Citation Nr: 1334192 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 04-31 736 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a back disorder. 2. Entitlement to service connection for a sinus disorder. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for onychomycosis of the toenails. 5. Entitlement to service connection for tinea pedis. 6. Entitlement to service connection for asbestosis. 7. Entitlement to service connection for a bilateral eye disorder. 8. Entitlement to service connection for right carpal tunnel syndrome. 9. Entitlement to service connection for arthritis of the right thumb. 10. Entitlement to service connection for a left knee disorder. 11. Entitlement to service connection for a bilateral hip disorder. 12. Entitlement to service connection for a left side lipoma. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs ATTORNEY FOR THE BOARD John Kitlas, Counsel INTRODUCTION The Appellant enlisted in the U.S. Army Reserves in April 1974, and remained enlisted for more than 35 years. She apparently separated from Reserve service in 2001. She had many periods of active duty for training (ACDUTRA) and many periods of inactive duty for training from 1974 through 2001. She had brief periods of active duty for special work (ADSW), including ADSW from April 23, 1999 to April 25, 1999, and from March 23, 2000, to March 26, 2000. These two periods of ADSW were apparently treated as ACDUTRA for pay purposes. This matter initially came before the Board of Veteran's Appeals (Board) on appeal from September 2003 and October 2003 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Board remanded the current appellate claims in June 2006, October 2007, December 2008, March 2010, December 2011, and December 2012. In pertinent part, the Board directed that attempts be made to obtain service treatment records regarding the Appellant's service in the Reserves, verify her dates of ACDUTRA and inactive duty training, and that she be accorded VA medical examination(s) to evaluate the nature and etiology of her claimed disabilities. A review of the record reflects efforts were made to obtain additional service records through official sources. Similarly, various efforts were undertaken to verify her dates of ACDUTRA and inactive duty training through official sources. Further, the Appellant was accorded VA medical examinations in August 2013, with a VA Independent Examiner's Review Opinion promulgated in September 2013 as well. For the reasons stated below, the Board finds that the competent medical opinions expressed therein are adequate for resolution of this case. All other development directed by the Board's prior remands appear to have been substantially accomplished. Accordingly, a new remand is not required in order to comply with the holding of Stegall v. West, 11 Vet. App. 268 (1998). See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (Remand not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). FINDINGS OF FACT 1. The preponderance of the competent medical and other evidence of record is against a finding the Appellant currently has a back disorder that was incurred in or otherwise the result of her military service, to include periods of ACDUTRA and/or inactive duty training. 2. The preponderance of the competent medical and other evidence of record is against a finding the Appellant currently has a sinus disorder that was incurred in or otherwise the result of her military service, to include periods of ACDUTRA and/or inactive duty training. 3. The preponderance of the competent medical and other evidence of record is against a finding the Appellant currently has bilateral hearing loss as defined by VA regulations that was incurred in or otherwise the result of her military service, to include periods of ACDUTRA and/or inactive duty training. 4. The preponderance of the competent medical and other evidence of record is against a finding the Appellant currently has onychomycosis of the toenails that was incurred in or otherwise the result of her military service, to include periods of ACDUTRA and/or inactive duty training. 5. The preponderance of the competent medical and other evidence of record is against a finding the Appellant currently has tinea pedis that was incurred in or otherwise the result of her military service, to include periods of ACDUTRA and/or inactive duty training. 6. The preponderance of the competent medical and other evidence of record is against a finding the Appellant currently has asbestosis that was incurred in or otherwise the result of her military service, to include periods of ACDUTRA and/or inactive duty training. 7. The preponderance of the competent medical and other evidence of record is against a finding the Appellant currently has a bilateral eye disorder that was incurred in or otherwise the result of her military service, to include periods of ACDUTRA and/or inactive duty training. 8. The preponderance of the competent medical and other evidence of record is against a finding the Appellant currently has right carpal tunnel syndrome that was incurred in or otherwise the result of her military service, to include periods of ACDUTRA and/or inactive duty training. 9. The preponderance of the competent medical and other evidence of record is against a finding the Appellant currently has arthritis of the right thumb that was incurred in or otherwise the result of her military service, to include periods of ACDUTRA and/or inactive duty training. 10. The preponderance of the competent medical and other evidence of record is against a finding the Appellant currently has a left knee disorder that was incurred in or otherwise the result of her military service, to include periods of ACDUTRA and/or inactive duty training that was incurred in or otherwise the result of her military service, to include periods of ACDUTRA and/or inactive duty training. 11. The preponderance of the competent medical and other evidence of record is against a finding the Appellant currently has a bilateral hip disorder that was incurred in or otherwise the result of her military service, to include periods of ACDUTRA and/or inactive duty training. 12. The preponderance of the competent medical and other evidence of record is against a finding the Appellant currently has a left side lipoma that was incurred in or otherwise the result of her military service, to include periods of ACDUTRA and/or inactive duty training. CONCLUSIONS OF LAW 1. The criteria for a grant of service connection for a back disorder are not met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304 (2013). 2. The criteria for a grant of service connection for a sinus disorder are not met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304 (2013). 3. The criteria for a grant of service connection for bilateral hearing loss are not met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304, 3.385 (2013). 4. The criteria for a grant of service connection for onychomycosis of the toenails are not met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304 (2013). 5. The criteria for a grant of service connection for tinea pedis are not met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304 (2013). 6. The criteria for a grant of service connection for asbestosis are not met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304 (2013). 7. The criteria for a grant of service connection for a bilateral eye disorder are not met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304 (2013). 8. The criteria for a grant of service connection for right carpal tunnel syndrome are not met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304 (2013). 9. The criteria for a grant of service connection for arthritis of the right thumb are not met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304 (2013). 10. The criteria for a grant of service connection for a left knee disorder are not met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304 (2013). 11. The criteria for a grant of service connection for a bilateral hip disorder are not met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304 (2013). 12. The criteria for a grant of service connection for a left side lipoma are not met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters The Board notes at the outset that, in accord with the Veterans Claims Assistance Act of 2000 (VCAA), VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice requirements of the VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The United States Court of Appeals for Veterans Claims (Court) has indicated that VCAA notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA must provide a claimant VCAA notice before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Dingess/Hartman, supra; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the Appellant was sent VCAA-compliant notification via letters dated in October 2002, October 2003, December 2003, June 2006, November 2007, February 2009, May 2010, March 2012, and January 2013. Although it is clear that all of these letters were not sent prior to the initial adjudication of the current appellate claims in September and October 2003, they were all sent prior to the last adjudication of these claims below via a September 2013 Supplemental Statement of the Case (SSOC). Such development "cures" the timing problem associated with inadequate notice or the lack of notice prior to the initial adjudication. Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (Mayfield III), citing Mayfield II, 444 F.3d at 1333-34. The Board notes that the aforementioned VCAA letters informed the Appellant, in pertinent part, of what was necessary to substantiate a service connection claim, what information and evidence she must submit, what information and evidence will be obtained by VA, as well as the information and evidence used by VA to determine disability rating(s) and effective date(s) should service connection be established. In view of the foregoing, the Board finds that the Appellant was notified and aware of the evidence needed to substantiate her claims and the avenues through which she might obtain such evidence, and of the allocation of responsibilities between herself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. In any event, the Appellant has not demonstrated any prejudice with regard to the content or timing of any notice. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). In addition, the Board finds that the duty to assist a claimant in the development of his or her case has been satisfied. The Board acknowledges that all of the Appellant's service treatment records are not on file, and that all reasonable efforts to obtain such records through official sources appear to have been exhausted. In such situations VA has a heightened obligation to explain its findings and conclusions and carefully consider the benefit-of-the-doubt rule. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). However, the case law does not lower the legal standard for proving a claim for service connection but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the Appellant. See Russo v. Brown, 9 Vet. App. 46 (1996). Moreover, there is no presumption, either in favor of the claimant or against VA, arising from missing records. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) (Wherein the Court declined to apply an "adverse presumption" where records have been lost or destroyed while in government control which would have required VA to disprove a claimant's allegation of injury or disease). Various other records were obtained and considered in conjunction with this case, to include from the Social Security Administration (SSA). Further, the Appellant has had the opportunity to present evidence and argument in support of her claims, and nothing indicates she has identified the existence of any relevant evidence that has not been obtained or requested. The Board further notes the Appellant was accorded VA medical examinations in August 2013. Granted, these examinations did not specifically opine as to the etiology of the claimed disabilities as it was noted the claims folder was not available for review. However, a VA Independent Examiner's Review Opinion was promulgated in September 2013 that included opinions that addressed the nature and etiology of the claimed disabilities. As these opinions were based upon accurate understanding of the Appellant's medical history based upon review of his VA claims folder which included the detailed findings of the August 2013 VA examination as to the current nature thereof, the Board finds they are supported by an adequate foundation. No competent medical evidence is of record which specifically refutes the findings of these competent medical opinions, and the Appellant has not otherwise identified any prejudice therein. As such, the Board finds that this development is adequate for resolution of this case. In view of the foregoing, the Board finds that the duty to assist the Appellant has been satisfied. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (The Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (Noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether a claimant's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the claimant, and the claimant's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). General Legal Criteria Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). Active service includes any period of ACDUTRA during which the individual was disabled from a disease or an injury incurred in the line of duty, or a period of inactive duty training during which the veteran was disabled from an injury incurred in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a). Further, ACDUTRA includes full-time duty in the Armed Forces performed by the Reserves for training purposes. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c). Inactive duty training includes duty, other than full-time duty, prescribed for the Reserves. 38 U.S.C.A. § 101(23)(A). Reserves includes the National Guard. 38 U.S.C.A. § 101(26), (27). The presumption of sound condition provides: [E]very veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. See 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). According to 38 U.S.C.A. § 1153, a "preexisting injury or disease will be considered to have been aggravated by active . . . service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease." Certain evidentiary presumptions - such as the presumption of sound condition at entrance to service, the presumption of aggravation during service of preexisting diseases or injuries which undergo an increase in severity during service, and the presumption of service incurrence for certain diseases, which manifest themselves to a degree of disability of 10 percent or more within a specified time after separation from service - are provided by law to assist veterans in establishing service connection for a disability or disabilities. 38 U.S.C.A. §§ 101, 1112; 38 C.F.R. § 3.304(b), 3.306, 3.307, 3.309. However, the advantages of these evidentiary presumptions do not extend to those who claim service connection based on a period of ACDUTRA or inactive duty training. Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995) (Noting that the Board did not err in not applying presumptions of sound condition and aggravation to appellant's claim where he served only on ACDUTRA and had not established any service-connected disabilities from that period); McManaway v. West, 13 Vet. App. 60, 67 (1999) (Citing Paulson, 7 Vet. App. at 469-70, for the proposition that, 'if a claim relates to period of [ACDUTRA], a disability must have manifested itself during that period; otherwise, the period does not qualify as active military service and claimant does not achieve veteran status for purposes of that claim.'). For the purpose of applying the laws administered by VA, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; or when the auditory threshold for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Further, the Court has indicated that the threshold for normal hearing is between 0 and 20 decibels and that higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). When audiometric test results at a veteran's separation from service do not meet the regulatory requirements for establishing a "disability" at that time, he may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley, 5 Vet. App. at 160. Regarding the asbestos-related claim, the Board notes that there is no specific statutory guidance with regard to asbestos-related claims, nor has the Secretary promulgated any regulations in regard to such claims. However, the VA Adjudication Procedure Manual, M21-MR, Park IV, Subpart ii, Chapter 2, Section C, provides information concerning claims for service connection for disabilities resulting from asbestos exposure. The Court has held that VA must analyze an appellant's claim for service connection for asbestosis or asbestos-related disabilities under the appropriate administrative guidelines. Ennis v. Brown, 4 Vet. App. 523 (1993); McGinty v. Brown, 4 Vet. App. 428 (1993). The Manual defines asbestos as a fibrous form of silicate mineral of varied chemical composition and physical configuration, derived from serpentine and amphibole ore bodies. M21-1MR, Part IV, Subpart ii, Chapter 2, Section C, Subsection (a). Common materials that may contain asbestos are steam pipes for heating units and boilers, ceiling tiles, roofing shingles, wallboard, fire-proofing materials, and thermal insulation. Id. at Subsection (a). Some of the major occupations involving exposure to asbestos include mining, milling, shipyard work, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products (such as clutch facings and brake linings), and manufacture and installation of products such as roofing and flooring materials, asbestos cement sheet and pipe products, and military equipment. Id. at Subsection (f). Asbestos fiber masses have a tendency to break easily into tiny dust particles that can float in the air, stick to clothes, and may be inhaled or swallowed. Id. at Subsection (b). Inhalation of asbestos fibers can produce fibrosis (the most commonly occurring of which is interstitial pulmonary fibrosis, or asbestosis), tumors, pleural effusions and fibrosis, pleural plaques, mesotheliomas of pleura and peritoneum, and cancers of the lung, bronchus, gastrointestinal tract, larynx, pharynx, and urogenital system (except the prostate). Id. at Subsection (b). The latent period for the development of disease due to exposure to asbestos ranges from 10 to 45 or more years (between first exposure and the development of disease). Id. at Subsection (d). The adjudication of a claim for service connection for a disability resulting from asbestos exposure should include a determination as to whether: (1) service records demonstrate the claimant was exposed to asbestos during service; (2) development has been accomplished sufficient to determine whether the claimant was exposed to asbestos either before or after service; and (3) a relationship exists between exposure to asbestos and the claimed disease in light of the latency and exposure factors. Id. at Subsection (h). Analysis In this case, the Appellant essentially contends that she developed various disabilities as a result of her service in the Reserves. For example, she contends that her current sinusitis is the result of "gas training" in "boot camp" in April 1974. She also contends that she was exposed to asbestos during periods of Reserve service and developed asbestosis as a result thereof. The Board notes that inhalations of certain substances may be considered an "injury" for purposes of this case. See VAOPGCPREC 08-2001 (Defining injury for purposes of 38 U.S.C.A. § 101(24)). In addition, the Appellant contends that she incurred tinea pedis and onychomycosis, among other diseases and injuries, in "boot camp" in 1974. Moreover, the Appellant contends that a hearing loss disability was incurred in 1997, and that a bilateral eye disorder, carpal tunnel syndrome, arthritis of the right thumb, left knee, and the hips was incurred during Reserve enlistment from 1998 through 2001. The Appellant contends that a lipoma of the left side resulted from lifting and strenuous training. However, she has not identified any specific period of ACDUTRA or inactive duty training during which the lipoma was incurred and was disabling. Initially, the Board acknowledges that the Appellant is competent, as a lay person, to describe visible symptoms such as pain and numbness of the back and joints, respiratory problems, vision problems, hearing problems, and skin problems. However, the Board also finds that competent medical evidence is required to determine whether these complaints are due to chronic disabilities, as opposed to acute and temporary disease or injury, and, if so, the etiology thereof. This is consistent, in part, with the fact that the Court has previously held that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Further, whether such complaints are due to a neurologic disability is the type of case that requires specific medical testing to verify. Similarly, specific medical testing is required to determine whether one has a hearing loss disability as defined by 38 C.F.R. § 3.385, and such testing must be conducted in accord with the requirements of 38 C.F.R. § 4.85(a) in order to be deemed valid for VA purposes. Competent medical testing also appears necessary to determine the specific nature of skin problems. In addition, vision loss - a refractive error of the eye - is one of the specific conditions that VA does not grant service connection for, as it is not considered a disability for VA purposes. See 38 C.F.R. §§ 3.303(c), 4.9. Such a condition is part of a life-long defect, and is normally a static condition which is incapable of improvement or deterioration. See VAOGCPREC 67-90 (1990). Thus, competent medical evidence is necessary to determine whether visual complaints are due to a condition other than refractive error, and, if so, whether such is due to an acquired disability. To the extent the Appellant is claiming arthritis and a lung disability, the Board notes that these are internal conditions, not subject to lay observation. Moreover, to the extent the Appellant claims a current disability is due to purported in-service asbestos exposure, this involves complex medical issues as such conditions can develop decades after exposure and requires medical testing to determine whether respiratory complaints are even due to such exposure. In view of the foregoing, the Board finds that competent medical evidence is necessary in order to determine the nature and etiology of the Appellant's claimed disabilities. Here, nothing on file shows that the Appellant has the requisite knowledge, skill, experience, training, or education to render a medical opinion. Consequently, her contentions cannot constitute competent medical evidence. 38 C.F.R. § 3.159(a)(1). A review of the Appellant's available service records reflect that her military occupational specialty (MOS) during the Reserves primarily consisted of duties of those of a supply clerk, to include supervision of other clerks and personnel in the supply chain. Further, the record reflects she consistently received positive performance evaluations in her conduct of these duties. Nevertheless, these duties appear to be inconsistent with several of the injuries identified by the Appellant, to include asbestos exposure. The Board also observes that the Appellant indicated on a Report of Medical History completed in conjunction with her April 1974 enlistment examination that she wore glasses or contact lenses. She did not indicate she had eye trouble at that time. The enlistment examination itself notes distant vision correctable to 20/20, but does not note the uncorrected vision. Subsequent examinations in May 1979, May 1982, May 1986, April 1990, November 1993, and January 1999 all indicated impairment of uncorrected distant vision, correctable to 20/20. The Appellant also indicated on Reports of Medical History beginning in May 1979 that she had eye trouble. She indicated on the April 1974, May 1979, and May 1982 Reports of Medical History that she had not experienced sinusitis, but indicated she had experienced sinusitis beginning with the May 1986 Report of Medical History. The physician's comments section to the May 1986 Report indicates these complaints were intermittent, while the April 1990 Report notes it occurred when the weather changes. On all of these Reports of Medical History, the Appellant indicated she had not experienced swollen or painful joints, hearing loss, skin diseases, tuberculosis, asthma, shortness of breath, recurrent back pain, nor "trick" or locked knee. Moreover, the Appellant's eyes, sinuses, ears, lungs and chest, upper and lower extremities, spine, and neurologic system were all consistently evaluated as normal on the examinations themselves. The Board also notes that while the Appellant was treated for puncture wound to the left lower tibia in June 1984 due to a cut from a broken ashtray, it does not appear she was specifically treated for any left knee problems. Further, there is no indication in the available service treatment records of any treatment for the back, skin problems to include onychomycosis of the toenails and/or tinea pedis, respiratory problems to include asbestosis, carpal tunnel syndrome, the right thumb, the hips, or lipoma. The Board does acknowledge that audiological evaluation conducted as part of the Appellant's service examinations reflect changes in her hearing acuity over the period of her Reserve service. For example, audiological evaluation conducted as part of the April 1974 enlistment examination revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 15 15 15 -- 15 -- LEFT 15 15 15 -- 15 -- The May 1979 audiological evaluation revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 15 15 15 15 -- 15 LEFT 10 15 15 10 -- 15 Audiological evaluation on the May 1982 examination showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 5 0 15 -- 5 20 LEFT 5 10 0 -- 40 20 Audiological evaluation conducted as part of a December 1982 follow-up obesity/weight evaluation examination revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 0 -10 5 -- 5 20 LEFT -5 5 0 -- 40 25 The May 1986 examination reflects that audiological evaluation revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 10 5 20 15 5 35 LEFT 5 5 0 35 40 25The A The April 1990 examination reflects audiological evaluation revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 5 5 0 -- 5 -- LEFT 5 0 0 -- 35 -- The November 1993 examination reflects audiological evaluation revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 10 10 10 -- 15 -- LEFT 15 10 10 -- 15 -- Finally, the January 1999 examination reflects audiological evaluation revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 5 0 5 15 15 40 LEFT 10 10 10 35 50 45 The Board also acknowledges that various complaints were noted in non-service medical records contemporaneous with and/or shortly after the Appellant's years of Reserve service. For example, she was treated for soreness in the left leg in July 1998. It was noted that she had no definite injury, but had been walking a lot. Examination of the knee and ankle, as well as X-rays, were noted as being unremarkable. Assessment was musculoskeletal pain. The Appellant was treated for complaints of sinus pressure of 3 weeks duration in August 1998. Assessments were sinusitis, UTI, and allergic rhinitis. Subsequent records from December 1998 noted complaints of pressure in the left side of face, yellow sinus drainage, and being a little bit light headed. Assessment were history of allergic rhinitis, sinusitis, and anemia with history of menorrhagia. She was again treated for allergic rhinitis, sinusitis, as well as bronchitis/bronchospasm, in December 1999. Similar findings were noted on March 2002 records. Records dated in February 1999 show impressions of lumbosacral strain, muscle spasm, and low back pain. The Appellant reported at that time she had been doing more lifting and working out than usual, and had the onset of some pain on Friday. Records dated in March 1999 note the Appellant complained that she had been sore in her chest recently with knots there. These complaints were assessed as chest wall pain most likely due to the lipoma of the chest wall. She was again treated for complaints of sore chest in April 2000 and February 2001, again assessed as chest wall pain most likely due to lipoma of chest wall. The April 2000 records also noted at that time that she had occasional shortness of breath, but did pass her recent physical evaluation for the Reserves. Other records dated in April 2000 reflect the Appellant reported her left hip had been hurting for the past few weeks, off and on. Physical examination of the back also showed soreness of the left sacroiliac (SI) joint, as well as the left lumbar region. X-rays showed mild degenerative changes of the left hip. Records from July 2000 reflect the Appellant reported her right wrist and hand had been bothering her the past few months, off and on, with numbness in the right thumb at times. X-rays of the right thumb/hand revealed degenerative changes. Assessment was degenerative arthritis - possible carpal tunnel symptoms. Similar findings were noted on August 2002 records. Additional records from August 2002 include X-ray findings of degenerative changes of the left knee. An August 2002 private medical statement reported that the Appellant had been evaluated and found to have several problems includes: high frequency hearing loss in both ears, left greater than right; degenerative arthritis of right thumb and left knee; probable carpal tunnel syndrome right wrist; and onychomycosis of toenails with some tinea pedis. The Board observes that these non-service medical records do not indicate any of the claimed disabilities were due to a disease or injury that occurred while the Appellant was participating in Reserve duty. Nevertheless, given the fact that there was evidence of these disabilities during this period of time, it does raise the possible that they developed or were aggravated by such service. This further supports the need for competent medical evidence to resolve the nature and etiology of the claimed disabilities. The Board notes that there is no competent medical opinion of record that specifically relates the etiology of any of the claimed disabilities to the Appellant's military service, to include periods of ACDUTRA or inactive duty training. For example, a September 2003 private medical statement from Dr. V. Moore noted that the Appellant had tinea pedis as well as onychomycosis of her toenails, as well as complaints of problems with hands tingling, legs hurting, and knees hurting. Dr. Moore noted that the Appellant related these complaints to her previous physical training exercises, and opined that these conditions were most likely related to these physical training exercises. The August 2013 VA medical examinations, in pertinent part, diagnosed sinusitis, right carpal tunnel syndrome, onychomycosis, lumbar spine strain, and left knee strain. However, it was also noted that there was no evidence of asbestosis on examination; that tinea pedis was not noted on examination; that there was no evidence of lipoma on examination (status-post excision); no evidence of hip joint condition on examination; and that there was no evidence of right thumb arthritis. In addition, VA audio examination revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 Average RIGHT 5 5 15 25 30 19 LEFT 10 5 5 40 50 25 Speech recognition scores were 96 percent both ears. Further, evaluation of the eyes resulted in diagnoses of cataracts and maculopathy. The September 2013 VA Independent Examiner's Review Opinion concluded that it was less likely than not that the Appellant's claimed back condition, sinus condition, hearing condition, onychomycosis of the toenails and tinea pedis, lipoma, right thumb and carpal tunnel syndrome, eye condition, left knee, and bilateral hip conditions were caused by or aggravated beyond its natural aging process by her time in military, ACDUTRA, or Reserve services. Further, this VA Independent Examiner also opined that it was less likely than not that the Appellant's claimed asbestosis was clinically present. In making these determinations, the VA Independent Examiner noted the Appellant's contentions, as well as relevant medical findings in the record to include that of the August 2013 VA examinations, and reference to medical literature regarding the nature of the claimed conditions. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a claimant for a long period of time or through a factually accurate medical history reported by a claimant. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. 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). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In this case, the September 2013 VA Independent Examiner is presumed to be qualified to render a competent medical opinion, and was shown to be familiar with the Appellant's medical history based upon review of the VA claims folder. The VA Independent Examiner also cited to relevant findings documented in the record as part of the report itself. Further, the opinions expressed by the VA Independent Examiner were not in speculative or equivocal language, and were supported by stated rationale which included references to relevant findings in the record and medical literature. As already noted, no competent medical evidence is of record which explicitly refutes these opinions. Therefore, the Board finds the opinions expressed by the September 2013 VA Independent Examiner regarding the nature and etiology of the Appellant's claimed disabilities to be persuasive and entitled to significant probative value in adjudicating this case. For these reasons, the Board finds that the preponderance of the competent medical and other evidence of record is against a finding the Appellant currently has a back disorder, sinus disorder, bilateral hearing loss, onychomycosis of the toenails, tinea pedis, a bilateral eye disorder, right carpal tunnel syndrome, right thumb arthritis, bilateral hips disorder, and/or left side lipoma that was incurred in or otherwise the result of her military service, to include periods of ACDUTRA and/or inactive duty training. As the preponderance of the evidence is against these claims, the benefit of the doubt doctrine is not for application in the instant case. See generally Gilbert, supra; see also Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Consequently, the benefit sought on appeal must be denied. ORDER Service connection for a back disorder is denied. Service connection for a sinus disorder is denied. Service connection for bilateral hearing loss is denied. Service connection for onychomycosis of the toenails is denied. Service connection for tinea pedis is denied. Service connection for asbestosis is denied. Service connection for a bilateral eye disorder is denied. Service connection for right carpal tunnel syndrome is denied. Service connection for arthritis of the right thumb is denied. Service connection for a left knee disorder is denied. Service connection for a bilateral hip disorder is denied. Service connection for a left side lipoma is denied. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs