Citation Nr: 1502310 Decision Date: 01/16/15 Archive Date: 01/27/15 DOCKET NO. 12-12 249 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for a low back disorder, diagnosed as degenerative disc and joint disease, including as secondary to service-connected right and left foot disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Appellant-Veteran ATTORNEY FOR THE BOARD D. M. Donahue Boushehri, Counsel INTRODUCTION The Veteran served on active duty in the United States Air Force from January 1966 to May 1969. He appealed to the Board of Veterans' Appeals (Board/BVA) from rating decisions by a Department of Veteran Affairs (VA) Regional Office (RO). In June 2013, as support for his claims, he testified at a hearing at the RO before the undersigned Veterans Law Judge (VLJ) of the Board, in other words at a Travel Board hearing. A transcript of the hearing is in the electronic (i.e., paperless) portion of the claims file. FINDINGS OF FACT 1. The medical and other evidence of record does not show the Veteran has sufficient hearing loss in either ear to be considered a ratable disability for VA compensation purposes, so there is no present-day disability to relate or attribute to his military service - including especially to any repeated exposure to loud noise and consequent injury (i.e., acoustic trauma) during his service. 2. It is, however, shown that he has tinnitus (ringing in his ears) on account of acoustic trauma sustained during his service. 3. But his low back disorder is not shown to be the result or consequence of his military service, including proximately due to, the result of, or aggravated by a service-connected disability - in particular, his right and left foot disabilities. CONCLUSIONS OF LAW 1. The criteria are not met for entitlement to service connection for bilateral hearing loss. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2014). 2. The criteria are met, however, for entitlement to service connection of tinnitus. 38 U.S.C.A. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303 (2014). 3. But the criteria are not met for entitlement to service connection for a low back disorder, including as secondary to a service-connected disability - namely, the right and left foot disabilities. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist obligations. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2014). April 2009 and May 2011 letters satisfied the notice requirements. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The letters also notified the Veteran of how VA determines a disability rating and effective date once entitlement to service connection has been established, so even concerning these "downstream" elements of the claims. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA also has met its duty to assist the Veteran in fully developing these claims. To this end, his service treatment records (STRs) and post-service treatment records have been obtained. 38 U.S.C.A § 5103A, 38 C.F.R. § 3.159. There is no suggestion of other existing records needing to be obtained, including from the Social Security Administration (SSA). This duty-to-assist obligation may also include providing a VA compensation examination for a medical nexus opinion, if necessary to assist in deciding a claim, and he was provided a VA spine examination for his low back disorder claim in June 2011. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). A review of the examination report confirms the examiner considered the Veteran's description and history of his symptoms, reviewed the claim file, performed a comprehensive evaluation, and provided a detailed report of the findings with a clear opinion and rationale connecting the evidence to conclusions. The examination and report therefore are adequate, such that additional examination and/or opinion is not required. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (requiring that VA ensure the adequacy of any examination and opinion provided). Although VA did not also provide the Veteran a medical examination regarding his hearing loss and tinnitus claims, evaluations are not required to fairly decide these claims. This development is necessary if the information and evidence of record does not include sufficient competent medical evidence to decide the claim, but contains: (1) competent lay or medical evidence of disability or recurrent or persistent symptoms of disability, (2) establishes that the Veteran experienced a relevant event, injury or disease during his service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates the claimed disability may be associated with the event, injury, or disease during his service, or with a service-connected disability. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). Here, though, as there is no indication of a presently ratable hearing loss disability, as will be explained according to the threshold minimum requirements of 38 C.F.R. § 3.385, element (1) is not satisfied, so the remaining elements (2) and (3) are of no significance. VA is not obligated to provide an examination for a medical 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. Moreover, the Board is granting the claim for tinnitus, even without an examination and opinion. Lastly, regarding the June 2013 Travel Board hearing, the presiding VLJ focused on the elements necessary to substantiate the claims and sought to identify any further development that was required to help substantiate the claims. This included explaining fully the issues and suggesting the submission of evidence that may have been overlooked and that might be potential advantageous to the Veteran's position. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010) (holding that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board, not just to a hearing instead before RO personnel). Rules and Regulations Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury sustained or disease contracted in the line of duty during active military service, or for aggravation during service of a preexisting condition - meaning for a chronic (permanent) worsening of the condition above and beyond its natural progression. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Disorders diagnosed after discharge will still be service connected if the evidence, including that pertinent to service, establishes the disorder was incurred in service. 38 C.F.R. § 3.303(d). In order to establish entitlement to service connection on a direct basis, there must be proof of: (1) the existence of the claimed disability, either currently or at some point since or contemporaneous to the filing of the claim; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a causal relationship ("nexus") between the disability presently being claimed and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). So in the absence of proof of a present disability, there necessarily can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease at any later date, no matter how remote, are generally service connected unless attributable to other ("intercurrent") causes. If a disease is noted in service but the chronicity of it is not adequately supported, or legitimately questionable, then a showing of continuity of symptomatology after separation from service is required to link current disability to service. Consider also that entitlement to service connection based on chronicity or continuity of symptomatology pursuant to § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C.A. § 1101(3) or 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Neither tinnitus nor hearing loss disability is on the list of chronic diseases in the statute or regulation. VA policy, however, is to consider sensorineural hearing loss as an organic disease of the nervous system, which is one of the chronic diseases listed in the statute and regulation. See, e.g., VA Adjudication Manual Rewrite, M21-1MR III.iv.4.B.12.a (June 5, 2012) ('Sensorineural hearing loss is considered an organic disease of the nervous system and is subject to presumptive service connection under 38 C.F.R. 3.309(a)'). The Veteran's low back disorder has been diagnosed as degenerative disc disease (DDD) and degenerative joint disease (DJD, i.e., arthritis), the latter of which also is one of the 'chronic' diseases listed in 38 C.F.R. § 3.309(a) as presumptively service connected, but only assuming it initially manifested to the required minimum compensable degree of at least 10-percent disabling within the initial post-service year. 38 U.S.C.A. §§ 1101(3), 1112(a)(1), 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). This presumption also is rebuttable by affirmative evidence to the contrary. Service connection may be granted, as well, on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) and (b). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). A finding of secondary service connection requires competent and credible evidence connecting the asserted disorder with the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Velez v. West, 10 Vet. App. 432 (1997). In deciding claims, VA adjudicators are directed to assess the probative value (competency and credibility) of both medical and lay evidence. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007)(a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002)(tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). A layperson is generally incapable of opining on matters requiring medical knowledge and, specifically is not competent to provide an opinion as to etiology in such cases. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see also Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service-connection claim). With respect to claims for service connection specifically for hearing loss, the United States Court of Appeals for Veterans Claims (Court/CAVC) has held that the threshold for normal hearing is from 0 to 20 decibels, and that higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The Court further opined that 38 C.F.R. § 3.385 then operates to establish when a hearing loss disability can be service connected. Id. at 159. For the purposes of applying the laws administered by VA, impaired hearing only will be considered to be an actual ratable disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies 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. I. Hearing loss and Tinnitus Factual Background and Analysis The Veteran claims he has a bilateral hearing loss disability due to noise exposure and consequent injury (acoustic trauma) during his service, especially while working on a flight line as an air policeman. The Board finds that he is competent to describe having experienced that type of noise exposure during his service, and his complaints of this are consistent with the circumstances of his service. 38 U.S.C.A. § 1154(a). He is competent to report on factual matters of which he had firsthand knowledge, and his reports of this type of activity also are credible, so ultimately probative of whether he sustained relevant acoustical injury during his service. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Although his DD Form 214 lists his military occupational specialty (MOS) as an administrative specialist, akin to a clerk typist, there is an additional notation that he completed air police courses in 1966 and 1967. Furthermore, his STRs include an October 1966 Medical Board report reiterating he was an air policeman and recommended for cross training into an administrative job. But the mere fact that he was exposed to loud noise during his service in that capacity is not tantamount to concluding he now has hearing loss, much less because of that noise exposure during his service. This is especially true since audiograms dated in October 1965 and May 1969, so from during his service, do not indicate he had hearing loss. Also, in a May 1969 medical history report during his separation examination in anticipation of his discharge from service, he himself denied having any hearing loss or running ears. In a private audiological examination report from many years later, in April 2009, the Veteran indicated he had a long history of tinnitus (i.e., ringing in his ears as opposed to hearing loss) that waxes and wanes in intensity and occasionally interferes with his sleep. He also mentioned, however, that his wife complains that he listens to the television too loud, so perhaps owing to hearing loss aside from the tinnitus. Regarding the tinnitus, he recalled the ringing beginning in the late 1960s, so during his service, following exposure to noise from jet aircraft. After a physical examination, the examiner indicated the Veteran's ear examination and audiogram were normal. In fact, his hearing was better than average for his age, and there was no evidence of prior noise damage, so including apparently owing to the noise exposure in service. Pure tone thresholds, in decibels, were as follows: HERTZ 500 A 1000 B 2000 C 3000 D 4000 RIGHT 10 5 15 -- 15 LEFT 10 5 10 -- 15 Speech recognition scores were 100 percent, bilaterally, so in each ear. During a more recent May 2011 private audio evaluation, the Veteran again complained of constant bilateral tinnitus that seemed to be getting more annoying. He also reiterated working on the flight line during his service resulting in repeated exposure to loud noise. He did not use ear protection. Pure tone thresholds, in decibels, were as follows: HERTZ 500 A 1000 B 2000 C 3000 D 4000 RIGHT 10 20 20 -- 20 LEFT 15 15 25 -- 25 His speech recognition scores again were 100 percent bilaterally. The examiner diagnosed unilateral moderate sensorineural hearing loss in the right ear at 6000 and 8000 Hz only; otherwise hearing was basically normal, so including in the lesser and more relevant frequencies of 500, 1000, 2000, 3000 and 4000 Hz. Absent indication of any present day hearing loss in either ear that could be considered a ratable disability according to the threshold minimum requirements of 38 C.F.R. § 3.385, there could be no attribution of this for all intents and purposes nonexistent current disability (though claimed) and any noise exposure the Veteran experienced during the course of his military service. The examiner, however, did indicate the Veteran's tinnitus is more likely than not related to the noise exposure experienced in the military. During his June 2013 hearing, the Veteran testified that, while stationed in Korea, he worked the flight line guarding aircraft, also worked as a gate guard and perimeter guard. He said that the majority of his time was on the flight line. He reported his hearing ability would decrease over the course of a day while working near the flight line, but that it would return to normal. He also reported that his tinnitus began in service, that it initially was just intermittent, but that it is now constant. In contrast, he indicated he was examined by a private audiologist, and that the examiner confirmed the hearing acuity conversely was normal. As already alluded to, tinnitus is "a noise in the ear, such as ringing, buzzing, roaring, or clicking." See Dorland's Illustrated Medical Dictionary 1714 (28th ed. 1994). It is often subjective in nature; indeed, because of its inherently subjective nature, even a layman such as the Veteran is considered competent to report the observable manifestations of this disease like this ringing, buzzing, roaring, or clicking sound. He is competent to provide evidence regarding tinnitus, as it is a condition readily apparent through the senses. See Charles v. Principi, 16 Vet. App. 370 (2002) (holding that tinnitus is subjective and the kind of condition lay testimony is competent to describe); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (a Veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses). And aside from that, there is attribution of his tinnitus to his military service, particularly to the noise exposure he experienced during his service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). The VA compensation examiner charged with making this important determination of causation confirmed this correlation. The claim for tinnitus consequently must be granted. On the other hand, the hearing loss claim is a different matter, and there has not been the required indication that the Veteran has sufficient hearing loss in either ear according to the threshold minimum requirements of 38 C.F.R. § 3.385 to be considered an actual ratable disability. Although he has some indication of hearing loss, meaning threshold losses exceeding 20dB, he does not have sufficient hearing loss according to this VA regulation (§ 3.385), so by VA standards, to be considered ratable. Thus, there necessarily cannot be any association of this for all intents and purposes nonexistent disability with his military service, even accepting he had the type of noise exposure during his service he alleges (and reason for service connecting his tinnitus, though not also hearing loss). The Veteran is not competent to provide probative opinion regarding complex medical questions such as whether he has sufficient hearing loss to meet the requirements of 38 C.F.R. § 3.385. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). This determination, instead, is based on the results of objective testing - namely, an audiogram and Maryland CNC speech discrimination. Whether lay versus medical evidence is needed to support a claim is determined on a case-by-case basis and dependent on the type of condition being claimed. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). See also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (lay testimony is competent when it concerns the readily observable features or symptoms of injury or illness); but see, too, Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger VA's duty to seek a medical opinion on the issue). There is nonetheless medical opinion in this instance, and it is unfavorable to this claim for hearing loss because it confirms the Veteran does not have sufficient hearing loss in either ear to be considered an actual ratable disability according to § 3.385. No less than two examiners agreed on this point. To reiterate, the most fundamental requirement for any claim for service connection is that the Veteran first must have proof he has the condition being 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 also 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). There is no such indication in this particular instance, however, of any present-day hearing loss that is sufficient to be considered an actual ratable disability according to the threshold minimum requirements of § 3.385. Indeed, this is true even when considering the evidence in the file immediately preceding the date of receipt of this claim. See Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (considering the application of McClain on a recent diagnosis predating the filing of a claim). Accordingly, unlike the claim for tinnitus, the claim for service connection for hearing loss must be denied. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine but has determined that it is inapplicable to this claim because the preponderance of the evidence is against this claim. 38 C.F.R. § 3.102. II. Low Back Disorder Factual Background and Analysis The Veteran contends that his current low back disorder is secondary to his service-connected right and left foot disabilities, meaning caused or being aggravated by them. 38 C.F.R. § 3.310(a) and (b). He is not alternatively alleging that his low back disorder is directly or presumptively related to his service, and there equally is no such suggestion or indication. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Indeed, to the contrary, his STRs are entirely unremarkable for any complaint, treatment, or diagnosis of a low back disorder. In a May 1969 separation report of medical history, he specifically denied experiencing recurrent back pain. The same is true for during the many ensuing years after his service had ended. The first post-service evidence of a back disorder is an April 2011 VA X-ray report showing multilevel degenerative changes. A May 2011 VA CT scan also showed degenerative changes. During his June 2011 VA examination, the Veteran complained of low back pain, which he said he had been experiencing for the past 10 years, so, if true, meaning only since 2001 or thereabouts. He denied any then recent treatment, but indicated he had recent X-rays. He reported doing little yard work, but said he can drive, though he has very limited bending and stooping ability. At standing position, his pelvis was level and there was no scoliosis. He was tender in the left paravertebral musculature, and range of motion was limited to 65 degrees of flexion. The diagnosis was multilevel disc disease of the lumbar spine with moderate central spinal stenosis and foraminal stenosis at the level of L2-L3, L3-L4, and L4-L5. The examiner also noted that the Veteran had "ankle conditions", right ankle sequelae of prior trauma resulting in subtalar ankylosis, and left ankle residuals of ankle sprain. But regarding the important issue of causation, the examiner explained that the Veteran's low back disorder is not due to or a result of the sequelae of his chronic foot/ankle problems as no medical rationale actually exists supporting a relationship between chronic disc disease of the lumbar spine and ankle or foot problems. That examiner therefore disassociated the low back impairment from the service-connected right and left foot disabilities. There is no medical evidence refuting this VA examiner's unfavorable opinion. Private physical therapy notes in the file dated in April 2010 do not include an etiology opinion. In VA progress notes dated in September 2011, the Veteran reported having chronic low back pain for 5 years. He indicated that his back pain had become progressively worse during the then past several years. He submitted a Disability Benefits Questionnaire (DBQ) from a private physician dated in June 2013 with an accompanying letter. The examination report included diagnoses of chronic lumbar back pain and DJD (so arthritis) of the spine. This doctor did not perform range-of-motion testing, but he noted the Veteran has guarding or muscle spasm of the thoracolumbar spine severe enough to result in an abnormal gait and spinal contour. In January 2012 and June 2013 the Veteran's private doctor provided statements indicating the Veteran's low back condition is at least as likely as not related to his feet problems (presumably referring to the service-connected disabilities). This doctor added that he has known the Veteran and his medical history over 20 years. Unfortunately, however, this private doctor did not provide any supporting rationale for his favorable opinion, therefore it is of little ultimate probative value. See Hernandez-Torens v. West, 11 Vet. App. 379, 382 (1998) (stating that the failure of the physician to provide a basis for his/her opinion affects the weight or credibility of the evidence). Most of the probative value of a medical opinion is derived from its underlying reasoning, not just from whether the claims file was reviewed or even the ultimate answer. See Nieves-Rodriguez v. Peake, 22 Vet App 295, 304 (2008) (the probative value of a medical opinion comes from when there is factually accurate, fully articulated, and sound reasoning for the conclusion, not just from mere review of the claims file). Indeed, the Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). See also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[a] medical opinion...must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Regarding the private doctor's mention of having known the Veteran and his medical history over 20 years, there is no "treating physician rule" requiring the Board to give deference to this doctor's opinion over that of the VA compensation examiner. Both the Federal Circuit Court and Veterans Court (CAVC) have specifically declined to adopt a "treating physician rule" that would give preference to statements from a treating physician. See White v. Principi, 243 F.3d 1378 (Fed. Cir. 2001); Guerrieri v. Brown, 4 Vet. App. 467 (1993). And this is true even accepting that a treating physician may be more intimately familiar with the Veteran's general state of health. Based on the unfavorable opinion of the VA examiner, whose opinion has more explanatory rationale or explanation - therefore more ultimate probative value - than the favorable private opinion lacking supporting rationale, the Board finds that the overall weight of the evidence is against granting service connection for the low back disorder being claimed, including as secondary to the service-connected right and left foot disabilities. The VA examiner specifically concluded that this was not the case, no such correlation. Moreover, there is no probative evidence that the DJD (arthritis) of the Veteran's low back initially manifested during his service or to the required minimum compensable degree within one year of his discharge from service, meaning by May 1970, therefore his claim also cannot be granted on a direct or presumptive basis as involving a chronic disease. 38 C.F.R. § 3.309(a). The Board has considered the Veteran's statements made in support of his claim, including his assertions during his hearing that his low back disorder is attributable to his service-connected right and left foot disabilities. But he has not demonstrated any specialized knowledge or expertise indicating he is capable of rendering a competent medical opinion on this determinative issue of causation. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the diagnosis and etiology of his low back disorder and whether it was caused or aggravated by his service or a service-connected disability, this falls outside the realm or purview of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and this claim of entitlement to service connection for a low back disorder, including as secondary to the service-connected right and left foot disabilities, resultantly must be denied. ORDER Service connection for tinnitus is granted. However, service connection for bilateral hearing loss is denied. Service connection for a low back disorder, diagnosed as DDD and DJD, including as secondary to service-connected right and left foot disabilities, also is denied. ______________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs