Citation Nr: 1330278 Decision Date: 09/20/13 Archive Date: 09/25/13 DOCKET NO. 07-30 728 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a headache disability. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for a skin disability. 5. Entitlement to service connection for a sinus disability. 6. Entitlement to service connection for a gastrointestinal disability. 7. Entitlement to service connection for a prostate disability. 8. Entitlement to service connection for a bilateral knee disability. 9. Entitlement to service connection for a bilateral hip disability. 10. Entitlement to service connection for a back disability. 11. Entitlement to an initial rating higher than 10 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD B. Elwood, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1967 to September 1969, which includes service in the Republic of Vietnam. He received the Combat Infantryman Badge and Bronze Star Medal. These matters initially came before the Board of Veterans' Appeals (Board) from an October 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In that decision, the RO denied entitlement to service connection for headaches, hearing loss, high blood pressure, skin discoloration, a sinus disability, indigestion, an enlarged prostate, a bilateral knee disability, a hip disability, and a back disability. In June 2011, the Board remanded these matters for further development. The Veteran had also perfected an appeal with regard to the issues of entitlement to service connection for tinnitus and PTSD, and the Board had remanded these issues in June 2011 for further development. In August and October 2012, the Appeals Management Center (AMC) granted service connection for these disabilities, and thereby resolved the appeal as to those issues. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claims. The documents in this file have been reviewed and considered as part of this appeal. In a November 2012 statement (VA Form 21-4138), the Veteran expressed disagreement with the amount of retroactive pay that he had been awarded following an October 2012 rating decision. This issue has not been addressed by the agency of original jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and this matter is referred to the AOJ for appropriate action. The issues of entitlement to service connection for a bilateral hip disability and a back disability and an increased rating for PTSD are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC, in Washington, DC. FINDINGS OF FACT 1. The Veteran does not have a current headache disability. 2. Hearing loss did not have its clinical onset in service, was not exhibited within the first post-service year, is not the result of herbicide exposure in service, and is not otherwise related to active duty. 3. Hypertension did not have its clinical onset in service, was not exhibited within the first post-service year, is not the result of herbicide exposure in service, and is not otherwise related to active duty. 4. The Veteran's current skin disability did not have its clinical onset in service, is not the result of herbicide exposure in service, and is not otherwise related to active duty. 5. The Veteran's current sinus disability did not have its clinical onset in service, is not the result of herbicide exposure in service, and is not otherwise related to active duty. 6. The Veteran's current gastrointestinal disability did not have its clinical onset in service, is not the result of herbicide exposure in service, and is not otherwise related to active duty. 7. The Veteran's current prostate disability did not have its clinical onset in service, is not the result of herbicide exposure in service, and is not otherwise related to active duty. 8. The Veteran's current bilateral knee disability did not have its clinical onset in service, was not exhibited within the first post-service year, is not the result of herbicide exposure in service, and is not otherwise related to active duty. CONCLUSIONS OF LAW 1. The Veteran does not have a current headache disability that is the result of a disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.303 (2013). 2. Hearing loss was not incurred or aggravated in service and it may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113(b), 1116, 1154(b), 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.385 (2013). 3. Hypertension was not incurred or aggravated in service and it may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113(b), 1116, 1154(b), 5107(b); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 4.104, Diagnostic Code (DC) 7101, Note (1) (2013). 4. The Veteran's current skin disability was not incurred or aggravated in service and it may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113(b), 1116, 1154(b), 5107(b); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 5. The Veteran's current sinus disability was not incurred or aggravated in service and it may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113(b), 1116, 1154(b), 5107(b); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 6. The Veteran's current gastrointestinal disability was not incurred or aggravated in service and it may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113(b), 1116, 1154(b), 5107(b); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 7. The Veteran's current prostate disability was not incurred or aggravated in service and it may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113(b), 1116, 1154(b), 5107(b); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 8. The Veteran's current bilateral knee disability was not incurred or aggravated in service and it may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113(b), 1116, 1154(b), 5107(b); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012) redefined VA's duty to assist the Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). Under the VCAA, VA 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; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In letters dated in May 2005 and August 2011, the RO notified the Veteran of the evidence needed to substantiate his claims of service connection for a headache disability, bilateral hearing loss, hypertension, a skin disability, a sinus disability, a gastrointestinal disability, a prostate disability, and a bilateral knee disability. These letters also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist him in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The claimant's Veteran status has been substantiated. He was notified of all other elements of the Dingess notice, including the disability rating and effective date elements of his claims, in a June 2006 letter. There was a timing deficiency in that the June 2006 and August 2011 letters were sent after the initial adjudication of the Veteran's claims. This timing deficiency was cured by readjudication of the claims in a September 2007 statement of the case and an October 2012 supplemental statement of the case. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA obtained the Veteran's service treatment records, all of the identified relevant post-service VA treatment records, and some of the identified relevant post-service private medical records. In addition, the Veteran was afforded VA examinations for his claimed hearing loss, hypertension, sinus disability, gastrointestinal disability, prostate disability, and bilateral knee disability and opinions have been obtained concerning the etiology of these disabilities. VA is obliged to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. The Veteran's reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon, 20 Vet. App. at 83. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon, 20 Vet. App. at 83. There must, however, be sufficient evidence of such a relationship to trigger VA's duty to provide an examination or obtain a medical opinion. Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). The Veteran was not afforded VA examinations for his claimed headache disability and skin disability and opinions as to the etiology of these claimed disabilities have not otherwise been obtained. As discussed below, there is no evidence that Veteran has been diagnosed as having any current headache disability at any time during the claim period and there is no evidence of any current headaches that may be related to any disease or injury in service. Also, there is no evidence that his current skin disability may be related to a disease or injury in service. The Veteran has not reported, and the evidence does not reflect, a continuity of symptomatology with respect to his claimed headaches. Although he has reported a continuity of symptomatology with respect to his claimed skin disability, the Board has determined that these reports are not credible. There is no medical evidence that any headaches or skin disability may be related to service, and the Veteran has not alluded to the existence of any such evidence. Hence, VA examinations or opinions for the claimed headache disability and skin disability are not necessary. See McLendon, 20 Vet. App. at 83. In June 2005, the Veteran submitted a signed and completed "Authorization and Consent to Release Information" form (VA Form 21-4142) for records of treatment for a knee disability from Dr. Slappey in Birmingham, Alabama. In July 2005, the AOJ sent a letter to this physician and requested copies of all available relevant treatment records. This letter was returned as undeliverable. In its June 2011 remand, the Board instructed the AOJ to, among other things, ask the Veteran to identify any additional relevant private treatment records, obtain any additional relevant private treatment records for which appropriate release forms were submitted (including from Dr. Slappey), and schedule the Veteran for VA examinations to obtain opinions as to the etiology of his claimed hearing loss, hypertension, sinus disability, gastrointestinal disability, prostate disability, and bilateral knee disability. In an August 2011 letter, the Veteran was asked to identify the name and location of any private medical facility from which he had received treatment for his claimed disabilities. He was also asked to complete the appropriate release form so as to allow VA to obtain any identified relevant private treatment records that had not already been obtained (including records from Dr. Slappey) and was advised to submit any relevant treatment records in his possession. Copies of the release form (VA Form 21-4142) were included with the letter. The Veteran did not submit any completed VA Form 21-4142, but he did submit additional treatment records from Dr. Slappey. VA is only required to seek pertinent records that are adequately identified and for which necessary releases are furnished. 38 U.S.C.A. § 5103A(b); See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (the duty to assist is not always a one-way street); 38 C.F.R. §§ 3.159(c)(1)(i), (c)(2)(i) (requiring a claimant to cooperate fully with VA's efforts to obtain federal and non-federal records). As the Veteran did not submit the appropriate release form so as to allow VA to obtain treatment records from Dr. Slappey or any other private treatment provider from whom records have not already been requested, VA has no further duty to attempt to obtain any additional private treatment records. Moreover, VA examinations were conducted in August 2011 and opinions were obtained concerning the etiology of the Veteran's claimed hearing loss, hypertension, sinus disability, gastrointestinal disability, prostate disability, and bilateral knee disability. Therefore, the AOJ substantially complied with all of the Board's pertinent June 2011 remand instructions and VA has no further duty to attempt to obtain any additional records or conduct additional examinations with respect to the claims being decided herein. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Analysis Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires (1) medical evidence of a current 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element for certain chronic disabilities listed in 38 C.F.R. § 3.309(a) (including organic diseases of the nervous system (e.g. sensorineural hearing loss), hypertension, and arthritis) is through a demonstration of continuity of symptomatology. See Clyburn v. West, 12 Vet. App. 296, 302 (1999). 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. See Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.309(a). In relevant part, 38 U.S.C.A. § 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (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, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between 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")). Service connection may also be granted for a disease first 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). A veteran, who, during active military service, served in Vietnam during the period beginning in January 1962 and ending in May 1975, is presumed to have been exposed to herbicides. 38 C.F.R. §§ 3.307, 3.309. If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected even though there is no record of such disease during service: chloracne or other acneform disease consistent with chloracne, Type 2 diabetes, Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). 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 organic diseases of the nervous system, hypertension, and arthritis) are presumed to have been incurred in service if such is manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). Notwithstanding the foregoing presumptions, a claimant is not precluded from establishing service connection with proof of direct causation. 38 U.S.C.A. § 1113(b); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. Headache Disability In the absence of proof of present disability there can be no successful claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). See also Degmetich v. Brown, 104 F.3d 1328 (1997) (also interpreting 38 U.S.C. § 1131 as requiring the existence of a present disability for VA compensation purposes). To be present as a current disability, there must be evidence of the condition at some time during the claim period. Gilpin v. West, 155 F. 3d 1353, 1356 (Fed. Cir. 1998); see also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the Gilpin requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves). In this case, the Veteran reported in his March 2005 claim (VA Form 21-526) that he experienced headaches in service associated with elevated blood pressure. Also, he reported in an August 2011 statement (VA Form 21-4138) that he was being treated by VA for the conditions listed in the August 2011 letter from the AOJ (which included headaches). He is competent to report headaches. See Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337. Moreover, there is nothing to explicitly contradict his reports and they are not inconsistent with the evidence of record. Thus, the Veteran's reports of headaches are deemed to be credible. Nevertheless, as explained below, the evidence dated since his claim was received in March 2005 reflects that he does not have any current underlying headache disability. The Veteran's post-service medical records (including VA treatment records and private medical records) do not reflect any evidence of treatment for headaches in the years since service. Also, a VA examination was conducted in August 2011 to assess the etiology of his current hypertension. The examination report reflects that the Veteran reportedly experienced headaches while serving in Vietnam, but he denied experiencing any headaches at the time of the August 2011 examination. Although a diagnosis is not always necessary to establish service connection, pain without a diagnosed or identifiable underlying malady or condition, does not constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet App 282 (1999); aff'd sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). In this case, the Veteran has reported headaches, but an underlying disability has not been identified. There is no other evidence of any current headache disability at any time since the Veteran's claim was received in March 2005, and neither the Veteran nor his representative have alluded to the existence of any such evidence. Thus, in light of the lack of evidence of a diagnosed disability, the weight of the evidence is against a finding of a current headache disability and the existence of a current disability is the cornerstone of a claim for VA disability compensation. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim and the claim of service connection for a headache disability must be denied. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57. B. Hearing Loss, Hypertension, and Skin, Sinus, Gastrointestinal, Prostate, and Bilateral Knee Disabilities Hearing loss is considered to be a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition thresholds using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. For VA purposes, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. The term hypertension means that the diastolic blood pressure is predominantly 90 mm or greater and isolated systolic hypertension means systolic blood pressure is predominantly 160 mm or greater with a diastolic blood pressure of 90 mm. 38 C.F.R. § 4.104, DC 7101, Note (1). An August 2011 VA audiologic examination report reveals that the Veteran has been diagnosed as having bilateral sensorineural hearing loss as defined by VA. See Id. Also, a February 2009 VA dermatology consultation note and VA examination reports dated in August 2011 include diagnoses of hypertension, dermatosis papulosa nigra, allergic rhinitis, gastroesophageal reflux disease (GERD), prostate hypertrophy, and degenerative joint disease of the knees. Thus, current disabilities have been demonstrated. The Veteran contends that all of his claimed disabilities are related to herbicide exposure in service. He also contends that his hearing loss is related to exposure to loud noises in service associated with military weaponry and that his bilateral knee disability is related to physical training and jumping out of helicopters while in service. As the Veteran served in Vietnam, he is presumed to have been exposed to herbicides, including Agent Orange. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307. However, his current hearing loss, hypertension, and skin, sinus, gastrointestinal, prostate, and bilateral knee disabilities are not conditions listed in 38 C.F.R. § 3.309(e). Presumptive service connection on the basis of his presumed exposure to herbicides is, therefore, not warranted. 38 C.F.R. § 3.309(e); see also 68 Fed. Reg. 27,630-41 (May 20, 2003) (stating that the Secretary of VA has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted). There is nothing in the record suggesting a direct relationship between herbicide exposure and any of the Veteran's claimed disabilities. The Veteran has not reported, and the evidence does not otherwise indicate, a continuity of symptomatology with regard to his hearing loss. However, in his March 2005 VA Form 21-526, he claimed that his hypertension and sinus, gastrointestinal, prostate, and bilateral knee disabilities all had their onset in service in 1967 and 1968. Thus, he appears to have alluded to a continuity of symptomatology. Furthermore, a September 2005 VA primary care outpatient treatment note and a May 2006 VA dermatology clinic consultation order indicate that he reportedly had experienced allergic rhinitis/sinusitis and an intermittent and itchy rash ever since service in Vietnam. Therefore, there are explicit reports of a continuity of symptomatology with regard to skin and sinus disabilities. He also reported on the March 2005 VA Form 21-526 that he experienced elevated blood pressure with associated headaches in service. The Veteran's DD 214 indicates that he engaged in combat in service, as he received the Combat Infantryman Badge. Where a veteran engaged in combat, satisfactory lay evidence that an injury or disease was incurred in service will be accepted as sufficient proof of service connection where such evidence is consistent with the circumstances, conditions, or hardships, of service. 38 U.S.C.A. § 1154(b). Section 1154(b) sets forth a three step sequential analysis that must be undertaken when a combat veteran seeks benefits under the method of proof provided by the statute. First, it must be determined whether the veteran has proffered "satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease." Second, it must be determined whether the proffered evidence is "consistent with the circumstances, conditions, or hardships of such service." Finally, if the first two requirements are met, VA shall accept the veteran's evidence as "sufficient proof of service connection," even if no official record of such incurrence exists. In such a case, a factual presumption arises that the alleged injury or disease is service-connected. Collette v. Brown, 82 F.3d 389, 393 (Fed. Cir. 1996); 38 C.F.R. § 3.304. The weighing of contrary evidence cannot be considered under 38 U.S.C.A. § 1154(b) as part of the first two steps but only as part of rebuttal of service incurrence under the clear-and-convincing evidence standard in the third step. Libertine v. Brown, 9 Vet. App. 521, 524 (1996), The presumptions of 38 U.S.C.A. § 1154(b) do not extend to the nexus element of a claim of service connection. Wade v. West, 11 Vet. App. 302 (1998); Turpen v. Gober, 10 Vet. App. 536 (1997). Although the Veteran served in combat, he does not contend, nor does the evidence indicate, that hypertension or skin, sinus, gastrointestinal, or prostate disabilities were incurred in combat with the enemy. Hence, the provisions of 38 U.S.C.A. § 1154(b) are inapplicable with respect to these disabilities. However, in-service noise exposure and trauma to the knees, such as that described by the Veteran, could be consistent with the circumstances of his service. The Veteran is competent to report noise exposure and trauma to the knees in service during combat situations. Such reports are satisfactory evidence, and his reports are consistent with the circumstances of his service in Vietnam. There is no clear and convincing evidence to the contrary. Hence the presence of in-service acoustic trauma and trauma to the knees is conceded. With regard to the remaining elements of the Veteran's service connection claims (including the claims of service connection for bilateral hearing loss and a bilateral knee disability), his reports must be weighed against the objective evidence and their credibility must be assessed. See Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337. There is no evidence of any complaints of or treatment for hearing loss, hypertension, or any skin, sinus, gastrointestinal, prostate, or knee problems in the Veteran's service treatment records and there were no elevated blood pressure readings (as defined in 38 C.F.R. § 4.104, DC 7101, Note (1)) recorded during service. Further, his August 1969 separation examination was normal and a blood pressure reading of 130/76 was recorded at the time of separation. The objective evidence otherwise indicates that the Veteran's current disabilities did not manifest until many years after service. The earliest post-service report of hearing loss is the Veteran's March 2005 VA Form 21-526 on which he reported that he experienced hearing loss as a result of loud noises in service associated with mortars. Also, the first post-service clinical evidence of hearing loss is the August 2011 VA examination report which includes a diagnosis of bilateral sensorineural hearing loss. Moreover, the first post-service clinical evidence of hypertension and skin, sinus, gastrointestinal, prostate, and knee problems are as follows, respectively: an April 1996 treatment note from Medical Center East, Inc. (Medical Center) which includes a diagnosis of hypertension; a September 1996 treatment note from Medical Center which reveals that the Veteran reported a mole under his right arm and that an examination revealed skin tags on both axilla; an April 2001 treatment record from Medical Center which reveals that the Veteran experienced nasal drainage and used Claritin; a private treatment record dated in January 2002 which includes a report of symptoms associated with reflux mainly at night and after meals (including indigestion and throat burning) and includes a diagnosis of GERD; a September 2003 examination report from Mell L. Duggan, Jr., M.D. which reflects that the Veteran experienced nocturia and some decreased stream and hesitancy, that an examination revealed a prostate gland with a 1+ benign feeling, and that a diagnosis of benign prostatic hyperplasia (BPH) was provided; an October 2004 private treatment record which reveals that the Veteran reported a popping sensation in the right knee and a 3 month history of the knee "giving out" and includes a diagnosis of knee pain (likely a meniscal injury); and treatment records from Dr. Slappey dated in November 2007 which include reports of left knee pain, swelling, popping, catching, and locking and a diagnosis of degenerative arthritis of the left knee with probable internal derangement. A progress note from Medical Center dated on "2/10" indicates that treatment for hypertension and sinus, digestion, prostate, and knee problems began in September 1988, April 2002, January 2002, April 2001, and October 2004, respectively. Furthermore, a September 2005 VA primary care treatment note indicates that hypertension was diagnosed in 1986. There is no clinical evidence of any earlier hearing loss, hypertension, or skin, sinus, gastrointestinal, prostate, or knee problems following service. The absence of any clinical evidence of these disabilities for, at the very least, nearly two decades after service weighs the evidence against a finding that the Veteran's current disabilities were present in service or in the year or years immediately after service. Moreover, the Veteran has provided varying statements as to the history of his hypertension and skin, sinus, gastrointestinal, prostate, and bilateral knee disabilities. For example, as explained above, he has contended that each of these disabilities began in service and he has provided reports of a continuity of symptomatology. However, he reported on an August 1969 report of medical history completed for purposes of separation from service that he was not experiencing, nor had he ever experienced, any "high or low blood pressure," "skin diseases," "ear, nose, or throat trouble," "chronic or frequent colds," "sinusitis," "frequent indigestion," "stomach, liver, or intestinal trouble," "frequent or painful urination," "swollen or painful joints," "arthritis or rheumatism," "bone, joint, or other deformity," "trick or locked knee," or any other medical problems other than mumps. Also, he reported during VA examinations conducted in August 2011 that his sinus problems (identified as allergic rhinitis) had their onset in 2000, that he had experienced intermittent buckling of the left knee since 1990 (but that there were no major left knee problems until an injury in 2007), and that his right knee "gave way in 2009," at which time he fell and underwent a partial ACL and quadriceps tendon repair. In light of the absence of any objective evidence of complaints of or treatment for hypertension or skin, sinus, gastrointestinal, prostate, or knee problems in service or for decades after service, the fact that the Veteran's August 1969 separation examination was normal and reflected a blood pressure reading which was within normal limits, and his inconsistent and contradictory statements concerning the history of his claimed disabilities, the Board concludes that his reports concerning the history of his hypertension and skin, sinus, gastrointestinal, prostate, and knee disabilities (including any reports of a continuity of symptomatology since service) are not credible. Thus, neither the clinical record nor the lay statements of record establish a continuity of symptomatology in this case, precluding an award of service connection on this basis. Nevertheless, even if there was credible evidence of a continuity of symptomatology with respect to the Veteran's skin, sinus, gastrointestinal, and prostate disabilities, an award of service connection on this basis would nonetheless be precluded because these current disabilities are not among the chronic conditions listed in 38 C.F.R. § 3.309(a). Service connection on the basis of a continuity of symptomatology may only be granted if a claimed disability is among this list of chronic conditions. See Walker, 708 F.3d at 1338. If a chronic disease (such as an organic disease of the nervous system (e.g. sensorineural hearing loss), hypertension, and arthritis), is shown in service and at any time thereafter, service connection will be conceded. 38 C.F.R. § 3.303(b). There must, however, be sufficient observations in service to identify the disease entity. Id. As discussed above, there is no credible evidence showing any diagnosed sensorineural hearing loss, hypertension, or arthritis in service. Hence, service connection cannot be granted on this basis here. The only medical opinions of record indicate that the Veteran's current hearing loss, hypertension and sinus, gastrointestinal, prostate, and bilateral knee disabilities are not related to service. The audiologist who conducted the August 2011 VA audiologic examination opined that the Veteran's hearing loss was not likely ("less likely as not") related to military noise exposure or acoustic trauma. She reasoned that the Veteran's June 1967 entrance examination and August 1969 separation examination both indicated hearing which was within normal limits bilaterally. The physician who conducted the additional August 2011 VA examinations opined that the Veteran's current hypertension and sinus, gastrointestinal, prostate, and bilateral knee disabilities were not likely ("less likely than not"/"less than 50 percent probability") incurred in or caused by service. With respect to hypertension, the examiner explained that the Veteran's blood pressure reading during service was less than 140/90 on several occasions. Also, hypertension was diagnosed in 1989, which was well after his active military duty. As for the Veteran's current sinus disability, the examiner reasoned that allergic rhinitis is not related to Agent Orange exposure and that there was no record of any treatment for the disability during service. Rather, the Veteran reported that symptoms began in 2000. With respect to the current gastrointestinal disability, the examiner explained that the Veteran had only been taking medications for the previous 7 to 8 years and that his treatment records did not indicate any prior symptoms or treatment. Also, GERD was not associated with Agent Orange exposure. The opinion concerning the Veteran's current prostate disability was based on the fact that benign prostatic hypertrophy developed years after his military service and was not associated with Agent Orange exposure. Furthermore, as for the diagnosed knee disabilities, the examiner reasoned that the Veteran fell in 2009 and sustained an injury to his right knee that required two operative procedures. There was no evidence of any prior significant injury to the right knee during service. Also, there was no record of any left knee injury in service. Rather, the Veteran underwent left knee surgery in 2007, which was long after his military service. In October 2012, a VA physician reviewed the Veteran's claims file and opined that his bilateral knee disability was not likely ("less likely as not"/"less than 50 percent") related to, caused by, or aggravated by his time in service (despite the fact that he received the Combat Infantryman Badge). The physician reasoned that there was no medical evidence in the Veteran's service treatment records showing that his knee disabilities had their onset in service. The medical evidence reflected that the disabilities had their onset decades after service, starting in the late 1990s and then the 2000s. The medical evidence showed the severity of the disability at its onset and since that time. The Veteran's knee disabilities were consistent with his age. If his time in the service was involved as an etiology of the disabilities, than their onset would have been much sooner. Also, there was evidence of minor injuries after service. The progression of the disabilities had continued "with his age" and had increased more recently with his weight gain. His body mass index (BMI) had been greater than 30 since 2007. The Board recognizes that the August 2011 examiner stated that the Veteran's hypertension was diagnosed in 1989. However, the progress note from Medical Center dated on "2/10" indicates that treatment for hypertension began in September 1988. Also, the September 2005 VA primary care treatment note indicates that hypertension was diagnosed in 1986. Nevertheless, the fact remains that there is no credible evidence of any hypertension in service or for well over a decade after service. Also, the physicians who provided the August 2011 and October 2012 opinions did not explicitly acknowledge and discuss the Veteran's reports of a continuity of hypertension, skin, sinus, gastrointestinal, prostate, and knee symptomatology in the years since service in formulating the opinions. However, as explained above, any reports of a continuity of symptomatology are not deemed to be credible and an opinion based on such an inaccurate history would be inadequate. See Boggs v. West, 11 Vet. App. 334, 345 (1998); Kightly v. Brown, 6 Vet. App. 200, 205-06 (1994); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). The August 2011 and October 2012 opinions were otherwise based upon examinations of the Veteran and a review of his medical records and reported history and are accompanied by specific rationales that are not inconsistent with the evidence of record. Thus, these opinions are adequate and entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The Veteran has expressed his belief that his claimed disabilities are related to herbicide exposure in service and that his hearing loss and bilateral knee disability are due to acoustic and knee trauma in service. However, as a lay person, he can only comment as to symptoms and immediately-observable relationships. He lacks the expertise in this case, not involving such an immediately observable cause-and-effect relationship, to conclude that his current disabilities are related to any specific injuries in service (including exposure to herbicides, acoustic trauma, and knee trauma), as opposed to some other cause. Rather, it would require medical expertise to evaluate the disabilities, consider all the potential causes, and determine that one was a more likely cause than another. Hence, the Veteran's opinion on this question is not competent evidence. 38 C.F.R. § 3.159(a)(1), (2) (2013). Although the Veteran has received treatment from medical professionals for his claimed disabilities, none have attributed these disabilities to any disease or injury in service. Also, the only medical opinions of record indicate that no relationship exists between the Veteran's claimed disabilities and service. There is no other evidence of a relationship between the Veteran's current disabilities and service, and neither he nor his representative has alluded to the existence of any such evidence. Also, as discussed above, the record fails to demonstrate any credible evidence of a continuity of symptomatology. Thus, the preponderance of the evidence is against a finding that the Veteran's current hearing loss, hypertension, and skin, sinus, gastrointestinal, prostate, or bilateral knee disabilities are related to service, manifested in service, or manifested within a year after his September 1969 separation from service. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claims. The benefit-of-the-doubt doctrine is therefore not for application in this case and the claims of service connection for bilateral hearing loss, hypertension, and skin, sinus, gastrointestinal, prostate, and bilateral knee disabilities must be denied. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57. ORDER Entitlement to service connection for a headache disability is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for a skin disability is denied. Entitlement to service connection for a sinus disability is denied. Entitlement to service connection for a gastrointestinal disability is denied. Entitlement to service connection for a prostate disability is denied. Entitlement to service connection for a bilateral knee disability is denied. REMAND Once the Secretary undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, he must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In this case, the Veteran claims that he has current hip and back disabilities that are the result of participation in combat operations in Vietnam, including jumping out of helicopters. He was afforded VA examinations in August 2011 to assess the nature and etiology of his claimed bilateral hip and back disabilities and was diagnosed as having a right hip strain and a back strain. The physician who conducted the August 2011 VA examinations opined that the Veteran's current right hip and back disabilities were not likely ("less likely as not"/"less than 50/50 probability") related to service. The examiner reasoned that there was no evidence of any hip problems or back injury in service and that the Veteran had not sought care for his back. Also, there was no leg length discrepancy or gait disturbance that would account for back symptoms. The August 2011 opinions are insufficient because they are entirely based on a lack of objective clinical evidence of hip and back problems in service and they do not reflect consideration of the Veteran's reports of trauma in service associated with combat operations in Vietnam (including jumping from helicopters). A medical opinion based solely on the absence of documentation in the record is inadequate and a medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). VA regulations provide that where an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. 38 C.F.R. § 4.2 (2013); see 38 C.F.R. § 19.9 (2013). Where the Board makes a decision based on an examination report which does not contain sufficient detail, remand is required "for compliance with the duty to assist by conducting a thorough and contemporaneous medical examination." Goss v. Brown, 9 Vet. App. 109, 114 (1996); Stanton v. Brown, 5 Vet. App. 563, 569. Moreover, in an October 2012 rating decision the AMC granted service connection for PTSD and assigned an initial 10 percent disability rating, effective March 1, 2005. In November 2012, the Veteran submitted a notice of disagreement with respect to the initial rating assigned in this decision. A statement of the case has not been issued as to this issue. 38 U.S.C.A. § 7105(a) (West 2002). Thus, the Board is required to remand this issue for issuance of the necessary statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: 1. The AOJ shall issue a statement of the case as to the issue of entitlement to a higher initial rating for PTSD. This issue shall not be certified to the Board unless a sufficient substantive appeal is submitted. 2. Schedule the Veteran for a VA examination to determine the etiology of any current hip disability. All indicated tests and studies shall be conducted. The claims folder, including this remand and any relevant records contained in the Virtual VA system, must be sent to the examiner for review. For each current hip disability identified (i.e. any hip disability diagnosed since March 2005), the examiner shall indicate whether it is at least as likely as not (50 percent probability or more) that the current hip disability had its clinical onset in service, had its clinical onset in the year immediately following service (with respect to any arthritis), is related to the Veteran's presumed exposure to herbicides in service, is related to his combat duties in Vietnam (including jumping out of helicopters), or is otherwise the result of a disease or injury in service. In formulating the above opinion, the examiner shall specifically acknowledge and comment on all hip disabilities diagnosed since March 2005, the Veteran's presumed exposure to herbicides in service, and the Veteran's reported combat duties in service (including jumping out of helicopters). For purposes of the above opinion, the examiner shall presume that the Veteran's reports of his combat duties in service are accurate. The examiner must provide reasons for each opinion given. 3. Schedule the Veteran for a VA examination to determine the etiology of any current back disability. All indicated tests and studies shall be conducted. The claims folder, including this remand and any relevant records contained in the Virtual VA system, must be sent to the examiner for review. For each current back disability identified (i.e. any back disability diagnosed since March 2005), the examiner shall indicate whether it is at least as likely as not (50 percent probability or more) that the current back disability had its clinical onset in service, had its clinical onset in the year immediately following service (with respect to any arthritis), is related to the Veteran's presumed exposure to herbicides in service, is related to his combat duties in Vietnam (including jumping out of helicopters), or is otherwise the result of a disease or injury in service. In formulating the above opinion, the examiner shall specifically acknowledge and comment on all back disabilities diagnosed since March 2005, the Veteran's presumed exposure to herbicides in service, and his reported combat duties in service (including jumping out of helicopters). For purposes of the above opinion, the examiner shall presume that the Veteran's reports of his combat duties in service are accurate. The examiner must provide reasons for each opinion given. 4. If any benefit on appeal remains denied, the AOJ shall issue a supplemental statement of the case. After the Veteran is given an opportunity to respond, the case shall be returned to the Board. No action is required of the Veteran until he is notified by the AOJ; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2013). 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). _______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs