Citation Nr: 1331105 Decision Date: 09/26/13 Archive Date: 09/30/13 DOCKET NO. 05-17 857 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUE Entitlement to service connection for multinodular goiter with prominent nodule (claimed as thyroid nodule) associated with radiation exposure. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD T. Blake, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1961 to August 1964. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. In May 2005, the Veteran testified at a local hearing before a Decision Review Officer (DRO). In June 2006, the Veteran testified at a Board hearing held before the undersigned Veterans Law Judge in Hartford, Connecticut (Travel Board hearing). A copy of each hearing transcript is of record. While the Veteran requested a second Travel Board hearing in August 2013, the Board finds this request must be denied. The Veteran has already had one opportunity to testify at a Travel Board hearing for the claim on appeal and has not shown good cause to warrant a second hearing. See 38 C.F.R. §§ 20.703, 20.1304 (2013). In December 2006 and September 2009 decisions, the Board remanded the claim for additional development and adjudicative action. The case has been returned to the Board for further appellate review. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. FINDINGS OF FACT 1. All relevant evidence necessary to decide the Veteran's appeal has been obtained. 2. The Veteran was exposed to ionizing radiation while in service. 3. The Veteran's multinodular goiter with a predominant left non-malignant thyroid nodule is contemplated with endocrinopathies among the "chronic diseases" listed under 38 C.F.R. § 3.309(a), is a "radiogenic disease" listed under 38 C.F.R. § 3.311, but is not among the diseases specific to radiation-exposed veterans listed under 38 C.F.R. § 3.309(d). 4. Multinodular goiter with a predominant left non-malignant thyroid nodule did not manifest during service, or to a compensable degree within one year of separation from active service; symptoms have not been continuous since separation from active service; nor is it related to or incurred in service. CONCLUSION OF LAW The criteria for service connection for multinodular goiter with prominent nodule, associated with radiation exposure, have not been met. 38 U.S.C.A. §§ 1110, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.311 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. The Board finds that the VCAA notice requirements have been satisfied by a January 2004 letter. In this letter, VA informed the Veteran that in order to substantiate a claim for service connection, the evidence needed to show he had a current disability, a disease or injury in service, and evidence of a nexus between the post service disability and the disease or injury in service, which was usually shown by medical records and medical opinions. As to informing the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf, VA informed the Veteran it had to obtain any records held by any federal agency. This letter also informed the Veteran that on his behalf VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the letter told the Veteran that he could obtain private records himself and submit them to VA. 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 a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, a March 2006 letter included the type of evidence necessary to establish a disability rating and effective date. Although this notice was not issued before the July 2004 rating decision on appeal, the Veteran has not been prejudiced, as the claim was readjudicated in an April 2006 supplemental statement of the case (SSOC). See Prickett v. Nicholson, 20 Vet. App. 370 (2006). Regarding the duty to assist, VA must make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the claim on appeal, the evidence of record includes the Veteran's service treatment records, private treatment records, an internet article, Social Security Administration records, and an October 2005 VA examination report. The VA examiner reviewed the Veteran's claims file and medical history, recorded pertinent examination findings, and provided conclusions with supportive rationale. The Board notes that the VA examination report is probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In June 2006, the Veteran testified at a Travel Board hearing held before the undersigned Veterans Law Judge. Any deficiencies in development were addressed in the subsequent Board remands, as discussed below. See Bryant v. Shinseki, 23 Vet. App. 488 (2010) (holding that the Veterans Law Judge who conducts a hearing fulfill the duty to fully explain the issues and the duty to suggest the submission of evidence that may have been overlooked). Pursuant to the December 2006 Board remand, the RO requested a DD 1141 record of exposure from the Defense Threat Reduction Agency (DTRA). In a May 2008 response, the DTRA stated that the Veteran's radiation exposure was not under the purview of the DTRA and suggested that the RO contact the Proponency Office for Preventative Medicine. The RO contacted the Proponency Office for Preventative Medicine and, again, received a negative reply regarding any records for the Veteran. The RO also requested records pertaining to the Veteran's alleged radiation exposure from the Modern Military Records and received a negative response. However, the response directed the RO to contact the U. S. Army Research, Development and Engineering Command. Although the RO sent a letter to the U. S. Army Research, Development and Engineering Command in April 2009, it does not appear that there was a response to this request. The RO failed to substantially comply with the remand instructions, and the Board remanded the claim again in September 2009. See also Dyment v. West, 13 Vet. App. 141 (1999) (a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where there is substantial compliance with the Board's remand instructions). Pursuant to the September 2009 remand instructions, the RO made an additional request to the U. S. Army Research, Development and Engineering Command for any records that would describe the activities of the 183rd Chemical Platoon and a test group called "Sandy Patch" for the time period of late 1963 to early 1964. A May 2010 response noted information related to the Veteran or his unit after 1946 is not available. The U. S. Army Public Health Command attempted to provide a dose estimate in August 2010. In May 2013, an opinion and dose estimate was provided on behalf of the Under Secretary for Health, then the Director of Compensation Service rendered an opinion a few days later. All responses were obtained and associated with the claims file. The Board concludes that the RO's responses, as noted above, were adequate and substantially complied with the September 2009 remand instructions. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim on appeal. The evidence of record provides sufficient information to adequately evaluate the claim, all obtainable evidence identified by the Veteran relative to the claim has been obtained and associated with the claims file, and the Board is not aware of the existence of any additional relevant evidence which was not obtained. Therefore, no further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Service Connection Laws and Regulations Under 38 C.F.R. § 3.303(a), service connection means that the facts, as shown by the evidence, establishes that a particular injury or disease was incurred coincident with service. It may be granting by affirmatively showing inception or aggravation during service. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection can also be established through application of statutory presumptions, including for chronic diseases, such as endocrinopathies, when manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2013). Under 38 C.F.R. § 3.303(b), if a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. When the fact of chronicity in service (or during the presumptive period) is not adequately supported, then a showing of continuity after discharge is required to support the claim. The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative route to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this case, the Board finds that multinodular goiter with a predominant left non-malignant thyroid nodule is contemplated with endocrinopathies among the "chronic diseases" listed under 38 C.F.R. § 3.309(a) (the term endocrinopathies contemplates thyroid diseases). Thus, 38 C.F.R. § 3.303(b) applies and the claim will be discussed below on a presumptive basis as due to a chronic disease. Certain disabilities, specific to radiation-exposed veterans, that are claimed to be attributable to exposure to ionizing radiation during service may be service connected on a presumptive basis. See 38 U.S.C.A. § 1112(c); 38 C.F.R. § 3.309(d); Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 71 (1997). However, the Board finds that multinodular goiter with a predominant left non-malignant thyroid nodule is not among the diseases specific to radiation-exposed veterans listed under 38 C.F.R. § 3.309(d). Thus, service connection on a presumptive basis as due to a disease specific to radiation-exposed veterans is not available in this case. Service connection for "radiogenic diseases" as due to exposure to ionizing radiation provides special procedures for evidentiary development and adjudication of a claim under 38 C.F.R. § 3.311. A "radiogenic disease" means a disease that may be induced by ionizing radiation, and includes non-malignant thyroid nodule disease. 38 C.F.R. § 3.311(b)(2)(xvii) (2013). Except as otherwise provided, the radiogenic disease must become manifest five years or more after exposure. 38 C.F.R. § 3.311(b)(5)(1)(iv). When a claimant contends that a radiogenic disease, which first became manifest after service though not to a compensable degree within any other applicable presumptive period, is the result of exposure to ionizing radiation in service, an assessment is made as to the size and nature of the radiation dose. 38 C.F.R. § 3.311(a). In this case, the Board finds that non-malignant thyroid nodule disease is a "radiogenic disease" listed under 38 C.F.R. § 3.311. Thus, the proper development and adjudication for the claim on appeal as due to exposure to ionizing radiation will be discussed below under 38 C.F.R. § 3.311. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In making all determinations, the Board must consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. See Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Analysis of Service Connection The Veteran contends that the multinodular goiter with left thyroid nodule he developed is due to his exposure to ionizing radiation in service while he was stationed at Fort Benning, Georgia. In a January 2004 statement in support of his claim, the Veteran reported that: "During this time [1962-1964] [he] was constantly exposed to radiation during testing and calibrating of radiological equipment in the U. S. Army." The Veteran also testified at the June 2006 Board hearing that when assigned to the 183rd Chemical Platoon at Fort Benning, Georgia, he was assigned to a test group called "Sandy Patch," which tested new radiation detection equipment. It was during this time that he states he wore badges to monitor his radiation exposure. At the outset, the Board finds the criteria for a current disability has been met. Review of private treatment records document the initial onset of multinodular goiter with a predominant left non-malignant thyroid nodule in 2002. A September 2002 private ultrasound report of the thyroid revealed findings of multinodular goiter with interval increase in size of complex nodule located within the mid left lobe. Subsequently, private treatment records note assessments of left thyroid nodule (November 2002, November 2003, and January 2004) and hypothyroidism (September 2002, November 2002, and June 2004). Following the October 2005 VA examination, the examiner concluded the "Veteran has stable multinodular goiter with a prominent left thyroid nodule, without evidence of malignancy confirmed by the [Fine Needle Aspiration biopsy] 2002. This is a form of non-malignant thyroid nodule. As a result, he is hypothyroid and on replacement therapy." In accordance with 38 C.F.R. § 3.311, the RO requested a radiation dose estimate. In August 2010, a response from the U. S. Army Public Health Command noted the following: Our investigation found that throughout the years, personnel radiation safety practices employed during Chemical, Biological and Radiological (CBR) training courses have not varied such that practices today are very similar to that of [the Veteran's] working conditions for radiological training in the 1960s. Maintaining low radiation doses has been a first principle of radiation safety since the first recommendations for radiation safety were issued in June 1915. Unfortunately, the records that we received . . . did not provide sufficient information for us to conclusively establish [the Veteran's] specific work activities around radiation or radioactive materials during his documented 2-week CBR training and we were unable to obtain records that would corroborate the Veteran's claim under 38 C.F.R. § 3.311. Due to the lack of information about [the Veteran's] specific duties while serving in the military, we were unable to perform a well-founded dose reconstruction. However, we expect that any student's upper bound occupational radiation dose during a standard 2-week CBR training was minimal, i.e., less than the current standard of 100 mrem/year. In a May 2013 memorandum, the Director, Post 9-11 Era Environmental Health Program for the Under Secretary for Health, assigned a total dose of 0.3 rem for the Veteran's three years of service (1961 to 1964). After noting the Health Physics Society Position Statement PS010-1, Radiation Risk in Perspective, revised in August of 2004, it was concluded that "[s]ince the Veteran's radiation dose did not exceed 5 rem in one year or 10 rem in a lifetime, it is our opinion that it is unlikely that the Veteran's multinodular goiter (non-malignant thyroid nodular disease) can be attributed to radiation exposure while in military service." A few days later, the Director of Compensation Service noted review of the claims folder and May 2013 memorandum, and concluded "there is no reasonable possibility that the [V]eteran's multinodular goiter (non-malignant thyroid nodular disease) can be attributed to the occupational exposure to ionizing radiation as during military service." The Board notes that this opinion is the only competent opinion that is based on the current individualized dose estimate. 38 C.F.R. § 3.311(a)(1). The Board acknowledges the evidentiary record also contains a private medical statement from Dr. T. G. dated November 2003. He noted "[the Veteran] has developed a thyroid nodule. He reports exposure to radiation while in the service. Patients with radiation exposure have a higher occurrence of thyroid nodules and the percent of these that are a thyroid cancer is higher than the general population." The Board finds this statement lacks probative value because is a general statement and not actually rendering a nexus opinion pertinent to the Veteran's claim on appeal. Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). As a result, the Board finds that the November 2003 private medical statement lacks probative value for this claim on appeal due to the absence of an opinion regarding a link between the Veteran's thyroid disorder and ionizing radiation exposure during active service. In addition, the October 2005 VA examiner rendered the following medical opinion after a review of the claims file and physical examination of the Veteran. Based on the medical records, his [service treatment records], and 'very little if any radioactive exposure' he has no thyroid malignancy. There is no objective evidence of his overt exposure to radiation in his military records and therefore, his multinodular goiter is not likely related to his service. In general there is a dose-response relationship with radiation exposure and development of thyroid cancer and benign masses. However, if there is definite objective evidence to confirm he wore a radiation badge and had high levels of radiation, then it can be concluded that his [multinodular goiter] is likely the result of this exposure. While the VA examiner provided sufficient rationale, the Board finds this medical opinion is based on an inaccurate factual history. As subsequently established, the Veteran has documented exposure to ionizing radiation during service. However, the examiner provides a speculative conclusion for "if there is definite objective evidence to confirm the Veteran wore a radiation badge and had high levels of radiation." As such, the October 2005 VA medical opinion lacks probative value. A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). The Board also acknowledges the Veteran's submission in May 2005 of an article titled "21 Cancers Linked to Radiation Exposure." The Court has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998). In this case, the Board finds the identified article is not relevant to the claim on appeal because, as discussed above, the fact remains that the Veteran has a diagnosis of non-malignant thyroid nodule, and not thyroid cancer. In light of the above discussion, the Board finds that service connection is not warranted on a direct basis or as due to ionizing radiation under the procedures as set forth in 38 C.F.R. § 3.311. Next, the Board considers whether service connection for multinodular goiter with a predominant left non-malignant thyroid nodule is warranted on a presumptive basis for a "chronic disease" because this claimed disorder is contemplated with endocrinopathies under 38 C.F.R. § 3.309(a). The Veteran was initially diagnosed with multinodular goiter with a predominant left non-malignant thyroid nodule in 2002. As such, the Board finds that the evidentiary record does not demonstrate this current disability manifested during service or to a compensable degree within one year of separation from active service, nor have symptoms been continuous since separation from active service. Moreover, neither the Veteran nor his representative contends that symptoms of multinodular goiter with a predominant left non-malignant thyroid nodule have been continuous since discharge. Therefore, service connection for multinodular goiter with prominent nodule, on a presumptive basis as a "chronic disease," is not available in this case. See 38 C.F.R. §§ 3.307, 3.309(a). The Federal Circuit has held that when a claimed disorder is not included as a presumptive disorder, direct service connection may nevertheless be established by evidence demonstrating that the disease was in fact "incurred" during service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Thus, the Board considers whether service connection is warranted for multinodular goiter with prominent nodule on a direct basis. As noted above, the criteria for a current disability has been met, evidenced by private treatment records and October 2005 VA examination report which document his diagnosis of multinodular goiter with a predominant left non-malignant thyroid nodule. With regard to whether an in-service incurrence or aggravation of a disease or injury occurred, review of the Veteran's service treatment records are silent as to any complaints, treatment, or diagnosis pertaining to the claimed disability. Nevertheless, as discussed above, the Board finds the Veteran was exposed to ionizing radiation while in service. In light of the Veteran's current disability and exposure to ionizing radiation while in service, the Board finds the evidence does not show the disability is either related to service, to include his ionizing radiation exposure, or incurred in service. As discussed above, the May 2013 opinion from the Director of Compensation Service is the only competent opinion of record that is based on the current individualized dose estimate. Specifically, it was concluded that "there is no reasonable possibility that the [V]eteran's multinodular goiter (non-malignant thyroid nodular disease) can be attributed to the occupational exposure to ionizing radiation as during military service." Moreover, the initial onset of the Veteran's disability was in 2002, which is approximately 38 years after separation from service, and demonstrates a post-service incurrence. Regarding the Veteran's statements, as noted above, asserting his current disability is due to exposure to ionizing radiation during service, the Board recognizes that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson, 581 F.3d at 1316 (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because he was a layperson, conflicts with Jandreau). However, in this case, the cause of the Veteran's multinodular goiter with prominent nodule involves a complex medical etiological question because it deals with the origin and progression of this disability. The Veteran is competent to relate symptoms of this disability that he experienced at any time, but is not competent to opine on whether there is a link between the current disability and service. Such diagnosis and opinion as to nexus requires specific medical knowledge and training. See Rucker, 10 Vet. App. at 74 (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). Therefore, the Board finds that service connection for the claim on appeal is not warranted on a direct basis. See 38 C.F.R. § 3.303(a), (d). For these reasons and bases discussed above, the Board finds that a preponderance of the evidence is against the claim for service connection for multinodular goiter with prominent nodule, associated with radiation exposure, on presumptive and direct bases. As a result, this claim must be denied and the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for multinodular goiter with prominent nodule (claimed as thyroid nodule) associated with radiation exposure is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs