Citation Nr: 1337094 Decision Date: 11/14/13 Archive Date: 11/26/13 DOCKET NO. 07-36 402 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Whether there is new and material evidence to reopen a claim of entitlement to service connection for an acquired psychiatric disorder, including major depressive disorder with psychotic features, anxiety (nervous) disorder, memory loss, and posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a skin disorder, including secondary to herbicide exposure. 3. Entitlement to service connection for a low back disorder. 4. Entitlement to service connection for a sleep disorder, including sleep apnea and manifested by insomnia. 5. Entitlement to service connection for a disorder manifested by head eruptions. 6. Entitlement to service connection for a stomach disorder, claimed as a milk allergy. 7. Entitlement to service connection for deformity of the penis. 8. Entitlement to service connection for a prostate disorder, including benign prostatic hypertrophy (BPH). 9. Entitlement to service connection for heart disease, including arterial hypertension and bradycardia. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD E. Pomeranz, Counsel INTRODUCTION The Veteran had active military service from November 1965 to November 1966. He appealed to the Board of Veterans' Appeals (Board/BVA) from July 2006 and January 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In regards to the new-and-material-evidence claim, the Veteran's original claim for service connection for PTSD was denied in a January 2003 rating decision. He was provided notice of that decision and his appellate rights but did not in response file a notice of disagreement (NOD) to initiate an appeal. Thus, that decision is a final and binding determination based on the evidence then of record. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.104(a), 3.160(d), 20.1103 (2013). In April 2006, he filed a claim of entitlement to service connection for major depression. A subsequent July 2006 rating decision, in pertinent part, determined that new and material evidence had not been submitted to reopen the claim for service connection for major depressive disorder with psychotic features, on the premise this disorder initially was claimed as PTSD. The Veteran appealed. In March 2007, he additionally filed a claim of entitlement to service connection for a generic nervous condition. As well, in an August 2007 statement he alleged that he had memory loss. In a subsequent January 2008 rating decision, the RO denied service connection for major depressive disorder with psychotic features, also claimed as loss of memory and a nervous condition. However, although the RO addressed this claim on a direct basis, it should have been considered instead as part of the new-and-material-evidence claim that was already on appeal. At the time of that January 2008 rating action, the Veteran already had filed and perfected a timely appeal of that other claim (petition to reopen it), which was characterized as whether new and material evidence had been submitted to reopen a claim for service connection for major depressive disorder with psychotic features, claimed as PTSD. Thus, his claims for service connection for a nervous condition and loss of memory derive from that other claim and are not, instead, separate claims. The U.S. Court of Appeals for the Federal Circuit (Federal Circuit Court) has held that, for purposes of determining whether a new claim has been submitted under 38 U.S.C.A. § 7104(b), the "factual basis" of a service-connection claim is the Veteran's disease or injury, rather than the symptoms of that disease or injury. See Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008); see also Ephraim v. Brown, 82 F.3d 399 (Fed. Cir. 1996). The lower U.S. Court of Appeals for Veterans Claims (Veterans Court/CAVC) has determined that the scope of Boggs and Ephraim is limited to claims to reopen. Specifically, the Court stated that Boggs, as well as Ephraim, relies upon a diagnosis to define the scope of a claim only retrospectively - after there has been a finding of fact based upon competent medical evidence. See Clemons v. Shinseki, 23 Vet. App. 1, 8 (2009). In contexts of section 5108 and requests to reopen, this accomplishes a balancing effect that preserves the finality of agency decisions while not precluding Veterans from pursuing claims based on evidence of injuries or diseases distinct from those upon which benefits have been denied. Id. However, the Court determined that the advantages of treating separate diagnoses as separate claims in cases to reopen do not exist where separate diagnoses are rendered for the same reported symptoms during the initial processing of a claim for benefits. Id. In determining whether new and material evidence is required, the focus of the Board's analysis must be on whether the evidence presented truly amounts to a new claim based upon distinctly diagnosed diseases or injuries or whether the evidence substantiates an element of a previously adjudicated matter. See Velez v. Shinseki, 23 Vet. App. 199 (2009). New arguments based on the same evidence of record at the time of the previous final denial do not constitute the presentation of new and material evidence. See Untalan v. Nicholson, 20 Vet. App. 467 (2006). The new-and-material-evidence claim is being recharacterized to include all possible diagnoses in light of the holding of the Court (CAVC) in Clemons. In Clemons, the Court held that a claimant seeking service connection for psychiatric disability who has no special medical expertise is not competent to provide diagnosis requiring application of medical expertise to facts such as his description of history and symptoms; VA therefore should construe a claim for service connection based on reasonable expectations of a non-expert claimant. Thus, the scope of a claim for service connection for a mental disability includes any mental disability that reasonably may be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Clemons at 5-6; see also Brokowski v. Shinseki, 23 Vet. App. 79, 85 (2009) (A claimant's identification of the benefit sought does not require any technical precision), citing Ingram v. Nicholson, 21 Vet. App. 232, 256-57 (2007) (It is the pro se claimant who knows what symptoms he is experiencing and that are causing him disability); see, too, Robinson v. Nicholson, 21 Vet. App. 545, 552 (2008) (The Board is required to consider all issues raised either by the claimant or the evidence of record). In January 2012, the Board remanded these claims for further development. The purposes of that remand have been met, to the extent possible and at least as concerning the claims now being decided. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand); but see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In November 2012 the Veteran submitted a statement in which he indicated he had injured his back during service and since had developed chronic low back pain. He maintained that he currently had a low back disability because of that low back injury in service. Although he did not expressly waive his right to have the RO, rather than the Board, initially consider his statement, his contentions in this statement are essentially duplicative of those he has made previously at other times during the pendency of his appeal. So obtaining a waiver permitting the Board to consider this statement in the first instance is unnecessary. 38 C.F.R. § 20.1304(c). This is especially true since the Board is remanding, rather than immediately deciding, this claim concerning his low back disability regardless. The Board also is remanding, rather than immediately deciding, the claims concerning whether there is new and material evidence to reopen the claim of entitlement to service connection for an acquired psychiatric disorder, including major depressive disorder with psychotic features, anxiety (nervous) disorder, memory loss, and PTSD, and regarding entitlement to service connection for a skin disorder, including as secondary to herbicide exposure. These claims require more development before being decided on appeal. The remand of these claims to the RO will be via the Appeals Management Center (AMC) in Washington, DC. The Board, instead, is going ahead and deciding the remaining claims. FINDINGS OF FACT 1. There is no competent and credible evidence of record showing a current diagnosis of a sleep disorder, including especially current diagnoses of sleep apnea and/or a disability manifested by insomnia. 2. There is no competent and credible evidence of record showing a current diagnosis of a disability manifested by head eruptions. 3. There is no competent and credible evidence of record showing a current diagnosis of a stomach disorder; the Veteran does not have a milk allergy because of his military service. 4. There is no competent and credible evidence of record showing a current diagnosis of a disability manifested by deformity of the penis. 5. The preponderance of the evidence is against finding a correlation between a current prostate disorder, including especially BPH, and his service. 6. The preponderance of the evidence also is against finding a correlation between current heart disease, including precursor arterial hypertension and bradycardia, and his service; his hypertension also did not incept during his service or within one year of his separation from service to a compensable degree. CONCLUSIONS OF LAW 1. The Veteran has not shown he has a sleep disorder, including especially obstructive sleep apnea and/or a disability manifested by insomnia, or a ratable disability manifested by head eruptions, or a stomach disorder, including a milk allergy, or a disability manifested by deformity of his penis as a result of disease or injury incurred in or aggravated by his active military service or that may be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2013). 2. A prostate disorder, including BPH, and heart disease, including precursor arterial hypertension and bradycardia, were not incurred in or aggravated by his service, may not be presumed to have been incurred in service, and are not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA enhanced VA's duties to notify a claimant of the information and evidence necessary to substantiate a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The VCAA also redefined VA's obligations with respect to the duty to assist the Veteran with the claim. Id. The Board finds that VA has satisfied these responsibilities. Duty to Notify VA has a duty to notify the Veteran of the information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. Letters provided the Veteran in May 2006, June 2007, and October 2007 duly apprised him of the information and evidence needed to substantiate and complete his claims, including apprising him of his and VA's respective responsibilities in obtaining the necessary supporting evidence. See 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), indicating that VCAA notice must: (1) inform the claimant of the information and evidence necessary to substantiate the claim; (2) inform the claimant of the information and evidence that VA will obtain; and (3) inform the claimant of the information and evidence he is expected to provide. See also Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Additionally, on March 3, 2006, the Court issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 484, 486 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim. Those five elements are: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability, i.e., disability rating; and (5) effective date of the disability. So, according to the holding in Quartuccio v. Principi, 16 Vet. App. 183 (2002), proper VCAA notice must advise the Veteran of all five of these elements, therefore including the "downstream" disability rating and effective date elements in the eventuality service connection is granted. The May 2006, June 2007, and October 2007 letters already mentioned satisfied this additional obligation. There is no issue as to providing an appropriate application form or completeness of the application. The Veteran received notice of the evidence needed to substantiate his claims, the avenues by which he might obtain such evidence, and the allocation of responsibilities between him and VA in obtaining such evidence. See Beverly, 19 Vet. App. at 394, 403; see also Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 (2005) (Mayfield I), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In addition, the June and October 2007 letters also informed him of how VA determines "downstream" disability ratings and effective dates, as required by Dingess. The Board also recognizes that, according to Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004), VCAA notice ideally should "precede an initial unfavorable [agency of original jurisdiction (AOJ)] decision on a service-connection claim." For the claim for service connection for a sleep disorder, written notice was provided in May 2006, prior to the rating decision denying this claim that was appealed, along with the subsequent notice provided in June and October 2007, after that decision. But this claim since has been readjudicated in June 2010 and November 2012 supplemental statements of the case (SSOCs), and that has rectified ("cured") the timing defect in the provision of those additional notices that did not precede the initial adjudication of the claim. If, for whatever reason, VCAA notice was not provided prior to initially adjudicating a claim or, if provided, was inadequate or incomplete, this timing error can be effectively "cured" by providing any necessary VCAA notice and then readjudicating the claim, including in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated, rather preserved, 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); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). VCAA notices errors, even when shown to have occurred, are not presumptively prejudicial, rather, must be judged on a case-by-case basis. And as the pleading party attacking the agency's decision, the Veteran, not VA, has this burden of proof of not only establishing error, but, above and beyond that, showing how it is unduly prejudicial, meaning outcome determinative of the claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). There is no such pleading, much less showing, in this particular instance. For the claims for service connection for a disability manifested by head eruptions, a stomach condition, claimed as a milk allergy, deformity of the penis, a prostate disorder, including BPH, and heart disease, including precursor hypertension and bradycardia, VA provided the Veteran the required VCAA notice concerning these claims in the June and October 2007 letters mentioned, so prior to the January 2008 decision deciding these claims that is the subject of this appeal. And also with respect to the Dingess requirements, he was provided notice of the type of information and evidence was needed to substantiate these claims, as well as the type of evidence and information necessary to establish a "downstream" disability rating or effective date of an award. Accordingly, he received timely and content-compliant notice concerning these claims. He has been provided opportunities to respond to VA correspondence and over the course of the appeal has had multiple opportunities to submit and identify evidence potentially supportive of his claims. He therefore has been provided a meaningful opportunity to participate effectively in the processing of his claims. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Duty to Assist VA also has a duty to assist the Veteran in obtaining evidence necessary to substantiate the claims. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the Veteran in obtaining records and providing medical examinations or obtaining medical opinions when necessary to make a decision on a claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth the Secretary's various duties to claimant). VA informed the Veteran of its duty to assist him in obtaining records and supportive evidence. To this end, his service treatment and personnel records have been obtained and associated with his claims file for consideration, as have his VA Medical Center (VAMC) outpatient treatment records. Records also from several private treatment providers he identified have been obtained. As for an examination and opinion, the RO did not provide him specific examinations regarding his claims. Regarding his claims for service connection for a sleep disorder, a disability manifested by head eruptions, a stomach disorder, and deformity of the penis, the Board finds that a VA examination is not necessary to decide these claims as the standards of the Court's decision in McLendon v. Nicholson, 20 Vet. App. 79 (2006), have not been met. According to McLendon, VA must provide a medical examination in a service-connection claim when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or a service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. Id. at 81. See also 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). See, too, Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (When determining whether a VA examination and opinion are 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.) This is not to say or suggest that VA is obligated to provide an examination for a medical nexus opinion merely as a matter of course. See Duenas v. Principi, 18 Vet. App. 512, 519 (2004). If such were the case, this would circumvent the craftily tailored language of the statute and regulation governing when examinations and opinions should be obtained and require provision of an examination and opinion in virtually every instance, so virtually without exception. Here, as discussed in greater detail below, there is no competent and credible evidence the Veteran has a sleep disorder, including sleep apnea and a disability manifested by insomnia, or a disability manifested by head eruptions, or a stomach disorder, or deformity of his penis. Therefore, the first factor in determining whether a medical examination and opinion are necessary is not satisfied, and the Board resultantly declines to afford him an examination concerning these claims. His mere personal belief that he has these conditions and, even further, that he has them because of his military service are insufficient to trigger the duty to assist by arranging for a VA compensation examination and opinion, because if that were the case every known Veteran imaginable could simply make such an assertion and, on that basis alone, claim consequent entitlement to a VA examination and opinion. To reiterate, VA is not required to schedule an examination for a medical opinion merely as a matter of course. See Duenas, 18 Vet. App. at 519 (indicating that, generally, VA is not obligated to provide an examination for a medical nexus opinion based on unsubstantiated lay statements alone). Accordingly, the Board finds that remand for a VA medical examination and opinion is unwarranted. With respect to his remaining claims, the Veteran did undergo some examinations that were related to those claims. However, the pertinent nexus questions were not addressed. For example, in November 2007 he underwent a VA examination and was diagnosed with BPH. However, the examiner did not address the pertinet question of whether the Veteran's currently diagnosed BPH was related to his service. In addition, in June 2006 he underwent a VA examination and was diagnosed with bradycardia and high blood pressure. However, the examiner did not address the pertinent question of whether the Veteran's currently diagnosed bradycardia and hypertension were related to his service. Regardless, the standards of McLendon are not met because there is no competent evidence indicating his currently diagnosed BPH, hypertension, and/or bradycardia may be related to his period of active military service. In addition, his lay statements alone would not be competent to link any of these disabilities to his service. The best he could do would be to say he has experienced continuous symptoms since his service, but even then he would be incompetent to ascribe those symptoms, whatever they may be, to a particular diagnosis, so could not say they necessarily were the result of these specifically alleged conditions. The Board recognizes he is competent even as a layman to proclaim having experienced relevant symptoms (e.g., urinary problems) ever since his service, even if not also competent to say they necessarily are the result of his military service and the claimed disorders. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). See also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). But, most importantly, he has not made specific contentions of experiencing continuous symptoms since service. With respect to his BPH, although he has reported having urinary problems, he has not maintained that he has had them since his service. In addition, during his November 2007 VA examination he stated that he could not remember when he had started having problems with his prostate. Moreover, with respect to his hypertension and bradycardia, he has not made any contentions regarding whether he has experienced continuous symptoms since service concerning these other claimed conditions, either. Furthermore, his service treatment records (STRs) are unremarkable for any relevant complaints or findings of a prostate disorder, including of BPH especially, or a heart disability, including precursor hypertension and/or bradycardia. On these facts, then, no examination is required. See Bardwell v. Shinseki, 24 Vet. App. 36, 39-40 (2010) (holding that VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service). For all of these reasons, it is the Board's determination that VA has comported with its duties to notify and assist the Veteran with these claims, and thus, no additional assistance or notification is required. He has suffered no prejudice that would warrant a remand of these claims being decided, and his procedural due process rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Governing Statutes, Regulations and Case Law Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the regulations, the Federal Circuit Court held that a three-element test must be satisfied in order to establish entitlement to service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a relevant disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases-namely those listed in 38 C.F.R. § 3.309(a)-benefit from a somewhat more relaxed evidentiary standard. See Walker, supra (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes"). 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show 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." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain or abnormal heart action in claims for arthritis or heart disease, for example) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. The Federal Circuit noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a veteran can establish service connection for a chronic disease" under subsection 3.303(b). Walker, supra. Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation"). Significantly, the Federal Circuit indicated that showing a continuity of symptomatology after service is a lesser evidentiary burden than the nexus requirement of the three-part test discussed above: "The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection . . . or service connection via continuity of symptomatology" (emphasis added). Id. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Id. Thus, if the claimant does not have one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and "medical nexus of a relationship [sic] between the condition in service and the present condition is required." Walker, supra. (holding that the claimant's allegation of a continuity of hearing loss ever since active service was not sufficient to support the claim under subsection 3.303(b), as hearing loss was not among the chronic diseases listed in section 3.309(a)). The evidence of record is not even suggestive of a sleep disability, including sleep apnea and a disability manifested by insomnia, a disability manifested by head eruptions, a stomach disability, and/or deformity of the penis. However, the evidence shows the Veteran been diagnosed with hypertension. Hypertension is defined as a chronic disease in section 3.309(a). Thus, the provisions of subsection 3.303(b) for chronic disabilities apply to this aspect of the service-connection claim and this claim may be supported by evidence of a continuity of symptomatology since service. Hypertension is also eligible for presumptive service connection. Specifically, where a Veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, service connection for hypertension may be established on a presumptive basis by showing the disease manifested to a compensable degree (meaning to a degree of at least 10-percent disabling) within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307; 3.309(a). However, this presumption will be rebutted if there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(d). The Veteran's currently diagnosed BPH and bradycardia are not "chronic diseases" according to 38 C.F.R. § 3.309(a). Therefore, 38 C.F.R. § 3.303(b) does not apply and, as such, he is not permitted to show continuity of symptomatology since his service as an alternative means of etiologically linking these claimed conditions to his military service. See Walker, supra. Lay evidence nonetheless can be competent and sufficient to establish a diagnosis of a condition when (1) a 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. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Lay persons can also provide an eye-witness account of an individual's visible symptoms. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that a layperson may comment on lay-observable symptoms). Competency of evidence differs from its credibility and ultimate probative weight. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, both lay and medical, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The standard of proof to be applied in decisions on claims for Veterans' benefits is set forth in 38 U.S.C.A. § 5107. A Veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also 38 C.F.R. § 3.102. When a Veteran seeks benefits and the evidence is in relative equipoise, the Veteran prevails. See Gilbert, 1 Vet. App. at 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). III. Claimed Entitlement to Service connection for a Sleep Disorder, Including Sleep apnea and a Disability Manifested by Insomnia; also a Disability Manifested by Head Eruptions; a Stomach Condition, claimed as a Milk Allergy; and Deformity of the Penis 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 or aggravated in service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Veteran's STRs are completely unremarkable for any complaints or findings of a sleep disorder, including sleep apnea and/or a disability manifested by insomnia, a disability manifested by head eruptions, a stomach disorder, a milk allergy, and/or a deformity of his penis. In November 1966 he had a separation examination. He denied frequent trouble sleeping, frequent indigestion, and stomach trouble. He noted that he was allergic to penicillin. His head, face, neck, and scalp, abdomen and viscera, and genitourinary system were all clinically evaluated as "normal." He was also clinically evaluated as "normal" for neurologic purposes. In April 2006, some 40 years later, he filed a claim of entitlement to service connection for insomnia. In June 2006, he had a VA examination. He maintained that he had experienced insomnia since 1966, so since his service. In March 2007 he filed a claim of entitlement to service connection for deformity of his penis. VAMC outpatient treatment records show that, in November 2006, he underwent a physical examination. Evaluation of his abdomen showed no masses or organomegaly. His abdomen was non-tender, non-distended, soft, and depressible. His penis was free of lesions, phimosis, or inflammation. It was noted that he had a history of a penile minimal superficial abrasion that had resolved. In July 2007 he filed a claim for service connection for allergy (stomach). He also submitted a letter in which he stated that he was allergic to all foods he ate, including lactose. In addition, he indicated that he had a very rare condition in that his penis was "cut around" and that he would "bleed at least twice a month." According to him, he had brown spots and scars. He further noted that, since leaving Vietnam, he had experienced insomnia. In August 2007 he filed a claim of entitlement to service connection for what he described as "head eruptions." He also noted that he was allergic to milk. A VA examination was performed in November 2007. At the conclusion the examiner indicated there was no evidence of penile skin lesions. In a private Pathology Consultation Report, dated in February 2008, it was noted the Veteran had undergone circumcision of his penis. A specimen was reviewed and noted to be unremarkable foreskin. When considering this and all other possibly relevant evidence to these claims, none shows current diagnoses of a sleep disorder, including sleep apnea and a disability manifested by insomnia, or a disability manifested by head eruptions, or a stomach disorder, or deformity of the penis. The only evidence of record even tending to support these claims is the Veteran's unsubstantiated lay opinion that he has these alleged disabilities. The most fundamental requirement for any claim for service connection is that the Veteran must have proof he has the condition claimed. See Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328 (1997) (indicating VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability); but see, too, McClain v. Nicholson, 21 Vet. App. 319 (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). Congress has specifically limited entitlement for service-connected disease or injury to cases where such incidents have resulted in actual disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998). A current disability means a disability shown by competent and credible evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). Here, in regards to his claim for service connection for a sleep disorder, including sleep apnea and a disability manifested by insomnia, the Veteran is competent to proclaim having problems sleeping, specifically insomnia, and the Board accepts his statements as credible. Layno v. Brown, 6 Vet. App. 465 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007). He is competent to give evidence about observable symptoms such as not being able to fall asleep. See Layno, 6 Vet. App. at 465; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer."). However, he is not competent to give an opinion as to whether he has an actual sleep disorder, including as examples obstructive sleep apnea and a disability manifested by insomnia, as these determinations involve highly complex medical questions concerning an internal physical process. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009). Indeed, obstructive sleep apnea often is only diagnosed after a formal sleep study, so only after considering the results of this objective test or measure of the Veteran's breathing and respiratory capacity while asleep and being continuously monitored. Determining the etiology of complex medical conditions requires medical training and would not be subject to lay observation, as contrasted with the situations contemplated by Jandreau and Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of varicose veins). Thus, the Veteran's mere lay opinion that he has a sleep disorder, including sleep apnea and a disability manifested by insomnia, is not competent evidence and cannot be considered as evidence favorable to his claim. In regards to his claim for service connection for a disability manifested by head eruptions, he has not made any specific contentions regarding this claim. Nevertheless, he is not competent to give an opinion as to whether he has a disability manifested by head eruptions because this issue also involves highly complex medical questions. Determining the etiology of complex medical conditions requires medical training and would not be subject to lay observation. His mere lay opinion that he has a disability manifested by head eruptions is not competent evidence and lacks probative value. In regards to his claim for service connection for a stomach disorder, he has not made any specific contentions regarding his claimed stomach disorder, other than he is allergic to milk. He is not competent to give an opinion as to whether he has a stomach disorder, per se, as this too involves highly complex medical questions. Determining the etiology of complex medical conditions requires medical training and would not be subject to lay observation. His mere lay opinion that he has a stomach disorder is not competent evidence and lacks probative value. He is competent to state, however, that he is allergic to milk and the Board accepts his statements as credible. Layno, 6 Vet. App. at 465 (1994); Barr, supra. Nevertheless, the question of causation extends beyond an immediately observable cause-and-effect relationship. He is not competent in this instance to opine that his allergy to milk is related to his service because that is a complex medical question that requires medical expertise and training. His mere lay opinion that his allergy to milk is related to his period of service is not competent evidence and cannot be considered as evidence favorable to his claim. There is no competent evidence of record linking his milk allergy to his period of service. Lastly, in regards to his claim for service connection for deformity of his penis, he is competent to give evidence about observable symptoms such as noticing lesions on his penis. But his VAMC outpatient treatment records show that, while he had a history of a penile superficial abrasion, it had resolved. The records are unremarkable for any suggestion of a present-day penile deformity. Other than the lesions/abrasion on his penis that apparently have resolved, he has not identified any specific deformity of his penis that currently exists or has at any point since the filing of this claim. Thus, there is no proof he currently has this claimed disability. Given that there is no competent evidence of record of current diagnoses of a sleep disorder, including sleep apnea and a disability manifested by insomnia, a disability manifested by head eruptions, a stomach disorder, or deformity of the penis, and that there is no competent evidence of record linking the Veteran's milk allergy to his service, the Board finds that there is a preponderance of evidence against these claims. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, since the preponderance of the evidence is against these claims, this doctrine has no application. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). IV. Prostate Disorder, Including BPH A. Factual Background The Veteran's STRs are unremarkable for any complaints or findings of a prostate disorder, including especially BPH. The records show that, in November 1966, he had a separation examination in anticipation of his service concluding. During that exit evaluation, he denied frequent or painful urination. Also, his genitourinary system was clinically evaluated as "normal." His post-service VAMC outpatient treatment records show that, in November 2006, so some 40 years later, he had a physical examination. Evaluation of his prostate showed that it was enlarged, albeit smooth and symmetric. There were no nodules or masses, and there was no tenderness. A VA compensation examination was performed in November 2007. He acknowledged not remembering when he had started having problems with his prostate. His symptoms were urgency, urinary frequency, straining to urinate, and weak and intermittent stream. According to him, he had visited his primary care physician who had told him that his prostate was enlarged. At present, he was not receiving any treatment and his condition was stable. Following the physical examination, BPH was diagnosed. B. Analysis Based on a thorough review of the record, the Board finds that there is a preponderance of evidence against this claim of entitlement to service connection for a prostate disorder, including BPH. The Veteran's STRs do not mention any complaints or findings of this now claimed disorder, nor do the records of his evaluation and treatment for many, many years after the conclusion of his service. It is noteworthy that, at the time of his November 1966 separation examination, his genitourinary system was clinically evaluated as "normal" and he had no pertinent complaints referable to his prostate. The first evidence of a prostate disorder, diagnosed as BPH, was not until November 2007, approximately 41 years after his discharge from service. With respect to negative evidence, the Court has held that the fact that there was no record of any complaint, let alone treatment, involving the Veteran's condition for many years could be decisive - just cannot be the only or sole reason for necessarily concluding he did not have the now claimed of disability during the many intervening years. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). See, too, Mense v. Derwinski, 1 Vet. App. 354 (1991) (holding that VA did not err in denying service connection when the Veteran had failed to provide evidence demonstrating continuity of symptomatology and had failed to account for the lengthy time period following conclusion of his service during which there was no clinical documentation of the claimed disorder). The Veteran also has not provided any medical opinions supporting his claim. The only evidence supporting his claim is his own lay evidence that he has a prostate disorder - namely, BPH - which is related to his military service. The Board acknowledges Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), in which it was held a lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation, such as a fall leading to a broken leg. The Veteran is certainly competent to testify as to symptoms such as urinary problems (e.g., incontinence, etc.). Here, however, the question of causation extends beyond an immediately observable cause-and-effect relationship. He is not competent in this instance to opine that his prostate disorder, currently diagnosed as BPH, is related to his service because that issue involves highly complex medical questions concerning an internal physical process. See Clemons v. Shinseki, 23 Vet. App. 1, 6, (2009). Determining the etiology of complex medical conditions requires medical training and would not be subject to lay observation, as contrasted with the situations contemplated by Jandreau and Barr. His mere lay opinion that he has a prostate disorder, diagnosed as BPH, which in turn is related to his military service, is not competent evidence and cannot be considered as evidence favorable to his claim. For these reasons and bases, the Board concludes that there is a preponderance of evidence against the Veteran's claim for service connection for a prostate disorder, including for BPH especially. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, since the preponderance of the evidence is against this claim, this doctrine has no application. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). V. Heart Disease, Including Arterial Hypertension and Bradycardia A. Factual Background The Veteran's STRs are negative for any complaints or findings of a heart disability, to include hypertension and/or bradycardia. The records show that, in November 1966, he underwent a separation examination. At that time, he denied any high or low blood pressure, pain or pressure in his chest, shortness of breath, and palpitation or pounding heart. His heart also was clinically evaluated as "normal." A private medical record shows that, in April 1994, he was hospitalized for 10 days for psychiatric reasons. Upon his discharge, it was noted that he had arterial hypertension. In June 2006, he had a VA compensation examination. At that time, he stated that he had experienced high blood pressure for the last 30 years. Following the physical examination, he was diagnosed with: (1) marked bradycardia, and (2) high blood pressure, stable, controlled. VAMC outpatient treatment records show that, in November 2006, he underwent a physical examination. At that time, it was noted that he was being treated for hypertension. In March 2007 he filed a claim for service connection for hypertension. In addition, in August 2007 he submitted a claim of entitlement to service connection for a heart condition. In October 2010 the RO received records from the Social Security Administration (SSA), which included a Disability Determination and Transmittal Report, dated in September 1995, and the medical records upon which the SSA's decision was based. The SSA Disability Determination and Transmittal Report shows that the Veteran was awarded Social Security disability benefits for major depression with psychotic features (primary diagnosis) and high blood pressure (secondary diagnosis). B. Analysis Based on a thorough review of the record, the Board finds that there is a preponderance of evidence against the Veteran's claim for service connection for heart disease, to include arterial hypertension and marked bradycardia. The Veteran's service treatment records are negative for any complaints or findings of heart disease, to include hypertension and bradycardia. In addition, at the time of the Veteran's November 1966 separation examination, his heart was clinically evaluated as "normal." The first evidence of heart disease, diagnosed as hypertension, was in April 1994, over 27 years after the Veteran's discharge. In addition, the first evidence of a diagnosis of bradycardia was in June 2006, over 39 years after his discharge. With respect to negative evidence, the Court has held that the fact that there was no record of any complaint, let alone treatment, involving the veteran's condition for many years could be decisive. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). See, too, Mense v. Derwinski, 1 Vet. App. 354 (1991) (holding that VA did not err in denying service connection when the Veteran had failed to provide evidence demonstrating continuity of symptomatology and had failed to account for the lengthy time period following conclusion of his service during which there was no clinical documentation of the claimed disorder). The Board also notes that, as there is no suggestion of hypertension within one year subsequent to service discharge, the presumptive provisions for this disease found in 38 C.F.R. §§ 3.307 and 3.309 are inapplicable. See also 38 U.S.C.A. §§ 1101, 1112, and 1113. Hypertension means persistently elevated blood pressure, not just the occasional high or abnormal reading. VA also only accepts the diagnosis when a certain amount of readings are taken over a prescribed amount of time. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2013). Under this code, the minimum compensable rating of 10 percent is warranted for hypertensive vascular disease when the diastolic pressure is predominantly 100 or more; or systolic pressure is predominantly 160 or more; or when continuous medication is shown necessary for the control of hypertension and there is a history of diastolic blood pressure of predominantly 100 or more. So this clearly is based on objective medical data, not mere subjective lay opinion. The Veteran therefore is both incompetent to say he had hypertension during his service or within the one-year presumptive period following his discharge, or that it was to the required minimum compensable degree even on the chance he did. The Board recognizes that the Veteran has heart disability, currently diagnosed as arterial hypertension and marked bradycardia. However, there is no competent and credible evidence of record of a nexus between his currently diagnosed hypertension and bradycardia and any incident of his service. He has provided no medical opinions supporting his claim to establish this required causation. The only evidence supporting his claim is his own lay evidence that he has heart disease, currently diagnosed as hypertension and bradycardia, which is related to his period of service. The Board acknowledges Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), in which it was held a lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation, such as a fall leading to a broken leg. Here, however, the question of causation extends beyond an immediately observable cause-and-effect relationship. He is not competent in this instance to opine that his hypertension and bradycardia are related to his service because that is a complex medical question that requires medical expertise and training. In addition, with respect to his hypertension, as indicated in Diagnostic Code 7101, hypertension involves the cardiovascular system and is diagnosed based upon blood pressure testing. It is not a disability capable of lay observation, such as varicose veins or tinnitus. Rather, it is far more analogous to rheumatic fever, as a disease involving internal organs. For that reason, his lay opinion, even if considered credible, does not constitute competent evidence and is of no probative value. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). As for continuity of symptomatology since service, he has not made any contentions in this respect. Regardless, he is not otherwise competent to have observed hypertension since service, as hypertension is a cardiovascular disease process not capable of lay observation. Such a determination is the province of trained medical professionals. Testing thresholds for blood pressure are required for a diagnosis of hypertension, as specified in 38 C.F.R. § 4.104, Diagnostic Code 7101. See 38 C.F.R. § 3.159(a)(2). For these reasons or bases, the Board concludes that there is a preponderance of evidence against his claim for service connection for heart disease, including for arterial hypertension and marked bradycardia. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, since the preponderance of the evidence is against the claim, this doctrine is inapplicable. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER The claim of entitlement to service connection for a sleep disorder, including obstructive sleep apnea and a disability manifested by insomnia, is denied. The claim of entitlement to service connection for a disability manifested by head eruptions is denied. The claim of entitlement to service connection for a stomach disorder claimed as a milk allergy is denied. The claim of entitlement to service connection for deformity of the penis is denied. The claim of entitlement to service connection for a prostate disorder, including BPH, is denied. The claim of entitlement to service connection for heart disease, including arterial hypertension and bradycardia, is denied. REMAND Concerning the petition to reopen the claim of entitlement to service connection for an acquired psychiatric disorder, including major depressive disorder with psychotic features, anxiety (nervous) disorder, memory loss, and PTSD, under 38 C.F.R. § 3.159(b) VA is required to notify the Veteran of the evidence necessary to establish his claim. And as the Court clarified in Kent v. Nicholson, 20 Vet. App. 1 (2006), to this end, for petitions to reopen previously denied, unappealed claims, VA must notify the Veteran of the elements of his claim and of the definition of "new and material evidence." Kent also requires that VA give him notice of precisely what evidence is necessary to reopen the claim, depending upon the basis of the previous denial. The RO sent him VCAA letters in May 2006, June 2007, and October 2007. However, these letters did not comply with the dictates of Kent. Instead, they only referred to the requirements for outright service connection. VA's Office of General Counsel, however, has issued informal guidance interpreting Kent as requiring the notice to specifically identify the kind of evidence that would overcome the prior deficiency rather than simply stating the evidence must relate to the stated basis of the prior denial. VA Gen. Couns. Mem., para. 2, 3 (June 14, 2006). So additional VCAA notice is needed to comply with Kent. In regards to the Veteran's claim of entitlement to service connection for a skin disorder, including as secondary to herbicide exposure, in March 2007 he filed a claim of entitlement to service connection for a skin condition as secondary to Agent Orange exposure. After he filed his claim, he was contacted and asked to clarify in detail what skin condition he was claiming. In response, he indicated "rash, itching, and white spots symptoms." In March 2007 the RO contacted the National Personnel Records Center (NPRC) and asked for verification of the Veteran's dates of service in Vietnam. The return response showed he had served in Vietnam from August 12, 1966 to October 17, 1966. Therefore, it has been confirmed that he had active service in Vietnam during the Vietnam era, so it is presumed he was exposed to herbicides while there. 38 U.S.C.A. § 1116(f). In November 2007 he had a VA compensation examination. He maintained that, since 1966, he had developed skin lesions that were characterized as an intermittent erythematous skin rash. He related the lesions to food allergies and that was later confirmed by his physician. He noted that, at present, he experienced intermittent skin rashes. The examiner stated that, upon examination, there was no evidence of any skin rash or skin lesions. In Ardison v. Brown, 6 Vet. App. 405 (1994), the Court held that VA was obligated to evaluate tinea pedis, a skin condition, while in an "active stage" of the disease in order to fulfill the duty to assist. In Voerth v. West, 13 Vet. App. 117 (1999), however, the Court stated that a new examination was warranted in Ardison because active tinea pedis was a condition that would exist for weeks or months. The holding in Ardison did not apply in Voerth because an orthopedic disability is different from a skin condition. A flare-up lasting only one or two days not only renders a new VA examination impractical, but a "person who experiences a worsened condition only for a few days out of a year simply is less impaired than someone who suffers from the worsened condition for weeks or months." Voerth, at 123. Here, however, although no skin disorders were shown at the time of the November 2007 VA compensation examination, the Board sees that since that examination the Veteran has been diagnosed with skin disorders. VAMC outpatient treatment records show that, in February 2010, he underwent a physical examination. It was noted that he had skin lesion, planar erythematous of his arms that was chronic. In addition, in May 2010, he underwent a dermatology consultation. He stated that he had a skin rash and redness of the skin on his left elbow, characterized as erythematous lichenified plaque. The diagnosis was lichen simplex chronicus. Thus, given that the evidence of record currently shows skin disorders, and in consideration of his confirmed in-service herbicide exposure, the Board is of the opinion that another VA compensation examination is warranted in order to determine the etiology of any present-day skin disorder. In regards to his claim for service connection for a low back disability, in July 2007 he submitted a letter in which he stated that during basic training he had injured his back and resultantly had developed low back pain. He indicated that he had sought medical treatment, but that X-rays were not taken. According to him, he was diagnosed with back pain. He maintained that he had continued to experience chronic low back pain after his discharge from service up to the present. He contended that he currently had a low back disability that was related to his period of service, specifically his back injury in service. His STRs are unremarkable for any complaints or findings of a back injury or consequent disability. The records show that, in November 1966, he had his military separation examination, and during that evaluation he denied experiencing recurrent back pain. Also, his spine and other musculoskeletal system were clinically evaluated as "normal." Nevertheless, he is competent under the law to describe what he experienced while in military service and during the many years since. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Thus, for the purposes of this remand only, the Board will accept that he injured his back during his service as alleged. The evidence of record shows he now has a diagnosed low back disability, so including to account for his complaints of chronic, persistent or recurring pain. A VAMC outpatient treatment records shows that, in July 2008, he underwent a magnetic resonance imaging (MRI) of his lumbosacral spine. The MRI was reported to show multilevel degenerative changes. Thus, given that for the purposes of this remand only, the Board will accept that he injured his back during his service, and in consideration of the fact that he currently has a low back disability, the Board finds that a VA examination and opinion are needed to assist in deciding this claim. Accordingly, these remaining claims are REMANDED for the following additional development and consideration: 1. Send the Veteran a supplemental VCAA notice letter to comply with the Court's holding in Kent v. Nicholson, 20 Vet. App. 1 (2006). In particular, this letter must: (1) notify him of the specific reason(s) for the previous denial of his claim for service connection for a psychiatric disorder in January 2003; (2) apprise him of the type of evidence and information necessary to reopen this claim, i.e., explain what would constitute new and material evidence; and (3) explain what specific evidence is required to substantiate the elements needed to grant the underlying claim on its merits. 2. Thereafter, make arrangements with the appropriate VA medical facility for the Veteran to be afforded the following examinations: A. A VA examination by an examiner with appropriate expertise to ascertain the etiology of any skin disability. The claims folder must be made available to the examiner for review in conjunction with the examination. The examiner must note that the Veteran had been diagnosed with skin lesion, planar erythematous of his arms in February 2010, and with lichen simplex chronicus in May 2010. All appropriate tests and studies should be accomplished. After a review of the examination findings and the entire evidence of record, the examiner must answer the following questions: (i) Does the Veteran have a current skin disability(ies)? If he does, specify the diagnosis. (ii) Regardless if confirmed he has a current skin disability, what is the likelihood (very likely, as likely as not, or unlikely) that any skin disability, to include planar erythematous of the Veteran's arms, lichen simplex chronicus, and/or any currently diagnosed skin disability, is causally linked to his exposure to herbicides in Vietnam, to include Agent Orange. (The Veteran's exposure to herbicides is presumed by law.) The examiner is advised that the term "as likely as not" means at least 50-percent probability. This term does not however mean merely within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against it. Very likely and as likely as not support the posited causal relationship between the current disability and the Veteran's military service, whereas a conclusion this is unlikely obviously instead weighs against the claim. If no link to military service is found, this should be expressly indicated but, more importantly, the examiner must discuss the underlying rationale of the opinion, regardless of whether it is favorable or unfavorable to the claim. Merely the examiner saying he/she cannot respond will not suffice, unless there is explanation as to why a response is not possible. B. A VA orthopedic examination to ascertain the nature and etiology of any low back disability, to include the Veteran's currently diagnosed degenerative arthritis of the lumbar spine. The claims folder must be made available to the examiner for review in conjunction with the examination. The examiner must specifically review the Veteran's service treatment records, to include his November 1966 separation examination wherein his spine and other musculoskeletal system were clinically evaluated as "normal." In addition, the examiner should review the June 2006 VA examination report. At that time, the Veteran stated that he had experienced low back pain since 1966. X-rays taken at the time of the examination were reported to show mild to moderate degenerative joint disease of the vertebral spine. Following the physical examination and a review of the x-rays, he was diagnosed with the following: (1) chronic low back pain, (2) lumbalgia, and (3) mild to moderate degenerative joint disease of the vertebral spine. Also, in March 2007, the Veteran submitted a copy of a VAMC outpatient treatment record. The record shows that in November 1987, the Veteran had x-rays taken of his lumbosacral spine. The x-rays were interpreted as showing mild lumbar spondylosis. Moreover, in a July 2008 VA MRI report, the Veteran's MRI of his lumbosacral spine was reported to show multilevel degenerative changes. So prior to commenting, in addition to considering this relevant evidence, all necessary diagnostic testing and evaluation is to be accomplished, including X-rays if deemed warranted. After a review of the examination findings and the relevant evidence of record, the examiner must address the following question: What is the likelihood (very likely, as likely as not, or unlikely) the Veteran's current low back disability, to specifically include his degenerative arthritis of the lumbar spine, is related or attributable to his period of active military service, to include his claimed in-service back injury? [FOR THE PURPOSES OF THIS OPINION ONLY, THE EXAMINER SHOULD ACCEPT AS TRUE THAT THE VETERAN INJURED HIS BACK DURING BASIC TRAINING.] The examiner is advised that the term "as likely as not" means at least 50-percent probability. This term does not however mean merely within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against it. Very likely and as likely as not support the posited causal relationship between the current disability and the Veteran's military service, whereas a conclusion this is unlikely obviously instead weighs against the claim. If no link to military service is found, this should be expressly indicated but, more importantly, the examiner must discuss the underlying rationale of the opinion, regardless of whether it is favorable or unfavorable to the claim. Merely the examiner saying he/she cannot respond will not suffice, unless there is explanation as to why a response is not possible. 3. Review the reports of these VA compensation examinations to ensure they contain responses to the questions posed. If not, take corrective action. 38 C.F.R. § 4.2. 4. After completion of the above and any other development deemed necessary, the RO should review and re-adjudicate the issues on appeal. If any such action does not resolve each claim to the Veteran's satisfaction, the RO must provide the Veteran and his representative, if any, a supplemental statement of the case and an appropriate period of time must be allowed for response. Thereafter, the case must be returned to this Board for appellate review. The Veteran has the right to submit additional evidence and argument concerning these claims the Board is remanding. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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). ______________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs