Citation Nr: 1337234 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 10-13 768 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a back disability. 2. Entitlement to service connection for a back disability. 3. Entitlement to service connection for a neck disability. 4. Entitlement to service connection for lower extremity peripheral neuropathy. 5. Entitlement to service connection for claimed "soft tissue deterioration". 6. Entitlement to service connection for a brain aneurysm. REPRESENTATION Appellant is represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION Appellant (the Veteran) had active service from August 1966 to August 1968. This appeal comes before the Board of Veterans' Appeals (Board) from a March 2008 rating decision of the VA Special Processing Unit in Cleveland, Ohio, and from a July 2009 rating decision of the RO in Chicago, Illinois. The Board notes that the VA Form 9 submitted by the Veteran on December 29, 2011, in response to the statement of the case addressing service connection for disabilities of the neck and back, as well as service connection for peripheral neuropathy, did not contain the Veteran's signature or any identification of the issues that were being appealed. The RO made note of this in a June 2012 deferred rating, and noted that the appeal should not be considered timely if the Veteran did not correct these deficiencies within 30 days. There is no subsequent reference to the matter either by the RO or the Veteran. The May 2013 supplemental statement of the case lists the December 2011 VA Form 9 as the substantive appeal. In Percy v. Shinseki, 23 Vet. App. 37 (2009), the United States Court of Appeals for Veterans Claims (Veterans Court) held that, by treating an issue as if it were part of a timely filed substantive appeal for, in that case, more than five years, VA waived any objections it might have had to procedural deficiencies such as timeliness. Here, the RO included these issues in the May 2013 supplemental statement of the case and certified them to the Board as being properly appealed. Accordingly, the Board finds that any procedural deficiency regarding the VA Form 9 is waived. Although the Veteran claimed entitlement to service connection for headaches in May 2008, after a request for clarification from the RO, the Veteran responded in December 2012 that he did not wish to pursue the claim. In reviewing this case the Board has not only reviewed the physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. All notification and development needed to fairly adjudicate the appeal has been accomplished. 2. In an unappealed August 2002 rating decision, the RO denied service connection for a back disability. 3. The evidence associated with the claims file subsequent to the August 2002 rating decision relates to the unestablished fact of a current disability, which is necessary to substantiate the claim; it is neither cumulative nor redundant of evidence already of record; and it raises a reasonable possibility of substantiating the claim. 4. The Veteran does not have a current disability manifested by soft tissue deterioration, nor does he have soft tissue sarcoma. 5. Arthritis of the back and neck, a brain aneurysm, and lower extremity peripheral neuropathy did not become manifest to any degree in service or within 1 year of service separation. 6. Disabilities of the back and neck, lower extremity peripheral neuropathy, and a brain aneurysm are not related to service, to include presumed exposure to herbicides therein. CONCLUSIONS OF LAW 1. The criteria for reopening the claim of entitlement to service connection for a back disability are met. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5108, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.156, 3.159 (2013). 2. A back disability was not incurred in service; arthritis of the thoracolumbar spine is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 3. A neck disability was not incurred in service; arthritis of the cervical spine is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 4. Peripheral neuropathy was not incurred in service and is not presumed to be associated with herbicide exposure therein; an organic disease of the nervous system is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 5. A brain aneurysm was not incurred in service; a brain hemorrhage is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 6. The basic criteria for service connection for the claimed disability manifested by soft tissue deterioration and/or soft tissue sarcoma are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Application to Reopen Denied Claim In an August 2002 rating decision, the RO denied service connection for claimed spinal arthritis. At the time of the August 2002 rating decision, the evidence of record did not include a diagnosis of spinal arthritis and did not establish a nexus between any back disability and service. The evidence received since the August 2002 rating decision includes a diagnosis of lumbar degenerative joint disease (arthritis) based on X-ray findings. In Shade v. Shinseki, 24 Vet. App. 100 (2010), the Veterans Court held that VA law does not require new and material evidence as to each previously unproven element of a claim for the claim to be reopened and the duty to provide an examination triggered. In a fact pattern similar to this one, where a prior denial was based on lack of current disability and nexus, the Veterans Court found that newly submitted evidence of a current disability was, in concert with evidence already of record establishing an injury in service, new and material and sufficient to reopen the claim and obtain an examination. As the evidence received since the August 2002 rating decision relates to the unestablished fact of a current back disability, which is necessary to substantiate the claim, and as it is neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim, and it raises a reasonable possibility of substantiating the claim, the Board finds that the criteria for reopening the claim of entitlement to service connection for a back disability are met, and the claim is reopened. 38 C.F.R. § 3.156(a). Service Connection Claims The Veteran is seeking service connection for multiple claimed disabilities on the asserted basis that each is related to herbicide exposure during his Vietnam Era service. The Board notes that the Veteran is currently in receipt of VA disability compensation at the 100 percent level due to posttraumatic stress disorder. Certain specific conditions are considered chronic diseases under VA Law. These include arthritis, brain hemorrhage, and organic diseases of the nervous system. 38 C.F.R. § 3.309(a). Where such chronic disease is shown to be chronic in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Where a veteran served 90 days or more during a period of war or after December 31, 1946, and any of the chronic diseases becomes manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 C.F.R. §§ 3.307, 3.309. A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, 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. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 C.F.R. § 3.307(a)(6)(iii). In addition to the presumption of herbicide exposure, certain diseases are deemed to be associated with herbicide exposure. These diseases include early onset peripheral neuropathy. 38 C.F.R. § 3.309(e). The regulations formerly referred to acute and subacute peripheral neuropathy; however, effective September 6, 2013, VA adopted a proposed rule to amend its adjudication regulations regarding presumptive service connection for acute and subacute peripheral neuropathy associated with exposure to certain herbicide agents. Specifically, based on findings from the September 29, 2010 National Academy of Sciences (NAS) report titled, Veterans and Agent Orange: Update 2010 (hereinafter "Update 2010"), which concluded that early-onset peripheral neuropathy associated with herbicide exposure is not necessarily a transient condition. The amendment replaced the terms "acute and subacute" in 38 CFR 3.307(a)(6)(ii) and 38 CFR 3.309(e) with the term "early-onset" and removed the Note to 38 CFR 3.309(e) requiring that the neuropathy be "transient." This change effectively removed the requirement that acute and subacute peripheral neuropathy appear "within weeks or months" after exposure and that the condition resolve within two years of the date of onset in order for the presumption to apply. This amendment clarified that VA will not deny presumptive service connection for early-onset peripheral neuropathy solely because the condition persisted for more than two years after the date of the last herbicide exposure. However, it did not change the requirement that peripheral neuropathy must have become manifest to a degree of ten percent or more within one year after the veteran's last in-service exposure in order to qualify for the presumption of service connection. In Update 2010, NAS found that evidence did not support an association between herbicide exposure and delayed-onset peripheral neuropathy, which NAS defined as having its onset more than one year after exposure. See 78 FR 54763-01. Indeed, VA has published a list of specific conditions for which a presumption of service connection based on exposure to herbicides used in Vietnam during the Vietnam era is not warranted. These include chronic peripheral nervous system disorders. See Notice, 75 Fed. Reg. 32540-03 (2010). Thus, to qualify for presumptive service connection, early onset peripheral neuropathy must have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a). The diseases are deemed to be associated with herbicide exposure do not include brain aneurysm, soft tissue deterioration, or musculoskeletal disabilities of the spine or neck. See 38 C.F.R. § 3.309(e). VA has determined that there is no positive association between exposure to herbicides and any other condition for which a specific determination has been made that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also Notice, 61 Fed. Reg. 41-442-449 (1996). As set out above, only a few specific diseases are presumed to have an association to herbicide exposure. With the exception of peripheral neuropathy, none of the disorders claimed by the Veteran in this case are included among those specific diseases. Accordingly, while the Veteran is presumed to have been exposed to herbicides in service, there is no presumption of service connection for claimed disabilities of the back and neck, brain aneurysm or soft tissue deterioration. Regarding the Veteran's assertion and claim that he has soft tissue deterioration, the Veteran has never clearly explained the symptoms of this claimed condition. Although originally claimed as soft tissue deterioration, the Veteran referred to a soft tissue sarcoma in January 2010 correspondence. He suggested that his brain aneurysm might be associated with a soft tissue sarcoma since blood vessels are soft tissue. To the extent the Veteran is claiming that he has the herbicide-presumptive disease of soft tissue sarcoma, and that any other claimed disability is related to it, the Board notes that there is no diagnosis of soft tissue sarcoma in the record nor is there any discussion of a diagnosis. The regulations stipulate that the term "soft-tissue sarcoma" includes the following: adult fibrosarcoma, dermatofibrosarcoma protuberans, malignant fibrous histiocytoma, liposarcoma, leiomyosarcoma, epithelioid leiomyosarcoma (malignant leiomyoblastoma), rhabdomyosarcoma, ectomesenchymoma, angiosarcoma (hemangiosarcoma and lymphangiosarcoma), proliferating (systemic) angioendotheliomatosis, malignant glomus tumor, malignant hemangiopericytoma, synovial sarcoma (malignant synovioma), malignant giant cell tumor of tendon sheath, malignant schwannoma, including malignant schwannoma with rhabdomyoblastic differentiation (malignant triton tumor), glandular and epithelioid malignant schwannomas, malignant mesenchymoma, malignant granular cell tumor, alveolar soft part sarcoma, epithelioid sarcoma, clear cell sarcoma of tendons and aponeuroses, extraskeletal Ewing's sarcoma, congenital and infantile fibrosarcoma, malignant ganglioneuroma. 38 C.F.R. § 3.309(e), Note 1. A review of the Veteran's medical records does not reveal any diagnosis or clinical finding of a "soft tissue sarcoma". While the Veteran was treated in July 1993 for a thyroglossal duct cyst, a biopsy performed following excision of the cyst was negative for malignant cells, providing highly probative medical evidence against the Veteran's claim. Thus, the medical evidence demonstrates no soft tissue sarcoma or any other cancer that might be associated with herbicide exposure. The Veteran's assertions regarding a soft tissue sarcoma would appear to be lay speculation. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), diagnosis of cancer falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The Veteran's assertions that he has soft tissue sarcoma are given no probative weight. The Board recognizes that the Veterans Court has held that the presence of a disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, Congress has specifically limited entitlement to service-connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. § 1110. Hence, where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, the Board finds that there is no current disability manifested by soft tissue degeneration, and that this amounts to an erroneous reference to soft tissue sarcoma. As the evidence establishes no diagnosis of soft tissue sarcoma, the Board concludes that service connection for the claimed disability is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Regarding peripheral neuropathy, the regulations specify that peripheral neuropathy must have become manifest to a degree of 10 percent or more within a year of service separation. In November 2008 correspondence, the Veteran asserted that peripheral neuropathy had bothered him ever since he returned from Vietnam. Again, the Veteran is competent to describe his symptoms and their time of onset. However, here, the Veteran has been inconsistent in his assertions. For instance, the Veteran reported at an October 2006 neurology consultation that he experienced sudden onset of left-sided numbness in June 2006. He reported to a VA physician during an April 2007 EMG that he had been experiencing intermittent numbness in the left leg for a few months. The Veteran reported in a June 2007 neurological clinic note that he had been experiencing tingling and numbness below the knees for about 1 year. In a June 2008 treatment note, the Veteran complained of pain in his legs from his thighs to his feet that had been present for more than a year and was getting progressively worse. In weighing the conflicting statements provided by the Veteran at various times, the purpose and circumstances surrounding the statement are important. Statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because there is a strong motive to tell the truth in order to receive proper care. In contrast, statements made to VA in pursuing a claim or appeal for VA benefits rather than medical treatment must be weighed in light of the self interest which any veteran has in promoting a claim for monetary benefits. The Board may properly consider the personal interest a claimant has in his or her own case, but the Board is not free to ignore his assertion as to any matter upon which he is competent to offer an opinion. See Pond v. West, 12 Vet. App. 341, 345 (1999); and see Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). There is no question that the Veteran is competent to relate events as he remembers them. Thus, his competency is not at issue with regard to recounting the onset of peripheral neuropathy symptoms. Rather, it is the accuracy of the Veteran's account to VA which the Board finds is lacking. Simply put, the medical reports establishing onset of symptoms of peripheral neuropathy in or around 2006 are more convincing than the Veteran's statement to VA adjudicators that he has experienced symptoms since service. As the Veteran's symptoms of peripheral neuropathy first became manifest more than 1 year after service separation, and the herbicide presumptive provisions do not apply. In sum, the herbicide presumptive provisions are not applicable to any of the claimed disabilities in this case. Regarding the presumptions applicable to certain chronic diseases, the Board notes that the Veteran has been diagnosed with arthritis of the lumbar and cervical spine, as well as well as a brain aneurysm and peripheral neuropathy. The enumerated chronic diseases include arthritis, brain hemorrhage, and organic diseases of the nervous system. However, in order for the presumption of service connection to attach, the disease must be manifest to a degree of 10 percent or more within a year of service separation. Here, as discussed above, the evidence establishes onset and manifestation of peripheral neuropathy decades after service separation. As to the brain aneurysm, the evidence indicates onset of the aneurysm and symptoms of neuropathy in 2006, also decades after service separation in 1968. Indeed, a brain CT was conducted in July 1995 to investigate the cause of partial seizures, and the results revealed no intracranial mass, hydrocephalus or contrast enhancing lesions. This is probative evidence that there was no brain aneurysm for many years after service separation. Indeed, the evidence reveals that the Veteran's aneurysm never ruptured. Therefore, it does not appear that the Veteran's aneurysm meets the definition of a brain hemorrhage as set out in the presumptive provisions. Regarding the neck and back, September and November 1998 treatment records show the Veteran's complaint of pain from the back of the neck down to the back since a work-related injury in February-March of that year, which was described as the "original injury." A February 1998 spine X-ray revealed mild spondylosis and degenerative disc disease throughout the thoracolumbar spine and cervical spondylosis at C4-7. A February 2000 medical resident report notes a past medical history of a back injury at home. The Veteran reported in a March 2009 neurology outpatient clinic report that he had been experiencing back pain for 15 years, which the Board notes is consistent with an original injury in the mid-1990s. He reported in a June 2009 neurological clinic note that his back pain started in 2001. The Veteran reported in a May 2011 pain clinic note that his low back pain started in 1995. While the Veteran has not been consistent in his recollections as to the date of onset of his back pain, each of the dates reported to medical examiners is well past the presumptive period. In effect, the Veteran's statements, as a whole, provide evidence against this claim. The Board finds it particularly persuasive regarding each of the disabilities to which presumptions are applicable that a November 1981 psychiatric hospitalization included a complete physical examination, which resulted in a finding of no major disorders, providing highly probative evidence against these claims. Moreover, in February 1997, the Veteran was treated after having been struck in the head with a bottle, and he denied a history of any medical problems, providing factual evidence against his own claims. This is probative evidence that each of the disorders in this case had onset many years after service, and well past the 1 year presumptive period. To summarize, as initial manifestation of each of the claimed disabilities was after the 1-year period following service separation, the herbicide presumptive provisions and the chronic disease presumptions do not apply regarding any issue on appeal. The Board also notes that an August 2008 record includes a rule-out diagnosis of fibromyalgia to account for neck and back pain. However, the Veteran had no service in the Persian Gulf during the Persian Gulf War, therefore, there is no presumption of service connection for fibromyalgia. It also does not appear that the diagnosis was ever confirmed, as there is no other reference to it. Regarding continuity of symptomatology, these provisions apply on to notation of chronic diseases in service that are not shown to be chronic at that time. In this case, there is no notation of arthritis, a brain hemorrhage, or an organic disease of the nervous system during service. Therefore the provisions governing continuity of symptomatology do not apply. In any case, the Board's finding that, in each case, symptoms were not manifest for decades after service provides a basis for an alternative finding that there was no continuity of symptomatology regarding any of the presumptive diseases. The Board's decision is not limited to presumptive service connection. In Combee v. Brown, the United States Court of Appeals for the Federal Circuit held that when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994), reversing in part Combee v. Principi, 4 Vet. App. 78 (1993). As such, the Board must not only determine whether the Veteran has a disability which is recognized by VA as being etiologically related to prior exposure to herbicide agents that were used in Vietnam, see 38 C.F.R. § 3.309(e), or whether the Veteran has a chronic disease that is recognized as being etiologically related to service, see 38 C.F.R. § 3.309(a), but must also determine whether any claimed current disability is the result of active service under 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303(d). Service treatment records reveal that the Veteran was treated in December 1966 for tenderness in the left paravertebral area and left lower latissimus dorsi area following having been kicked in the back. The impression was myalgia. The Veteran was not treated for neck complaints, peripheral neuropathy, or a brain aneurysm during service. The report of examination at service separation in August 1968 reveals normal clinical findings for the spine, neck, head, vascular system, and neurological system. The Veteran reported at service separation that he had no history of recurrent back pain or arthritis. The Board finds that this is probative evidence that, to the extent of any back injury in service, there was no chronic disability at service separation. The Veteran also reported that he had no history of neuritis, which is probative evidence against onset of peripheral neuropathy in service. The Veteran has alternatively asserted that a neck tumor was caused by "shrap metal" in the neck from service. The Board interprets the Veteran's intended terminology as "shrapnel." Service treatment records reveal no shrapnel injuries. Nevertheless, the Veteran served as an artilleryman and cannoneer in the Republic of Vietnam. He is acknowledged to have likely engaged in combat. His report of neck shrapnel is therefore accepted as true. However, post-service treatment records reveal no reference to a shrapnel injury or post-service residuals. The Veteran was found to have a thyroglossal duct cyst in July 1993; however there is no finding or assertion in the record that relates this cyst to a shrapnel injury. Indeed, the normal clinical findings for the neck at service separation, and the Veteran's assertion that he had no history of cysts at service separation, are more persuasive as to the lack of any neck disability at service separation than the Veteran's recent speculative assertion that a shrapnel injury caused all of his claimed disabilities. In fact, the Veteran reported at the time of the July 1993 cyst excision that he had only had the neck mass for the prior 6 years. Again, the Board accords higher probative weight to an account of onset provided to a medical treatment provider than to assertions made in support of a disability claim, particularly where, as here, the Veteran's assertions to VA on numerous matters has been somewhat inconsistent. There is no medical opinion that purports to relate any of the claimed disabilities to service or to presumed herbicide exposure in service. In fact, several of the claimed disabilities have been related to other non-service causes. As discussed above, the Veteran reported in November 1998 that his neck and back complaints were due to a work related injury. There are conflicting findings regarding the etiology of the Veteran's peripheral neuropathy. Some clinical evidence has related it to the Veteran's back injury, and other evidence has related it to a transient ischemic attach (TIA), also diagnosed as a stroke, which prompted the discovery of his brain aneurysm. It is notable that the onset of symptoms reported as peripheral neuropathy corresponds with the TIA in June 2006. In addition, an EMG in April 2007 showed no radiculopathy at that time, but showed diffuse mixed (primarily demyelinating) motor sensory polyneuropathy. The Veteran was hospitalized in June 2008 for alcohol intoxication, at which time the Veteran's mixed motor sensory polyneuropathy was thought to be due to alcohol. A June 2007 neurology consultation also includes the notation that the Veteran's peripheral neuropathy could be due to alcohol. A partial report from a private physician in March 2004 includes the notation that the Veteran has had many years of alcohol abuse and may well have some minor nerve damage to his feet in the way of alcoholic peripheral neuropathy. While these references are somewhat speculative, the Board need not, and is not attempting to establish the actual cause of the Veteran's peripheral neuropathy. The Board simply emphasizes that there is no suggestion other than from the Veteran of a service-related etiology for the peripheral neuropathy. While the Veteran has asserted that each of the disabilities is related to service, his opinion that the claimed disabilities of the neck and back, peripheral neuropathy, and brain aneurysm are related to presumed herbicide exposure is not competent evidence. Although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, linking the claimed disorders to remote herbicide exposure falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4. In addition, linking any of the claimed peripheral neuropathy and brain aneurysm to a remote shrapnel injury to the neck is outside the realm of common knowledge of a lay person. While the Veteran may be competent to relate a disability of the back or neck to a remote shrapnel injury, or the reported in-service kick to the back and diagnosis of myalgia, the Board has found the Veteran's assertions on these points to be inaccurate based on his reports to treatment providers establishing the onset of symptoms in the mid-1990s as a result of a work-related injury, and establishing the onset of a neck cyst 6 years prior to the July 1993 excision. In sum, the Board finds that current neck and back disability are not related to service, nor are the Veteran's brain aneurysm and peripheral neuropathy. Accordingly, service connection for the claimed disabilities is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Veteran has not asserted any deficiencies in the notice provided under the Veterans Claims Assistance Act of 2000 (VCAA) and the Board finds that there is none. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records, hospital records from the University of Illinois Medical Center, medical and adjudication records from the Social Security Administration, and the Veteran's written assertions. The Veteran identified additional records on the VA Form 9 received in December 2011; however, those records pertained to a psychiatric hospitalization and do not pertain to any issue on appeal. The Veteran has not been provided a VA examination regarding any of these claims. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service would not suffice to meet the standard as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Here, the only evidence that the Veteran's claimed disabilities are related to his military service are his own conclusory generalized lay statements, which are unsupported by even speculative medical evidence and significant evidence against the claims, as cited above. While the Veteran sustained a paravertebral muscle injury in service, his spine was normal at service separation. Arthritis, although subject to a presumption of service connection for chronic diseases that become manifest within a year of service, did not become manifest for decades after service. Moreover, the clinical evidence relates the Veteran's current back and neck complaints to a post-service work injury, providing highly probative evidence against this claim. Accordingly, the Board finds that referral for a VA medical examination as to the etiology of the claimed neck and back disabilities is not warranted. The Veteran's brain aneurysm, although subject to a presumption of service connection for chronic diseases that become manifest within a year of service, did not become manifest for decades after service separation; it is not an herbicide presumptive disease, and there is otherwise no disease or injury in service that may be related to it. Accordingly, the Board finds that referral for a VA medical examination as to the etiology of the brain aneurism is not warranted. Early onset peripheral neuropathy is an herbicide presumptive disease, but must become manifest to a compensable degree within a year of service for the presumption to attach. In addition, organic diseases of the nervous system are subject to a presumption of service connection for chronic diseases that become manifest within a year of service. However, in this case, the Veteran's peripheral neuropathy did not become manifest until decades after service and has been variously related to alcohol abuse and a nonservice-connected back disability. Other than the presumed exposure to herbicides in service, there is no injury or disease in service that may be related to the current peripheral neuropathy. Accordingly, the Board finds that referral for a VA medical examination as to the etiology of the lower extremity peripheral neuropathy is not warranted. The Board has found that there is no current disability manifested by soft tissue degeneration, and that the Veteran was attempting to file a claim for soft tissue sarcoma. As there is no competent evidence of a current or post-service soft tissue sarcoma, the Board finds that referral for a VA medical examination as to the etiology of the claimed disability is not warranted. Neither the appellant nor his or representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. ORDER Reopening of the claim of entitlement to service connection for a back disability is granted. Service connection for a back disability is denied. Service connection for a neck disability is denied. Service connection for lower extremity peripheral neuropathy is denied. Service connection for claimed soft tissue deterioration is denied. Service connection for a brain aneurysm is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs