Citation Nr: 1504830 Decision Date: 02/02/15 Archive Date: 02/09/15 DOCKET NO. 10-42 772 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for polyostotic fibrous dysplasia. 2. Entitlement to service connection for a neck condition. REPRESENTATION Appellant represented by: Connecticut Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD B. Muetzel, Associate Counsel INTRODUCTION The Veteran had active service from September 1978 to August 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut, declining to reopen the claim of entitlement to service connection for polyostotic fibrous dysplasia and denying the claim of entitlement to service connection for a neck condition. In February 2011, the Veteran testified at a video conference hearing before the undersigned Acting Veterans Law Judge. A written transcript of this hearing has been prepared and associated with the evidence of record. Then, in April 2014, the Board found that new and material evidence sufficient to reopen the claim of entitlement to service connection for polyostotic fibrous dysplasia had been received. The Board remanded the claims of entitlement to service connection for polyostotic fibrous dysplasia and for a neck condition. The file has been returned to the Board for further appellate review. After the RO transferred the claims file to the Board, additional evidence was added to the Virtual VA file. Specifically, in October 2014, the requested addendum opinion was provided and uploaded. However, because the evidence was received after the file was transferred, the Board may determine what action is required with respect to the additional evidence. 38 C.F.R. § 19.37(c). As such, the Board will consider this evidence in the adjudication of the Veteran's claims. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of these electronic records. FINDINGS OF FACT 1. Polyostotic fibrous dysplasia, a congenital disease, clearly and unmistakably pre-existed the Veteran's entrance to active duty and clearly and unmistakably was not aggravated beyond the normal progression by the Veteran's military service. 2. There is no competent and credible evidence that the Veteran's neck condition was caused or aggravated by service. CONCLUSIONS OF LAW 1. The criteria for service connection for polyostotic fibrous dysplasia have not been met. 38 U.S.C.A. §§ 1110, 1111 (West 2014); 38 C.F.R. § 3.303, 3.304 (2014). 2. A neck condition was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.310 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2014). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Prinicipi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. In this appeal, in an October 2009 pre-rating letter, the RO provided notice to the Veteran regarding the need to submit new and material evidence to reopen his previously denied claim, and advised the Veteran of the bases for the prior denial. See Kent v. Nicholson, 20 Vet. App. 1 (2006). The RO also explained what was necessary substantiate his claim for service connection and informed the Veteran of what information and evidence must be submitted by the appellant and what information and evidence would be obtained by VA. The October 2009 letter also provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations. The December 2009 rating decision reflects the initial adjudication of the claim after the issuance of this letter. Hence, the October 2009 letter meets the VCAA's timing of notice requirement. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent evidence associated with the claims file consists of service treatment records, service personnel records, private treatment records, VA treatment records, a report of VA examination, an addendum VA opinion, Social Security Administration records and the Veteran's statements. Additionally, the RO substantially complied with prior remand instructions regarding his claim. Instructions pertinent to the claims being decided included requesting and associating with the record any information and records related to the Veteran's application for Social Security Administration disability benefits. Those records were requested and received in April 2014. Furthermore, the remand requested that the RO obtain an addendum opinion, or if the examiner deemed necessary, another VA examination, to determine if the Veteran's polyostotic fibrous dysplasia was clearly and unmistakably not aggravated by service. That opinion was obtained in October 2014. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The Veteran has been afforded a hearing before a Veterans Law Judge (VLJ) in which he presented oral argument in support of his claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2014) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. The undersigned identified the issue on appeal and noted what evidence was necessary to substantiate the claim. Specifically, he informed the Veteran that new and material evidence would be needed to reopen the Veteran's claim for service connection and solicited testimony to that end; he also elicited testimony regarding the Veteran's claim of service connection for a neck condition. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim. As such, the Board finds that no further action pursuant to Bryant is necessary. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO/AMC, the Veteran has been notified and made aware of the evidence needed to substantiate this claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 539, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). When considering evidence supporting a service-connection claim, the Board must consider, on a case-by-case basis, the competence and sufficiency of lay evidence offered to support a finding of service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (reiterating that "'[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.'") (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 Fed. Cir. 2007)). Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. 1110, 1131 (West 2014); 38 C.F.R. 3.303(a) (2014). Under 38 C.F.R. § 3.310, service connection may also be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, absent a diagnosis of a chronic disease as defined in 38 C.F.R. § 3.309(a), service connection may not be awarded based on continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this case, polyostotic fibrous dysplasia is an organic nervous system disorder and is recognized as chronic disease. Even so, as will be discussed below, the Board finds that polyostotic fibrous dysplasia is a developmental disease that clearly and unmistakably pre-existed the Veteran's entrance to active duty and clearly and unmistakably did not permanently increase in severity beyond the nature progression of the disease in service. Therefore, consideration of service connection on a presumptive basis is not applicable. Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. See 38 U.S.C.A. §§ 1111; 38 C.F.R. § 3.304(b). The presumption of soundness attaches only where there has been an induction examination during which the disability about which the veteran later complains was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulations provide expressly that the term "noted" denotes "[o]nly such conditions as are recorded in examination reports," 38 C.F.R. § 3.304(b), and that "[h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions." Id. at (b)(1). If a condition is not noted upon entrance into service, then to rebut the presumption of soundness at service entrance VA must show by clear and unmistakable evidence both that there was a pre-existing condition and that it was not aggravated during or by the Veteran's service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); VAOPGCPREC 3-2003 (July 16, 2003). To satisfy this second-prong requirement for rebutting the presumption of soundness, the government must show by clear and unmistakable evidence either that there was no increase in disability during service or that any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845, 847 (Fed. Cir. 2006). Defects are defined as "structural or inherent abnormalities or conditions which are more or less stationary in nature." VAOPGCPREC 82-90 (July 18, 1990). Congenital or developmental "defects" automatically rebut the presumption of soundness and are therefore considered to have pre-existed service. 38 C.F.R. §§ 3.303(c), 4.9. Service connection is generally precluded by regulation for such "defects", because they are not "diseases" or "injuries" within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9, 4.127; accord Terry v. Principi, 340 F.3d 1378, 1383-84 (Fed. Cir. 2003); Palczewski v. Nicholson, 21 Vet. App. 174, 179 (2007). VA's Office of General Counsel has distinguished between congenital or developmental defects, for which service connection is precluded by regulation, and congenital or hereditary diseases, for which service connection may be granted, if initially manifested in or aggravated by service. See VAOPGCPREC 82-90, VAOPGCPREC 67-90. The VA General Counsel draws on medical authorities and case law from other federal jurisdictions and concludes that a defect differs from a disease in that a defect is "more or less stationary in nature", while a disease is "capable of improving or deteriorating." See VAOPGCPREC 82-90 at para. 2. In this regard, the presumption of soundness does not apply to congenital defects because such defects "are not diseases or injuries" within the meaning of 38 U.S.C.A. §§ 1110 and 1111. See 38 C.F.R. § 3.303(c); see also Quirin v. Shinseki, 22 Vet. App. 390, 397; Terry v. Principi, 340 F.3d1291, 1385-86 (holding that the presumption of soundness does not apply to congenital defects); Winn v. Brown, 8 Vet. App. 510, 516 (1996) (holding that a non-disease or non-injury entity such as a congenital defect is "not the type of disease- or injury-related defect to which the presumption of soundness can apply"). However, a congenital defect can still be subject to superimposed disease or injury. VAOPGCPREC 82-90. If such superimposed disease or injury does occur, service connection may be warranted for the resulting disability. Id. However, if it is determined during service that a Veteran suffers from a congenital disease, as opposed to a defect, VA cannot simply assume that, because of its congenital nature, the disease must have preexisted service. That is, the presumption of soundness still applies to congenital diseases that are not noted at entry. Quirin, 22 Vet. App. at 396-397. Since the presumption of soundness at entrance attaches, VA must show by clear and unmistakable evidence that the congenital disease preexisted service. Monroe v. Brown, 4 Vet. App. 513, 515 (1993). VA may not rely on a regulation as a substitute for the requirement that it rely on independent medical evidence. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). VA's Office of General Counsel has also confirmed that the existence of a congenital hereditary disease under 38 C.F.R. § 3.303(c) does not always rebut the presumption of soundness, and that service connection may be granted for congenital hereditary diseases which either first manifest themselves during service or which preexist service and progressed at an abnormally high rate during service. See VAOPGCPREC 67-90; 55 Fed. Reg. 43,253 (1990). In short, service connection is available for congenital diseases, but not defects, that are aggravated in service. Quirin, 22 Vet. App. at 394; Monroe v. Brown, 4 Vet. App. 513, 515 (1993). In cases where the appellant seeks service connection for a congenital condition, the Board must indicate whether the condition is a disease or defect and discuss the presumption of soundness. Quirin, 22 Vet. App. at 394-397. It follows that in such cases where a congenital condition is at issue, a VA medical opinion may be needed to determine whether the condition is a disease or defect, whether the presumption of soundness has been rebutted, and if so whether there was aggravation during service. Id. at 395. Polyostotic Fibrous Dysplasia The Veteran contends that he is entitled to service connection for polyostotic fibrous dysplasia on the basis that it was aggravated during his period of active service. Similarly, he asserts that his current neck condition is related to the injury he had in service, to include the aggravating incident involving his polyostotic fibrous dysplasia. The Veteran was not provided a VA examination at entrance to service or there is no record of an examination, and he was medically separated from active duty in August 1979. The service treatment records indicate that the Veteran injured his shoulder in April 1979 while playing basketball; at that time, the diagnosis was probable multiple giant cell tumors. The injury did not cause the tumors. Instead investigation of the Veteran's symptoms exposed the presence of the tumors. In June 1979, the recommended disposition of the Air Force physical evaluation board included a diagnosis of polyostotic fibrous dysplasia without service aggravation. The findings concluded that the Veteran was unfit for long term service due to his physical disability and that the disability was permanent. The Veteran reported low back pain in his May 1979 report of medical history. After service, the Veteran worked as a designer at a commercial shipyard for 30 years that was primarily a sedentary position but required climbing ladders when inspecting ships under construction. The Veteran has submitted post-service private medical opinions regarding the etiology of his polyostotic fibrous dysplasia. According to a statement dated January 2010 from a physician with the initials T.M.B., the Veteran's polyostotic fibrous dysplasia was aggravated by an injury sustained while in the Air Force. Dr. T.M.B. provided no rationale in support of this opinion. The Court has held that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). Thus, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). In August 2010, the Veteran was provided a VA examination to determine whether the Veteran's polyostotic fibrous dysplasia had been aggravated by service. The examiner explained that the Veteran's polyostotic fibrous dysplasia is complicated by cervical spine impingement resulting in decreased upper and lower extremity sensation, chronic pain, and gain impairment status post-cervical spine fusion. The examiner opined that the Veteran's neck condition is "likely the result of the natural progression of polyostotic fibrous dysplasia and is not likely the result of or aggravated by the reported neck injury" the Veteran had during active duty. This, the examiner explained, is based on the Veteran having already established bone disease of polyostotic fibrous dysplasia at the time of his reported neck injury in 1979 and the natural pathophysiology of this bone condition which is comprised of medullary bone being replaced by fibrous tissue, which results in pain and alters the integrity and structure of the affected bone and can result in significant bone deformities and associated complications. Further, the examiner found that there is no medical basis to support the opinion offered by Dr. T.M.B. because the polyostotic fibrous dysplasia was established and subsequent to the reported neck injury records, the Veteran remained active in competitive sports despite being advised against doing so. Finally, the examiner stated that it is not likely that the Veteran's polyostotic fibrous dysplasia was aggravated during active duty based on the extent of the disease present during active service, the nature of the reported injury during active service, the reported activity level and status of the Veteran through 1991, and the natural history and progression of the condition. Then, in August 2011, another private opinion was provided from Dr. C.T.B. , suggesting that, as a result of a number of fractures sustained during military service, the Veteran's condition was aggravated, contributing to his current pain symptoms. Again, no rationale was provided in support of this opinion. As noted above, the Board previously remanded the claim to obtain an addendum opinion regarding whether the Veteran's polyostotic fibrous dysplasia was aggravated during service. Thus, in October 2014, an addendum opinion was provided. The examiner reviewed all of the evidence of record, including the positive etiological opinions provided from Dr. T.M.B. and Dr. C.T.B., the VBMS file, and the VA treatment records. The examiner stated that there is no evidence that the Veteran's polyostotic fibrous dysplasia has been permanently aggravated beyond its natural progression or that it was aggravated as a result of military service or any injury sustained therein. The examiner went on to explain that polyostotic fibrous dysplasia is a bone disease characterized by areas of abnormal bone growth in several bones where normal bone is replaced with fibrous bone tissue. The examiner stated that the disease is due to a mutation that occurs in utero. She further explained that the disorder has no symptoms and is diagnosed by accident during investigation for an unrelated medical problem. The examiner noted that the Veteran was medically discharged from service because of the polyostotic fibrous dysplasia diagnosis, and she reviewed the transcript of the formal physical evaluation board. The Veteran reported playing at least four sports in high school. He also described the shoulder injury he sustained during service while playing basketball. He stated that it "corrected itself." The examiner discussed the opinion by Dr. C.T.B.; she noted that it lacked a rationale and that it was not clear that the physician had reviewed any evidence, to include the Veteran's service treatment records or claims file. Thus, the examiner found that there was no basis upon which Dr. C.T.B. could opine that the Veteran's disorder was aggravated by injuries he sustained in service. Further, the examiner pointed out that Dr. C.T.B. rested his opinion on an inaccurate factual premise, stating that the Veteran sustained "multiple fractures while serving in the military." The VA examiner clarified that the Veteran's service treatment records do not support that the Veteran sustained multiple fractures in the military. Similarly, the examiner discussed Dr. T.M.B.'s opinion. The VA examiner pointed out that Dr. T.M.B. did not provide a rationale for his opinion or review the records in conjunction with providing it. Further, the examiner noted that she reviewed the Veteran's private treatment records from Dr. T.M.B. from 1990 to 2009 and that the records lack any visits pertaining specifically to any symptoms or complications relating to his polyostotic fibrous dysplasia. Thus, the examiner found there was no medical basis to support Dr. T.M.B.'s opinion. Finally, the examiner discussed the Veteran's post-service private treatment records, which show that the Veteran remained active after his military service. The examiner specifically noted that the Veteran was treated in December 1991 for a neck injury he sustained while playing basketball. It was also noted that the Veteran remained very active and continued with competitive sports despite being advised against doing so. The examiner also noted that the Veteran's X-ray and CT scan of the cervical spine did not show any fracture or neurologic deficit. The examiner noted that the Veteran was diagnosed with rheumatoid arthritis in the early to mid-200s and was treated for it for many years. The examiner opined that there is clear and unmistakable evidence that the Veteran's pre-existing polyostotic fibrous dysplasia was not aggravated as a result of military service or any injury sustained therein. The Veteran is competent to provide descriptions of his symptoms and events in service as they are observable by a lay person. His statements to VA and to his clinicians are credible as they were accepted by the examiners without challenge and are consistent with the military records and nature of his duties. The Veteran did not offer an opinion on the onset and origin of his disease nor did he object to the determination that the disease is developmental and first manifest prior to service. The Veteran submitted medical evidence that his disease was aggravated by service but did not offer any lay statements on the causes for the progression of his symptoms. In this case, the Veteran was not provided an examination at entrance to service or that the record of any examination has not been recovered. As there was no notation of a disease at entry, as described above, the presumption of soundness does attach. Nevertheless, the October 2014 VA examiner explained that the Veteran's polyostotic fibrous dysplasia is a disease that occurs due to a mutation that occurs in utero. This is consistent with notations in the reports of the service medical examination and physical evaluation boards. As such, the Veteran's polyostotic fibrous dysplasia is a congenital disease that pre-existed service. Thus, the Board must determine whether the Veteran's disorder was aggravated by service. As discussed above, the VA examiners provided complete opinions regarding the Veteran's disorder, with thorough rationales explaining that the Veteran's polyostotic fibrous dysplasia was clearly and unmistakably not aggravated by service, to include the injury he sustained therein. The Board places less probative weight on the briefly stated conclusions by the private physicians in January 2010 and August 2011 that the disorder was aggravated by service. The physicians did not elaborate on the conclusions they reached, and no rationales were provided. Further, as pointed out by the VA examiner who provided the October 2014 VA opinion, there is no evidence that either private physician reviewed the Veteran's claims file or the service treatment records. By contrast, the VA examiners took into consideration the Veteran's service treatment records, entire claims file, and the opinions offered by his private physicians. These physicians were in a position to examine the Veteran with the best understanding of the history and the Veteran's military activities. Therefore, the Board concludes that the probative evidence of record as offered by the military attending physicians and members of the medical evaluation board (four different physicians) and the VA examiners reveals that the Veteran's polyostotic fibrous dysplasia, which pre-existed service, was clearly and unmistakably not aggravated beyond the normal progression of the disease during service, to include any injuries he sustained therein. Therefore, service connection must be denied. The Board considered whether the report and opinion in October 2014, added to the file after the most recent supplemental statement of the case, must be returned to the Agency of Original Jurisdiction for review in the absence of a waiver by the Veteran. Although pertinent, the opinion additionally addressed the August 2011 private opinion that was substantially the same as the January 2010 private opinion. Further, the October 2014 VA opinion was substantially the same as the earlier August 2010 VA opinion. Therefore, the content of the evidence received in October 2014 was duplicative of that of record at the time of the most recent AOJ adjudication. Further remand for AOJ review is not warranted and the Veteran was not prejudiced by proceeding with a decision based on the evidence of record. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for polyostotic fibrous dysplasia. As such, there is no reasonable doubt to resolve in his favor, and his claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. Neck Condition The Veteran also seeks service connection for a neck condition, to include as secondary to his polyostotic fibrous dysplasia. As an initial matter, service connection on a secondary basis is denied as the Veteran is not service-connected for his polyostotic fibrous dysplasia. 38 C.F.R. § 3.310. Service connection must therefore be denied as a matter of law. Next, the Board will address service connection on a direct-incurrence basis. The service treatment records indicated that the Veteran had multiple lytic lesions with some element of sclerosis on the cervical spine that was associated with the polyostotic fibrous dysplasia. However, upon separation, the Veteran did not report any problems with his back and on clinical evaluation, and no other abnormalities were noted. The Veteran's private treatment records show that the Veteran was hospitalized in December 1991 and diagnosed with fibrous dysplasia of the cervical spine. Additional MRI studies from November 2008 show abnormalities of the cervical vertebra consistent with his diagnosis of fibrous dysplasia. There is no evidence that the Veteran has a neck condition that is not associated with his polyostotic fibrous dysplasia. The Board notes that the only contrary opinion of record comes from the Veteran himself, who maintains that his neck condition is related to his period of active service. 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 a cervical spine condition falls outside the realm of common knowledge of a lay person. In this regard, while the Veteran can competently report the onset and symptoms of his neck condition, any actual diagnosis requires objective testing to diagnose, and can have many causes. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Significantly, determining the precise etiology of the Veteran's neck condition is not a simple question, as there are conceivably multiple potential etiologies of the Veteran's symptoms, and he has been diagnosed with polyostotic fibrous dysplasia by medical professionals. Ascertaining the etiology of a neck condition involves considering multiple factors and knowledge of the medical condition from which the Veteran suffers. In this case, the facts are complex enough that the Veteran's intuition about the cause of his neck condition is not sufficient to outweigh the opinion of the experts that carefully considered the specific facts of this case. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (Lance, J., concurring) ("The question of whether a particular medical issue is beyond the competence of a layperson-including both claimants and Board members-must be determined on a case-by-case basis.") Thus, the Board finds that the Veteran's opinion is not entitled to significant weight as compared to the opinions offered by the medical board examiners and the VA examiners. The Board reiterates that the Veteran's service treatment records are negative for any neck condition not related to his polyostotic fibrous dysplasia during service. Therefore, the Board finds that the preponderance of the evidence indicates that the Veteran did not have a neck condition not related to his polyostotic fibrous dysplasia in service; and there is no credible evidence indicating that the Veteran currently has a neck condition that is not associated with the polysototic fibrous dysplasia. The weight of the competent and credible evidence does not show the Veteran's neck condition is related to his period of service. Therefore, service connection is not warranted for a neck condition on any basis. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for polyostotic fibrous dysplasia. As such, there is no reasonable doubt to resolve in his favor, and his claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. ORDER Entitlement to service connection for polyostotic fibrous dysplasia is denied. Entitlement to service connection for a neck condition, to include as secondary to polyostotic fibrous dysplasia, is denied. ____________________________________________ J. W. FRANCIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs