Citation Nr: 1327902 Decision Date: 08/30/13 Archive Date: 09/05/13 DOCKET NO. 05-17 375A ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for a gastrointestinal disability. 2. Entitlement to service connection for a nasal disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from June 18, 1976, to June 7, 1980, and from June 20, 1980, to June 30, 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2004 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington, which denied, in pertinent part, the Veteran's claims of service connection for a gastrointestinal disability (which was characterized as gastroenteritis) and for a nasal disability (which was characterized as sinusitis). Although the Veteran initially requested a Board hearing in October 2005, he failed to report for this hearing when it was scheduled in June 2007. Thus, his Board hearing request is deemed withdrawn. See 38 C.F.R. § 20.704 (2012). In February 2007, the Veteran's service representative notified VA that the Veteran had moved to the jurisdiction of the RO in Huntington, West Virginia. Because the Veteran still lives within the jurisdiction of the RO in Huntington, West Virginia, that facility retains jurisdiction. In March 2009, the Board denied, in pertinent part, the Veteran's claims of service connection for a gastrointestinal disability (which was characterized as gastroenteritis) and for a nasal disability (which was characterized as sinusitis). Both the Veteran, through an attorney, and VA's Office of General Counsel filed a Joint Motion for Partial Remand (Joint Motion) of the Board's March 2009 decision with the United States Court of Appeals for Veterans Claims (Court) in January 2010. The Court granted the Joint Motion in February 2010, vacating and remanding the Board's March 2009 denial of the Veteran's claims of service connection for a gastrointestinal disability and for a nasal disability. In February 2011, July 2012, and in February 2013, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development. FINDINGS OF FACT 1. Resolving all reasonable doubt in the Veteran's favor, the record evidence suggests that his current gastrointestinal disability is related to active service. 2. The record evidence indicates that the Veteran does not experience any current nasal disability which could be related to active service. CONCLUSIONS OF LAW 1. A gastrointestinal disability was incurred in active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. A nasal disability was not incurred in active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. Given the favorable disposition of the action here with respect to the Veteran's claim of service connection for a gastrointestinal disability, which is not prejudicial to him, the Board need not assess VA's compliance with the VCAA with respect to this claim. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92, 57 Fed. Reg. 49,747 (1992). With respect to the Veteran's claim of service connection for a nasal disability, the Board notes that, in letters issued in October 2003, October 2004, and in January 2007, VA notified the Veteran of the information and evidence needed to substantiate and complete this claim, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). These letters informed the Veteran to submit medical evidence relating the claimed nasal disability to active service and noted other types of evidence the Veteran could submit in support of his claim. The Veteran also was informed of when and where to send the evidence. After consideration of the contents of these letters, the Board finds that VA has satisfied substantially the requirement that the Veteran be advised to submit any additional information in support of his claim of service connection for a nasal disability. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Additional notice of the five elements of a service-connection claim was provided in the January 2007 VCAA notice letter, as is now required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As will be explained below in greater detail, the evidence does not support granting service connection for a nasal disability. Because the Veteran was fully informed of the evidence needed to substantiate this claim, any failure of the RO to notify the Veteran under the VCAA cannot be considered prejudicial. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Veteran also has had the opportunity to submit additional argument and evidence and to participate meaningfully in the adjudication process. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With respect to the timing of the notice, the Board points out that the Court has held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a Veteran before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the October 2003 notice was issued prior to the currently appealed rating decision issued in March 2004; thus, this notice was timely. Because the Veteran's claim of service connection for a nasal disability is being denied in this decision, any question as to the appropriate disability rating or effective date is moot. See Dingess, 19 Vet. App. at 473. And any defect in the timing or content of the notice provided to the Veteran and his service representative has not affected the fairness of the adjudication. See Mayfield, 444 F.3d at 1328. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the RO and the Board. As noted in the Introduction, the Veteran failed to report for his Board hearing when it was scheduled in June 2007. It appears that all known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Veteran's Virtual VA claims file has been reviewed. The Veteran also does not contend, and the evidence does not show, that he is in receipt of Social Security Administration (SSA) disability benefits such that a remand to obtain his SSA records is required. Pursuant to the Board's February 2013 remand, the Veteran was provided with a VA examination in April 2013 which addressed the contended causal relationship between the claimed nasal disability and active service. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4) ; McLendon v. Nicholson, 20 Vet. App. 79 (2006). Given that the pertinent medical history was noted by the examiner, this examination report sets forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the April 2013 VA examination is adequate for rating purposes and additional examination is not necessary regarding the claim of service connection for a nasal disability adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. Service Connection Claims The Veteran contends that he incurred a gastrointestinal disability and a nasal disability during active service. He specifically contends that these current disabilities first were manifested during active service when he complained of multiple gastrointestinal and nasal problems. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may 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). Certain chronic diseases, including peptic ulcers, 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. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Establishing service connection generally requires (1) medical evidence of a presently existing disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); Hickson v. West, 12 Vet. App. 247, 253 (1999). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-498. In Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Federal Circuit recently overruled Savage and limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also 38 C.F.R. § 3.309(a). Because a gastrointestinal disability other than peptic ulcers and a nasal disability are not explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a), the Board finds that Savage and the theory of continuity of symptomatology in service connection claims are inapplicable to these claims. By contrast, because peptic ulcers are considered a "chronic" disability under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology remains valid in adjudicating that part of the Veteran's claim of service connection for a gastrointestinal disability. It is the defined and consistently applied policy of VA 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. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. Factual Background The Veteran's service treatment records show that, at his enlistment physical examination in June 1976, clinical evaluation was normal. The Veteran denied all relevant pre-service medical history. In an undated outpatient treatment record included in his service treatment records, the Veteran complained of flu symptoms. A 1 month history of nasal congestion, itchy eyes, ear fullness, and a "scratchy throat" was noted. Objective examination showed nasal congestion, no sinus pain or tenderness, a normal throat, and clear lungs. The assessment was allergic rhinitis. On outpatient treatment in January 1979, the Veteran's complaints included upper respiratory infection symptoms which had lasted for 2 weeks, including a constant, non-productive cough, head congestion, and rhinorrhea. Objective examination showed negative ears and clear lungs. The assessment was upper respiratory infection. In October 1979, the Veteran complained of flu symptoms which had lasted for 3 days. Physical examination showed dull gray tympanic membranes, a clear chest, eyes within normal limits, rhinorrhea, and no nasal adenopathy. The impression was "full blown cold, head." On April 17, 1980, the Veteran's complaints included a productive cough with sputum, headache, chills, fever, sore throat, and paroxysmal nocturnal dyspnea which had lasted for 2 days. Physical examination showed mild erythema in the pharynx, no neck adenopathy, ears without injection, and a clear chest. The assessment was upper respiratory infection. On April 24, 1980, the Veteran complained of a viral syndrome, a cold, a productive cough, and headaches. Physical examination showed an erythematous throat that was "fiery red," reddened tympanic membranes, and sinuses within normal limits. The impression was viral syndrome. At his separation physical examination on May 28, 1980, just prior to the end of his first period of active service on June 7, 1980, clinical evaluation of the Veteran was normal. His chest x-ray was within normal limits. In December 1980, the Veteran complained of 1 week of sinus congestion. Physical examination showed his eyes, ears, nose, and throat (EENT) was within normal limits and no "pain on rebound of sinuses." The impression was sinus congestion. On periodic physical examination in February 1981, there is no indication of whether the Veteran's sinuses were examined clinically. Clinical evaluation of the Veteran's abdomen and viscera was normal. He reported a history of ear, nose, or throat trouble, chronic or frequent colds, and hay fever. The in-service examiner stated that the Veteran's sinuses were "constantly draining." This examiner also stated that the Veteran's chronic or frequent colds were "only recent[] & not severe." He finally stated that the Veteran's reported "hay fever causes sinus problems." In August 1981, the Veteran complained of cold symptoms, including rhinorrhea, persistent sinus congestion and drainage, and thick yellow mucus. He had a non-productive cough. Physical examination showed clear tympanic membranes and ear canals, no erythema or exudate, mild maxillary sinus tenderness, and a few rhonchi in the right lung field. A chest x-ray was within normal limits. The impression was sino-bronchial syndrome. A chest x-ray taken in September 1981 was normal. On periodic physical examination in January 1983, clinical evaluation of the Veteran was normal. He reported a history of ear, nose, and throat trouble and sinusitis. In October 1983, the Veteran complained of headaches, a cough with a yellow substance, and "real bad" sinuses that were "yellow + thick." He also complained that he was unable to sleep due to sinus congestion and cough. Physical examination showed normal tympanic membranes bilaterally, tenderness to frontal sinuses, and inspiratory wheezing in the bilateral lung bases. The assessment was sinusitis, questionable bronchitis, and questionable asthma. On periodic physical examination in March 1984, clinical evaluation of the Veteran showed nasal congestion. He reported a history of frequent sinus congestion. His chest x-ray was within normal limits. Sinus congestion was listed in the summary of defects and diagnoses. A chest x-ray taken in June 1984 was within normal limits. On periodic physical examination in January 1985, clinical evaluation of the Veteran was normal. He denied any relevant medical history. On outpatient treatment later in January 1985, the Veteran complained of nausea which had lasted for 1 day and 2 episodes of watery diarrhea. He was "keeping fluids down." Physical examination showed a quiet, flat, soft abdomen without tenderness or palpable organs and good hydration. The impression was gastroenteritis. The Veteran was advised to follow a clear liquid diet as tolerated. On periodic physical examinations in January and in June 1986, clinical evaluation of the Veteran was normal. On periodic physical examination in February 1987, clinical evaluation of the Veteran was normal. He denied any relevant history. Sinus x-rays showed bilateral maxillary sinus mucosal thickening. On periodic physical examination in July 1989, clinical evaluation of the Veteran was normal. He denied any relevant history. In July 1994, the Veteran's complaints included nausea, vomiting, and stomach cramps. Objective examination showed that, the prior evening, the Veteran felt nausea and "crampy" abdominal pain 2 hours after eating a "7-11 club sandwich." He denied any vomiting and was tolerating liquids by mouth. Physical examination showed he was slightly ill-appearing with full orientation, clear lungs, normo-active bowel sounds, and a soft, non-tender abdomen without hepatosplenomegaly, masses, rebound, or guarding. The assessment was gastroenteritis due to a probable food-borne infection. The Veteran was advised to push fluids and was authorized "sick in quarters" leave for 2 days. He also was advised to return to the medical clinic if vomiting or unable to tolerate fluids. On periodic physical examination in October 1994, clinical evaluation of the Veteran was normal. He reported that he was in "good health." On periodic physical examination in March 1998, just prior to his separation from service at the end of his second period of active service in June 1998, clinical evaluation of the Veteran was normal. He denied any relevant medical history. The post-service evidence shows that, on VA outpatient treatment on July 23, 2002, the Veteran reported to establish a new primary care physician (PCP). His complaints included new onset nausea every morning "and intermittently throughout the day." Physical examination showed clear lungs and a benign abdomen. The assessment included nausea and possible gastroesophageal reflux disease (GERD). The VA clinician stated that he would check the Veteran's H. pylori and gave him a trial of a proton-pump inhibitor (PPI). On July 24, 2002, the Veteran complained of "extreme concerns about stomach and bowels." A history of chronic intermittent diarrhea, "often with bright red blood mixed in for the past year" was noted. "At first thought it was hemorrhoids but getting worse and seems like too much blood." The Veteran also reported that had had taken Motrin twice in the last 12 hours and experienced severe abdominal pain and dyspepsia. Physical examination showed a soft, non-tender, non-distended abdomen with increased bowel sounds, no masses, and no hepatosplenomegaly. The assessment was dyspepsia with peptic symptoms exacerbated by a non-steroidal anti-inflammatory drug (NSAID) and hematochezia with a "most likely" diagnosis of colitis. The VA clinician recommended that the Veteran take Tylenol instead of Motrin and gave him a prescription for Flexeril and PPI "double dose" to treat his dyspepsia. The Veteran also was scheduled for H. pylori testing and a colonoscopy. In September 2002, it was noted that the Veteran was being seen in follow-up for his gastrointestinal issues. He had a normal colonoscopy "and bleeding has stopped" with a proton-pump inhibitor (PPI). He also reported that his upper gastrointestinal symptoms "have pretty much resolved as well." Physical examination was deferred although he appeared well. The assessment included gastrointestinal issues with a note that peptic ulcer disease (PUD) type symptoms had resolved "and no source of bleeding found in" the lower gastrointestinal tract. The VA clinician stated that "it is clearer that [the Veteran] carries a lot of internal stress that could contribut[e] to PUD and also" irritable bowel syndrome (IBS). In November 2002, the Veteran reported that he "has been doing well with Aciphex." He reported some continued cramping prior to a bowel movement but otherwise no gastrointestinal complaints. He had tried to cut back on his PPI "but gets heartburn." He denied experiencing any melena or bright red blood per rectum (BRBPR). Physical examination was deferred although he appeared well. The assessment included IBS/GERD. The Veteran was advised to continue his current treatment regimen. Following VA outpatient treatment in March 2003, the assessment included GERD with a note that the Veteran had a negative H. pylori test. He was advised to continue taking a PPI. On VA outpatient treatment in August 2003, the Veteran's complaints included that "[h]is sinuses are bothering him with the smoke in the air. He has been experiencing epistaxis on [a] daily basis." Physical examination showed clear lungs, clear mucus and injected swollen mucosa in the nares, and tympanic membranes within normal limits. The assessment included allergic rhinitis and GERD. The Veteran was prescribed Flonase 2 puffs twice daily. He also was advised to continue taking Aciphex for GERD. In December 2003, no relevant complaints were noted. The assessment included GERD which was controlled with a PPI. In October 2004, the Veteran reported that his "heartburn [is] much better since cutting out coffee." He was taking Prilosec "once daily with good results." Physical examination showed clear lungs. The assessment included GERD/PUD which was stable on a PPI and IBS which was stable. In a December 2004 statement, the Veteran's wife stated: I am witness to the many, many times he is doubled over and has horrible stomach aches when he has a sensation to have a bowel movement, and it comes on so sudden[ly]. There have been several occasions when he was embarrassed because of all of the sudden urges to have a bowel movement. I can tell by his actions that he is in a lot of pain...[and] something is terribly wrong with his stomach. He is always blowing his nose [and] he insists I have a box of Kleenex in every room of our home. He has had numerous nose bleeds. On VA outpatient treatment in February 2005, no relevant complaints were noted. The Veteran reported that, other than significant back problems, "he had been doing very well, and feels that as a whole he is quite healthy." Physical examination showed clear lungs. The assessment included stable gastrointestinal problems. In May 2005, no new complaints were noted. The Veteran reported that he had to discontinue drinking coffee again for gastrointestinal issues. Physical examination was unchanged. The assessment included PUD which was stable. In June 2006, the Veteran "presents in emotion/social crisis. He is going through a divorce, and has lost his home, and his dog." He also had been drinking heavily. "His stomach is bothering him, but he notes it is better when not drinking [alcohol]." Physical examination showed he was anxious "and on the verge of tears" but was "physically comfortable" with clear lungs. The assessment included PUD. The VA clinician renewed the Veteran's prescription for Prilosec and noted that it was "unclear how regularly he is taking PPI, as it has not been filled since 2005." In September 2009, the Veteran was advised by his VA clinician that his recent chest x-ray had been unremarkable. On VA digestive conditions examination in May 2011, the Veteran's complaints included "stomach issues, which include chronic nausea before or after meals and dry heaves" with nausea "primarily in the morning" " since active service and "basically runny nose or rhinitis for the last 20 to 30 years." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. A history of rhinitis and nausea with dry heaves was noted. "Please note the Veteran has not been diagnosed for any conditions related to these symptoms." The Veteran had not smoked for several years although he had smoked 4-5 cigars per year prior to that. He also drank 2 betters "on a weekend if that. He has a history of heavy drinking for approximately between 2004 and 2006 while going through a divorce." He reported being treated in service for gastrointestinal problems with antacids "none of which were effective." He denied any dysphagia, pyrosis, epigastric or other pain, hematemesis, melena, or reflux or regurgitation. He also denied any current treatment or being diagnosed with any gastrointestinal disorder. He further denied experiencing any sinus congestion, "interference with breathing through either nostril," purulent discharge, speech impairment, chronic sinusitis with tenderness or crusting. "He would get common colds while [on] active duty." Physical examination in May 2011 showed mild rhinitis, no inflammation of the nasal turbinates, no visualized nasal polyps, mild erythema of the nasal turbinates, no nasal septal deviation, no sinus tenderness, clear lungs, a soft, non-tender abdomen with no hepatosplenomegaly. The VA examiner stated: The Veteran has not been diagnosed or treated for either condition, or any other gastrointestinal disorder, to include gastroenteritis, or a nasal disorder, to include sinusitis, and is not currently followed for either. There is no documentation to support the Veteran's contention that these conditions are related to military service. There is no documentation or current treatment to support other more specific diagnoses. Thus, it is not likely that the Veteran has either a gastrointestinal disorder or nasal condition that had its origin in military service. The diagnoses were chronic rhinitis "by Veteran report" and gastritis with chronic nausea and vomiting "by Veteran report." On VA sinusitis/rhinitis Disability Benefits Questionnaire (DBQ) in September 2012, the Veteran's complaints included chronic clear rhinorrhea and post-nasal drip for "many years out of both sides of[his] nose," intermittent pressure and a sensation of water in the ears, "very rarely getting sick with thick purulent drainage, congestion, [and] cough." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. "He has been prescribed a nasal spray and oral medication which helps which he takes as needed." Physical examination showed no greater than 50% obstruction of the nasal passage on both sides due to rhinitis or deviated nasal septum, no complete obstruction on one side due to rhinitis or deviated nasal septum, no permanent hypertrophy of the nasal turbinates, no nasal polyps, no granulomatous conditions, no chronic laryngitis, and no vocal cord paralysis or any other pharyngeal or laryngeal conditions. The VA clinician stated that the Veteran was "not sure" if x-rays of the sinuses had been taken "and I could not find any record of this" in the claims file. Nasal endoscopy showed mild nasal septal deviation to the left, mild mucous, mild turbinate hypertrophy, and normal middle meatus bilaterally. The VA clinician stated: The Veteran has evidence of chronic rhinitis and vasomotor rhinitis, but no clinical evidence of chronic sinusitis, which he states he has had for over 20 years. There are no notes in the records that I reviewed that indicate this was present while he was in the service. Given that the only sinonasal problems seen in the chart were occasional episodes of acute, probably viral rhinosinusitis, [it] is not at least as likely as not that the chronic rhinitis was present during military service or is related to his service. The diagnosis was non-allergic rhinitis. On VA stomach and duodenal conditions DBQ in September 2012, the Veteran's complaints included "almost daily episodes of nausea with vomiting. This can occur at any time of the day and is not triggered by food." These episodes lasted 15-30 minutes "and resolve spontaneously" or to Rolaids. "He has regular bowel movements every other day." The Veteran had lost 15-18 pounds of weight "since earlier this year and he is actively trying to [lose] weight. There is no change in bowel habits or blood in his stool." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran's history was reviewed. Physical examination showed recurrent episodes of symptoms of a stomach or duodenal condition that were not severe 4 or more times a year, weight loss, transient nausea occurring 4 or more times a year for 10 days or more at a time, and no incapacitating episodes of a stomach or duodenal condition. An upper gastrointestinal series taken in September 2002 had been unremarkable. A colonoscopy performed in May 2010 showed diverticulosis and hemorrhoids. The VA clinician stated that he had advised the Veteran that the fact that his current nausea responds to Rolaids "suggests that he might have ongoing acid reflux that had been documented and treated for several years since 2002." This clinician also advised the Veteran to retry taking daily omeprazole. "Although he carries a diagnosis of irritable bowel as well since 2002, this does currently not appear [sic] to cause him any problems." This clinician opined that the Veteran's claimed gastrointestinal disability was less likely than not incurred in or caused by active service. The rationale for this opinion was that the Veteran "had two documented self-limited episodes of gastrointestinal disease while he was on active duty" with no follow-up visits. The Veteran also checked "no" on numerous periodic physical examination "when asked about frequent indigestion, stomach, liver, or intestinal trouble. It therefore appears that these two episodes were isolated, self-limited events and it is difficult to see a link between these two episodes and the currently reported nausea." This clinician also noted that the initial documentation of the Veteran's "presumptive GERD, IBS, and 'PUD-like' symptoms was not made until" July 2002. The diagnoses were gastric ulcer, irritable bowel, GERD, gastroenteritis, and food poisoning. On VA sinusitis/rhinitis DBQ in April 2013, the Veteran complained of "clear watery discharge from [his] nose" every morning on awakening "which lasts for [a] short period & resolves by noon." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran denied experiencing any nasal discharge in the evening or at night. There was no nasal discharge present while he was asleep. He also denied any history of seasonal allergies, allergy tests, "antibiotics use for suspected sinus condition," headaches, or fever. "His symptoms are under control." It was noted that the Veteran had rhinitis "per history during service & he was treated during service (self therapy)." Physical examination showed no greater than 50 percent obstruction or complete obstruction of the nasal passage on both sides due to rhinitis, no permanent hypertrophy of the nasal turbinates, no nasal polyps, and no granulomatous conditions. Sinus x-rays were normal. The VA examiner opined that the Veteran's claimed nasal disability was less likely than not related to active service. The rationale for this opinion was the Veteran's in-service nasal problems "were self-limited and left no sequelae. [The] Veteran has no evidence of chronic sinusitis at present. He has no nasal disability." The diagnoses were non-allergic rhinitis "per history" which was diagnosed during service, no evidence of chronic sinusitis, and no nasal disability. On VA stomach and duodenal conditions DBQ in April 2013, the Veteran's complaints included feeling nauseated early in the morning without vomiting. His nausea cleared up "as [the] day goes by in [a] few hours." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran denied any history of heartburn, indigestion "with or after meals," nocturnal heartburn, acid "eructations," melena, hematemesis, diarrhea, abdominal cramps, or watery or loose bowels. He reported a good appetite, weight gain, and regular bowels. A history of alcohol and substance abuse was noted. The Veteran was not taking continuous medication for a stomach or duodenum condition. Physical examination showed recurrent nausea which occurred 4 times a year with each episode lasting less than 1 day and no incapacitating episodes of a stomach or duodenum condition. An upper gastrointestinal series showed minimal sliding hiatal hernia with Valsalva maneuver, no gastroesophageal reflux, and no mass lesions or ulcers. The VA examiner opined that it was less likely than not that the Veteran's gastrointestinal disability was related to active service. The rationale for this opinion was that, following a review of the claims file, the Veteran's gastrointestinal conditions during service "had resolved & were self-limiting & left no sequelae." He also stated, "[The] conditions diagnosed after service in 2002 onwards - are possible GERD & PUD type symptoms. These were not diagnosed on any solid evidence & were educated guess[es]." He stated further that, on questioning the Veteran, there was no evidence of IBS. This examiner concluded that the Veteran "has no gastrointestinal disability apart from" transient nausea. The diagnosis was early morning nausea. Analysis The Board finds that the evidence is in relative equipoise as to whether the Veteran's gastrointestinal disability is related to active service. There is evidence both for and against the Veteran's claim of service connection for a gastrointestinal (GI) disability. His available service treatment records show that he complained of and was treated for a variety of GI problems during active service, to include nausea and gastroenteritis. The Veteran has asserted consistently in statements submitted to VA that he experienced continuous GI disability since his service separation. The post-service evidence (in this case, the Veteran's VA outpatient treatment records and examination reports) show that he has complained of and been treated for a variety of GI problems since approximately 2002, to include GERD, IBS, PUD, gastritis with vomiting, and nausea. The Veteran's service representative contended in a June 2013 appellate brief that the medical opinions of record concerning the contended causal relationship between the Veteran's current GI disability and active service are not competent evidence. The Board agrees. For example, following VA examination in May 2011, the VA examiner incorrectly concluded that the Veteran had not been diagnosed as having a GI disability when, in fact, the claims file contains such diagnoses. The May 2011 VA examiner also impermissibly found the lack of medical records demonstrating an etiological link between the Veteran's GI disability (which was diagnosed as gastritis with chronic nausea and vomiting "by Veteran report") and active service to be persuasive evidence supporting his negative nexus opinion concerning the contended causal relationship between this disability and active service. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). The September 2012 VA stomach and duodenal conditions DBQ examiner similarly found the lack of medical records documenting the Veteran's GI problems since his service separation to be persuasive evidence supporting his negative nexus opinion concerning the contended causal relationship between the Veteran's GI disability (which was diagnosed as gastric ulcer, irritable bowel, GERD, gastroenteritis, and food poisoning) and active service. Id. Finally, the April 2013 VA stomach and duodenal conditions DBQ examiner found the lack of records demonstrating continued GI symptomatology to be persuasive evidence supporting his negative nexus opinion concerning the contended causal relationship between the Veteran's GI disability (which was diagnosed as transient nausea) and active service. Id. The Court has held that the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. Wilson v. Derwinski, 2 Vet. App. 614 (1992). A medical opinion based upon an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). A bare conclusion, even one reached by a medical professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A bare transcription of lay history, unenhanced by additional comment by the transcriber, does not become competent medical evidence merely because the transcriber is a medical professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). The Court also has held that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). Thus, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Having reviewed the opinions of record concerning the nature and etiology of the Veteran's GI disability, the Board finds that they are not conclusive on the issue of whether the Veteran's current GI disability is related to active service. The April 2013 VA examiner also disagreed with the Veteran's prior post-service GI diagnoses because, in his view, they "were not diagnosed on any solid evidence & were educated guess[es]." This clinician provided no rationale for this conclusion. Nor is there any indication what factual predicate in the record or "clinical data or other rationale" supported this conclusion. Accordingly, the Board finds that the April 2013 VA stomach and duodenal conditions DBQ is inadequate for adjudication purposes. See Miller, 11 Vet. App. at 348, Bloom, 12 Vet. App. at 187, and Black, 5 Vet. App. at 180. The evidence demonstrates that the Veteran experienced a GI disability during service. He has asserted consistently that he experienced continuous GI disability since his service separation. The Veteran's assertions are supported by the record evidence which demonstrates multiple complaints of and treatment for a variety of GI disabilities since his service separation. In summary, and after resolving any reasonable doubt in the Veteran's favor, the Board finds that service connection for a gastrointestinal (GI) disability, currently manifested by nausea is warranted. The Board finally finds that the preponderance of the evidence is against the Veteran's claim of service connection for a nasal disability. The Veteran has asserted that he incurred a nasal disability during active service and experienced continuous nasal disability since his service separation. The record evidence does not support his assertions concerning a continuity of symptomatology since his service separation due to a nasal disability, however. It shows instead that, although the Veteran complained of and was treated for a variety of nasal problems during active service, to include rhinitis and sinus congestion, he does not experience any current nasal disability which is attributable to active service. It appears that, following his service separation in June 1998, the Veteran next was treated for a nasal disability in August 2003, or more than 5 years later, when he was diagnosed as having allergic rhinitis. The Board notes that evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board acknowledges that the May 2011 VA examiner opined that, because "[t]he Veteran has not been diagnosed or treated for...a nasal disorder, to include sinusitis," it was less likely than not that his claimed nasal disability was related to service. As noted above, the claims file contains multiple diagnoses of a nasal disability so the basis for the May 2011 VA examiner's contrary conclusion is not clear from a review of the record. And, as noted above, a medical opinion which is based on an inaccurate factual predicate is not probative. See Reonal, 5 Vet. App. at 461. By contrast, the September 2012 VA examiner correctly noted that "[t]he Veteran has evidence of chronic rhinitis and vasomotor rhinitis." This examiner concluded, however, that because "the only sinonasal problems seen in the chart were occasional episodes of acute, probably viral rhinosinusitis, [it] is not at least as likely as not that the chronic rhinitis was present during military service or is related to [the Veteran's] service." This persuasively suggests that the September 2012 VA examiner found the lack of records documenting the presence of chronic nasal disability to be persuasive support for his negative nexus opinion concerning the contended causal relationship between the Veteran's nasal disability and active service. Accordingly, the Board again finds that the May 2011 and September 2012 VA examiner's opinions are not probative on the issue of whether the Veteran's claimed nasal disability is related to active service. See Buchanan, 451 F.3d at 1337, and Barr, 21 Vet. App. at 303. The remaining evidence shows that, although the Veteran has complained of and been treated for a nasal disability since his service separation, he does not experience any current nasal disability which could be attributed to active service. At his most recent VA examination in April 2013, it was noted that the Veteran's nasal symptoms were under control. Sinus x-rays were normal. The VA examiner opined that the Veteran's claimed nasal disability was less likely than not related to active service. The rationale for this opinion was the Veteran's in-service nasal problems "were self-limited and left no sequelae. [The] Veteran has no evidence of chronic sinusitis at present. He has no nasal disability." The diagnoses were non-allergic rhinitis "per history" which was diagnosed during service, no evidence of chronic sinusitis, and no nasal disability. A service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability. Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection is not warranted in the absence of proof of current disability. The Board has considered whether the Veteran experienced a nasal disability at any time during the pendency of this appeal. Service connection may be granted if there is a disability at some point during the claim even if it later resolves or becomes asymptomatic. McClain v. Nicholson, 21 Vet. App. 319 (2007). In this case, although there is evidence that the Veteran experienced a nasal disability since service separation, the evidence does not support a finding that it is related to active service. Absent evidence of current disability which could be attributed to active service, the Board finds that service connection for a nasal disability is not warranted. In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"); 38 C.F.R. § 3.303(a) (service connection claims "must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown,6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A Veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr, 21 Vet. App. at 309 (holding that, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, a nasal disability falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan, 451 F.3d at 1337, and Barr, 21 Vet. App. at 303. In determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). As part of the current VA disability compensation claim, in recent statements and sworn testimony, the Veteran has asserted that his symptoms of a nasal disability have been continuous since service. He asserts that he continued to experience a nasal disability (rhinitis, nasal discharge, and sinus congestion) after he was discharged from service. In this case, after a review of all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of a nasal disability after service separation. Further, the Board concludes that his assertion of continued symptomatology since active service, while competent, is not credible. The Board finds that the Veteran's more recently-reported history of continued symptoms of a nasal disability since active service is inconsistent with the other lay and medical evidence of record. Indeed, while he now asserts that this disorder began in service, at his separation physical examination on May 28, 1980, just prior to the end of his first period of active service on June 7, 1980, clinical evaluation of the Veteran was normal and his chest x-ray was within normal limits. Similarly, on periodic physical examination in March 1998, just prior to his separation from service at the end of his second period of active service in June 1998, clinical evaluation of the Veteran was normal and he denied any relevant medical history. His in-service history of symptoms at the time of service separation at the end of each period of active service is more contemporaneous to service so it is of more probative value than the more recent assertions made many years after service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994). The post-service medical evidence does not reflect complaints or treatment related to a nasal disability for several years following active service. The Board emphasizes the multi-year gap between discharge from active service (1998) and initial reported symptoms related to a nasal disability in approximately 2003 (a 5-year gap). See Maxson, 230 F.3d at 1333; 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). When the Veteran sought to establish medical care with VA after service on VA outpatient treatment on July 23, 2002, his complaints focused on his GI disability, including new onset nausea every morning "and intermittently throughout the day." No relevant history of a nasal disability was noted in the July 2002 VA outpatient treatment record. Such histories reported by the Veteran for treatment purposes are of more probative value than the more recent assertions and histories given for VA disability compensation purposes. Rucker, 10 Vet. App. at 67 (holding that lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). He did not claim that symptoms of his disorders began in (or soon after) service until he filed his current VA disability compensation claim. Such statements made for VA disability compensation purposes are of lesser probative value than his previous more contemporaneous in-service histories and his previous statements made for treatment purposes. See Pond v. West, 12 Vet. App. 341 (1999) (finding that, although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). These inconsistencies in the record weigh against the Veteran's credibility as to the assertion of continuity of symptomatology since service. The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation, the absence of complaints or treatment for years after service, and his previous statements made for treatment purposes. For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of continuity of symptoms since service separation. ORDER Entitlement to service connection for a gastrointestinal disability is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to service connection for a nasal disability is denied. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs