to obtain or that VA was obligated to obtain under the VCAA. VA's duty to assist includes providing a VA examination and opinion where there is "an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service," but there is "insufficient competent medical evidence on file for the Secretary to make a decision on the claim." See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran was examined and medical opinions were obtained in June and September 2010. In these opinions, the VA examiner reviewed and referred to the claims file and medical records, considered the Veteran's lay statements, and rendered an opinion consistent with the other evidence of record. See Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (holding that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion" even when the rationale does not explicitly "lay out the examiner's journey from the facts to a conclusion") (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012). See Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011) (holding that although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"). The Board finds that there has been substantial compliance with its October 2009 remand. Stegall v. West, 11 Vet.App. 268 (1998) (holding that a remand by the Court or the Board confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders); see Dyment v. West, 13 Vet.App. 141 (1999) ((holding that remand not required under Stegall v. West, 11 Vet.App. 268 (1998) where there was substantial compliance with remand directives)). Accordingly, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of this claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Service connection may be granted if it is shown the Veteran developed a disability resulting from an injury sustained or disease contracted in the line of duty, or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.306. A three-element test must be satisfied in order to establish entitlement to service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004)). Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases-namely those listed in 38 C.F.R. § 3.309(a)-benefit from a somewhat more relaxed evidentiary standard. See Walker, 708 F.3d at 1339 (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show 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." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain or abnormal heart action in claims for arthritis or heart disease, for example) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed under 38 C.F.R. § 3.309(a). Walker, supra. Thus, if the veteran does not have one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and the "nexus" requirement of the three-element test must be met. Id. Additionally, if a veteran served continuously for ninety (90) or more days during a period of war or after December 31, 1946, and if a chronic disease, listed in section 3.309(a) became manifest to a degree of 10 percent or more within one year from the date of the veteran's termination of such service, that condition would be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). Such a presumption would be rebuttable, however, by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Hypertension The Veteran asserts he has hypertension as a result of being exposed to lead-based paint. As the preponderance of the evidence is against service connection, the Board is denying his appeal. The Veteran entered active duty in April 1969 with a normal clinical evaluation. His blood pressure was 122/70. He made no complaint of a history of high blood pressure. He separated in January 1971 with a normal clinical evaluation in all aspects, except for whether the Veteran had any identifying body marks. His blood pressure was 112/78. In March 2001, it was noted the Veteran had hypertension with mild left ventricular hypertrophy. His hypertension was controlled. At the January 2004 VA general examination, the Veteran was diagnosed with stage 1 hypertension. The examiner did not comment on etiology. In January 2010, the Veteran's primary care physician noted he had essential hypertension. At the June 2010 VA examination, he was diagnosed with hypertension. The Veteran said he was first diagnosed with hypertension about twenty years previously. The examiner noted the Veteran's then-current level of lead in the blood was low, which is normal, but he did not have access to the Veteran's blood lead level when he was diagnosed. The Veteran had no specific symptoms of high blood pressure, and no history of complications caused by hypertension. His medical records showed normal renal function from 2001 through 2010. There was no evidence of renal or renal tubular dysfunction, which might be seen with acute lead poisoning. The examiner indicated that it is well-documented that acute lead poisoning of sufficient degree can lead to renal failure with hypertension. Lead nephropathy manifests as progressive impairment in renal function that is often accompanied by hypertension. There was no evidence the Veteran ever had renal failure. The examiner noted that studies regarding the relationship between lead exposure and hypertension had been conducted, resulting in mixed and sometimes divergent conclusions. He further indicated that a meta-analysis of medical literature was conducted on www.uptodate.com, which found a weak association between blood pressure and blood lead. The June 2010 VA examiner opined that the Veteran's hypertension was more likely than not essential in nature, based upon the Veteran's history and a review of the records. He said without knowing the Veteran's historic blood lead levels, it would be impossible to comment on whether lead exposure during service caused or aggravated his current hypertension. He reiterated that the Veteran showed no renal impairment, and indicated that it is more statistically likely that his hypertension was essential. Based on the foregoing, the preponderance of the evidence is against this claim. It is undisputed that the Veteran currently has hypertension and that he was exposed to lead-based paint while in service. The inquiry, then, is whether his current disability is related to service. The Veteran has asserted there is a connection; however, the probative evidence weighs against a relationship. The Veteran's statement asserting that his hypertension resulted from lead poisoning is not probative. He has not been shown to have the medical expertise to render a competent opinion on the etiology of his hypertension. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). His assertion has been investigated by a physician, who found it unlikely. Jandreau, 492 F.3d at 1377. The June 2010 VA examination report is the most probative evidence addressing the issue, and does not support service connection. He indicated that it would be impossible to opine on the issue without knowing the level of lead in the Veteran's blood when he was initially diagnosed with hypertension, but opined that it more statistically likely that his hypertension was essential in nature. He noted that acute lead poisoning can lead to renal failure that is accompanied by hypertension, but the Veteran did not have renal failure. He also noted that studies had been conducted on whether there was a direct relationship between lead exposure and hypertension, with conflicting results, but that meta analysis of the medical literature showed a weak association between the two. This opinion is supported by the Veteran's treating physician, who also labeled the Veteran's hypertension as essential. The Veteran's hypertension is a chronic disability under 38 C.F.R. § 3.309(a). Therefore, the Board considered whether service connection can be established by way of the presumptions set forth in 38 C.F.R. §§ 3.307(a) and 3.303(b). Under section 3.307(a), a chronic disability is presumed to be service connected if it manifests to a compensable degree within the first year following service. The Veteran reported that he was diagnosed with hypertension about twenty years prior to his June 2010 VA examination, i.e., in or around 1990, which is nearly twenty years after separation from service. The Veteran has not alleged that it began any sooner. Under section 3.303(b), if a chronic condition was shown in service and then subsequently manifested after separation from service, it will be presumed to be service connected. The Veteran did not show and was not diagnosed with hypertension during service. Thus, the Veteran's claim cannot be granted on the basis of the chronicity presumptions. The preponderance of the evidence is against this claim, and the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2011). See also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Accordingly, this claim must be denied. Muscle and Joint Pain The Veteran asserts he has a disability that manifests as muscle and joint pain as a result of being exposed to lead-based paint. As the preponderance of the evidence is against service connection, the Board is denying his appeal. The Veteran entered active duty with a normal clinical evaluation. He made no complaints of a history of painful or swollen joints, but the examining physician elaborated that the Veteran had a history of low back pain prior to service without also having a history of trauma. His separation examination in December 1970 resulted in a normal clinical evaluation in all aspects, except for whether the Veteran had any identifying body marks. An August 1996 radiological report of the cervical spine showed small osteophytes in the lower cervical spine. A January 2001 radiologic image of the lumbosacral spine showed moderate degenerative arthritis. In March 2001, his low back pain was attributed to osteoarthritis. At the January 2004 VA general examination, the Veteran was diagnosed with degenerative joint disease of the cervical and lumbosacral spine and arthralgia of the bilateral hands and right elbow. The examiner did not comment on etiology. A radiologic image of the cervical spine showed early degenerative arthritis. In August 2008, the Veteran was referred to a rheumatologist regarding his joint and muscle pain. He denied having swelling or a rash. An August 2008 radiologic image of the cervical spine and shoulders revealed degenerative arthritis. An October 2008 rheumatology consultation found the Veteran not to have lupus or any other inflammatory disease. He had a positive ANA (antinuclear antibodies), but it was of low titer, and was not corroborated by any other symptoms suggesting lupus. Instead, he was diagnosed with osteoarthritis of the hands, knees, and neck. In December 2009, the Veteran complained of having muscle and joint pain for the previous nine years. He asked whether it could be connected to lead poisoning. His pain control medication was continued. At the June 2010 VA spine examination, the examiner noted the Veteran's STRs showed a history of low back pain but no trauma. The Veteran did not describe having any injuries in service. After service, there was a history of bilateral arm pain in 1996, which was attributed to atypical bilateral carpal tunnel syndrome. He was diagnosed with osteoarthritis in 2001, which was not attributed to service by the January 2004 VA examiner. In October 2008, he was evaluated for lupus erythematosus by the rheumatology department, who did not find lupus or any other inflammatory disease after review of X-rays. The examiner reviewed those X-rays and did see a trace of soft tissue calcification in the superior capsule of the shoulder with minimal joint irregularity, but indicated those changes were negligible. During the examination, the Veteran complained that his ankles, knees, calf muscles, elbows, hands, neck, and low back bothered him. Radiological reports of the right and left ankles show calcaneal spurs; of the left knee show narrowing of the medial compartment and patellar spurs; of the right knee show patellar spurs and probably Osgood-Schlatter's disease; of the right and left elbows show no abnormality in either joint; of the left hand show no abnormality; of the right hand show a probable old mild fracture deformity of the middle phalanx of the third digit with degenerative changes; and, of the lumbosacral spine show scoliosis and hypertrophic osteoarthritis of the lumbar spine. He was diagnosed with spinal osteoarthritis involving the neck and low back, polyarthralgia involving elbows and hands bilaterally with associated avascular necrosis of the right lunate with secondary osteoarthritis of the right wrist, osteoarthritis of the distal interphalangeal joint of the right middle finger, polyarthralgia involving the knees and ankles and mild osteoarthritis of the left knee. The examiner, an orthopedist, opined that he could not relate the Veteran's diagnoses to service because of the lack of evidence of an injury in service. He indicated that a rheumatologist would be able to comment on the relationship of his diagnoses to lead poisoning. In a September 2010 addendum, a rheumatologist also noted the Veteran's STRs showed a history of back pain, but no trauma. The separation examination did not reference joint or muscle pain. He was noted to have been diagnosed with osteoarthritis and polyarthralgia since separation. The September 2010 rheumatologist examiner indicated that the most common cause of lead arthropathy is related to gouty arthropathy, which is associated with elevated levels of uric acid, the presence of tophi, hypertension, and renal insufficiency. The Veteran did not have elevated levels of uric acid, or tophi, or renal insufficiency. In acute cases of lead poisoning, joint and muscle pain can be observed, but there was no evidence the Veteran was recently exposed to lead. His blood lead levels at the time of the examination were below the level that is considered to be due to exposure. The examiner indicated the medical literature does not show a clear correlation between lead poisoning and osteoarthritis, except in cases of a direct injury to a joint due to foreign material containing lead. The examiner rheumatologist did not find any evidence that the Veteran had a muscle disease, and also knew of no chronic muscle disease associated with lead poisoning. He opined the most probable cause of the Veteran's joint pain was osteoarthritis, which he did not find related to service or to lead exposure. Before addressing service connection, the Board observes the Veteran entered active duty with a reported history of low back pain. Every veteran who served in the active military, naval, or air service after December 31, 1946, is 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 the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1111 , 1137 (West 2002). Only those conditions recorded in examination reports can be considered as "noted," 38 C.F.R. § 3.304(b) (2012), and a history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions. Id. Thus, because the Veteran's spine was clinically evaluated as "normal," and only a history of back pain was reported, he is considered to have been in sound condition upon entrance. No evidence has been submitted alleging the Veteran's muscle and joint pain pre-existed service. Accordingly, his claim will be analyzed to determine whether his joint and muscle pain manifested as a result of service, rather than analyzed to determine whether service aggravated pre-existing joint and muscle pain. The Veteran's statement asserting that his pain, diagnosed as osteoarthritis and polyarthralgia, resulted from lead poisoning is not probative. He has not been shown to have the medical expertise to render a competent opinion on the etiology of his pain. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). His assertion has been investigated by a physician, who found it unlikely. Jandreau, 492 F.3d at 1377. The September 2010 rheumatology opinion is the most probative evidence addressing the issue, and does not support service connection. The examiner indicated that lead arthropathy is most commonly associated with elevated levels of uric acid, the presence of tophi, hypertension, and renal insufficiency. The Veteran only has hypertension. He said that joint and muscle pain can be observed in acute cases of lead poisoning, but the Veteran's level of lead in the blood was too low to be considered acute. He indicated that medical literature does not describe a relationship between lead exposure and osteoarthritis, except in the case of a direct injury by a foreign object that contains lead, which is not shown here. He indicated the medical literature showed no muscle disease associated with lead exposure, but the Veteran also had not been diagnosed with a muscle disease. He said that osteoarthritis was the most likely cause of the Veteran's pain, and that it did not likely arise as a result of exposure to lead during service. The Veteran's arthritis is a chronic disability under 38 C.F.R. § 3.309(a). Therefore, the Board considered whether service connection can be established by way of the presumptions set forth in 38 C.F.R. §§ 3.307(a) and 3.303(b). Under section 3.307(a), a chronic disability is presumed to be service connected if it manifests to a compensable degree within the first year following service. The Veteran was first diagnosed with arthritis in 2001, thirty years following separation from service. The Veteran has not alleged that it began any sooner. Under section 3.303(b), if a chronic condition was shown in service and then subsequently manifested after separation from service, it will be presumed to be service connected. The Veteran did not show and was not diagnosed with arthritis during active duty service. Thus, the Veteran's claim cannot be granted on the basis of the chronicity presumptions. The preponderance of the evidence is against this claim, and the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2011). See also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Accordingly, this claim must be denied. ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for a disorder manifested by muscle and joint pain is denied. REMAND The Veteran's remaining claims must be remanded for further development. In regard to his claim of entitlement to service connection for a digestive condition as due to exposure to lead-based paint, the Veteran has not been provided with notice of the manner in which effective dates and disability ratings are assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Such should be provided upon remand. The Veteran was examined in June 2012 for the purpose of obtaining a medical opinion on whether his digestive condition was related to service. The VA examiner found a relationship statistically unlikely, however, also noted that the Veteran had never had a detailed gastrointestinal evaluation to rule out any of the possible causes of abdominal pain. Upon remand, he should be provided with a complete evaluation. The examiner also indicated that the report of a colonoscopy that reportedly occurred at the West Plains CBOC or Poplar Bluff VAMC a few years prior to the examination would be helpful, as well as a report of a recommended consultation for gallstones, if available. In regard to his claim for an increased disability rating for his anxiety with memory and concentration loss, the Veteran's attorney sent a letter to the St. Louis RO in June 2013 that has not been addressed. He has asked for a copy of a medical report referenced in the April 2013 SSOC and additional time to formulate a response. The RO must respond accordingly to this letter. In regard to his claim for a TDIU, it is inextricably intertwined with his claim for an increased rating. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined). Accordingly, the case is REMANDED for the following action: 1. Respond to the Veteran's attorney's June 25, 2013, letter as soon as possible. If the March 2003 medical report referred to in the April 2013 SSOC is not located, immediately readjudicate the Veteran's claim for an increased disability rating for his anxiety with memory and concentration loss, which also includes consideration of whether the Veteran is entitled to a TDIU. If the full benefit is not granted, forward an SSOC to the Veteran and his attorney, and allow an appropriate time for response. 2. Contemporaneously with the above, send the Veteran a VCAA notice that advises him of the manner in which effective dates and disability ratings are assigned. 3. Contemporaneously with the above, ask the Veteran if he has received any VA, non-VA, or other medical treatment for his anxiety with memory and concentration loss and his digestive condition that is not evidenced by the current record, and specifically ask whether he attended a consultation with a private physician for gallstones. Provide the Veteran with the necessary authorizations for the release of any non-VA treatment records not currently on file. Obtain these records and associate them with the claims folder. Also specifically obtain updated records of any VA treatment, including any reports of colonoscopies . If the records are not obtainable (or none exist), the Veteran should be notified and the record clearly documented. 4. Following completion of the above directives, provide the Veteran with a complete gastrointestinal evaluation and associate the report of the examination with the claims file. 5. Following completion of the above directive, forward the claims file, with updated treatment records and a copy of the gastrointestinal evaluation, to the examiner who conducted the June 2010 VA digestive examination for an addendum opinion as to whether a digestive condition, if diagnosed, is directly related to service, including as due to exposure to lead-based paint, or secondarily related to service because it has been caused or aggravated by the Veteran's other service-connected disability, anxiety with memory and concentration loss. If the June 2010 VA examiner is not available, please forward the file to an appropriate physician for an opinion. The examiner is advised the Veteran is competent to attest to having abdominal pain. In rendering the opinion, the examiner is asked to describe the types of digestive or gastrointestinal symptoms that would result from lead poisoning, including their duration. 6. Following completion of the above directive, and after undertaking any other development deemed necessary, review the entire record and readjudicate the Veteran's claims. If the appeal is denied, provide the Veteran and his attorney with a supplemental statement of the case (SSOC) and allow an appropriate time for response. Thereafter, return the claims file to the Board for further review. 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). 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). ______________________________________________ VITO A. CLEMENTI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs