Citation Nr: 1333291 Decision Date: 10/23/13 Archive Date: 10/24/13 DOCKET NO. 09-32 119 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for asthma. 2. Entitlement to service connection for coronary artery disease (CAD), claimed as secondary to asthma. 3. Entitlement to service connection for cellulitis of both legs. 4. Entitlement to service connection for arthritis of both knees. 5. Entitlement to service connection for restless leg syndrome. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from April 1968 to April 1970. This case comes to the Board of Veterans' Appeals (Board) on appeal from an August 2008 RO decision that in pertinent part, denied entitlement to service connection for asthma, CAD, cellulitis of both legs, arthritis of both knees, and restless leg syndrome. The Veteran initially requested a Board videoconference hearing before a Veterans' Law Judge, but in September 2011, he withdrew this request. See 38 C.F.R. § 20.704(e). In April 2012, the Board remanded this case to the Appeals Management Center (AMC) for additional development, and the case was subsequently returned to the Board. In November 2012 the Veteran submitted additional pertinent evidence to the Board and waived his right to have the RO initially consider it. See 38 C.F.R. § 20.1304. Meanwhile, at the RO, other claims were being processed, and additional documents were associated with the Veteran's electronic Virtual VA folder. In a June 2013 rating decision, the RO denied entitlement to service connection for chronic obstructive pulmonary disease (COPD), and diabetes mellitus, Type II. These issues are not in appellate status and will not be addressed by the Board. 38 U.S.C.A. § 7105. The issues of entitlement to service connection for arthritis of both knees and restless leg syndrome 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 Veteran does not have current chronic cellulitis of either leg. 2. There is an approximate balance of evidence for and against the claim as to whether the Veteran's current scars of both kneecaps were incurred during an episode of acute cellulitis during his military service. No other current chronic residuals of cellulitis have been shown by the preponderance of the evidence. 3. Asthma was not noted on entry into service, and the most probative (competent and credible) medical and other evidence of record does not show a current diagnosis of chronic asthma that is related to military service. 4. The most probative (competent and credible) medical and other evidence of record indicates the Veteran's current CAD developed many years after service and is not related to his military service or a service-connected disability. CONCLUSIONS OF LAW 1. Chronic cellulitis of both legs was not incurred in or aggravated by the Veteran's military service. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). 2. Resolving all reasonable doubt in his favor, the Veteran's scars of the bilateral kneecaps were incurred during an episode of acute cellulitis during active service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 3. Chronic asthma was not incurred in or aggravated by the Veteran's military service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). 4. CAD was not incurred in or aggravated by the Veteran's military service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist As provided by the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102 , 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will obtain and assist the claimant in obtaining; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). These VCAA notice requirements apply to all five elements of a service-connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Further, this notice must include information that a downstream disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and then readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In this case, a pre-adjudication letter satisfying the notice requirements of 38 C.F.R. § 3.159(b)(1) was sent to the Veteran in November 2007, prior to initially adjudicating his claims for service connection for asthma, cellulitis of the legs, and CAD. (Pelegrini II). The letter informed him of the evidence required to substantiate this claim and of his and VA's respective responsibilities in obtaining this supporting evidence, and he was advised of the "downstream" disability rating and effective date elements of his claim in these letters. As the pleading party attacking the agency's decisions, he, not VA, has the evidentiary burden of proof of showing there is a VCAA notice error in timing or content and that the error is unduly prejudicial, meaning outcome determinative of his claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). There is no such pleading or allegation in this instance. VA also fulfilled its duty to assist the Veteran by obtaining all relevant evidence in support of the claim that is obtainable. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). The RO obtained his VA treatment records, private medical records, records from the Social Security Administration (SSA) and relevant lay statements. A VA compensation examination was conducted in May 2012, and the VA examiner provided medical opinions regarding the etiology of the claimed asthma and cellulitis disabilities after a clinical examination and a review of the Veteran's reported history, his claims file, and his medical records, with an adequate supporting rationale. Therefore, the Board concludes that the appellant was afforded an adequate examination. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board acknowledges that, to date, the Veteran has not been afforded a VA examination in regard to his claim for service connection for CAD. In determining whether the duty to assist requires that a VA examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. 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 v. Nicholson, 20 Vet. App. 79 (2006). In this case, no examination is necessary in order to adjudicate the Veteran's claim of entitlement to service connection for CAD. The Veteran does not contend, and the evidence does not reflect, that his current CAD may be related to his active service. Rather, he contends CAD is secondary to asthma or cellulitis. As will be discussed further below, service connection is denied for these disabilities, and thus service connection is not possible on a secondary basis. See 38 C.F.R. § 3.310. While the Veteran has been diagnosed with CAD, there is no evidence of CAD or hypertension in service or for many years thereafter, there is no evidence of manifestation of the condition during any applicable presumptive period, and there is no medical evidence of a nexus relating the asserted condition to service or a service-connected disability. As such, the necessity for a VA examination has not been triggered. The Board previously remanded this case in order for the AMC to obtain additional VA medical records, and for VA examinations of the claimed conditions. The requested remand actions have been completed. The Board is therefore satisfied there was sufficient compliance with these remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) and Dyment v. West, 13 Vet. App. 141, 146-47 (1999). A Court or Board remand confers upon the appellant the right to substantial, but not strict, compliance with that order. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). VA has complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. Law and Regulations It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "[i]t is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Service connection is granted if it is shown the Veteran suffers from disability resulting from an injury sustained or a disease contracted in the line of duty during active military service, or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.306. Other diseases initially diagnosed after service also may be service connected if the evidence, including that pertinent to service, shows the diseases were incurred in service. 38 C.F.R. § 3.303(d). To establish entitlement to service connection, there must be: (1) competent and credible evidence confirming the Veteran has the claimed disability or at least has since filing the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). VA compensation may only be awarded to an applicant who has disability existing on the date of application, not for past disability. Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997)); but see McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (further clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). Certain diseases including cardiovascular-renal disease, including hypertension, are considered chronic, per se, and therefore will be presumed to have been incurred in service if manifested to a compensable degree (meaning to at least 10-percent disabling) within one year of separation from service. This presumption, however, is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). To establish a showing of chronic disease in service, or within a presumptive period per § 3.307, a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic," is required. 38 C.F.R. § 3.303(b). Subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Id. If chronicity (i.e., permanency) of disease or injury in service is not shown, or legitimately questionable, then a showing of continuity of symptomatology following service is required to support the claim. 38 C.F.R. § 3.303(b). Establishing continuity of symptomatology under 38 C.F.R. § 3.303(b) is an alternative method of satisfying the second and third Shedden requirements to establish chronicity (permanency) of disease or injury in service and, in turn, link the currently claimed disability to service. See also Clyburn v. West, 12 Vet. App. 296, 302 (1999). The Federal Circuit Court recently held that the theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Cardiovascular-renal disease, including hypertension, is a chronic condition under 38 C.F.R. § 3.309(a). However, cellulitis and asthma are not such listed chronic conditions. Service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, the tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). See also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). So medical evidence is not always required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Factual Background The Veteran's DD Form 214 reflects that he served on active duty in the U.S. Marine Corps from April 1968 to April 1970, and had no foreign or sea service. He did not receive any combat citations. STRs show that on pre-induction medical examination in January 1968, his lungs and chest were listed as normal. The examiner noted a 1/2-inch scar on the left knee cap. A January 1968 report of medical history reflects that the Veteran reported a history of asthma. The reviewing examiner noted that the Veteran said he had asthma as a young child. An April 1968 note reflects that a screening physical examination was conducted and the Veteran was found to be physically fit to undergo military training. A June 1968 treatment note reflects that the Veteran had a pimple over the left knee cap and there was now swelling, redness and heat all over the knee. On examination, the skin over the left kneecap was red, hot and swollen, and he had a temperature of 100 degrees. He was given Streptomycin, Erythromycin, Ananase, and hot soaks. The examiner indicated that he responded well to the treatment, and he was discharged to duty after six days. A July 1968 treatment note reflects that the Veteran reported a past history of asthma, and said his father had asthma. He complained of shortness of breath, a productive cough and nasal congestion. On examination, there were rhonchi and wheezes in the right lower lobe. A chest X-ray study was within normal limits. The diagnostic impression was asthmatic bronchitis. The next day, there were bilateral rhonchi, without any wheezes. The diagnostic impression was acute bronchitis. He was placed on no duty status for 24 hours. Subsequent STRs are negative for treatment of respiratory complaints, and chest X-ray studies in August 1969 and March 1970 were negative. On medical examination performed for release to inactive duty purposes in March 1970, the Veteran's lungs, chest, and lower extremities were clinically normal. No scars of the legs were noted. His blood pressure was 118/62. The Veteran was examined and found physically qualified for release to inactive duty. Post-service medical evidence reveals no indication of asthma or any lung disorder for many years after service, and post-service medical records are negative for cellulitis. The earliest post-service medical evidence available for review is dated in 1975. A private medical record dated in September 1975 reflects that he was seen for a cold with a cough; the examiner noted that his chest was clear. The diagnostic impression was viral syndrome. Forms completed by the Veteran's physician in May 1976 and April 1977 cleared him for employment involving "sustained strenuous work while wearing oxygen breathing apparatus." In these May 1976 and April 1977 forms, the examining physician indicated that his chest and lungs were normal upon examination. His blood pressure was 140/80 in May 1976 and 128/76 in April 1977. In December 1979, the Veteran complained of right knee pain that he woke up with the day before. On examination of the right knee, there was no swelling, and the knee joint was stable. An X-ray study was negative. He was seen for right knee pain in July 1981, which reportedly came on the previous day. The diagnostic impression was fibrositis of the right knee. A March 1984 chest X-ray study reflects that the lung fields were clear except for several small granulomatous lesions in the lungs and hilar nodes. The heart was within normal limits of size and configuration, and there was no abnormality of the pleura, diaphragm, or bony thorax. The diagnostic impression was no evidence of active intra-thoracic disease. Laboratory tests showed elevated cholesterol in August 1991. In December 2001, the Veteran requested an echocardiogram because of exposure to fenfluramine/phentermine (fen-phen). On examination, his blood pressure was 142/98, and he was assessed with elevated blood pressure without a diagnosis of hypertension, and with high cholesterol. A January 2002 echocardiogram showed left ventricular hypertrophy with normal left ventricular systolic function, trace mitral regurgitation, trace tricuspid regurgitation, and a suggestion of left ventricular diastolic dysfunction. In February 2005 he was diagnosed with hypertension. Private medical records from University of Tennessee Memorial Hospital reflect that in April 2005, the Veteran had a myocardial infarction and underwent an emergency three-vessel coronary artery bypass grafting. An April 2005 cardiothoracic surgery consultation report reflects that the Veteran reported that he was a coal miner, and quit smoking in 1985. He had a history of some chest discomfort. The physician stated that the Veteran had no history of known chronic lung disease. By a letter dated in October 2005, Dr. C., a private cardiologist, indicated that the Veteran had CAD, status post CABG and an ischemic cardiomyopathy, and also had hypertension, diabetes and dyslipidemia. His symptoms included shortness of breath, chest pain, palpitations and dizzy spells. Private pulmonary function tests in November 2005 were normal. A March 2007 private cardiology consultation by Dr. P. reflects that the Veteran had a family history of CAD. After an examination, he diagnosed ischemic cardiomyopathy, ischemic heart disease, CAD status post CABG surgery and recent left heart catheterization which revealed patent grafts, diabetes mellitus, hypertension, hyperlipidemia and history of palpitations in February 2007. A March 2007 chest X-ray study showed evidence of status post CABG, COPD, and small reticular nodular densities scattered throughout the lung. A March 2007 note by a private pulmonologist reflects that the Veteran reported that he spent more than 30 years in the coal mines, and that he was a non-smoker. The diagnostic assessment was coal worker's pneumoconiosis, chronic bronchitis, and chronic dyspnea. Subsequent private medical records reflect treatment for these conditions. VA medical records reflect that the Veteran was first seen at VA in June 2007. On initial primary care visit in June 2007, he reported an extensive medical history including hypertension, diabetes mellitus type II, myocardial infarction in April 2005, obesity, arteriosclerotic cardiovascular disease (ASCVD), COPD, restless legs in 2006, sleep apnea, and status post coronary artery bypass graft (CABG) times three. He reported that he was formerly a smoker, and smoked one to two packs of cigarettes per day for eleven years, stopping in 1985. With respect to his respiratory system, he said he had asthma as a youngster, and had occupational exposures. Diagnoses included hypertension, diabetes mellitus type II, restless leg syndrome, obesity, hyperlipidemia, sleep apnea, tobacco use history, and COPD. SSA records reflect that he was awarded benefits in May 2007. The SSA found that he became disabled in April 2005 based on a primary diagnosis of degenerative disc disease and a secondary diagnosis of diabetes mellitus. It was noted that he had not worked since he had a myocardial infarction in April 2005. In two July 2007 forms, a private physician, Dr. K., stated that the Veteran reported that he developed asthma in 1968 during service, and reported that he was hospitalized for two weeks in 1968 for cellulitis of both legs during service. With respect to cellulitis, Dr. K. indicated that that his present diagnosis was "history of cellulitis both legs," and opined that this current condition was "possibly related to" service. In the July 2007 form pertaining to asthma, Dr. K. diagnosed asthma, and noted that the Veteran was currently taking Advair, Spiriva, and Combivent, as well as requiring a nebulizer for sleep apnea. He opined that his current condition was "possibly related to" service. However, in his treatment records dated in 2006 and 2007, Dr. K. did not diagnose asthma, but instead diagnosed COPD and coal worker's pneumoconiosis. He noted that the Veteran was using inhalers and other medication. In August 2007, the Veteran filed claims for service connection for cellulitis in both legs, bilateral knee problems, asthma, and heart problems secondary to cellulitis and asthma. In a November 2007 statement, the Veteran reported that he was treated and diagnosed with asthma during boot camp at Parris Island in service, and he was treated for cellulitis of both legs from June to August at Parris Island or Camp Geiger. He said he had lost all of his records in a house fire, and that he worked in the mining industry for 35 years. He said that he had trouble with his breathing and legs ever since service, but never previously filed for disability because he was making a living and had insurance. He said he had been unable to work since his heart surgery in 2005. He reiterated his assertions in subsequent statements. In February 2009, he said that he had scars on his legs from the in-service cellulitis. In August 2009, the Veteran said that he did not have asthma for ten years prior to service, that he was treated for asthma in service, and was offered the chance to leave service based on his asthma, which he declined. He asserted that since the military let him stay in service, it accepted responsibility for this condition. He said that after service he self-treated his medical problems, including when he had trouble with his asthma. He said he had never been diagnosed with "black lung." With respect to cellulitis, he said he was treated for cellulitis of both knee caps and legs during service, and that his knees were infected and swollen. He said he had holes in his knee caps and he was treated with hot soaks and antibiotics. He asserted that he was in the sick bay barracks for one to two months for this condition. He said that after service, "I was never able to work directly on my knees because of my history with the cellulitis." On VA compensation examination in May 2012, the Veteran reported that in 1968, while he was on Parris Island, he developed "little pimples" on both knees, and a big "blister" formed on his left knee as big as his fist. He was hospitalized for two or three days and then held in a sick bay undergoing whirlpool treatments and wound packing for a month or more. He said he was diagnosed with cellulitis, and that thereafter the area resolved and he was sent to Camp Lejeune. He stated that ever since then, kneeling had been painful for his knees. On examination, there was no evidence of current erythema or evidence of cellulitis involving either knee. There was a trivial shallow 1.0 centimeter circular scar over the left patella which the Veteran said was a residual of the cellulitis. There was also a shallow trivial 0.5 by 1.0 centimeter scar inferior to the left patella. There was a 6.0 centimeter linear well-healed scar inferior to the medial joint line of the left knee which was the result of a non-service-connected injury. The examiner stated that there was no evidence of an active skin disorder, and no evidence of an active skin disorder of his knees. The VA examiner also diagnosed degenerative arthritis of both knees. The VA examiner stated that the claims file had been reviewed. She noted that the Veteran's records showed that he was treated for cellulitis of the left knee from June 6 to 12, 1968, and no mention was made of the right knee. The Veteran described cellulitis involving both knees over a longer period of time and of greater severity than is recorded in the claims file. However, the Veteran did not currently have any evidence of an active cellulitis. She added that this was to be expected, as cellulitis is usually of brief existence if properly treated. There were trivial scars of the knees bilaterally of no clinical or functional significance. The examiner stated that while they are most likely related to the cellulitis he describes, they were of absolutely no functional significance. The examiner stated that cellulitis is a limited infection of the skin and soft tissues, and has no relationship with the underlying bones and joints and never at any time involved the Veteran's bones or joints. The examiner concluded that the Veteran's current osteoarthritis, in her opinion is therefore not related to his brief episode of cellulitis 44 years ago. On VA respiratory examination in May 2012, the Veteran reported that prior to age 9-10 he experienced asthma. It then resolved and he had no additional difficulty until he was in the Marines at Parris Island. He said he was treated there and was offered the opportunity for a discharge from the service. He reported occasional difficulty breathing during service, and said he was diagnosed with COPD in 2007. He started smoking while in the service and then quit in the early 1980s. While smoking, he smoked a pack of cigarettes per day. The examiner diagnosed COPD, and did not diagnose asthma. The examiner indicated that the Veteran used inhalational bronchodilator therapy, inhalational anti-inflammatory medication and Titropium inhaler on a daily basis for COPD. On physical examination, the lungs were clear without rales or rhonchi, and there was decreased flow in expiration without wheezing. The examiner noted that an April 2011 chest X-ray study showed no acute disease, and that May 2012 pulmonary function tests were normal pre-bronchodilator. The examiner stated that the claims file was reviewed, and that at the time of his induction physical, the Veteran was noted to have a history of asthma in childhood. During his term of service he was treated for a single episode of asthmatic bronchitis in July 1968. He had subsequent diagnoses of COPD and coal miner's pneumoconiosis, but not asthma. Although he currently reported limitations in his physical capabilities due to pulmonary disease, his pulmonary function tests were rated as "essentially normal." She concluded that therefore any current pulmonary limitation he might have is less likely than not (less than 50 percent) related to his remote history of asthma and is more likely than not (50 percent or greater) related to COPD and/or pneumoconiosis. Analysis The Board has reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Asthma The evidence reflects that the Veteran has consistently and credibly reported that he had asthma as a child, but that he did not have this condition for several years prior to entry into service. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has distinguished between those cases in which the preexisting condition is noted upon entry into service, and those cases in which the preexistence of the condition must otherwise be established. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); Horn v. Shinseki, 25 Vet. App. 231, 234 (2012); see also 38 U.S.C. § 1111 (presumption of sound condition). In a case where there is no preexisting condition noted upon entry into service, the Veteran is presumed to have entered service in sound condition, and the burden falls to the government to demonstrate by clear and unmistakable evidence that (a) the condition preexisted service and (b) the preexisting condition was not aggravated by service. Wagner, 370 F3d. at 1345; Horn, 25 Vet. App. at 234; 38 U.S.C. § 1111. To be "noted" within the meaning of the presumption of soundness statute, the condition must be recorded in the entrance examination report. 38 C.F.R. § 3.304(b); see also 38 U.S.C. § 1111; Crowe v. Brown, 7 Vet. App. 238, 245 (1994). History of pre-service existence of a disease does not constitute a notation of such condition. See id. at 240 (holding that "asthma" was not noted where, although the Veteran checked a box indicating that he had a history of the disease, a clinical evaluation detected no abnormalities of the lungs). However, the disease need not be symptomatic at the time of the evaluation, so long as a diagnosis is provided. See Verdon v. Brown, 8 Vet. App. 529, 530 (1996) (holding that "bunions" were noted at induction examination where orthopedic examiner diagnosed "bunions," despite also stating "no problem [with] feet."). Here, the Board finds that the condition of asthma was not noted upon entry into service. Although the Veteran reported a history of asthma as a young child, no relevant disability was noted on the entrance examination. Accordingly, the presumption of soundness applies as to the Veteran's asthma. Therefore, if the Board is to find that the presumption of soundness is rebutted and that the Veteran's asthma preexisted service, it must find (1) that clear and unmistakable evidence shows that asthma preexisted service; and (2) that clear and unmistakable evidence shows that his asthma was not aggravated by service. Horn, 25 Vet. App. at 234. The Board finds that these requirements are not shown, and thus the Veteran is presumed to have been in sound condition as to asthma upon entry into service. STRs reflect that the Veteran was treated for a single episode of acute asthmatic bronchitis in service, and that his lungs and chest were normal on separation examination. The post-service evidence is entirely negative for treatment of asthma, and is negative for any respiratory disorder for many years after service. On physical examination in 1976 and 1977, the examining physician indicated that his chest and lungs were normal upon examination. Treatment records since 2006 reflect a diagnosis of COPD, and some physicians have diagnosed coal worker's pneumoconiosis. Although Dr. K. diagnosed asthma in his July 2007 form completed for VA, in his contemporaneous treatment records, he did not diagnose this disorder. Rather, he diagnosed COPD and coal worker's pneumoconiosis. Moreover, in that form, he stated that asthma was "possibly" related to service. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). On VA examination in May 2012, the VA examiner diagnosed COPD, and did not diagnose current asthma. She noted that pulmonary function tests were rated as "essentially normal," and concluded that therefore any current pulmonary limitation he might have is less likely than not (less than 50 percent) related to his remote history of asthma and is more likely than not (50 percent or greater) related to COPD and/or pneumoconiosis. In Brammer v. Derwinski, 3 Vet. App. 223 (1992), the Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in disability. See also Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) [service connection may not be granted unless a current disability exists]. A "current disability" means a disability shown by competent medical evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). Here, though, the Board finds that the weight of the competent and credible evidence shows that the Veteran does not have current chronic asthma, and did not have it at any point since filing this claim. See McClain, supra. The Veteran himself has asserted that he has chronic asthma that is related to service. But he is not shown to be competent to determine whether he has asthma, much less as a result of his military service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." This determination necessarily is based on the results of objective clinical testing and data. Therefore, the Veteran has failed to satisfy the most essential requirement for service connection, which as explained is first establishing he has a current disability of asthma. Absent establishment of this required current disability, there necessarily is no disability to attribute to his military service so as to, in turn, warrant service connection. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). See, too, Maggitt v. West, 202 F.3d 1370, 1375 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); and Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998). Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for asthma. So there is no reasonable doubt to resolve in his favor, and this claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Cellulitis of the Legs The Veteran contends that he has chronic residuals of in-service cellulitis of the knees, to include scars on his kneecaps. STRs reflect that the Veteran was treated for a single episode of cellulitis of the left knee in service, and that his lower extremities were normal on separation examination in 1970. No scars of the legs were noted at that time, although a left kneecap scar was previously noted on entrance examination in 1968. The post-service evidence is entirely negative for treatment of cellulitis. In July 2007, the Veteran's private physician only diagnosed "history" of cellulitis, not current cellulitis. The May 2012 VA examiner indicated that the Veteran did not currently have any evidence of an active cellulitis. She added that this was to be expected, as cellulitis is usually of brief existence if properly treated. There were trivial scars of the knees bilaterally of no clinical or functional significance. The examiner stated that while they are most likely related to the cellulitis he describes, they were of absolutely no functional significance. In sum, the Board finds that the weight of the competent and credible evidence shows that the Veteran does not have current chronic cellulitis of the legs, and did not have it at any point since filing this claim. See McClain, supra. The Veteran himself has asserted that he has chronic cellulitis of the legs that is related to service. However, he is not competent to make this conclusion. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the issue of whether he has chronic cellulitis that is related to service 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)." Similarly, as the medical evidence does not reflect a current disability of cellulitis, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for chronic cellulitis. So there is no reasonable doubt to resolve in his favor, and this claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. However, despite the notation of a left kneecap scar on service entrance examination in 1968, the Board finds that the evidence is in relative equipoise as to whether the current bilateral knee scars were incurred during service as a result of acute cellulitis. In consideration of the Veteran's statements and the May 2012 positive opinion by the VA examiner, and resolving all reasonable doubt in his favor concerning the origin of his bilateral kneecap scars, the Board finds that service connection is warranted for these scars as a residual of in-service cellulitis. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 An "absolutely accurate" determination of etiology is not a condition precedent to granting service connection, nor is "definite" or "obvious" etiology; this need only be an as likely as not proposition, which in this instance it is. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). CAD A review of the evidence reflects that the Veteran has current CAD. Consequently, the determinative issue is whether or not this disability is attributable to his military service. See Watson, supra. STRs are entirely negative for CAD and hypertension, and hypertension was not diagnosed until many years after service. CAD was diagnosed even later. The Veteran does not contend, and the evidence does not reflect, that his current CAD is related to his active service. Rather, he contends CAD is secondary to asthma or cellulitis. As discussed above, service connection is denied for these disabilities, and thus service connection is not possible on a secondary basis. See 38 C.F.R. § 3.310. While the Veteran has been diagnosed with CAD, there is no evidence of CAD or hypertension in service or for many years thereafter, there is no evidence of manifestation of the condition during any applicable presumptive period, and there is no medical evidence of a nexus relating the asserted condition to service or a service-connected disability. The Veteran also does not contend that he had continuous cardiac symptoms since service. As discussed above, the Board finds that the most probative evidence demonstrates that the Veteran's CAD is not attributable to his military service. Even considering the Veteran's lay statements with regard to the matters it is competent to address, the most probative evidence weighs against the claim of entitlement to service connection. In sum, the Board finds that the preponderance of the evidence indicates that CAD was not shown in service or for years thereafter, and the current CAD has not been shown by competent and probative medical evidence to be etiologically related to his active service or a service-connected disability. As the preponderance of the evidence is against the claim for service connection for CAD, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 49. ORDER Service connection for asthma is denied. Service connection for chronic cellulitis is denied. Service connection for residual cellulitis scars of the bilateral kneecaps is granted, subject to the laws and regulations governing the payment of monetary benefits. Service connection for CAD is denied. REMAND While the previously remanded issues have been pending at the AMC, the RO has been adjudicating other claims and conducting additional development, including obtaining VA medical records, which have been associated with the Veteran's electronic Virtual VA file. Moreover, the Veteran submitted a private medical record pertaining to left knee replacement surgery in November 2012. Some of this additional evidence is relevant to the issue of service connection for a bilateral knee disability, but has not yet been reviewed by the RO in the context of the instant appeal, with issuance of a supplemental statement of the case. Such must be done prior to appellate review in order to provide due process to the Veteran. See 38 C.F.R. §§ 19.31, 19.37(a) (2012). With respect to the claim for service connection for restless leg syndrome, the Board finds that an addendum medical opinion is necessary regarding this disorder. A December 2006 private medical record reflects that he was diagnosed with restless leg syndrome. The Veteran contends that this disorder is related to his documented in-service cellulitis of the knees. This issue is remanded for a medical opinion as to the etiology of this condition. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). See also McLendon v. Nicholson, 20 Vet. App. 79 (2006) and Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (When determining whether a VA examination is required under 38 U.S.C. § 5103A(d)(2), the law requires competent evidence of a disability or persistent or recurrent symptoms of a disability, but does not require competent evidence of a nexus, only that the evidence suggest an association between the disability and service or a service-connected disability.) Any additional relevant VA medical evaluation and treatment records should be obtained. 38 U.S.C.A. § 5103A(c); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have treated him for bilateral knee disabilities and/or restless leg syndrome since service (the records of which have not already been submitted or obtained). After securing any necessary releases, obtain any records that are not duplicates of those already in the claims file. 2. Forward the claims file to the examiner who conducted the May 2012 VA examination, for an addendum medical nexus opinion concerning the etiology of restless leg syndrome. In particular, medical opinion is needed concerning the likelihood (very likely, as likely as not, or unlikely) that any current restless leg syndrome is related to incidents in service, to include cellulitis. A complete rationale should be provided to support the medical opinion. If the May 2012 VA examiner is unavailable, an appropriate examiner should be asked to provide the requested opinion. 3. The RO should readjudicate the appeals for service connection for a bilateral knee disability and restless leg syndrome, with consideration of all of the evidence received since the November 2012 supplemental statement of the case. If the benefits sought on appeal remain denied, the appellant and his representative should be furnished a supplemental statement of the case and given the opportunity to respond. Thereafter the case should be returned to the Board for appellate review. 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 that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs