Citation Nr: 1533111 Decision Date: 08/04/15 Archive Date: 08/11/15 DOCKET NO. 09-08 361 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for a skin disorder, to include chloracne, as a result of exposure to herbicides. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD K. Hubers, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1967 to January 1969. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a rating decision issued in November 2007 by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In February 2013, the Board remanded the above-listed issues for further development and readjudication. With respect to development, the Board requested that the AOJ obtain updated treatment records and then afford the Veteran VA examinations with respect to the above listed conditions. The requested actions having been completed and the claim having been readjudicated by the RO in a May 2013 Supplemental Statement of the Case, the matter has properly been returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). The record contains evidence not yet considered by the AOJ, but the Veteran submitted a September 2013 waiver of his right to have his case remanded to the AOJ for review of the additional evidence. The Board may proceed to the merits. See 38 C.F.R. § 20.1304(c). FINDINGS OF FACT 1. The Veteran was exposed to acoustic trauma during active military service, but the weight of the evidence is against finding that his current bilateral hearing loss either began during or was otherwise caused by his military service. 2. The Veteran was exposed to acoustic trauma during active military service, but the weight of the evidence is against finding that his current tinnitus either began during or was otherwise caused by his military service. 3. The weight of the evidence is against a finding that the Veteran's currently-diagnosed skin disorder either began during or was otherwise caused by his military service, including exposure to herbicide agents. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307 (2014). 2. The criteria for service connection for tinnitus have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307 (2014). 3. The criteria for service connection for a skin disorder have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Assist When VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In the instant case, notice was provided to the Veteran in November 2006 prior to the initial adjudication of his claims in November 2007. The contents of the notice letter fully comply with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Board concludes that VA satisfied its duties to notify the Veteran. VA must also make reasonable efforts to assist the appellant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2014). VA's duty to assist includes assisting the claimant in the procurement of service and other relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO associated with the claims file the Veteran's service treatment records, private treatment records, Social Security Administration (SSA) records, and VA treatment records. The Veteran has not identified any relevant records aside from those that are already in evidence. So, the Board concludes that VA has made every reasonable effort to obtain all records relevant to the Veteran's claim. VA also satisfied its duty to obtain medical examinations. As noted in the Introduction, the Board remanded this matter in February 2013 to schedule VA examinations. Pursuant to the remand instructions, VA provided the Veteran with April 2013 medical examinations with respect to his hearing loss, tinnitus, and skin disorder. The examinations are adequate as the VA examiners reviewed the Veteran's pertinent medical history, conducted a clinical evaluation of the Veteran, and provided adequate discussion of relevant symptomatology. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007); Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). As will be discussed below, the opinions contain thorough rationales based on accurate factual and medical histories. The Board acknowledges that the audiologist who provided the April 2013 opinion on tinnitus noted that she lacked the expertise to opine as to any potential medical causes of the Veteran's tinnitus other than traumatic noise exposure. However, she was able to opine that, more likely than not, the Veteran's tinnitus was related to his hearing loss and was not related to in-service acoustic trauma. This opinion is sufficient to decide the claim. Moreover, the Veteran has not alleged, nor is there any other indication in the record, that his tinnitus is related to a cause other than acoustic trauma, so additional examination regarding other possible causes is not warranted. See 38 U.S.C. § 5103A(d)(2); McLendon v. Nicholson, 20 Vet.App. 79, 81-86 (2006) (including in the criteria to warrant an examination both: "an indication that the disability...may be associated with the veteran's service or with another service-connected disability" and "insufficient competent medical evidence to make a decision on the claim"). In reaching this conclusion, the Board notes that the Veteran's multiple, prior VA medical examinations have never indicated an association between tinnitus (as a symptom or otherwise) and any of his service-connected conditions or any in-service event or injury. See September 2007 VA Examination (Diabetes); see also April 2009 VA Examination (General Medical). The medical evidence already of record (including particularly the April 2013 VA examination reaching conclusion to the requisite degree of medical certainty) is sufficient to determine the merits of the tinnitus claim. VA has no obligation to obtain further medical examinations or opinions in connection with the claims on appeal. See 38 U.S.C.A. § 5103(A)(d); see also Wells v. Principi, 326 F.3d 1381, 1384 (Fed. Cir. 2003). In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to the issues on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103 and 5103A; 38 C.F.R. § 3.159. II. General Legal Standards Under 38 U.S.C.A. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. The law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000). The Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). In deciding the Veteran's claim, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event; or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Shedden v. Prinicipi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Further, where the veteran asserts entitlement to a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service or diagnosis within the presumptive period after service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013). The Veteran's claims relate to bilateral hearing loss, tinnitus, and a skin disorder (claimed as chloracne and diagnosed during the appeal period as eczema, folliculitis, dermatitis, and urticarial vasculitis). "Purpura idiopathic, hemorrhagic" is a skin disorder and is included in the list of chronic diseases under 38 C.F.R. § 3.309(a). Therefore, giving the Veteran the benefit of every doubt, the Board will apply the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology to the claim of entitlement to service connection for a skin disorder. Sensorineural hearing loss and tinnitus are encompassed by the list of chronic diseases under 38 C.F.R. § 3.309(a). See M21-1MR, Part III.iv.4.B.12.a. (noting "other organic diseases of the nervous system" includes sensorineural hearing loss and tinnitus). Therefore, the Board will apply the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology in analyzing the Veteran's claims with respect to bilateral hearing loss and tinnitus. The Veteran has alleged that he was exposed to herbicide agents during his service in Vietnam and that the exposure to herbicide agents caused his current skin disorder. A Veteran who "served in the Republic of Vietnam" between January 9, 1962 and May 7, 1975 is presumed to have been exposed during such service to herbicide agents (e.g. Agent Orange). 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). The record establishes that the Veteran served in Vietnam during the relevant period, so he is presumed to be have been exposed to herbicide agents. There is no evidence that he was not, in fact, exposed, so the presumption is not rebutted. Exposure to herbicide agents is established. Diseases associated with exposure to certain herbicide agents (e.g. Agent Orange) during the Vietnam era will be considered to have been incurred in service. 38 U.S.C.A § 1116(a)(1). Chloracne is among the diseases presumptively associated with herbicide exposure. 38 C.F.R. § 3.309(e) ("Chloracne or other acneform disease consistent with chloracne"). With respect to chloracne or other acneform disease, the regulations require manifestation of the disease "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)(6)(ii). Neither sensorineural hearing loss nor tinnitus are included in the list of diseases associated with herbicide exposure. See 38 C.F.R. § 3.309(e). The presumptions are not applicable to those conditions. In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant's uncorroborated account of his active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). When evaluating the evidence of record, the Board must assess the credibility and probative value of the evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). III. Hearing Loss The Veteran claims entitlement to service connection for bilateral hearing loss. He asserts that exposure to acoustic trauma during his military service caused his current hearing loss. The Veteran's service records establish, and VA has previously conceded, that the Veteran had in-service acoustic trauma. See May 2013 Statement of the Case (SOC). Therefore, the in-service element of a service connection claim is met. Service connection for hearing loss shall only be established when hearing status, as determined by audiometric testing, meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels) over a range of frequencies (in Hertz). See Hensley v. Brown, 5 Vet. App. 155, 158 (1993). The determination of whether a veteran has a disability based on hearing loss is governed by 38 C.F.R. § 3.385. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385. On the authorized audiological evaluation in April 2013, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 20 30 40 LEFT 30 25 25 35 40 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 94 percent in the left ear. With a bilateral hearing disability and in-service acoustic trauma established, the remaining question is whether the Veteran's current bilateral hearing disability is causally related to his military service. See Shedden, 381 F.3d at 1167. Medical Evidence Prior to October 31, 1967, service department audiometric results were reported in standards set forth by the American Standards Association (ASA). Since November 1, 1967, those standards have been set by the International Standards Organization (ISO)-American National Standards Institute (ANSI). In order to facilitate data comparison, where applicable, the ASA standards have been converted to ISO-ANSI standards. In this regard, the ASA pure tone thresholds as noted in the Veteran's service treatment records (STRs) are represented by the digit not contained in parentheses, while the converted ISO-ANSI pure tone threshold for results recorded prior to November 1, 1967, are contained in the parentheses. On the audiological evaluation performed at the Veteran's induction examination in February 1967, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 (15) 0 (10) 0 (10) 0 (10) 0 (5) LEFT 0 (15) 0 (10) 0 (10) 0 (10) 0 (5) Speech audiometry testing was not performed. On the audiological evaluation performed in July 1967 during the Veteran's service, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 (20) 5 (15) 0 (10) - 0 (5) LEFT 20 (35) 10 (20) 0 (10) - 0 (5) Speech audiometry testing was not performed. On the audiological evaluation performed in December 1967 during the Veteran's service, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 - 0 LEFT 0 0 0 - 0 Speech audiometry testing was not performed. On the audiological evaluation performed at the Veteran's discharge in January 1969, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 15 - 5 LEFT 0 0 10 - 5 (The Board notes that the handwritten entry for 500 Hz is unclear, but is definitely a single digit. Thresholds are typically recorded in or rounded to multiples of five, so to give the Veteran the benefit of every doubt, it has been set forth as 5 db above.) Speech audiometry testing was not performed. On the authorized audiological evaluation in September 2007, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 25 10 20 30 LEFT 25 20 15 20 35 Speech audiometry revealed speech recognition ability of 86 percent in the right ear and of 92 percent in the left ear. However, the examiner indicated the speech audiometry results were "depressed from the veteran's true potential" and, for that reason, "should not be used for rating purposes." The September 2007 VA examiner provided a negative etiological opinion. However, as discussed in the February 2013 Board remand, the rationale for that opinion was inadequate. The April 2013 VA examination revealed current bilateral sensorineural hearing loss, but the examiner opined that it was less likely than not related to the acoustic trauma the Veteran suffered in service. The examiner explained that the Veteran had normal hearing thresholds on each of his in-service audiological evaluations and the lack of any "significant decreases in hearing thresholds during active duty." In further support of that conclusion, the examiner noted post-service noise exposure including "lawn equipment, power tools, factory noise (overhead crane)" as well as a history of "ear infections from colds and dizziness when diabetes is 'off'." Analysis As the above evidence indicates, the Veteran did not have sensorineural hearing loss upon discharge from service. In fact, the first diagnosis of sensorineural hearing loss was made in the September 2007 VA audiological examination, though even at that point the mild hearing loss did not constitute a disability for VA purposes. See 38 C.F.R. § 3.385. In reaching these conclusions, the Board acknowledges the July 1967 audiological test results which indicate a threshold of 35 db at 500 Hz. See Hensley, 5 Vet. App. at 157 ("the threshold for normal hearing is from 0 to 20db, and higher threshold levels indicate some degree of hearing loss"). However, the July 1967 results differ significantly from testing just a few months previously and, more importantly, a few months later. In addition, as noted above, the discharge examination found no hearing loss and no significant threshold shifts from the entrance examination. The Board finds that the July 1967 results were an aberration. The VA examiners' opinions, including findings of no significant threshold shifts during service, support this interpretation. The greater weight of the evidence indicates that the Veteran did not have symptoms of and was not diagnosed with hearing loss during his active service or within one year after discharge. Because the Veteran's bilateral hearing loss was not diagnosed or manifest to a compensable degree within one year of the Veteran's separation from service, service connection may not be presumed on that basis. See 38 C.F.R. §§ 3.307, 3.309(a). In addition, as discussed above, service connection for a sensorineural hearing disability may be established by showing a continuity of symptomatology because the VA treats sensorineural hearing loss as an organic disease of the nervous system. 38 C.F.R. §§ 3.303(b), 3.309(a); M21-1MR III.iv.4.B.12.a; see also Walker, 708 F.3d at 1338-39. However, the evidence of record indicates that the Veteran has not had continuous trouble hearing since service. He was first diagnosed with hearing loss well after he left the service. See September 2007 VA Examination (finding no hearing disability for VA purposes); April 2013 VA Examination (diagnosing hearing loss for the first time); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (permitting consideration of delay in reporting symptoms). The Board finds that the preponderance of the evidence is against finding that the Veteran has experienced continuous symptoms of hearing loss since his active service and service connection under Section 3.303(b) is not warranted on this record. Walker, 708 F.3d at 1338-39. The only remaining avenue for service connection is by showing in-service incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). See Walker, 708 F.3d at 1338-39. The Board acknowledges the Veteran has submitted for consideration his belief that his hearing disability was caused by in-service noise exposure. While the Veteran is competent to report (1) symptoms observable to a layperson (e.g. decreased hearing); (2) a diagnosis that is later confirmed by clinical findings; or (3) a contemporary diagnosis, the Board need not find a lay Veteran competent to render opinions regarding etiology nor need the Board give any probative weight to bald assertions by a lay Veteran regarding the etiology of a medical condition. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed.Cir. 2009); King v. Shinseki, 700 F.3d 1339, 1344-45 (Fed. Cir. 2012). The Board finds that the etiological opinions of this Veteran, who lacks relevant medical training and whose opinions address a complex acoustic and medical history which includes post-military exposure to high-risk noise and delayed onset of symptoms, are not competent evidence of the etiology of the Veteran's bilateral hearing loss. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The only medical evidence regarding the etiology of the Veteran's hearing loss disability is in the reports of the September 2007 and April 2013 VA examinations. As already noted, the September 2007 VA examiner's opinion has been deemed inadequate. However, the April 2013 VA examiner reviewed the Veteran's service treatment records, medical history, and subjective reports of hearing loss and noise exposure. The VA examiner noted that the Veteran did have noise exposure in the military, that the Veteran did not have a hearing disability on separation, that there was no significant threshold shift during service, that the Veteran had a history of ear infections, and that the Veteran had some post-military noise exposure. Based on these facts, the results of audiometric testing, the examiner's medical expertise, and review of relevant medical literature, the VA examiner concluded that the Veteran's hearing loss was not caused by or the result of military noise exposure. The Board finds the VA examiner's etiological opinion to be competent and credible evidence of the etiology of his hearing loss disability. The Board finds that the VA examination opinion is adequate and, further, finds its reasoning and analysis to be of significant probative value. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). The VA examiner's opinion is also supported by the absence, in the record, of any complaint regarding hearing loss for many years following the Veteran's separation from service. See Maxson, 230 F.3d at 1333. The Veteran has been accorded ample opportunity to furnish medical and other evidence in support of his claim, but he has submitted no competent medical evidence contrary to the findings of the VA examiner. See 38 U.S.C.A. § 5107(a). The Board concludes that there is no etiological link between the Veteran's current bilateral hearing disability and his active service. In making each of the above determinations (e.g. inapplicability of the presumptions regarding chronic diseases, the absence of a continuity of symptomatology, and the lack of a causal nexus), the Board has considered the Veteran's lay reports but, to the extent his testimony is competent (e.g. reporting subjective experience of decreased hearing acuity), the service treatment records documenting audiological evaluations have far greater probative value than the Veteran's subjective evaluation of his hearing acuity. See Curry v. Brown, 7 Vet. App. 59, 68 (1994). The Veteran's combat experience in Vietnam warrants consideration of the presumption in 38 U.S.C. § 1154(b), but the presumption, while sufficient to establish an in-service acoustic trauma (i.e. an injury consistent with the circumstances of his service as a gunner), does not supply the necessary causal nexus between the current disability (e.g. hearing loss) first diagnosed many years many years after discharge and the in-service acoustic trauma. In making this finding, the Board notes that the overwhelming weight of the medical evidence establishes that the Veteran had normal hearing at separation and for many years after discharge. Any subjective reports of decreased hearing acuity during his active service contradict the audiological evaluations by medical professionals during his service. In other words, the issue here is not an absence of an official report of an in-service injury or disease, but whether the Veteran's subjective reports have greater probative value, including as a result of the combat presumption, than contemporaneous medical evaluations. The Board finds they do not. The subjective reports of decreased hearing acuity cannot supply, on the record currently before the Board, the nexus element of the Veteran's service connection claim. The preponderance of the evidence is against the claim for service connection for bilateral hearing loss. Thus, the benefit of the doubt rule does not apply, and the Veteran's claim is denied. See 38 U.S.C.A. § 5107 (West 2014). IV. Tinnitus As with hearing loss, the determinative element of the Veteran's tinnitus claim is a causal nexus between in-service acoustic trauma and his current tinnitus. There is no indication in the record that the Veteran was diagnosed with tinnitus during his active service or that it manifested to a compensable degree within one year of his discharge. In addition, the Board finds that the evidence is against finding a continuity of symptomatology since the Veteran's active service. At his September 2007 VA examination, the Veteran reported that his tinnitus "may have been first noted in the 1970s", but the Veteran provided "[n]o specifics, however, regarding dates or circumstances of onset." As previously noted, the Veteran's service treatment records (including his separation examination and his own reports of his medical history while in service and at separation) consistently indicate that his hearing is normal and fail to document any symptoms (e.g. ringing in the ears) of tinnitus. The Veteran's first documented complaints of the symptoms of tinnitus were made many years after discharge at the September 2007 VA examination in the context of a claim for benefits. Caluza, 7 Vet. App. at 511-12; see also Cartright, 2 Vet. App. at 25 (interest may affect the credibility of testimony). In any case, the Veteran was discharged in January 1969, so a diagnosis in the "1970s" suggests an onset of symptoms more than one year after his discharge. The Board finds that the preponderance of the evidence is against finding that the Veteran has experienced continuous symptoms of tinnitus since his active service and service connection under Section 3.303(b) is not warranted on this record. Walker, 708 F.3d at 1338-39. The only remaining avenue for service connection is by showing in-service incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). See Walker, 708 F.3d at 1338-39. To the extent the Veteran relies on his own opinion that his tinnitus is related to in-service acoustic trauma, the Board finds that his opinions are not competent where he has acknowledged a post-service onset, he has no medical training or expertise, and resolving the etiology of tinnitus typically requires specialized knowledge, training, and experience to identify and evaluate various potential causes. The Veteran's opinions are not competent evidence regarding a causal nexus. Davidson, 581 F.3d at 1316; King, 700 F.3d at 1344-45; Jandreau, 492 F.3d at 1377. As already discussed in the context of the hearing loss, the presumptions of 38 U.S.C. § 1154(b) applicable to injuries or diseases sustained in combat cannot supply the necessary nexus element on this record, which includes the Veteran's explicit statement that his symptoms had onset post-service and the etiological opinions of two VA audiologists that flatly contradict his own lay opinions. While the Board previously determined that the September 2007 VA examiner's opinion was inadequately explained, the April 2013 VA examination resulted in a thoroughly reasoned opinion based on an accurate medical history. The April 2013 examiner explained that the Veteran's tinnitus was more likely than not related to his hearing loss and that the hearing loss was less likely than not related to in-service acoustic trauma. See Fountain v. McDonald, 27 Vet.App. 258, 275 (Feb. 9, 2015) (discussing correlation between hearing loss and tinnitus and the need for medical opinions to address any medical connection between the two where both are diagnosed). The examiner also opined, more generally, that the Veteran's tinnitus was less likely than not caused by or related to his military noise exposure. The April 2013 VA examiner's opinion is entitled to probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). No medical professional has provided a contrary opinion. Accordingly, after considering the evidence of record in its entirety, the Board concludes that the preponderance of the evidence is against the claim for service connection for tinnitus. Thus, the benefit of the doubt rule does not apply, and the Veteran's claim is denied. See 38 U.S.C.A. § 5107 (West 2014). V. Skin Disorder The Veteran alleges that he first had symptoms of a skin disorder ("jungle rot") during his active service and that his later diagnosed skin disorders are related to his active service to include his presumed exposure to herbicide agents (e.g. Agent Orange). As discussed above, the presumption of service connection for chloracne or other acneform disease consistent with chloracne requires manifestation of the disease 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)(6)(ii). Here, the evidence is against finding any such manifestation. The Veteran's January 1969 separation examination indicated that his skin was normal and failed to otherwise indicate any ongoing skin disorders, rashes, or other abnormalities. The Veteran also indicated, on his January 1969 Report of Medical History that he had not ever had and did not have then any skin disease. Likewise, every other examination during the Veteran's service, including in February 1967, July 1967, and December 1967, also found his skin to be "normal" and the Veteran reported on the corresponding Reports of Medical History that he did not have and had not ever had a skin disease. While the Veteran reported at his April 2013 VA examination that he had skin problems beginning "about 1970", these statements do not establish, on this record, a manifestation of chloracne to a degree of 10 percent or more within one year of his discharge. This is particularly so where the medical evidence is against finding that the Veteran now has or has ever had chloracne. See, e.g., April 2013 VA Examination (diagnosing urticarial vasculitis instead of the alleged chloracne); May 2013 Private Clinic Note of Dr. J.M. ("I don't see any evidence of chloracne at this time."); see also, generally, VA Progress Notes (including diagnoses of eczema, dermatitis, folliculitis, and, ultimately, urticarial vasculitis, but not chloracne). The VA examiner, while noting the Veteran's allegations, has specifically opined that it is less likely than not that the current skin condition is related to "any events or conditions of military service." The greater weight of the evidence is against finding that chloracne or other acneform disease consistent with chloracne was diagnosed during service or manifested to a degree of 10 percent or more within one year of service. The presumption of service connection for chloracne as due to herbicide exposure is not applicable on the record currently before the Board. As already discussed, the Board has considered the presumptions for chronic diseases (specifically, idiopathic purpura, hemorrhagic). Initially, the Board notes that the Veteran has not been diagnosed with "idiopathic purpura, hemorrhagic." Instead, his currently diagnosed skin disorder is urticarial vasculitis. See April 2013 VA Examination. In addition, the Veteran's service treatment records are silent for any in-service skin condition and specifically document "normal" skin on multiple occasions including at discharge. Given the finding above that the Veteran's current skin condition did not manifest in service or within one year of discharge, the evidence of record does not establish a continuity of symptomatology since his service either. This conclusion is also supported by the April 2013 VA examiner's opinion, upon reviewing the medical evidence and acknowledging the Veteran's allegations, that the current skin condition is not related to any in-service disease or injury (to include the claimed in-service "jungle rot"). See April 2013 VA Examination. Service connection for a skin disorder under the provisions relating to chronic diseases and continuity of symptomatology is not warranted on the evidence of record. The failure of the Veteran to establish entitlement to service connection for a skin disorder based on the Agent Orange and chronic disease presumptions does not necessarily end the Board's discussion. See 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d) (2010) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994) (Radiation Compensation Act does not preclude a Veteran from establishing service connection with proof of actual direct causation). The Veteran may still prevail by showing that a disease first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). See Walker, 708 F.3d at 1338-39. The determinative element of his direct service connection claim is whether there is a causal nexus between an in-service disease or injury (to include exposure to herbicides) and his currently diagnosed skin disorder (urticarial vasculitis). While the Veteran is competent to report (1) symptoms observable to a layperson (e.g. a rash); (2) a diagnosis that is later confirmed by clinical findings; or (3) a contemporary diagnosis, the Board need not find a lay Veteran competent to render opinions regarding etiology nor need the Board give any probative weight to bald assertions by a lay Veteran regarding the etiology of a medical condition. See Davidson, 581 F.3d at 1316; King, 700 F.3d at 1344-45. The Board finds that the etiological opinions of this Veteran are not competent evidence of the etiology of his skin disorder where he lacks relevant medical training and where his opinions address a complex medical history, delayed onset of symptoms, and a skin condition which required biopsy to accurately diagnose. See Jandreau, 492 F.3d at 1377. As with hearing loss and tinnitus, the combat presumptions of 38 U.S.C. § 1154(b) cannot supply the missing nexus element of his skin disorder claim. The Board is not presented with allegations of an undocumented injury or disease and silence in the service records. Instead, the Board must evaluate a record including service treatment records which document examination of the Veteran's skin (as well as extremities) with explicit notations that his skin (and extremities) were "normal" during service and at discharge, the Veteran's allegation that his current skin disorder first began in "about 1970" (i.e. after discharge), and a competent, thorough April 2013 medical opinion that the current skin disorder is not related to any in-service disease or injury. The nexus element of the Veteran's claim cannot be supplied by the combat presumption on the evidence currently of record. The competent medical evidence regarding a causal nexus is against the Veteran's claim. Although the Veteran has relied on the findings of his private dermatologist, see July 2015 Veteran's Appellate Brief, the private dermatologist specifically declined to provide an etiological opinion. See May 2013 Private Clinic Note of Dr. J.M. (diagnosing "nonspecific dermatitis" and stating: "I am not certified to do service connected evaluations"). The private dermatologist's findings provide no support for the Veteran's claims and, in fact, contradict the Veteran's own opinions in that the dermatologist specifically rejects a diagnosis of chloracne and affirmatively diagnosed dermatitis. The only other etiological opinion of record is the negative opinion of the April 2013 VA examiner. The VA examiner carefully reviewed the Veteran's contentions and the medical evidence of record, including biopsies of the Veteran's skin, to reach her diagnosis and etiological conclusions. On the basis of that evidence, a thorough examination, and her medical training, knowledge, and experience, the examiner concluded that it is less likely than not that the Veteran's current skin disorder "is secondary to any events or conditions of military service." She explained that the medical evidence was against finding the Veteran had the skin condition "during or within 1 year after military service" and that the current skin disorder "is an auto-immune type of disorder" which is "thought to have genetic predisposing factors". She specifically noted that there is "no known association between Agent Orange exposure" and urticarial vasculitis. Based on all of these findings, as well as her review of the medical record and service treatment records, she concluded that the Veteran's urticarial vasculitis was not incurred during and is not otherwise related to his active service. The April 2013 VA examiner's opinion is well-supported, convincingly explained and, therefore, of significant probative value. Nieves-Rodriguez, 22 Vet. App. at 304. The preponderance of the evidence is against the claim for service connection for a skin disorder, to include as due to exposure to herbicide agents, so the benefit of the doubt rule does not apply. See 38 U.S.C.A. § 5107 (West 2014). The Veteran's claim is denied. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for a skin disorder is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs