Citation Nr: 1331347 Decision Date: 09/27/13 Archive Date: 10/01/13 DOCKET NO. 07-04 561 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a skin disorder to include boils and staphylococci (staph) infections, to include as due to chemical exposure. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel INTRODUCTION The Veteran served on active duty from December 1965 to November 1967. Service records show that the Veteran served in Vietnam from May 1966 to May 1967. This case comes before the Board of Veterans' Appeals (Board) on appeal from September 2006 and May 2007 rating decisions of the Waco, Texas, Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's service connection claims for disorders of the skin and back were denied by the Board in June 2011. The Veteran subsequently appealed those determinations to the U.S. Court of Appeals for Veterans Claims (Court), which issued a February 2012 order granting a Joint Motion for Remand (Joint Motion). This order had the effect of vacating the Board's denials of service connection for these disorders, and returning those claims to the Board for additional development and adjudication. In January 2013, the Board remanded this matter to the RO/AMC for additional development. The Board asked that the RO/AMC provide the Veteran a VA examination to obtain medical evidence as to the nature and etiology of the claimed disabilities and request the Veteran to identify any pertinent treatment records. The RO/AMC provided VA examinations in March 2013 and obtained addendum opinions in April and June 2013. The RO also asked the Veteran to identify any pertinent treatment records. As the requested development has been completed to the extent possible, no further action to ensure compliance with the remand directives is required. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). In evaluating this case, the Board has not only reviewed the Veteran's physical claims file, but has also reviewed the Veteran's file on the "Virtual VA" system to ensure a complete assessment of the evidence. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam during the Vietnam era. 2. No disease or chronic symptoms of a low back disorder were manifested during service. 3. The Veteran did not continuously manifest symptoms of a low back disorder in the years after service. 4. A low back disorder to include degenerative changes, arthritic changes, and disc disease of the lumbar spine, was not manifested to a degree of ten percent within one year of service separation. 5. The Veteran's low back disorder to include degenerative changes, spinal stenosis, arthritic changes, and disc disease of the lumbar spine, is not caused by any in-service event and is not related to active service. 6. Disease or symptoms of a skin disease were not manifested during service. 7. The Veteran did not continuously manifest recurrent symptoms of skin disease in the years after service. 8. The Veteran's current skin disease to include hidradenitis suppurative did not first manifest during active service and is not caused by or related to any in-service event including herbicide exposure. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disorder to include degenerative changes, spinal stenosis, arthritic changes, and disc disease of the lumbar spine are not met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 2. The criteria for service connection for skin disease to include hidradenitis suppurative are not met. 38 U.S.C.A. §§ 1110, 1116, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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. 2012); 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 letters dated in April 2006, prior to the initial adjudication of the claim for service connection for a back disability; in February 2007, prior to the initial adjudication of the claim for service connection for a skin disorder; and in February 2013 and April 2013. In these letters, VA informed the Veteran of the evidence and information needed to substantiate a claim for service connection and informed 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. These letters 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 letters 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 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, the February 2007 letter explained the type of evidence necessary to establish service connection and the type of evidence necessary to establish a disability rating and effective date for the claims on appeal. The claims were readjudicated in June 2007, July 2007, September 2007, and July 2013 Supplemental Statements of the Case and/or Statements of the Case, thus curing any lack of timeliness of notice. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). VA has a duty to assist a veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board notes that the Veteran's service treatment records are associated with the claims folder. VA treatment records dated in 2006 and 2007 are associated with the claims folder. The Veteran provided private treatment records in support of his claims. In a February 2013 letter, the RO asked the Veteran to identify any treatment for the claimed back and skin disorders. The Veteran did not respond to this letter and did not identify any treatment for the claimed disorders. VA provided an examinations in March 2013 to obtain medical evidence as to the nature and likely etiology of the claimed disorders and additional medical opinions as to etiology were obtained in April and June 2013. The examinations are adequate because the examinations were performed by medical professionals based on review of claims file, solicitation of history and symptomatology from the Veteran, and an examination of the Veteran. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The VA examiner considered the Veteran's service treatment records and the Veteran's own lay statements as to the onset of the symptoms. The examiners provided a medical opinion as to whether the claimed disabilities are related to active service. Neither the Veteran nor his representative has challenged the adequacy of the examination obtained for the issue on appeal. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). For these reasons, the Board finds that the duties to notify and assist the Veteran have been met, so that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). The Board finds that no reasonable possibility exists that any other assistance would aid in substantiating the claims and VA met its duty to assist the Veteran. Laws and Regulations Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. 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). Service connection requires competent evidence showing, (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), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In this case, arthritis is listed among the "chronic diseases" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as arthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Presumptive service connection on the basis of herbicide exposure is provided for specified diseases manifested to a degree of 10 percent within a specified period in a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 U.S.C.A. § 1116(a). If a veteran was exposed to a herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 U.S.C.A. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113 and 38 C.F.R. § 3.307(d) are also satisfied: chloracne or other acneform diseases consistent with chloracne, Type II diabetes mellitus, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy (defined as transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of the date of onset), porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). Effective on August 31, 2010, VA amended 38 C.F.R. § 3.309(e) to add hairy cell leukemia and other chronic B-cell leukemias, Parkinson's disease and 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) to the list of diseases associated with exposure to certain herbicide agents. The intended effect of this amendment is to establish presumptive service connection for these diseases based on herbicide exposure. The final rule is applicable to claims received by VA on or after August 31, 2010 and to claims pending before VA on that date. Note 3 indicates that for purposes of this section, the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of Ischemic heart disease. 38 C.F.R. § 3.309(e). The final rule is applicable to claims received by VA on or after August 31, 2010 and to claims pending before VA on that date. Additionally, VA will apply this rule in readjudicating certain previously denied claims as required by court orders in Nehmer v. Department of Veterans Affairs, No. CV-86-6161 TEH (N.D. Cal.). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more any time after service, except that chloracne and porphyria cutanea tarda shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). 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. See Diseases Not Associated With Exposure to Certain Herbicide Agents, 61 Fed. Reg. 41442, 41448 (1996). Notwithstanding the provisions of §§ 3.307, 3.309, the Veteran's Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984) does not preclude an appellant from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). 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. § 7105; 38 C.F.R. §§ 3.102, 4.3, 4.7. Analysis Service Connection for a low back disability The Veteran contends that he injured his low back in service after carrying 196 pounds of artillery rounds for extended periods of time. He asserts that he was told to take the rest of the day off to rest, and was denied permission to see a doctor. The Veteran also reported that he felt pressure in his back and at times a sharp pain during service, but he never demanded treatment from a physician at that time. See the Veteran's 2007 personal statement. March 2006 and September 2006 VA outpatient treatment records indicate that the Veteran reported that he had back problems since getting out of service. He stated that he underwent an X-ray evaluation with a chiropractor in 1974 and was told he had bad discs, but he noted that the chiropractor treatment records were unavailable. A March 2013 VA examination report indicates that the Veteran reported that he strained his back in service while carrying an artillery shell weighing over 150 pounds. He reported that the pain started about three days after the incident. There is competent evidence of a current low back disability. A March 2006 VA X-ray report shows findings of moderate degenerative changes of the lumbar spine with osteophytosis, narrowing of the disc space at L4-L5, and arthritic changes in the facets at the lower lumbar spine. An August 2012 magnetic resonance imaging report shows an impression of mild canal stenosis, mild annular disc bulging at L2-L3 and L3-L4, bilateral foraminal stenosis at L4-L5, and degenerative multilevel lumbar facet arthropathy throughout the lumbar spine. The 2013 VA examination report shows a diagnosis of multilevel lumbar spine spinal stenosis. Based upon a review of all the lay and medical evidence, the Board finds the weight of the competent and credible evidence shows that the low back disability did not manifest in service or to a compensable degree within one year of service separation and is not otherwise related to active service. The Board finds the weight of the competent and credible evidence shows that the Veteran did not have chronic symptoms of a low back disability in service or continuous symptoms after service. As noted above, the Veteran contends that he injured his low back in service after carrying 150 to 196 pounds of artillery rounds for extended periods of time. He reported that he had back problems since service. In a June 2007 statement, the Veteran's sister stated that the Veteran had a back injury in service due to carrying 196 pounds of artillery rounds. She indicated that she took care of the Veteran at her house when he was down due to his back. She indicated that the Veteran did not have these conditions prior to being in the military. The Veteran's sister indicated that she has been a registered nurse for 30 years and she was now retired. The Veteran is competent to report an observable or firsthand event such as carrying heavy objects or sustaining an injury and to report observable symptoms such as pain. See Jandreau; supra. The Veteran's sister is competent to report observable and firsthand events such as treating the Veteran when he was ill. See Jandreau; supra. The record further shows that the Veteran's sister has training as a nurse and the Board finds that the she has some medical expertise and may be competent to provide a medical opinion. The Board has the duty to assess the credibility and weight to be given to the evidence. See Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997), and cases cited therein. The Court in Madden held that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence." Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997). The Board finds that the Veteran's statements that he injured his back in service to be competent and credible. The statements are competent because the Veteran is reporting an firsthand event and observable symptoms. The Board finds that the Veteran's statements are credible because they are consistent with his service. Service records show that he served with the 18th Artillery while serving in Vietnam. The Board finds that there is sufficient evidence to establish that the Veteran sustained a low back injury in service. The Board finds that the Veteran's statements that he has had "back problems" since service are not t credible and, therefore, of no probative value. The Board finds that the Veteran's statements are not credible because the statements are inconsistent with the Veteran's own statements made at the time of service and upon service separation and are not supported by lay and medical evidence of record. Service treatment records reflect no complaints of, treatment for, or a diagnoses related to the low back. Moreover, there was no reference to a back injury of any kind. Service records show that the Veteran was seen at the dental clinic on several occasions, was treated for an upper respiratory infection in January 1966, and had blood work and a urinalysis in April 1967. On the questions of whether the Veteran sustained a back injury or disease in service and whether low back symptoms were chronic in service, the service treatment records reflect that the Veteran sought treatment for various disorders or symptoms. In light of the various visits for treatment and hospitalization, in the context of service treatment records that appear to be complete, the Board finds that, had the Veteran sustained a back injury and had been suffering from chronic low back symptoms during service, such complaints would have been reflected in the treatment records. See Kahana v. Shinseki, 24 Vet. App. 428, 439 (2011) (citing Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (Lance, J., concurring) (VA may use silence in the service treatment records as evidence contradictory to a veteran's assertions if the service treatment records appear to be complete and the injury, disease, or symptoms involved would ordinarily have been recorded had they occurred). Upon discharge from service, the November 1967 report of medical examination at separation reported no abnormalities of the Veteran's spine. Similarly, he self-reported no recurrent back pain at the time of discharge and he did not report a history of a back injury. The Board finds that the weight of the evidence shows that while the Veteran sustained a back injury in service, he did not have chronic low back symptoms in service. The Board finds the weight of the competent and credible evidence shows that the Veteran did not have continuous low back symptoms after service. The Board finds that the Veteran's statements that he has had "back problems" since service are competent but these statements are not credible and, therefore, of no probative value. The Board finds that the Veteran's statements are not credible because the statements are too general, lack detail and are not supported by lay and medical evidence of record. Post-service treatment records do not reflect complaints or treatment for a low back disorder for many years after discharge. Specifically, private chiropractic records dated in 1978 documented intersegmental traction and diathermy therapy for the Veteran's cervical spine on seven visits. The records show that the Veteran underwent a pelvic manipulation on one visit and he underwent an additional manipulation but the record does not indicate which part of the body was manipulated. He also had two other appointments, including x-ray and examination but the record does not indicate the body part examined. The first medical evidence of record of lumbar spine pathology is in March 2006, when the Veteran sought VA treatment for the first time. At that time, an X-ray report noted moderate degenerative changes of the lumbar spine with osteophytosis, no loss of lumbar lordosis, narrowing of the disc space at L4-L5, and arthritic changes in the faces at the lower lumbar spine. Further, VA outpatient treatment records from March 2006 and September 2006 reveal complaints and treatment for chronic low back pain, and he was prescribed etodolac and methocarbamol. As indicated, at the November 1967 service separation examination, the Veteran's spine was clinically evaluated as normal. Following service separation in November 1967, the evidence of record shows no complaints, diagnosis, or treatment for any spine disability until September 1978, over ten years after service discharge. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor that tends to weigh against a claim for service connection). The Veteran asserts that he was treated for a back disability in the 1960's and 1970's, but he has not been able to find the treatment records. Even if the Board concedes that he was treated for low back symptoms in the 1960's (post service) and in the 1970's, there is no evidence of any treatment for a back disability from September 1978 until March 2006, a period of over 20 years. The absence of post-service complaints, findings, diagnosis, or treatment after service for many years is one factor, considered in addition to the other factors stated in this decision, which tend to weigh against a finding of either chronic low back symptoms in service or continuous symptoms of a low back disability after service separation. See Buchanan, 451 F.3d at 1337 (holding that the Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence). The Board notes that the Veteran first asserted that he had chronic low back symptoms in service and continuous low back symptoms since service in the context of the February 2006 claim for service connection (VA disability compensation) for a low back disability. The Board finds that these assertions are outweighed by the other, more contemporaneous, lay and medical evidence of record, and are not credible. See Charles v. Principi, 16 Vet. App. 370 (2002). The recent statements of chronic low back symptoms in service and continuous post-service low back symptoms are inconsistent with the service treatment record evidence including the Veteran's own reported medical history at the November 1967 separation examination and an absence of complaints or treatment for several years after service. Specifically, the service separation examination report reflects that the Veteran was examined and his spine was clinically normal. His in-service history of symptoms at the time of service separation is more contemporaneous to service, so is of more probative value than the more recent assertions made many years after service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the veteran wrote during treatment than to his subsequent assertion years later). Next, although not determinative, the multi-year gap between discharge from active duty service (1967) and the first evidence of medical treatment in 1978 (almost 11 years after service), and the first evidence of a medical diagnosis of a lumbar spine disorder in 2006 (39 years) is significant. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where Veteran failed to account for lengthy time period between service and initial symptoms of disability). The Veteran's recent account of when his symptoms began has been inconsistent. When reporting for VA outpatient treatment in March 2006 and September 2006, he complained of back problems since service separation; however, in a February 2007 personal statement, he asserted that he started having complications in his lower back in his mid-20s, which the Board notes is approximately four years after service separation. In addition, when the Veteran sought to establish medical care with VA in March 2006, he did not report a past medical history of low back symptomatology. His only post-service past medical history was treatment for shoulder pain and pneumonia in 2000. A review of the medical evidence from the 2000 work-up reflected that he denied a past medical history of low back problems, he denied low back pain at that time, and a clinical evaluation of his back was normal. Such histories reported by the Veteran for treatment purposes are of more probative value than the more recent assertions and histories given for VA disability compensation purposes. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). As such, the Board finds that the Veteran's current recollections and statements made in connection with his claims for benefits to be of lesser probative value than the normal discharge examination and absence of treatment records for a considerable time after service. See Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). Therefore, continuity has not been established either through the medical evidence or through the Veteran's lay statements. In a June 2007 statement, the Veteran's sister asserted that the Veteran injured his back in service carrying 196 pounds of artillery rounds. She stated that she treated the Veteran for back symptoms after service and that the Veteran stayed at her house when he was down with his back. The Veteran's sister is competent to report firsthand events and observable symptoms, so the Board finds these statements to be competent. However, the Board finds the statements to have limited credibility because the statements are too general and lack detail. The Veteran's sister does not report the frequency of the back treatment or provide the dates or a time frame for this treatment. She does not describe the type of back symptoms that the Veteran had or what the medical treatment entailed. Thus, these statements are too general and inconclusive and are not sufficient to establish continuity of symptomatology. Thus, the Board finds that the weight of the competent and credible evidence establishes that the Veteran did sustain an injury to the low back during service but he did not experience chronic low back symptoms in service, and he did not experience continuous post service symptoms of a low back disability after service. See 38 C.F.R. § 3.303(b). Therefore, presumptive service connection pursuant to 38 C.F.R. § 3.303(b) for chronic in service symptoms and continuous post service symptoms is not warranted. The Board finds that the weight of the competent and credible evidence establishes that the claimed low back disability to include spinal stenosis, degenerative and arthritic changes, and disc disease of the lumbar spine did not manifest within one year of service separation and first manifested many years after service separation. The first diagnosis of degenerative arthritis of the lumbar spine based upon x-ray findings is upon x-ray examination in 2006. The March 2006 x-ray report notes moderate degenerative changes with osteophytosis of the lumbar spine and arthritis changes in the facet joints of the lower lumbar spine. Therefore, presumptive service connection pursuant to 38 C.F.R. § 3.309(a) for a chronic disease manifested to 10 percent within one year from service separation is not warranted. Finally, the Board finds that the weight of the evidence demonstrates that the low back disability is not caused by any in-service event or injury and is not related to service. The more probative evidence of record, specifically the 2013 VA medical opinions and the service treatment records establish that the low back disability did not first manifest in service and is not medically related to service. The Veteran was afforded a VA examination in March 2013. The VA examiner reviewed the claims folder, considered the Veteran's reported medical history, examined the Veteran, and offered an opinion as to the etiology of the claimed low back disability in April and June 2013. The VA examination report notes that the Veteran reported that he strained his back in service while carrying artillery shells weighing over 150 pounds. He reported that the pain started about 3 days after the incident. He reported that currently, he had chronic daily low back pain with radiation to the left leg. It was noted that the Veteran reported that he was employed doing auto body repair for 35 years but quit in 2001 due to low back pain. He reported severe flare-ups of low back pain while working over the years. The Veteran reported that the back was less symptomatic now due to a much lower activity level. The Veteran did not report any flare-ups of pain that impacted the function of the thoracolumbar spine. In the April 2013 VA opinion, the VA examiner stated that the claimed back disability was less likely than not incurred in or caused by the claimed in-service injury. The examiner indicated that the service treatment records were silent for any condition of the back and the Veteran had no complaints at the time of the separation examination. The June 2013 VA addendum opinion indicates that the examiner reviewed the Veteran's claims folder. The examiner opined that the reported incident of lumbar strain in service was unlikely to have any relationship to the current 3 level spinal stenosis. The examiner noted that the Veteran has been a laborer for 35 years doing painting and auto body work. The examiner indicated that the chiropractor notes in 1978 clearly state manipulation of the neck and there was no reference to the lumbar spine and even then, this was 11 years after service. The Board finds the 2013 VA medical opinion to have great evidentiary weight as the opinion reflects a comprehensive and reasoned review of the entire evidentiary record. The VA examiner reviewed the claims folder including the service treatment records and the Veteran's medical history, considered the Veteran's own reported medical history, and examined the Veteran before rendering the medical opinion. The VA examiner specifically addressed the reported back injury in service and discussed the examination findings generated at the time of service and contemporaneous to the reported injury. Factors for assessing the probative value of a medical opinion are the examiner's access to the claims file and the thoroughness and detail of the opinion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The medical opinion is based on sufficient facts and data. In Nieves-Rodriguez, 22 Vet. App. 295, the Court held that guiding factors in evaluating the probity of a medical opinion are whether the opinion was based on sufficient facts or data, whether the opinion was the product of reliable principles and methods, and whether the medical professional applied the principles and methods reliably to the facts of the case. For these reasons, the Board has assigned great probative weight to the VA medical opinion and finds that it outweighs the statements of the Veteran and his sister. The Board finds that the 2013 VA medical opinion, the service treatment records, and the post service evidence establish that the Veteran's low back disability first manifested many years after service separation and is not related to active service. The Veteran has not submitted any medical opinions in support of his claim other than the statement from his sister, the retired registered nurse. In the June 2007 personal statement, the Veteran's sister stated, in pertinent part, that the Veteran stayed at her house when he was down with his back. The Veteran's sister reported that she was a retired registered nurse. As discussed above, the Board finds the statement by the Veteran's sister to have little probative value because the statement is too general, lacks detail as to pertinent facts relating to the type of back symptoms the Veteran experienced the type of treatment the sister furnished, and the statement does not appear to be based upon a complete review of the medical evidence in this matter but is based upon solely the report of the Veteran and the events witnessed by the sister. Medical opinions based upon insufficient facts and data or based upon an inaccurate premise have no probative value. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions that are speculative, general, or inconclusive in nature cannot support a claim). See also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, the Board finds that this evidence is not probative to warrant a grant of the claim and it outweighed by the 2013 VA medical opinion. The Veteran himself has attempted to relate his low back disability to his active service, specifically to in-service back strain and carrying heavy artillery. The Veteran, as a lay person, is competent to describe observable symptoms such as pain and firsthand events. Although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, as to the specific issue in this case, an opinion as to the etiology and onset of a lumbar spine disability to include spinal stenosis, falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4 (lay persons not competent to diagnose cancer). Some medical issues require specialized training for a determination as to diagnosis and causation; therefore such issues are not susceptible of lay opinions on etiology. Lay testimony on the question of relating the current lumbar spine spinal stenosis to service is not competent in the present case because the Veteran is not competent to state that this disability was incurred in service. See Davidson v. Shinseki, 581 F.3d 1313, 316 (Fed. Cir. 2009); Kahana (lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent). Such diagnoses require clinical or diagnostic testing such as x-ray examination or magnetic resonance imaging, and these tests are not found within the record during or immediately following his service period. Additionally, an opinion of etiology would require knowledge of the complexities of the musculoskeletal system and the various causes of spinal stenosis and it is not shown that the Veteran has this knowledge. The Board finds that the weight of the competent and credible evidence establishes that the low back disorder to include degenerative changes, spinal stenosis, arthritic changes, and disc disease of the lumbar spine did not manifest in service or within one year of service separation, the Veteran did not have chronic or continuous symptoms of a low back disability in service or soon after service, the low back disability first manifested many years after service separation, and it is not medically related to injury or other incident of active service. For the reasons and bases discussed above, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for a low back disability to include degenerative changes, spinal stenosis, arthritic changes, and disc disease of the lumbar spine including as a presumptive disease and on a direct basis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for a Skin Disorder to include as due to chemical exposure The Veteran asserts that he has had recurring boils and staph infections since his tour of duty in Vietnam, and therefore service connection for a skin disease is warranted. Based upon a review of all the lay and medical evidence, the Board finds the weight of the competent and credible evidence shows that the current skin disorder did not manifest in service and is not otherwise related to active service. The Board finds the weight of the competent and credible evidence shows that the Veteran did not have chronic symptoms of a skin disorder in service or recurrent symptoms after service, and the current skin disorder is not related to his period of active service. There is competent evidence of a current skin disorder. The 2013 VA examination report indicates that the Veteran has a diagnosis of hidradenitis suppurative. In a February 2007 personal statement, the Veteran reported that has suffered from recurring boils and staph infections since his tour of duty in Vietnam. At the VA examination in March 2013, the Veteran reported that the onset of the abscesses in sweat glands in the groin and axillae in 1968 and he had recurrent infections in the groin. The Veteran submitted personal statements from his wife, sister, step-daughter, and friend discussing their observations of his skin disability. His wife reported that she knew him for several years before they married in 1971. She noted that he developed staph infections, boils, and cysts several months after his service separation and that he never had these conditions prior to service. He had large scars in his groin area and under his arms from the boils bursting, as well as crusted sores from the staph infections. She treated him with intravenous antibiotics and it was her belief that he was exposed to chemicals during service. The Veteran's sister, a retired registered nurse, reported that no one in her family had ever had staph infections, cysts, or boils, and that the Veteran never had any of these conditions before he went to the military. It was her belief that his skin disorder was a result of being exposed to chemicals from the military. The Veteran's step-daughter reported that since she moved in with the Veteran in 1971, he has had numerous staph infections for no reason over the years. She indicated that one particular hospital stay, the doctors repeatedly asked him if he had ever been exposed to any chemicals or drugs because the infection was usually related to such exposure. She also noted with assurance that he never took or been around drugs or chemicals that were hazardous. The Veteran's friend noted that she has been closely involved with the Veteran and his wife since 1985. She lived with them from 1995 to 1996 and has witnessed his outbreaks of staph infections and boils over the years, some of which included hospital stays. The Veteran and his family and friends, as lay persons, are competent to report observable symptoms such as boil and observable or firsthand events. See Jandreau; supra. Lay persons are competent to report observable and firsthand events such as treating the Veteran when he was ill. See Jandreau; supra. The record further shows that the Veteran's sister has training as a nurse and the Board finds that the she has some medical expertise and may be competent to provide a medical opinion. However, the Board finds that the Veteran's statements are not credible and the statements by his family members and friends (that the Veteran has had recurrent boils and skin infections since soon after service) to have limited credibility and, therefore, limited probative value. The Board finds that the Veteran's lay statements are not credible because the statements are inconsistent with his own statements made at the time of service, upon service separation, and upon receiving post-service medical treatment for a skin disorder. The Veteran's lay statements are not supported by the other lay and medical evidence of record. The Veteran's more recently-reported history of chronic in-service symptoms are inconsistent with the other lay and medical evidence of record. The service treatment records which are contemporaneous to his time in active service show that the Veteran did not have any complaints or diagnosis of a skin disorder in service. Upon discharge from service, the November 1967 report of medical examination at separation reported no abnormalities of the skin. Similarly, he self-reported no tumors, growths, cysts, or skin disease. Therefore, a skin disorder was not shown during service. Post-service treatment records do not reflect complaints or treatment for a skin disorder for many years after discharge. Further, when the Veteran sought post-service medical treatment for the skin symptoms and a skin disorder, he did not report a medical history of recurrent skin symptoms since service separation. March 2006 and September 2006 VA outpatient treatment records noted the Veteran's complaint of a dark blister with throbbing pain upon touch on the right forearm for the past 2 to 3 years. He also complained of a confluent cyst with open drainage under the scrotum, lower mid gluteal line, for the past 10 to 12 years. He reported that he had never sought treatment for the blister or cyst until then. After the clinical evaluation, the Veteran was assessed with a blister and possible deep vascular growth of the right forearm, and suspect hidradenitis suppurative of the scrotum; he was referred to a surgery clinic. In November 2006, the Veteran underwent an excisional biopsy for removal of a skin lesion on the right forearm. He reported a 3 to 10 year history of painful purple papule anterior forearm lesion. These are the first documented post-service skin disorder noted in the record. Therefore, the medical evidence does not reflect continuity of symptomatology for the skin. The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an 'absolute bar' to the service connection claim); Barr, 21 Vet. App. at 303 ('Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms.'). The Board finds that the Veteran's own statements that he had recurring boils and staph infections since his tour of duty in Vietnam are not credible because these statements are inconsistent with his own statements made contemporaneous to his time in service and the statements he made in the course of post-service medical treatment. In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board finds that the Veteran's more recently-reported history of continued symptoms since active service, made in connection with his compensation claim, have less probative value than and are outweighed by the statements the Veteran made during service and at separation and the statements the Veteran made in the course of post-service medical treatment. Indeed, while he now asserts that his disorders began in service, in the more contemporaneous medical history he gave at the service separation examination, he denied any history or complaints of symptoms related to the skin. Specifically, the service separation examination report reflects that the Veteran was examined and his skin was found to be clinically normal. His in-service history of symptoms at the time of service separation is more contemporaneous to service, so is of more probative value than the more recent assertions made many years after service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the veteran wrote during treatment than to his subsequent assertion years later). Further, the statements the Veteran made in connection with his compensation claim are at odds with the Veteran's own reported history of the skin disorder. As noted, the Veteran sought treatment at VA in 2006 for the skin disorder. In September 2006 he reported having the symptoms for 10 to 12 years, which shows an onset of in about 1994 to 1996. In November 2006 he reported a 3 to 10 year history of an anterior forearm lesion which shows an onset of 1996 to 2003. The Veteran separated from service in May 1967. Such histories reported by the Veteran for treatment purposes are of more probative value than the more recent assertions and histories given for VA disability compensation purposes. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). The Veteran's statements about the onset of the skin disorder, which he made in the course of medical treatment, relate the onset of the skin disorder to the 1990's at the earliest and this is still almost 30 years after service separation. Thus, the Board finds the weight of the competent and credible evidence shows that the Veteran did not have chronic and continuous symptoms of a skin disorder in service or recurrent symptoms since service. The Board finds the weight of the competent and credible evidence shows that the skin disorder first manifested in the 1990's. The lay statements from the Veteran's friends and family and the statement by his sister, a registered nurse, have limited credibility and therefore limited probative value. The Board finds that these statements have limited credibility because the statements are inconsistent with other lay and medical evidence of record. The Board finds that the lay statements by the Veteran's family members and friends are outweighed by the Veteran's own statements made at the time of service, upon service separation, and upon receiving post-service medical treatment for a skin disorder. As discussed in detail above, the lay and medical evidence generated at the time of service shows that the Veteran did not have any skin symptoms or a skin disorder. The Veteran's lay statements made in the course of post-service treatment for a skin disorder indicate that the onset of the skin disorder was in the 1990's. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the veteran wrote during treatment than to his subsequent assertion years later). The Board also notes that histories reported by the Veteran for treatment purposes are of more probative value than the more recent assertions and histories given for VA disability compensation purposes. Rucker v. Brown, 10 Vet. App. 67, 73 The lay statements made by the Veteran's family members and friends are not consistent with the Veteran's own statements made regarding the onset of and treatment for the skin disorder. The family members and friends reported that the Veteran was treated by intravenous antibiotics and he was hospitalized for treatment of the skin disorder. However, VA treatment records show that when the Veteran first sought treatment for a skin disorder in the 2006, he denied having previous treatment. He did not report undergoing intravenous antibiotic treatment or hospitalization. The Board also notes that the statements by the family members and friends were made in 2007, over 30 years after the Veteran's service separation. The statements are inconsistent with the other lay and medical evidence of record. For these reasons, the Board finds that these statements have limited probative value and are outweighed by the lay and medical evidence which is contemporaneous to the Veteran's time of active service and the Veteran's statements made during treatment which relate the onset of the skin symptoms to the 1990's. The lay evidence from the Veteran's family and friends is not sufficient to establish continuity of symptomatology or recurrent skin symptoms since service. Finally, the Board finds that the weight of the evidence demonstrates that the skin disorder is not caused by any in-service event or injury and is not related to service. The more probative evidence of record, specifically the 2013 VA medical opinion and the service treatment records establish that the skin disorder did not first manifest in service and is not medically related to service. The Veteran was afforded a VA examination in March 2013. The VA examiner reviewed the claims folder, considered the Veteran's reported medical history, examined the Veteran, and offered an opinion as to the etiology of the claimed skin disorder in April and June 2013. The VA examination report notes that the Veteran reported that the onset of abscesses in the sweat glands of the groin and axillae began in 1968 and he continued to have recurrent infections the groin. The diagnosis was hydradenitis suppuritiva. In the April 2013 VA opinion, the VA examiner stated that the claimed skin disorder was less likely than not incurred in or caused by the claimed in-service injury. The examiner indicated that the service treatment records were silent for any condition of the skin and the Veteran had no complaints at the time of the separation examination. The June 2013 VA addendum opinion indicates that the examiner reviewed the Veteran's claims folder. The examiner opined that the diagnosis of hidradenitis suppurativa is caused by follicular occlusion in apocrine glands leading to abscess formation and it is not known to be related to any type of chemical exposure. The Board finds the 2013 VA medical opinion to have great evidentiary weight as the opinion reflects a comprehensive and reasoned review of the entire evidentiary record. The VA examiner reviewed the claims folder including the service treatment records and the Veteran's medical history, considered the Veteran's own reported medical history, and examined the Veteran before rendering the medical opinion. The VA examiner discussed the examination findings generated at the time of service and contemporaneous to the reported injury. Factors for assessing the probative value of a medical opinion are the examiner's access to the claims file and the thoroughness and detail of the opinion. See Hernandez-Toyens; supra. See also Prejean; supra. The medical opinion is based on sufficient facts and data. Nieves-Rodriguez; supra. For these reasons, the Board has assigned great probative weight to the opinion of the VA examiner and finds that it outweighs the statements of the Veteran and his family members and friend. The Board finds that the 2013 VA medical opinion, the service treatment records, and the post service evidence establish that the Veteran's skin disorder first manifested many years after service separation and is not related to active service. The Veteran's sister made a general assertion that the Veteran's skin disorder was caused by chemical exposure in service. The Board finds that this statement is not credible and has no probative value. The medical opinion is conclusory and too general. The Veteran's sister does not provide any details as to the chemical exposure the Veteran sustained in service and she does not provide any basis for her conclusion. This medical opinion is not based on sufficient facts and data. See Nieves-Rodriguez; supra. Further, while the Veteran's sister has medical training as a nurse, it is not shown that she has any training with respect to etiology of a skin disorder or expertise in the field of chemical exposure. Thus, this lack of evidence limits the probative value of her statement as a medical opinion concerning the Veteran's claimed skin disorder. Black v. Brown, 10 Vet. App. 279, 284 (1997) (opinion of a veteran's wife, a nurse, was not probative because, while medically trained, she gave no indication that she had special knowledge regarding cardiology). The claim of service connection for hidradenitis suppurativa on a presumptive basis as due to Agent Orange exposure must fail because the herbicide presumption set forth in 38 U.S.C.A. § 1116 and 38 C.F.R. § 3.307 does not apply. This skin disorder is not one of the enumerated disabilities that are presumed due to herbicide exposure that are listed under 38 C.F.R. § 3.309(e). The Veteran himself and his spouse have attempted to relate is current skin disorder to his period of active service including chemical exposure in service. As discussed in detail above, the Veteran, as a lay person, is competent to describe observable symptoms. Although lay persons are competent to provide opinions on some medical issues, see Kahana, supra; as to the specific issue in this case, an opinion as to the cause of a specific skin disorder falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4 (lay persons not competent to diagnose cancer). Some medical issues require specialized training for a determination as to diagnosis and causation, and such issues are therefore not susceptible of lay opinions on etiology. Lay testimony on the question of relating the current skin disorder to service is not competent in the present case, because the Veteran and his spouse are not competent to state that this disease was caused by a certain event such as chemical exposure. See Davidson, supra; Kahana, supra. An opinion of etiology of the skin disorder would require knowledge of the complexities of dermatology and the expertise in the topic of chemical exposure and side effects of such exposure. There is no evidence that the Veteran or his spouse have such medical or scientific expertise. The Board finds the weight of the competent and credible evidence shows that current skin disorder to include hidradenitis suppurativa did not manifest in service and is not related to active service. The current skin disorder is not a "chronic disease" listed under 38 C.F.R. § 3.309(a), and the provisions of 38 C.F.R. § 3.303(b) are not applicable. For the reasons and bases discussed above, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for a skin disorder to include hidradenitis suppurativa, and the claim must be denied. ORDER Service connection for a low back disability to include degenerative changes, spinal stenosis, arthritic changes, and disc disease of the lumbar spine is denied. Service connection for a skin disorder to include hidradenitis suppurativa is denied. ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs