Citation Nr: 1331311 Decision Date: 09/27/13 Archive Date: 10/01/13 DOCKET NO. 07-01 322 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for vision problems. 2. Entitlement to service connection for basal cell carcinoma, to include as due to exposure to ionizing radiation. 3. Entitlement to service connection for a left elbow disability, to include epicondylitis. 4. Entitlement to service connection for a left ankle disability. 5. Entitlement to service connection for a bilateral hip disability, to include as secondary to osteoarthritis of the thoracolumbar spine. 6. Entitlement to service connection for digestive problems, to include diverticulitis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. P. Simpson, Counsel INTRODUCTION The Veteran served on active duty from August 1959 to August 1991. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a September 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This case was previously before the Board in August 2009. At that time, there were additional service-connection issues pending, such as chronic ear condition, facial pain due to shrapnel on the nerve, chronic respiratory disability, a low back disability, a right elbow disability, a right ankle disability, and hypertension. The Board remanded these issues and issues (1) through (6) on the title page for additional development and adjudicative action. In an April 2013 rating decision, the RO granted service connection for the above-listed issues. Thus, the issues of entitlement to service connection for these disabilities are no longer pending. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (notice of disagreement following denial of a particular claim for service connection cannot be construed as a notice of disagreement following the granting of service connection for that claim). The Board has reviewed the Veteran's claims file and the record maintained in the Virtual VA paperless claims processing system. In a November 2006 rating decision, the RO granted service connection for multiple disabilities, such as patellofemoral syndrome of the bilateral knees, instability of the bilateral knees, status post left inguinal hernia, bilateral hearing loss, seborrheic keratosis, episodic vertigo, and tinnitus. In August 2011 the Veteran submitted a VA Form 21-4138, Statement in Support of Claim, wherein he requested earlier effective dates for the award of service connection for these disabilities. Such statement from the Veteran was not a timely notice of disagreement, as it was not received within one year of the November 2006 rating decision. (The Veteran also did not characterize the submission as a notice of disagreement.) The RO properly issued a rating decision in May 2013 addressing the claims of entitlement to earlier effective dates for the award of service connection for these disabilities. There has been no notice of disagreement associated with the claims file or in Virtual VA in response to this rating decision. Thus, these issues are not part of the current appeal. The issues of entitlement to service connection for digestive problems, to include diverticulitis, and a bilateral hip disability, to include as secondary to osteoarthritis of the thoracolumbar spine, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran has residual vision problems as a result of the metal foreign body that had gotten into his left eye during service and been removed; the Veteran's current visual problems have been attributed to refractive error, which is not a disability under the law. 2. The preponderance of the evidence is against a finding that the Veteran has basal cell carcinoma. 3. The preponderance of the evidence is against a finding that a left elbow disability, to include epicondylitis, is attributable to service. 4. The preponderance of the evidence is against a finding that a left ankle disability is attributable to service. CONCLUSIONS OF LAW 1. Vision problems were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.9 (2013). 2. Basal cell carcinoma, to include as due to exposure to ionizing radiation, was not incurred in or aggravated by service and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.311 (2013). 3. A left elbow disability, to include epicondylitis, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2013). 4. A left ankle disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013), 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify a claimant of the evidence that is necessary, or would be of assistance, in substantiating his or her claims, and to provide notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006). The notice required by the VCAA can be divided into three elements. Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Further, VA must review the information and the evidence presented with the claim and provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the instant case, notice was provided to the Veteran in December 2004, prior to the initial adjudication of his claims in September 2005. The Veteran was told it was his responsibility to support the claims with appropriate evidence, and he was provided with his and VA's responsibilities for obtaining evidence. The Veteran was provided with the Dingess elements of VCAA notice with respect to the claims in January 2010 correspondence. The claims were subsequently readjudicated after providing the Veteran with an opportunity to respond to the notice. Any timing deficiency was thereby cured. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (holding timing deficiencies in VCAA notice are cured by readjudication in a supplemental statement of the case). As such, the Board finds that VA satisfied its duty to notify under the VCAA in accordance with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1). In next addressing whether VA satisfied its duty to assist the Veteran with respect to his claims, the Board concludes that pertinent records from all relevant sources identified by him, and for which he authorized VA to request, have been associated with the claims file. 38 U.S.C.A. § 5103A. The Veteran's service treatment records and VA treatment records are in the claims file. VA is only required to make reasonable efforts to obtain relevant records that the Veteran has adequately identified. 38 U.S.C.A. § 5103A(b)(1) (West 2002). The Veteran identified military medical facility records, and these records have been obtained. Not all of these records (military medical facility records) were obtained at the time the case was before the Board in August 2009. Part of the basis for the 2009 remand was to obtain additional military medical facility records, and these additional records were received and associated with the claims file. Thus, VA has made every reasonable effort to obtain all records relevant to the Veteran's claims. Additionally, part of the basis for the August 2009 remand was to have the RO follow the steps in adjudicating disabilities that involve allegations of radiation exposure. In the remand, the Board noted that this could involve obtaining a radiation dose estimate from the Defense Threat Reconstruction Agency and possible referral in compliance with the provisions of 38 C.F.R. § 3.311 (2013). The RO did not follow these steps, and the Board finds that such steps were not required, as the evidence shows that the Veteran has not been diagnosed with basal cell carcinoma during the appeal period or at any time during service, which will be discussed in more detail below. Thus, while the Board's remand instructions included further development involving obtaining information pertaining to possible radiation exposure, such development was not necessary without evidence of a disability that results from radiation exposure. The Veteran has not been prejudiced by the lack of development, and the Board finds there was substantial compliance with the Board's remand instructions on this issue. VA is required to provide an examination 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) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). 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. The threshold for finding a link between current disability and service is low. Id.; Locklear v. Nicholson, 20 Vet. App. 410 (2006). The Veteran was provided with examinations with respect to his claims in August and September 2006. In August 2009, when the case was before the Board, it found that such examinations were inadequate because the claims file had not been reviewed, and the medical opinions had no rationales to support the opinions. It then remanded all six claims to have the Veteran provided with new examinations with adequate medical opinions (ones based on review of the claims file with rationales for such opinions). The Veteran was provided with new examinations in March 2013. However, a visual examination was not provided, as requested by the Board. The Board finds that the Veteran has not been prejudiced by this and thus a remand for a visual examination is not necessary, which is explained below. Specifically, in reviewing the claims file again, the Board finds that it erred when it included the August 2006 VA visual examination as part of the conclusion that the examination reports were inadequate. Upon further review, the Board concludes that the examiner did, in fact, review the claims file and acknowledged the eye injury the Veteran sustained in service, where a metal foreign body was removed from the left eye. The examiner also provided a medical opinion, which included consideration of the inservice injury. Therefore, the Board finds that the August 2006 VA examination was, in fact, adequate. This is the basis for why the Board concludes that the Veteran has not been prejudiced by the failure to provide the Veteran with a new examination following the August 2009 remand. In the August 2009 remand, the Board requested that the Veteran be provided new examinations for all the disabilities listed on the title page. As addressed above, a visual examination was not needed. The Veteran was provided with VA examinations for the other disabilities on appeal; however, as will be addressed in the remand portion of the decision, the VA medical opinions with respect to the claims for service connection for digestive problems and a bilateral hip disability are inadequate, and these claims will be remanded for further development. As to the other issues, the examiner reviewed the claims file and provided medical opinions with rationales to support the opinions. For these reasons, the Board finds there was substantial compliance with the Board's remand instructions. On this note, the inadequacies associated with the September 2006 VA examination report are harmless given that VA thereafter obtained a thorough and adequately supported opinions in March 2013. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). Based upon the foregoing, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A or 38 C.F.R. § 3.159, and that the Veteran will not be prejudiced as a result of the Board's adjudication of the claims being decided herein. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2013). Generally, in order to establish service connection for a claimed disorder, the following must be shown: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board now turns to the merits of the Veteran's claims. Vision problems The Veteran contends that he has vision problems that began during service, which he attributes to a metal foreign body that had gotten into his left eye and been removed. He has not been specific in why he believes that the foreign body in the left eye has caused the current vision problems, and has not precisely described which of current vision problems he attributes to the inservice injury. For example, in a January 2005 VA Form 21-4138, Statement in Support of Claim, the Veteran wrote his vision problems "[r]esulted from scar tissue and rust residue in eye after a piece of steel stuck in my eye." After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against the grant of service connection for vision problems. The service treatment records show that in February 1962, the Veteran had small flecks of foreign bodies removed from the left eye. The examiner described it as metallic foreign bodies and that there was some remaining "rust rings." Four days later, he was seen again with most of the foreign material removed. Three days later, the examiner noted the Veteran's vision was improving subjectively, but that there was still some stain left on the cornea. He was seen in March 1962, when the examiner noted there was still a small stain on the cornea. By April 1962, the Veteran denied any eye symptoms. He reported having a blurred spot if he looked a certain way, but otherwise had no visual symptoms. The examiner found a small corneal scar where the foreign body had been lodged. The examiner noted no rust could be identified. Following the removal of the foreign body in 1962, there is one finding of "early conjunctivitis" involving the left eye in June 1987. The examiner noted specifically that there was "no foreign body [in] either eye." Other than this one report more than 20 years after the foreign body was removed from the left eye, there is a lack of evidence of continuing eye symptoms. For example, in multiple Reports of Medical Examinations from February 1966 to May 1986 (a period of 20 years), ophthalmoscopic evaluations were all normal. In Reports of Medical History completed by the Veteran in February 1966, March 1967, April 1968, February 1979, May 1981 and January 1982, he specifically denied ever having or having then eye trouble. Thus, 20 years after the foreign body was removed, the Veteran was denying having eye trouble, other than having to wear glasses. Following service discharge, in March 1992, the Veteran was seen for a routine glaucoma examination. In the reason for the request for the eye examination, the examiner wrote, "No previous eye problems." Examination of the eyes was within normal limits. In December 1996, the Veteran received a prescription for eye glasses, and the examiner noted the eyes were free of pathology. In March 2001, the Veteran was seen by an optometrist. The Veteran reported he had had two instances of diplopia. The examiner examined the Veteran and found no pathology for either eye. He concluded he could find "no ocular source for the occasional diplopia." Thus, 10 years following service discharge, a medical professional found a lack of eye pathology. When the Veteran underwent the VA examination in August 2006, the examiner noted that the Veteran had a history of a piece of metal in the left eye while in service. He stated the Veteran reported occasions when his vision was temporarily obscured in the left eye with no additional reported eye injury, surgery or disease. The examiner concluded that the Veteran's ocular health was within normal limits with no evidence of permanent damage from the foreign body in the left eye. He added that there was no etiology determined for reported intermittent pain and blurriness of vision. A September 2006 military medical facility record shows the Veteran was seen for follow-up related to his visit to the emergency room, which did not involve the eyes. The examiner examined the Veteran's eyes, including extraocular movements, pupils, external eye, and sclera, and there were no positive clinical findings. A February 2007 military medical facility record shows that the examiner reviewed the Veteran's systems and wrote, "No eye symptoms." A February 2010 Neurological Consultation shows that the Veteran was seen with a longstanding history of back pain. The examiner examined the Veteran's eyes and wrote that there were no gross abnormalities in visual acuity, visual fields were full to confrontation, discs were flat and fundi were benign, no afferent defect was present, extraocular movements were full and conjugate and pupils were equally round and reactive to light directly and consensually. Thus, the examiner made no positive findings pertaining to the eyes. A May 2010 military medical facility record shows the examiner examined the Veteran's eyes, including the pupils, external eye, and sclera, and there were no positive clinical findings. In January 2012, the Veteran was seen by VA with complaints of waking up with "crusty matter" over the left eyelid the prior morning. He stated his eye was painful all day and vision seemed to have a film or a fog over the left eye. The Veteran reported the left eye felt better and that he had virtually no pain at this time and no visual disturbances. The examiner stated the left eye did not appear swollen and that there was minimal redness below the eye. The examiner discussed this with the Veteran's primary care physician, who also examined the Veteran. The examiner wrote that the Veteran was informed there did not appear to be an acute infection or concern at this time. While there is one instance of "crusty matter" shown in January 2012, the preponderance of the evidence is against a finding that the Veteran has visual problems due to the foreign body that was removed from his left eye during service or any other eye pathology, other than needing glasses. Other than the January 2012 incident, the Veteran has not reported any symptoms limited to the left eye only. Rather, his symptoms have involved both eyes, but each time, there was no pathology, other than presbyopia and hyperopia, which are refractive errors of the eye, and are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9. The Veteran is competent to report symptoms associated with his eyes. However, following the removal of the foreign body in 1962, he specifically denied eye problems for the next 20 years while still in service. When he was being treated for his eyes following service discharge, he was not alleging continuing problems with his eyes due to the foreign body. He would report such incident for past medical history purposes, but he was not alleging to medical professionals that he was having symptoms due to the inservice incident. As the Veteran does not allege continuity of symptomatology, and examining clinicians have not identified any residuals of the inservice injury, the Board finds that the preponderance of the evidence is against a finding that the Veteran has any residual disability due to the foreign body that was removed from his left eye decades ago, nor any other eye disability that had its onset during service. Because the preponderance of the evidence is against the claim, there is no doubt to be resolved. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Basal cell carcinoma, to include as due to exposure to ionizing radiation The Veteran alleges that he developed basal cell carcinoma from exposure to radiation during service. In the August 2006 VA examination report, the examiner wrote that the Veteran reported his father had died from malignant melanoma and that he was diagnosed with "something and has been on annual surveillance for his skin where they freeze off these little areas called 'sun spots.'" The examiner also wrote that the Veteran reported having a right scalp basal cell carcinoma removed without sequelae three to four years ago. In the March 2013 VA examination report, the examiner wrote that the Veteran had basal cell carcinoma moved from his scalp while in service in 1987. After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against the grant of service connection for basal cell carcinoma, to include as being due to exposure to ionizing radiation. Specifically, the Board finds there is no competent evidence in the claims file that the Veteran has basal cell carcinoma, to include while he was in service. As shown in the above paragraph, the Veteran has alleged to two different VA examiners that he was diagnosed with basal cell carcinoma in service in 1987 and in approximately 2002 or 2003 (three to four years ago from August 2006). These allegations by the Veteran are not substantiated by the evidence of record. The evidence does reflect that he had skin problems in service and following service discharge, but at no time in the service treatment records or during the current appeal is there evidence corroborating the Veteran's report of a diagnosis of basal cell carcinoma. The Board will address both the service records and the post-service records separately. The Veteran's service treatment records show that in April 1982 he had three lesions removed from the skin on the right back, left back, and left thigh. The April 1982 pathology report shows the right back lesion was hypertrophic seborrheic keratosis, the left back lesion was intradermal nevus, and the left thigh lesion was fibroepithelial polyp. Thus, none of these lesions were found to be basal cell carcinoma. The Board was unable to find a service treatment record that addressed removal of a skin lesion on the scalp. The Veteran had consistently reported "yes" to ever having or having then "tumor, growth, cyst or cancer" in multiple Reports of Medical History, however, he would specify that this involved the removal of a cyst on the right side of his neck when he was 15 years old, which was prior to the Veteran's entrance into service. The Veteran was very consistent in reporting this medical history. The Veteran is competent to report having skin issues in service, which is substantiated in the service treatment records, however, he is not competent to state that the his skin issue involved skin cancer, as that 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 Board notes that service connection for seborrheic keratosis has been awarded. See November 2006 rating decision. Following service, there is also a lack of evidence of basal cell carcinoma. There is a February 2001 private medical record where the examiner wrote that the Veteran complained of "skin cancer." A separate February 2001 private medical record shows that the Veteran was seen for follow-up of an oozing skin lesion on the right side of his forehead. The assessment was skin lesion. A private medical record dated five days later shows that the examiner entered an assessment of pigmented macular lesion and that the Veteran would watch and return if necessary. The Board notes that these private medical record are dated prior to the Veteran's November 2004 application for benefits, wherein he alleged having basal cell carcinoma. Medical records dated after November 2004 are silent for any skin problems or diagnoses. In fact, the evidence shows that the Veteran denied having any skin problems during this time period that related to service, to include radiation exposure. For example, a September 2006 military medical facility record shows the examiner wrote, "Skin symptoms: no skin symptoms and no skin lesions." (Bold in original.) A March 2007 military medical facility record shows "Skin symptoms: No skin symptoms. Skin lesion(s); Small crusted areas on back and [right] forearm from tick bites." (Bold in original.) In February 2008, June 2008, April 2009, November 2009 and February 2010 military medical facility records, the examiner wrote the Veteran had no skin symptoms each time. In the August 2006 VA examination report, the examiner noted a history of basal cell carcinoma, which was based upon the Veteran having reported that he had such diagnosis previously. However, at that time, the examiner did not diagnose active basal cell carcinoma. When the Veteran was examined in March 2013, the examiner also diagnosed basal cell carcinoma based upon the Veteran's medical history. However, following the examination, the examiner wrote, "I am unable to confirm basal cell carcinoma of scalp in his C-file." Although the Veteran is competent to report having been told of a diagnosis of basal cell carcinoma, his assertions in this regard are not credible, given that the evidence of record fails to corroborate his assertions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran reported two, different stories when examined in August 2006 and March 2013. In August 2006, he reported having basal cell carcinoma three to four years ago, which would place such diagnosis in approximately 2002 or 2003. In March 2013, he stated that he had basal cell carcinoma in 1987. In the VA Form 21-526, Veteran's Application for Compensation or Pension, received in November 2004, the Veteran reported the basal cell carcinoma in 1982. As the service treatment records show, in 1982, the skin lesions removed from the back and thigh were not found to be basal cell carcinoma. While there is a February 2001 notation by the examiner that the Veteran complained of "skin cancer," there is no documentation of a diagnosis of basal cell carcinoma. To reiterate, the Veteran is competent to report having skin lesions removed from his body, but there is no medical documentation that any skin lesion the Veteran has had involved skin cancer, and the Veteran is not competent to state that a skin lesion he had was skin cancer. Such an objective finding is usually based upon a pathology report. Additionally, no medical professional has confirmed a diagnosis of basal cell carcinoma. As such, there is no evidence of a diagnosis of basal cell carcinoma either in service or following service, including during any period of the pendency of the appeal. As such, the Board finds that service connection for basal cell carcinoma cannot be granted because of the lack of evidence of a current disability. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board recognizes that the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, where, as here, the overall evidence of record fails to support a diagnosis of the claimed disability, that holding is of no advantage. The preponderance of the evidence is against the claim, and there is no doubt to be resolved. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 53-56. Left elbow and left ankle disabilities In the Veteran's November 2004 claim, he alleged having, "Recurring joint prob[lems] in elbow, ankle, knees, hip." See VA Form 21-526 at Part B. The Veteran has not provided more specific statements for why he believes service connection for left elbow and ankle disabilities is warranted. After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against the grant of service connection for left elbow and left ankle disabilities. The Board notes that the service treatment records show multiple complaints of right elbow and right ankle pain. For example, in 1987, the Veteran was seen on multiple occasions involving pain in the right ankle. A May 1987 record shows that the Veteran reported his right ankle was sore and denied any trauma or injury. An X-ray was taken at that time, which showed a possible old avulsive injury. In January 1991, the Veteran was seen with a tender right elbow for six to eight weeks. The right elbow complaints continued into April 1991 and July 1991. However, what is missing in the service treatment records are complaints involving the left ankle and the left elbow. Given that the service treatment records reflect complaints regarding the right elbow and right ankle, the Board concludes that such symptoms were limited to the right side of the Veteran's body. The Board finds as fact that had the Veteran been having pain in the left elbow and the left ankle, it would have been documented in the service treatment records, such as the times he complained of right ankle and right elbow pain. See Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) ("[T]he Board may use silence in the [service medical records] as contradictory evidence only if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the [service medical records]." citing to FED.R.EVID. 803(7) (the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded).). Here, the Veteran made very specific complaints that he had right elbow pain and right ankle pain, which examiners documented in the service treatment records. If he was experiencing pain in both ankles and both elbows, the Board finds it is reasonable for it to conclude that he would have complained of pain on the left side as well. The Board may make this conclusion if it finds that the service treatment records are complete. The Board finds that the service treatment records are complete. The Veteran has not provided any additional facts during the appeal to explain why he believes that service connection for the left ankle and left elbow is warranted or if he sustained injuries to those areas. When the Veteran was examined in March 2013, the VA examiner noticed the same facts as the Board has found as to both disabilities (that the Veteran reported problems on the right side but not the left side during service). The examiner wrote that because the right ankle injury was documented in the service treatment records, it was at least as likely as not that the current right ankle strain was related to service; however, because there was no showing of a left ankle disability in service, it was less likely as not that the left ankle strain was related to service. The examiner wrote the same conclusion as to the right and left elbows (finding that the right elbow was documented in service and thus that it was at least as likely as not that it was related to service and that there was no evidence of left elbow problems in service and it was therefore less likely as not that the Veteran developed a left elbow disability in service). The Board accords these opinions high probative value, as the examiner made the finding based upon the medical history the Board finds is accurate (no complaints of left ankle or left elbow pain in service). Again, the Veteran has not provided more detailed allegations for why he believes that he has left ankle and left elbow disabilities due to service. Although the Veteran is competent to describe current disabilities of the left elbow and left ankle, without providing an explanation as to why he believes his current symptoms, whatever they may be, are related to injuries sustained in service, the Board is not capable of addressing the competence of his statements, except to note that there is no evidence more probative than the March 2013 medical opinion. Accordingly, the Board finds the preponderance of the evidence is against the claims for service connection for left elbow and left ankle disabilities, and there is no doubt to be resolved. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 53-56. ORDER Entitlement to service connection for vision problems is denied. Entitlement to service connection for basal cell carcinoma, to include as due to exposure to ionizing radiation, is denied. Entitlement to service connection for a left elbow disability, to include epicondylitis, is denied. Entitlement to service connection for a left ankle disability, to include strain, is denied. REMAND The Board finds that additional development is warranted. The Board remanded the claims for service connection for a bilateral hip disability, to include as secondary to a low back disability (which is now service connected) and for digestive problems, to include diverticulitis, to provide the Veteran with VA examinations and obtain medical opinions regarding the likely etiology of the disabilities. In reviewing the examination reports for these two disabilities, the Board finds that the examinations were inadequate. As to the claim for service connection for a bilateral hip disability, the Board asked the examiner to address whether the Veteran's current bilateral hip disability had its onset during service, was in any other way causally related to active service or was proximately due to or aggravated by the Veteran's back disability. In the examination report, the examiner wrote the following: Because there is no evidence of a hip problem found in his [claims] file and there is no evidence in the medical literature that osteoarthritis of the lumbar [spine] can cause bilateral hip osteoarthritis[, t]herefore, it is less likely as not that bilateral hip arthritis is service related. The problem with the medical opinion is that it is unclear what the examiner meant when he said there was no evidence of a hip problem found in the claims file. The Veteran has complained of hip problems during the appeal, and was diagnosed with bilateral hip arthritis in the March 2013 VA examination. So there is evidence of a bilateral hip disability in the claims file. It is possible the examiner was addressing the service treatment records when he said there was no evidence of a hip problem, as the service treatment records are silent for complaints of hip pain, either right or left. Regardless, the examiner's opinion did not address whether it is at least as likely as not that the service-connected osteoarthritis of the thoracolumbar spine aggravated the bilateral hip disability. Thus, the case must be remanded for the examiner to clarify the medical opinion. As to the claim for service connection for digestive problems, to include diverticulosis, the examiner wrote, "Because there is no evidence of a [gastrointestinal] disorder while the [V]eteran was on active duty[,] it is less likely as not that diverticulitis is service related." However, the service treatment records show some complaints of gastrointestinal symptoms during service and thus the medical opinion appears to be based upon an inaccurate factual premise. The Board will seek clarification of this medical opinion. Accordingly, the case is REMANDED for the following action: 1. Forward the claims file to the examiner who performed the March 2013 VA examinations involving the bilateral hip disability and a gastrointestinal disorder. If the examiner needs to perform a physical examination to address the questions below, such should be scheduled. Inform the examiner of the following: i. As to the bilateral hip disabilities, in the March 2013 VA examination report pertaining to the bilateral hips, the examiner concluded, "Because there is no evidence of a hip problem found in [the Veteran's] C-file and there is no evidence in the medical literature that osteoarthritis of the lumbar [spine] can cause bilateral hip osteoarthritis[, t]herefore it is less likely as not that bilateral hip arthritis is service related." The examiner is asked to clarify his medical opinion. The Board finds as fact that there were no complaints of bilateral hip pain in service (the Veteran served from August 1959 to August 1991). Also, while the examiner addressed whether the bilateral hip osteoarthritis was due to the Veteran's service-connected osteoarthritis of the thoracolumbar spine, he did not address whether the bilateral hip osteoarthritis was permanently aggravated by the service-connected osteoarthritis of the thoracolumbar spine. Thus, the examiner is asked to answer the following questions: * Is it at least as likely as not (50 percent probability or greater) that that the Veteran's current bilateral hip osteoarthritis had its onset during service, or is in any other way casually related to active service? * If the above answer is negative, is it at least as likely as not (50 percent probability or greater) that the current bilateral hip osteoarthritis is proximately due to or permanently aggravated by the Veteran's osteoarthritis of the thoracolumbar spine? Please provide a rationale for the opinions. ii. As to the gastrointestinal disability, in the March 2013 VA examination report, the examiner made a finding that there was no evidence of a gastrointestinal disorder while the Veteran was on active duty. However, the service treatment records show some gastrointestinal complaints. In January 1970, the Veteran complained of loose stools without blood. The examiner diagnosed diarrhea. In July 1977, the Veteran complained of diarrhea. In February 1979, May 1981 and January 1982 Reports of Medical History, the Veteran denied having stomach or intestinal problems. A February 1996 private medical record shows the Veteran reported intermittent lower quadrant abdominal pain, and he was diagnosed with diverticulitis following a barium enema. This diagnosis is shown approximately four and one-half years following service discharge. Thus, the examiner is asked to answer the following: * Is it at least as likely as not (50 percent probability or greater) that the Veteran's post service digestive problems, including diverticulitis, had their onset during service, or is in any other way causally related to active service? Please provide a rationale for the opinions. 2. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraph, the Veteran's service connection claims should be readjudicated. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant 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 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. 2013). ______________________________________________ S. C. KREMBS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs