Citation Nr: 1327122 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 08-14 135 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for sarcoidosis. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. G. Alderman, Counsel INTRODUCTION The Veteran served on active duty from September 1975 to August 1979 and from November 1990 to April 1991. He also served with the Army National Guard. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Veteran appeared and provided testimony before the undersigned in June 2012. A transcript of the hearing has been associated with the claims file. FINDING OF FACT Sarcoidosis did not become manifest during service or within a year of discharge from service, and is otherwise unrelated to service. CONCLUSION OF LAW Sarcoidosis was not incurred in or aggravated by active duty service, and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Duties to Notify and Assist With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Proper notice from VA must inform the claimant of any information and medical or lay 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. As noted above, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473. In this case, although the notice provided prior to the February 2006 rating decision did not address either the rating criteria or effective date provisions that are pertinent to the Veteran's claim, such error was harmless given that service connection is being denied, and hence no rating or effective date will be assigned with respect to this claimed condition. In addition, the duty to assist the Veteran has also been satisfied in this case. The Board has reviewed the Veteran's Virtual VA file. The Veteran's service treatment records, as well as identified private and VA medical treatment records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In September 2012, the Board sent the Veteran's claims folders to a VA expert pulmonologist for a medical opinion regarding the etiology of the Veteran's sarcoidosis. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159; see McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). The VA expert pulmonologist submitted an opinion in January 2013 and an addendum opinion in May 2013. The opinion and addendum are adequate for rating purposes as they were based on a complete review of the medical and lay evidence of record and are supported with rationale. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112 (West 2002); 38 C.F.R. § 3.304 (2012). See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as sarcoidosis are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, 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 Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Routen v. Brown, supra. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. The Veteran seeks service connection for a pulmonary disorder, claimed as sarcoidosis. Throughout the pendency of his claim, he has alleged that his sarcoidosis had its onset during active service and is evidenced by radiological reports as well as symptoms such as sinus problems, headaches, fatigue and shortness of breath, all of which he claims had their onset during service and persisted until he was officially diagnosed with sarcoidosis in June 2005 via lung biopsy. Treatment records from the Veteran's periods of active service and time with the National Guard do not show a diagnosis of sarcoidosis. In October 1988, the Veteran had a normal chest x-ray. The April 1991 examination conducted at separation from active duty shows normal lungs and chest. The accompanying report of medical history (RMH) does not indicate fatigue, headaches, or lung or sinus complaints. The Veteran did not report fatigue, headaches, or symptoms related to the lungs or sinuses when completing his RMH for the National Guard in October 1992. The accompanying retention examination shows all testing was normal. An October 1992 radiology report shows that the heart and lungs were grossly normal. No acute changes were noted since the March 1991 films. Notably, the March 1991 x-ray report is not available; however, as noted above, the April 1991 separation examination did not note abnormalities of the lungs. The first indication of treatment for sinus related problems is dated April 1993 when the Veteran was diagnosed with sinusitis. The Veteran had a quadrennial examination for the National Guard in February 1995. The RMH did not indicate headaches or chest, lung, or sinus conditions. X-rays showed prominent hilar markings that were "probably just vascular in nature and essentially unchanged" since October 1992 and March 1994. The x-ray report states that a tiny faint nodular density overlying the left fifth anterior rib had remained unchanged since then. In March 1995, additional x-rays were taken which revealed right hilar lymph nodes that might have been calcified and a nodule in the left lower lobe. A March 1995 computerized tomography (CT) report revealed abnormalities that were "probably from old granulomatous process, especially histoplasmosis or tuberculosis." The Board observes that an active pulmonary disorder was not diagnosed during this period. The Veteran submitted additional copies of the March 1995 CT report with his notation that the findings could not be true because his x-rays from 1988 were normal. However, the Veteran is not competent to opine as to the significance of findings noted in radiology reports because as a layperson, he does not have the medical expertise to render such opinions. See Woehlaert, 21 Vet. App. at 462; see also Routen, 10 Vet. App. at 186. Treatment records show that the Veteran complained of sinus problems in May 1995. The diagnosis was allergic rhinitis. In August 1995, the Veteran said he had chronic rhinitis and recurrent sinusitis that had plagued him since 1991. He said he had persistent cold-like symptoms while serving in the Gulf War but that his sinus problems did not start until after returning from the Gulf War. The diagnosis was non-allergic rhinitis and chronic sinusitis. A January 1996 annual medical certificate shows the Veteran reported having sinus problems and fatigue since returning from the Gulf War. He complained of sinus problems again in October 1996, 1997 and 1998. X-ray reports dated April 1996, October 1999, and June 2000 show various findings; however, the reports do not show a diagnosis of sarcoidosis or other pulmonary disorders. In February 1998, the Veteran complained of fatigue. The diagnosis was hypogonadism, erectile dysfunction, and depressive features. In December 1998, the Veteran was sent to Dr. W.E.A., M.D., because of complaints of lethargy, weakness and headaches and the diagnosis of pituitary tumor with a necrotic center. In January 1999, Dr. W.E.A. removed the pituitary tumor. In May 1999, the Veteran complained of allergies, headache, and sinus related problems. The assessment was headaches probably related to allergic rhinitis. A November 1999 letter from Dr. S.B.L., M.D., states that the Veteran had a pituitary hypophysectomy for a microadenoma in January and that he had had persistent hyperprolactinemia, fatigue, lassitude, and decreased libido since that time. Additional studies were ordered to determine whether the Veteran had residual disease. In September 2000, the Veteran complained of tiredness and fatigue. He said he was having stress related problems. The provider suspected underlying depression. Another September 2000 treatment record shows that the Veteran complained of tiredness and fatigue. Medications were adjusted. In March 2001, doctors prescribed growth hormone for his residuals of the pituitary hypophysectomy, including fatigue. In July 2001, he presented as an emergency visit because of fatigue, lethargy, lassitude, and shortness of breath. The provider said the testosterone and growth hormone injections should not cause the symptoms. His chest showed expectory wheezing. Etiology of the symptoms was not discussed. In November 2001, the Veteran said he stopped taking the growth hormone because he felt short of breath and congested. His symptoms cleared upon stopping the medication. In October 2002, the Veteran continued to complain of feeling tired and said he had had fatigue and headaches since Desert Storm. In December 2002, the Veteran had a CT of the thorax due to his complaints of shortness of breath. The findings suggested "more likely an inflammatory or immunologic process such as sarcoidosis, silicosis or granulomatous infection." A January 2003 letter from Dr. S.B.L. states that the CT findings suggest the possibility that sarcoidosis or another such disorder might explain his persistent shortness of breath. In January 2003, the Veteran testified before a decision review officer (DRO) that he started having problems with his lymph nodes in 1992 or 1993 and that his symptoms included fatigue and shortness of breath. He discussed the x-ray and CT findings. He noted that he did not smoke but was around smoke while stationed overseas during Desert Storm. A February 2004 VA treatment record states that the Veteran's shortness of breath had its onset three years prior. During a March 2004 appointment with VA providers, the Veteran said his sarcoidosis started during active service with sinus problems and headaches and progressed to shortness of breath. He said he retired from service in 1998 because of shortness of breath and his inability to pass the physical requirements. In June 2005, the Veteran reported recent onset of progressive shortness of breath and fatigue. He underwent a lung biopsy which confirmed advanced sarcoidosis. A June 2005 letter from Dr. C.M.H., D.O., states that the Veteran has an aggressive sarcoidosis; however, the etiology was not indicated. In another June 2005 letter, Dr. S.B.L. indicated that the primary cause of the Veteran's fatigue, lethargy and hyperprolactinemia was sarcoidosis. In an October 2007 letter from the Veteran's wife, she said that within a year of returning from Desert Storm, the Veteran started complaining of minor chest pains. She said x-rays showed spots on his lungs; however, his doctors told him not to worry. She said his lung problems got worse over the years and he was eventually diagnosed with sarcoidosis. In his May 2008 substantive appeal, the Veteran said his private provider opined that the medically documented lymph node issues dating back to 1990 and 1991 were sarcoidosis and have gotten worse. However, the Board was unable to find a treatment record in the claims file substantiating this statement. In January 2009, a VA physician, Dr. R.L.P., M.D., reviewed x-ray and CT reports from 1988, 1992, and 1995. In the assessment, Dr. R.L.P. said that when comparing the CT scans between 1995 and June 2008, there were changes over time and that raised the concern that he may have chronic smoldering sarcoidosis. In April 2010 and August 2011 statements, the Veteran discussed his x-ray and CT findings from 1988, 1992, and 1995, and argued that his sarcoidosis was overlooked. In March 2011, the Veteran's VA pulmonologist, Dr. G.G.C., M.D., observed that sarcoidosis was diagnosed by lung biopsy. He said the Veteran had prominent hilar markings in 1995 and that a radiologist found that this finding was unchanged from 1992 and 1994. A limited CT of the chest in 1995 showed mediastinal lymphadenopathy. Considering the findings, to include the Veteran's pulmonary function tests (PFTs), Dr. G.G.C. opined that the Veteran may have had sarcoidosis since 1992 and that the obstructive component on the full PFT in a non-smoker is classic for sarcoidosis. During his June 2012 hearing before the Board, the Veteran testified that while in Desert Storm, he repaired vehicles and was exposed to dust and other particles. He did not have a respirator. While overseas, he had headaches and was sick constantly. He said he started having problems breathing in 1991 but assumed that the problems were sinus related. He noted that x-rays were taken in 1991 but that the reports could not be found; however, he said x-rays taken in 1992 showed spots on his lungs. His doctor told him the spots were calcium buildup. He testified that x-rays were also taken in 1994 and 1995 because of shortness of breath. He reported that the x-rays showed more spots and that a CT scan revealed enlarged lymph nodes. In September 2012, the Board asked a VA expert pulmonologist to provide an opinion as to whether the Veteran's sarcoidosis is etiologically related to or had its onset during his second period of active duty service or had onset within a one-year period from service discharge. The claims folders were sent for review. In January 2013, based on October 1992 and February 1995 x-ray reports and the CT scan from 1995, the expert found no evidence of sarcoidosis during that time. She found that the calcified granuloma in the left lower lung field and calcified mediastinal, hilar nodes were "extremely unlikely" to be secondary to sarcoidosis. The expert said the findings are suggestive of prior granulomatous infection like histoplasmosis or tuberculosis. She also said the evidence does not document complaints or workups for dyspnea during the above period, to include PFTs. She found that the complaints of fatigue were nonspecific and not adequate to make a diagnosis of sarcoidosis without some other manifestation of the disease. She concluded that it is less likely than not that the Veteran's current diagnosis of sarcoidosis is related to or had its onset during active service between November 1990 and April 1991 or had onset within one year of discharge from April 1991. The expert did not address the March 2011 opinion from Dr. G.G.C.; therefore, the Board asked for an addendum opinion addressing this matter. In a May 2013 addendum, the expert pointed out that Dr. G.G.C. said the Veteran had prominent hilar markings in 1995 that were unchanged from 1994 and 1992, implying that the disease was present back in 1992. However, the expert notes that the images Dr. G.G.C. referred to are x-rays. She observed that the only CT taken during that period showed enlarged calcified nodes. She found that the findings were highly suggestive of a prior granulomatous infection and not sarcoidosis. The expert said the Veteran may have had enlarged calcified nodes showing up as prominent hila on x-rays as far back as 1992 or prior, but that the finding does not mean the Veteran had sarcoidosis. The expert also noted that Dr. G.G.C. referred to PFTs showing an obstructive defect, "which in a nonsmoker is classic for sarcoidosis." However, she was unable to find PFTs from the period of interest. The first PFT available for review is dated 2002, around the time he presented with bilateral patchy and nodular densities. Regardless, the expert stated that "even if patient had an obstructive defect during and after his service, namely from November 1990 to April 1992, the finding by itself or even in consideration with CT findings in 1995, is not adequate to make a diagnosis of sarcoidosis." In June 2013, in response to the VA expert pulmonologist's opinion, the Veteran submitted a letter from Dr. B.B., M.D. However, Dr. B.B.'s argument is only that the current evidence is sufficient to diagnose stage IV sarcoidosis. Dr. B.B. does not address whether the sarcoidosis had its onset during or within one year of separation from active service or that the condition is otherwise related to active service. The existence of a current disability is not in dispute. Therefore, the letter has no probative value with regard to the etiology of sarcoidosis and determining whether service connection is warranted. The Board has reviewed all of the evidence but finds that the preponderance of the evidence is against the claim. First, the medical evidence does not show a diagnosis of sarcoidosis or the onset of symptoms of sarcoidosis during or within one year of separation from active duty service. The first medical evidence of a diagnosis of sarcoidosis is dated December 2002, over 10 years after separation from service. In June 2005, Dr. S.B.L. stated that the primary cause of the Veteran's fatigue, lethargy, and hyperprolactinemia was sarcoidosis. Records show complaints of fatigue starting in 1998 that were initially attributed to a pituitary gland condition. Even if the Board attributes the sole cause of fatigue to sarcoidosis, the complaints and treatment had their onset in February 1998, more than one year after separation from service. Second, the medical evidence does not show that the sarcoidosis is otherwise related to service. The medical evidence in favor of the Veteran's claim includes the January 2009 VA treatment record which insinuates that the Veteran may have had chronic smoldering sarcoidosis since 1995 based on comparison of CT scans from 1995 and 2008. However, this opinion is speculative. Medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. See e.g. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (finding doctor's opinion that "it is possible: and "it is within the realm of medical possibility" too speculative to establish medical nexus); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (medical opinion framed in terms of "may or may not" is speculative and insufficient to support an award of service connection for the cause of death); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (physician's statement that the veteran "may have been having some symptoms of his multiple sclerosis for many years prior to the date of diagnosis" was insufficient to award service connection.) Applicable regulations also provide that a finding of service connection may not be based on a resort to speculation or a remote possibility. See 38 C.F.R. § 3.102 (2012). Even if the opinion was not speculative, at most, the opinion would relate the condition back to 1995, more than one year after separation from service. Therefore, the Board finds that this opinion does not support a finding of service connection. Also favoring the Veteran's claim is the March 2011 opinion from Dr. G.G.C., who opined that the Veteran "may" have had sarcoidosis since 1992. Again, a finding of service connection may not be based on speculative opinions. Id. Even if the opinion was not speculative, in May 2013, the VA expert pulmonologist indicated that the images Dr. G.G.C. referred to were x-rays. She said that the CT report during that period showed findings that were highly suggestive of a prior granulomatous infection and not sarcoidosis. The expert said the Veteran may have had the enlarged calcified nodes showing up as prominent hila on the x-rays as far back as 1992 or prior, but that the finding does not mean he had sarcoidosis. The expert also noted that Dr. G.G.C. referred to PFTs showing an obstructive defect, "which in a nonsmoker is classic for sarcoidosis." However, she was unable to find PFTs from the period of interest. The first PFT available for review is dated 2002, around the time he presented with bilateral patchy and nodular densities. Regardless, the expert stated that "even if patient had an obstructive defect during and after his service, namely from November 1990 to April 1992, the finding by itself or even in consideration with CT findings in 1995, is not adequate to make a diagnosis of sarcoidosis." Consequently, the Board finds that the March 2011 opinion is not sufficient to support a finding of service connection. The Board has also considered whether service connection is warranted based on continuity of symptomatology. However, as noted above, the first indication of sarcoidosis was noted in December 2002, over 10 years after separation from service, which weighs against a finding of service connection based on continuity of symptomatology. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability). The Board has also considered the Veteran's lay statements alleging that sinus problems, headaches, shortness of breath, and fatigue had their onset during or within one year of separation from active duty service, persisted subsequent to service, and were, in essence, early symptoms of sarcoidosis. First, the Veteran is competent to state that his sinus problems and headaches had onset during or within one year of separation from his second period of active duty service and persisted subsequent to active duty service. See Layno, 6 Vet. App. at 470. However, the Board finds that the competent medical evidence weighs against a finding of credibility. Specifically, the Veteran did not report sinus problems or headaches during his second period of active duty service or at the time of his April 1991 separation examination or his October 1992 retention examination for the National Guard. He was treated for sinusitis in April 1993, more than one year after separation from service, but did not indicate continuing sinus conditions on his February 2005 quadrennial examination for the National Guard. Regular complaints and treatment of sinus conditions did not start until May 1995. Treatment records do not show complaint of headaches until December 1998. Thus, the medical evidence does not show that the conditions had their onset during or within one year of separation from his second period of active duty service. Even if the Board assumes that his sinus conditions and headaches had their onset during or within one year of separation from his second period of active duty service and persisted subsequent thereto, the Veteran is not competent to opine as to the relationship between his sinus conditions and sarcoidosis or his headaches and sarcoidosis because the relationship, if any, is not readily observed by laypersons and involves medical questions requiring specialized skill which the Veteran, as a layperson, does not possess. See Woehlaert, 21 Vet. App. at 462. The competent and credible medical evidence does not show that his headaches or sinus conditions were symptoms indicating the onset of sarcoidosis. The Veteran is also competent to report symptoms such as shortness of breath and fatigue and that his symptoms had onset during and persisted subsequent to his second period of active duty service. See Layno, 6 Vet. App. at 470. However, the Board finds that his statements are outweighed by the medical evidence. Specifically, the Veteran did not report fatigue or shortness of breath during his second period of active duty service or at the time of his April 1991 separation examination, his October 1992 retention examination for the National Guard, or his February 2005 quadrennial examination for the National Guard. The evidence shows only one complaint of fatigue in January 1996 at which time he said he had problems with fatigue since returning from the Gulf War. Treatment records show that chronic complaints of fatigue did not start until 1998 and were initially attributed to his pituitary hypophysectomy. In June 2005 his fatigue was attributed to sarcoidosis. Complaints of shortness of breath were not noted until the 2000s. Consequently, while the Veteran asserts that he has suffered symptoms of fatigue and shortness of breath during and since active duty service, the Board finds that the lay statements alleging continuity of symptomatology are not credible and are outweighed by the medical evidence. As such, the statements do not support a finding of service-connection based on continuity of symptomatology since service. Even if the Board presumes that the Veteran's statements regarding the continuity of his symptoms are credible, he is not competent to opine as to the etiology of his symptoms or to the onset and etiology of his sarcoidosis. Here, treatment records have attributed his symptoms to his pituitary gland condition, which was diagnosed in 1998, and to medications prescribed for this condition. The symptoms have also been attributed to sarcoidosis, which was diagnosed in 2002. In this case, the pathology of these symptoms cannot be readily observed by laypersons and involves complex medical questions requiring specialized skill which the Veteran, as a layperson, does not possess. See Woehlaert, 21 Vet. App. at 462. The Board has also considered the Veteran's arguments regarding the changes in his x-ray and CT films over time. However, he is not competent to opine as to the significance, if any, of the changes documented in radiology reports as he does not have the specialized skills to interpret such reports. Id. Regarding the statement from the Veteran's wife, while she is competent to report her observations of the Veteran's condition and to report his complaints to her regarding his symptomatology, she is not competent to opine as to whether his complaints and observable symptoms indicated the onset of his sarcoidosis because sarcoidosis is not readily observed by laypersons and she lacks the specialized skill to diagnose the disorder. Consequently, the Board finds that the statement does not support a finding of service connection for sarcoidosis based on continuity of symptomatology. In this case, the Board finds that the most probative evidence has been provided by the VA expert pulmonologist who opined that it is less likely than not that the Veteran's current diagnosis of sarcoidosis is related to or had its onset during active service between November 1990 and April 1991 or had onset within one year of discharge from April 1991. Her opinions are supported by a complete rationale and take into consideration the past films and the Veteran's medical history. Considering the expert's opinions, the lack of onset or diagnosis of sarcoidosis during active duty service or within one year of separation from active duty service, and the lengthy time between separation from service and the diagnosis of sarcoidosis in 2002, the Board finds that the preponderance of the evidence is against the claim. The evidence is not so evenly balanced to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The appeal is denied. ORDER Entitlement to service connection for sarcoidosis is denied. ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs