Citation Nr: 1337104 Decision Date: 11/14/13 Archive Date: 11/26/13 DOCKET NO. 06-15 030 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for hearing loss. 2. Entitlement to service connection for a skin disorder, to include as the result of exposure to herbicides. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Scott Walker, Counsel INTRODUCTION The Veteran had active military service from October 1967 to October 1969. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a September 2005 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, that, among other things, denied the Veteran's claims for service connection for hearing loss and a skin disorder. The Veteran perfected an appeal to the Board, which denied the Veteran's claim for hearing loss in a May 2009 decision. In that decision, the Board also remanded the Veteran's skin disorder claim to the agency of original jurisdiction (AOJ) for further evidentiary development and adjudication. The Board instructed the AOJ to provide the Veteran with a VA examination and then re-adjudicate the claim. The Appeals Management Center (AMC) scheduled the Veteran for a VA examination, which was conducted in April 2010. Following the examination, the AMC issued a supplemental statement of the case in May 2010, again denying the Veteran's claim of service connection for a skin disorder. In April 2010, the Veteran's representative and VA's General Counsel filed a Joint Motion for Remand (Joint Motion) with the United States Court of Appeals for Veterans Claims (Court) to vacate the Board's denial of service connection for hearing loss. The Court granted the Joint Motion in April 2010, setting aside the Board's May 2009 decision and remanding the claims to the Board for further adjudication. Consistent with the Court's order, the Board remanded the Veteran's claim for service connection for hearing loss for further evidentiary development in October 2010. The Board also found that further evidentiary development was necessary before a decision could be reached on the merits of the Veteran's claim for service connection for a skin disorder, and that issue was also remanded. The Veteran was afforded a Board hearing, held by the undersigned, in March 2013. A copy of the hearing transcript (Transcript) has been associated with the record. The Board requested an opinion from a specialist with the Veteran's Health Administration (VHA) in May 2013. That opinion, authored in June 2013, has been associated with the Veteran's claims file. FINDINGS OF FACT 1. Hearing loss was incurred during the Veteran's period of active service. 2. The preponderance of the evidence currently of record does not indicate that folliculitis, or any other currently-diagnosed skin disorder, was initially- manifest in service or aggravated therein. 3. The Veteran does not carry a current dermatological diagnosis which has been presumptively-associated with exposure to herbicides. CONCLUSIONS OF LAW 1. Hearing loss was incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 2. A skin disorder was not incurred in or aggravated by active service, and is not the result of exposure to herbicides. 38 U.S.C.A. §§ 1101, 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304. 3.307 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran 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). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Further, the Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. I. Veterans Claims Assistance Act of 2000 (VCAA) As a preliminary matter, the Board notes that regulations enacted under the VCAA require VA to notify claimants and their representatives of any information that is necessary to substantiate a claim for benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103(a), 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159(b), 3.326(a) (2012). In the instant case, the Veteran's claim for service connection for hearing loss is granted herein. As such, any deficiencies with regard to VCAA for this issue are harmless and non-prejudicial. With regard to the Veteran's other claim, proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These 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 v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letter dated in March 2005 of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. This letter accordingly addressed all notice elements and predated the initial adjudication by the AOJ/RO in September 20050. He also was notified of how VA determines disability ratings and effective dates if service connection is awarded. Nothing more is required in this case. Further, the Veteran's service treatment records and pertinent post-service medical records have been obtained, to the extent available. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). While the Veteran indicated that he was on disability from the Social Security Administration (SSA), a December 2010 Formal finding indicated that that these records are not available. The Board finds that no additional evidence, which may aid the Veteran's claim or might be pertinent to the bases of the claim, has been submitted, identified or remains outstanding, and the duty to assist requirement has been satisfied. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. See Green v. Derwinski, 1 Vet. App. 121 (1991). Here, a VA examination was provided in April 2010 to ascertain whether the Veteran's skin disorder was etiologically-related to service. To that end, when VA undertakes to provide a VA examination, it must ensure that the examination is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The opinion obtained is adequate, as the examiner provided findings relevant to the issues at hand. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA opinion with respect to this issue has been met. See 38 C.F.R. § 3.159(c)(4) (2012). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Service Connection The Veteran claims that his current hearing loss, as well as a dermatological disorder, are etiologically-related to his period of active service. He contends that his decreased hearing acuity is the result of his exposure to acoustic trauma from serving in an infantry unit. See Transcript, p. 4. The Veteran's exposure to in-service acoustic trauma has been conceded by VA in this case, as his duties as an infantryman are established by his personnel records. With regard to his claim for entitlement to service connection for a skin disorder, he testified that a rash began during his period of active service, and that those symptoms have persisted to the present day. See Transcript, pp. 10, 11. Service connection may be established for a disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303, 3.304 (2012). To prevail on the issue of service connection on the merits, there must be medical evidence of (1) a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). In addition, certain chronic diseases, such as sensorineural hearing loss, may be presumed to have been incurred or aggravated during service if they became disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). If a chronic disease or injury is shown in service, subsequent manifestations of the same chronic disease or injury at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b) (2012). The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a), which does not include shin splints. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 3.102 (2012). Hearing Loss For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 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 (2012). The Veteran's most recent VA audiological examination in August 2011 demonstrates puretone thresholds, bilaterally, that meet the criteria for hearing loss for VA compensation purposes. The Board points out, however, that the absence of in-service evidence of hearing loss is not fatal to a claim for service connection. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability (i.e., one meeting the requirements of 38 C.F.R. § 3.385, as noted above) and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). The Court has held that "the threshold for normal hearing is from 0 to 20 dB [decibels], and higher threshold levels indicate some degree of hearing loss." See Hensley. The Court, in Hensley, indicated that 38 C.F.R. § 3.385 does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service if there is sufficient evidence to demonstrate a relationship between the Veteran's service and his current disability. The Board notes that the Court's directives in Hensley are consistent with 38 C.F.R. § 3.303(d) which provides that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2012). Relevant medical evidence consists of the Veteran's service treatment records, treatment records from the St. Louis VAMC, private medical opinions dated in April 2006 and January 2011, and VA examinations conducted in June 2005, with a medical opinion issued in September 2005, and August 2011, with an addendum opinion issued in November 2011, as well as a June 2013 VHA opinion. Turning to his period of active service, he responded "No" when asked at his August 1969 separation examination whether he experienced any problems with hearing loss. He was provided audiological examination at separation which revealed puretone thresholds within normal limits per VA regulations. Post-service, at the time of the Veteran's June 2005 VA examination, he reported difficulty hearing since service. He further reported that he was exposed to acoustic trauma during combat while serving in Vietnam, to which he attributed his hearing loss and tinnitus (now service-connected because exposure to in-service acoustic trauma has been conceded by VA). He also noted post-service noise exposure from power tools, employment in automobile assembly plants, and working with sheet metal. The examiner specifically questioned the Veteran about a family history of hearing loss and the use of ototoxic medications, both of which he denied. The examiner diagnosed the Veteran with bilateral sensorineural hearing loss. In a September 2005 addendum opinion, the examiner opined that the Veteran's hearing loss was not as likely as not related to his active service, stating that without evidence of hearing loss or acoustic damage at the time of the Veteran's separation from service, she was unable to link hearing loss to in-service noise exposure. The Veteran submitted a letter from his private physician, dated in April 2006, in which the physician provided a diagnosis of sensorineural hearing loss, bilaterally. The physician stated that the Veteran's "hearing loss in the mid[dle] to higher frequencies may have been caused by exposure to loud gunfire." The Board notes, however, that the term "may" renders this opinion speculative. An April 2010 Joint Motion indicated that the June 2005 VA examination, and its September 2005 addendum opinion, were inadequate because the examiner "did not provide any discussion as whether [the Veteran's] current hearing loss was related to the acoustic trauma he described in service or to 'post service acoustic trauma, family history of hearing loss, use of ototoxic drug[s], or some other cause' as requested by the VA Regional Office." To comply with the joint motion, the Board remanded the claim for an additional VA examination in October 2010 to specifically addresses, among other issues, the medical probabilities that the Veteran's extensive post-service exposure to acoustic trauma through his employment at automobile assembly plants, and his work with sheet metal and power tools, is etiologically-related to his current hearing loss. An additional private opinion was authored in January 2011. Following an examination, the provider found that the Veteran's hearing loss was at least as likely as not the result of in-service noise exposure, and that this type of hearing loss was typical and appeared to be noise-induced. He noted that the Veteran had "no history of noise exposure in his civilian life." The Board notes that the Veteran worked in the construction industry for 30 years. Further, there is no indication that the Veteran's claims file was reviewed, to include the Veteran's service treatment records. The most recent VA audiological examination was conducted in August 2011. In a November 2011 addendum opinion, the examiner stated that, at the time of his separation from service, audiometric evaluation was well within normal limits. It was noted that the Veteran denied hearing loss at that time, and that there were no complaints or treatment for hearing loss within his service treatment records. It was further noted that the Veteran worked in an automobile assembly plant for three years, in the construction industry for more than thirty, and that he was a hunter. The examiner stated that, without audiological testing between 1969 and 2005, he was unable to pinpoint when hearing loss began, or what precipitated the condition. He merely stated that, "based on the fact that audiometric testing indicated his hearing was well within normal limits at the time he separated from the military, it is not as likely as not that his hearing loss is related to his military service." He went on to note that current research does not support the concept of delayed-onset hearing loss, though he himself indicated that he was unsure as to when the Veteran's hearing loss began. In May 2013, the Board found the examiner's opinion wholly speculative. As noted above, the examiner stated that delayed-onset hearing loss was unsupported by medical data, however, the examiner was admittedly unsure as to the date of onset. He did not provide an analysis of the Veteran's audiogram, to include a determination as to whether puretone thresholds suggest noise-inducted hearing loss, or hearing loss caused by another factor such as advancing age. Further, the examiner did not address the fact that the Veteran is currently service connected for tinnitus as a direct result of in-service acoustic trauma. Most importantly, his negative nexus opinion stands in direct contrast to the Court's holding in Hensley, as he based his opinion on the fact that the Veteran's hearing loss was within normal limits at the time of separation. During his Board hearing, the Veteran's representative pointed out this inadequacy in the November 2011 opinion, and the Veteran testified that his exposure to noise post-service was minimal during his stint at the automobile factory, in that he did not work in the noisy part of the building. He also indicated that his hunting experience included bow hunting and black powder hunting, both of which were much quieter than hunting with a typical weapon. His work in the construction industry, however, was not addressed. As such, the Board requested a VHA opinion in May 2013. The June 2013 opinion found that it was less likely than not that the Veteran's hearing loss was related to in-service acoustic trauma. Once again, it was noted that the Veteran did not demonstrate hearing loss on separation, and this, once again, this was the crux of the report. While the specialist pointed to a study, referred to as the "IOM Report," which indicates that there is no medical data to support delayed-onset hearing loss, this opinion nevertheless runs afoul of the Court's ruling in Hensley. Therefore, like the other VA opinions of record, this opinion holds little probative value in this case. When viewing the opinions of record, the Board finds that each opinion proffered by a VA provider in this case is inadequate, based solely on the Court's holding in Hensley. Despite the Board's repeated attempts to obtain an opinion of significant probative value, this challenge has been insurmountable in the case at hand. As such, the only opinions of record which are not inadequate on their face were authored by private providers, and these ultimately support the Veteran's claim. The Board further notes, in regard to the Veteran's assertion that he experienced hearing loss during service and at the time of separation, the Veteran is competent to report in-service symptomatology, such as decreased hearing acuity, from his period of service to the present. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Further, the evidence is deemed credible, as his military service is commensurate with his claims of in-service acoustic trauma. The Veteran's lay statements have been afforded significant probative value due to their competency and credibility in the context of this appeal. These statements are further reinforced by the Veteran's verified infantry service, as well as VA's determination that he was exposed to in-service acoustic trauma. Although his service treatment records are negative for hearing loss at separation, in Hensley, the Court noted that the absence of qualifying hearing loss at the time of discharge from service does not preclude the possibility that subsequent hearing loss is related to service. Therefore, the most probative medical evidence of record, while far from conclusive, coupled with the Veteran's competent and credible lay statements, results in, at the very least, equipoise. As such, the Board has no choice but to find that his current hearing loss is related to in-service noise exposure. The Veteran's claim for entitlement to service connection for hearing loss is granted. Skin Disorder At the outset, the Board notes that the Veteran has a current diagnosis of folliculitis. See VA examination report, April 2010. Thus, element (1) of Hickson has been satisfied for this service connection claim. With regard to an alternate theory of entitlement which has arisen during the course of this appeal, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1974, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii) (2013). Service in the Republic of Vietnam includes service in the waters offshore, or service in other locations if the conditions of service involved duty or visitation in Vietnam. 38 C.F.R. § 3.313 (2013). If a veteran was exposed to a herbicide agent during active military, naval, or air service, diabetes mellitus shall be service-connected if the requirements of 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113; 38 C.F.R. § 3.307(d) are also satisfied. The Veteran in this case is legally-presumed to have been exposed to herbicide agents, to include Agent Orange. See 38 C.F.R. §§ 3.307(a)(6), 3.313. In cases such as these, the following diseases are deemed associated with herbicide exposure, under VA law: AL amyloidosis, chloracne or other acneform diseases consistent with chloracne, diabetes mellitus, type 2, Hodgkin's disease, all chronic B-cell leukemias, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma), Parkinson's disease, and ischemic heart disease. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6)(iii); 38 C.F.R. § 3.309. Turning to the Veteran's service treatment records, the Board notes that the Veteran's service treatment records are negative for complaints, findings, or treatment for any chronic skin disorder. While a heat rash was noted in January and February, and a rash on the arms and chest was noted in a report with an obscured date, his August 1969 separation examination indicated normal dermatological testing, and the Veteran denied any skin condition during his Report of Medical History. Post-service, a private opinion authored in April 2005 noted that the Veteran had been under the provider's care since December 1992. It was further noted that the range of his skin conditions included acne, folliculitis cysts, suspicious moles, dermatitis, warts, and eczema. The provider stated that the Veteran was in Vietnam, and that his expression of his dermatological condition could be related to his exposure to Agent Orange, though the exclusivity of its nature could not be ruled in or out. The Veteran reported for a VA compensation and pension examination in June 2005 to address this issue. The Veteran reported multiple bumps on his thighs since 1969 that burn and itch. Following an examination, an opinion could not be offered, as a copy of the claims file was not available. In September 2005, following a review of the claims file, the examiner noted that service treatment records were negative for clinical skin findings at entrance or separation, and opined that folliculitis was not likely related to service, as it did not manifest during that period. The same opinion was offered as to the Veteran's diagnosis of seborrheic keratosis. Most recently, the Veteran was afforded a VA examination to address this claim in April 2010. At that time, the examiner noted the diagnoses of tinea cruris and intertrigo (heat rash) during the Veteran's period of active duty. After separation, however, there are no reports of treatment for any skin disorder until 1992 (more than two decades later). The Veteran reported folliculitis outbreaks since 1968, occurring intermittently depending on the weather. The rash was mainly on his thighs. On examination, papules were noted on the arms, and one papule was observed on the lower extremities. The Veteran's thighs were clear with no evidence of folliculitis. He was diagnosed with folliculitis, intermittent, and it was noted that this disorder has no causal relationship to herbicides. The examiner opined that, since the Veteran's skin was clear on separation, with no evidence of treatment for a long period thereafter, the documents of record did not support the Veteran's claim. As to the private opinion, it was noted that the opinion neither established or refuted the relationship of folliculitis to herbicides. As such, it was less likely than not that the Veteran's diagnosis was causally-related to his period of service. Regarding the conflicting medical opinions of record, the private opinion of record is wholly speculative in nature, and far from conclusive. Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009) (holding doctor's statement that brain tumor "may well be" connected to Agent Orange exposure was speculative); Bloom v. West, 12 Vet. App. 185, 187 (1999) (noting that the use of the term "could," without other rationale or supporting data, is speculative); Goss v. Brown, 9 Vet. App. 109, 114 (1996) (noting that use of the phrase "could not rule out" was too speculative to establish medical nexus); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (holding that medical opinions are speculative and of little probative value when a physician makes equivocal findings that a relationship between service and the claimed disorder "may" be presented). First, the opinion states that the disorders which were listed, which did not contain chloracne or any other disorder associated with chloracne, was possibly related to exposure to Agent Orange. However, there is no evidence that the provider had access to VA regulations, or any other study linking acne, folliculitis cysts, suspicious moles, dermatitis, warts, and eczema, to herbicide exposure. Second, it does not appear that the provider reviewed all evidence currently of record, as no service treatment records were cited in the opinion, to include the Veteran's negative separation examination. Third, the provider indicated that the Veteran's various skin disorders can be related to herbicide exposure, without ruling such etiology in or out, and this language is equivocal at best. Finally, there is absolutely no rationale to support this opinion. In contrast, the VA examiners of record discussed the Veteran's service treatment records, and discussed the Veteran's post-service medical history in detail. The most recent examiner concluded that the passage of time, greater than 20 years, between the Veteran's separation and his first documented post-service skin complaint, did not establish the requisite chronicity to share a common etiology with those acute manifestations during service. As such, it was less likely than not that these incidents were related, and the Veteran's current complaints were unrelated to his military career. As to the separation examination, the Board notes again that the report was negative for any complaints or diagnoses of any skin disorder. As to the Veteran's assertions that he currently suffers from skin disorders that are etiologically-related to his period of active duty, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that lay evidence is one type of evidence that must be considered, and competent lay evidence can be sufficient in and of itself. The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). This would include weighing the absence of contemporary medical evidence against lay statements. Acknowledgement is given to the Veteran's assertions that his skin disorders began during service. In that regard, he is deemed competent to report symptoms of a skin disorders, such as a rash on his thigh. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this case, such reports are even documented within his service treatment records. However, laypersons are competent to diagnose a disability only if (1) the condition is simple to identify (such as a broken leg), (2) he is reporting a contemporaneous medical diagnosis, or (3) his description of symptoms at the time supports a later diagnosis by a medical professional. Id. Here, the Veteran has not demonstrated competence to provide an opinion as to the onset or cause of a complex medical diagnosis, and the record reflects that the Veteran's current diagnoses (acne, folliculitis cysts, suspicious moles, dermatitis, warts, and eczema) are different than those found during service (tinea cruris and intertrigo). See Jandreau. Based on the foregoing, in order to establish service connection, the record would have to contain competent medical evidence of record linking the Veteran's claimed disorder to his period of active service, or contain a diagnosis of a disorder associated with herbicide exposure. The Board may not base a decision on its own unsubstantiated medical conclusions but, rather, may reach a medical conclusion only on the basis of independent medical evidence in the record. Neither the Board nor the Veteran is competent to supplement the record with unsubstantiated medical conclusions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Conversely, health professionals are experts and are presumed to know the requirements applicable to their practice and to have taken them into account in providing a diagnosis. See Colvin. Despite the presence of current skin diagnoses throughout the appellate period, as well as a non-probative opinion with regard to the Veteran's various dermatological disorders and their possible relationship to Agent Orange, the preponderance of the medical evidence is against the finding of a relationship between the Veteran's currently-diagnosed skin disorders and his period of active service. In sum, the most probative evidence of record does not establish that the Veteran's skin disorders are related to service or causally-related to his presumed exposure to herbicides. There are no contemporaneous records of any complaints, findings, treatment, or diagnosis of a chronic skin disorder during service, as each instance was self-limiting and resolved prior to separation. Instead, the record establishes that, more than 20 years after separation, the Veteran reported with skin complaints. Following years of ongoing treatment, the record lacks a probative medical opinion linking any skin disorder to either active duty, or to herbicides. While the Board has taken the Veteran's statements regarding long-term rash symptomatology into account, he has not demonstrated the medical competency to provide an etiological link between any current disorder and his period of active service. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). Therefore, the preponderance is against the Veteran's claim for entitlement to service connection for a skin disorder, and as such the claim must be denied. ORDER Entitlement to service connection for hearing loss is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to service connection for a skin disorder, to include as the result of exposure to herbicides, is denied. ____________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs