Citation Nr: 1604914 Decision Date: 02/09/16 Archive Date: 02/18/16 DOCKET NO. 14-44 281 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for diabetes mellitus, type II. 2. Entitlement to service connection for benign prostate hyperplasia. 3. Entitlement to service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD), sleep disorder, major depressive disorder (MDD), and generalized anxiety disorder (GAD). 4. Entitlement to service connection for hypertensive cardiovascular disease. 5. Entitlement to service connection for hiatal hernia. 6. Entitlement to service connection for gastroesophageal reflux disease (GERD). 7. Entitlement to service connection for peptic ulcer disease (PUD). 8. Entitlement to service connection for chronic colitis. 9. Entitlement to service connection for degenerative disc disease of the cervical spine. 10. Entitlement to service connection for degenerative disc disease of the lumbar spine. 11. Entitlement to service connection for degenerative joint disease of both hips. 12. Entitlement to service connection for degenerative joint disease of both knees. 13. Entitlement to service connection for degenerative joint disease of both feet. 14. Entitlement to an increased rating in excess of 10 percent for conjunctivitis. 15. Entitlement to a total rating by reason of individual unemployability due to service-connected disability (TDIU). ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from May 1966 to April 1968. His service included duty in the Republic of Vietnam (RVN). This case comes to the Board of Veterans' Appeals (Board) on appeal of rating decisions of the San Juan, the Commonwealth of Puerto Rico, Regional Office (RO) of the Department of Veterans Affairs (VA). The issues of service connection for hypertensive cardiovascular disease and the issue of entitlement to TDIU, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if additional action is required on his part. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. Diabetes mellitus, type II, has not been demonstrated at any time. 2. Benign prostate hyperplasia was not evident during service or until many years thereafter and is not shown to have been caused by any in-service event. 3. A diagnosis of PTSD has not been clinically confirmed in the record. 4. An acquired psychiatric disorder, including PTSD, sleep disorder, MDD, and GAD, was not evident during service or until many years thereafter and is not shown to have been caused by any in-service event. 5. Hiatal hernia was not evident during service or until many years thereafter and is not shown to have been caused by any in-service event. 6. GERD was not evident during service or until many years thereafter and is not shown to have been caused by any in-service event. 7. PUD was not evident during service or until many years thereafter and is not shown to have been caused by any in-service event. 8. Chronic colitis was not evident during service or until many years thereafter and is not shown to have been caused by any in-service event. 9. Degenerative disc disease of the cervical spine was not evident during service or until many years thereafter and is not shown to have been caused by any in-service event. 10. Degenerative disc disease of the lumbar spine was not evident during service or until many years thereafter and is not shown to have been caused by any in-service event. 11. Degenerative joint disease of both hips was not evident during service or until many years thereafter and is not shown to have been caused by any in-service event. 12. Degenerative joint disease of both knees was not evident during service or until many years thereafter and is not shown to have been caused by any in-service event. 13. Degenerative joint disease of both feet was not evident during service or until many years thereafter and is not shown to have been caused by any in-service event. 14. Throughout the appeal, the Veteran's conjunctivitis has been manifested by conjunctival injection and complaint of burning eyes, with no visual impairment or disfigurement. CONCLUSIONS OF LAW 1. Diabetes mellitus, type II, was neither incurred in nor aggravated by service and may not be presumed to have been. 38 U.S.C.A. §§ 1101, 1110, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 2. Benign prostate hyperplasia was neither incurred in nor aggravated by service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2015). 3. An acquired psychiatric disorder, including PTSD, sleep disorder, MDD, and GAD, was neither incurred in nor aggravated by service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.304(e) (2015). 4. Hiatal hernia was neither incurred in nor aggravated by service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2015). 5. GERD was neither incurred in nor aggravated by service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2015). 6. PUD was neither incurred in nor aggravated by service nor may it be presumed to have been. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 7. Chronic colitis was neither incurred in nor aggravated by service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2015). 8. Degenerative disc disease of the cervical spine was neither incurred in nor aggravated by service nor may it be presumed to have been . 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 9. Degenerative disc disease of the lumbar spine was neither incurred in nor aggravated by service nor may it be presumed to have been. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 10. Degenerative joint disease of both hips was neither incurred in nor aggravated by service nor may it be presumed to have been . 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 11. Degenerative joint disease of both knees was neither incurred in nor aggravated by service nor may it be presumed to have been. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 12. Degenerative joint disease of both feet was neither incurred in nor aggravated by service nor may it be presumed to have been . 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 13. The criteria for an increased rating in excess of 10 percent for chronic conjunctivitis have not been met for any period. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.79, Diagnostic Code (Code) 6018 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between a veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to the initial adjudication of the claims. May, June and July 2013 letters explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing. This letter also informed the Veteran of disability rating and effective date criteria. The Veteran has had ample opportunity to respond and supplement the record. With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records have been secured. The Veteran was afforded VA medical examinations, most recently in June 2014. The Board finds that the opinions obtained are adequate as to the issues decided herein. The opinions were provided by qualified medical professionals and were predicated on a full reading of all available records. The examiners also provided a detailed rationale for the opinions rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran has not challenged the adequacy of the examinations obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist, including with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(c)(4) (2015). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition, as identified in 38 C.F.R. § 3.309(a), noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as diabetes mellitus, PUD, or arthritis, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection for PTSD requires that three elements must be present according to VA regulations: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed inservice stressor occurred; and (3) a link, established by medical evidence, between the current symptoms and the claimed inservice stressor. 38 C.F.R. § 3.304(f) (2015). See Cohen v. Brown, 10 Vet. App. 128, 138 (1997). The diagnosis of a mental disorder must conform to the Diagnostic and Statistical Manual of Mental Disorders (5th ed. 2013) (DSM-V), and be supported by the findings of a medical examiner. See 38 C.F.R. § 4.125(a). In adjudicating a claim for service connection for PTSD, VA is required to evaluate the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the service member served, the service member's military records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2014); 38 C.F.R. §§ 3.303(a),3.304 (2015). The evidence necessary to establish the occurrence of a recognizable stressor during service to support a diagnosis of PTSD will vary depending upon whether the service member engaged in "combat with the enemy." If the evidence establishes that the service member engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, (and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the appellant's service), the service member's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(d) (2015); see also 38 U.S.C.A. § 1154(b) (West 2014); VAOPGCPREC 12-99. VA General Counsel has held that "[t]he ordinary meaning of the phrase 'engaged in combat with the enemy,' as used in 38 U.S.C.A. § 1154(b), requires that a veteran have participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality." The determination whether evidence establishes that a service member engaged in combat with the enemy is resolved on a case-by-case basis with evaluation of all pertinent evidence and assessment of the credibility, probative value, and relative weight of the evidence. VAOGCPREC 12-99; 65 Fed. Reg. 6,256 -58 (Feb. 8, 2000). 38 C.F.R. § 3.304(f) was amended by liberalizing, in certain circumstances, the evidentiary standards for establishing the occurrence of an in-service stressor for non-combat veterans. Previously, VA was required to undertake extensive development to determine whether a non-combat veteran actually experienced the claimed in-service stressor and lay testimony, by itself, was not sufficient to establish the occurrence of the alleged stressor. Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Instead, credible supporting evidence of a corroborated in-service stressor was required. Credible supporting evidence was not limited to service department records, but could be from any source. See YR v. West, 11 Vet. App. 393, 397 (1998); see also Moreau v. Brown, 9 Vet. App. 389, 395 (1996). Further, credible supporting evidence of the actual occurrence of an in-service stressor could not consist solely of after-the-fact medical nexus evidence. See Moreau, 9 Vet. App. at 396. The amended version of 38 C.F.R. § 3.304(f)(3) eliminated the need for stressor corroboration in circumstances in which the service member's claimed in-service stressor is related to "fear of hostile military or terrorist activity." Specifically, the amended version of 38 C.F.R. § 3.304(f)(3) states that if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. See 38 C.F.R. § 3.304 (f)(3) (2015). The VA General Counsel has held that where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the service member had prior to enactment of the new rule. See VAOPGCPREC 7-2003 (Nov. 19, 2003). However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C.A. § 5110(g), can be no earlier than the effective date of that change. VA can apply only the earlier version of the regulation for the period prior to the effective date of the change. The appellant in this case receives consideration under the amended version of 38 C.F.R. § 3.304(f). The statutory provision specifically covering Agent Orange is 38 U.S.C.A. § 1116. Under 38 U.S.C.A. § 1116(f), a claimant, who, during active service, served in the Republic of Vietnam during the Vietnam era, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that he was not exposed to any such agent during that service. Disease associated with exposure to certain herbicide agents, listed in 38 C.F.R. § 3.309, will be considered to have been incurred in service under the circumstances outlined in that section even though there is no evidence of such disease during the period of service. If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: Chloracne or other acneform disease consistent with chloracne; Hodgkin's disease; type 2 diabetes, non-Hodgkin's lymphoma; early-onset peripheral neuropathy; porphyria cutanea tarda; prostate cancer; multiple myeloma, respiratory cancers (cancers of the lung, bronchus, larynx, or trachea), soft-tissue sarcoma, ischemic heart disease, "all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia)," and Parkinson's disease. 38 C.F.R. § 3.309(e) (2015). Aside from these presumptive provisions, service connection may be established by satisfactory proof of direct service connection. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In accordance with VA regulations, the National Academy of Science (NAS) issued "Veterans and Agent Orange: Update 2012" (Update 2012). The attached notice explains a determination made by the Secretary, based upon Update 2012 and prior NAS reports, that a presumption of service connection based on exposure to herbicides in the Republic of Vietnam is not warranted for the following health outcomes: Hypertension; Stroke; Cancers of the oral cavity (including lips and tongue), pharynx (including tonsils), and nasal cavity (including ears and sinuses); Cancers of the pleura, mediastinum, and other unspecified sites within the respiratory system and intrathoracic organs; Cancers of the digestive organs (esophageal cancer; stomach cancer; colorectal cancer (including small intestine and anus); hepatobiliary cancers (liver, gallbladder and bile ducts); and pancreatic cancer); Bone and joint cancer; Melanoma; Nonmelanoma skin cancer (basal cell and squamous cell); Breast cancer; Cancers of reproductive organs (cervix, uterus, ovary, testes, and penis; excluding prostate); Urinary bladder cancer; Renal cancer (kidney and renal pelvis); Cancers of brain and nervous system (including eye); Endocrine cancers (including thyroid and thymus); Leukemia (other than all chronic B-cell leukemias including chronic lymphocytic leukemia and hairy cell leukemia); Cancers at other and unspecified sites (other than those as to which the Secretary has already established a presumption); Reproductive effects (including infertility, spontaneous abortion other than after paternal exposure to TCDD; and - in offspring of exposed people - neonatal death, infant death, stillborn, low birth weight, birth defects (other than spina bifida), and childhood cancer (including acute myeloid leukemia));Neurobehavioral disorders (cognitive and neuropsychiatric); Neurodegenerative diseases (including amyotrophic lateral sclerosis, but excluding Parkinson's disease); Chronic peripheral nervous system disorders (other than early-onset peripheral neuropathy); Respiratory disorders (wheeze or asthma, chronic obstructive pulmonary disease, and farmer's lung); Gastrointestinal, metabolic, and digestive disorders (including changes in liver enzymes, lipid abnormalities, and ulcers); Immune system disorders (immune suppression, allergy, and autoimmunity); Circulatory disorders (other than ischemic heart disease); Endometriosis; Effects on thyroid homeostasis; Hearing loss; Eye problems; and Bone conditions. See Notice, 77 Fed. Reg. 47,924 (Aug. 10, 2012). In order to prevail on the issue of service connection, there must be medical evidence of current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1990). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1990); 38 C.F.R. § 3.303(a). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2015). When all of the evidence is assembled, 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Lay statements may support a claim for service connection by establishing the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), they are not competent to provide opinions on medical issues that fall outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d 1372. Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Diabetes Mellitus, Type II The Veteran contends that service connection should be established for diabetes mellitus, type II, which, as noted, is one of the disorders for which service connection may be presumed from defoliant exposure while serving in the RVN. The Veteran saw such service while on active duty, but review of the evidence of record shows no evidence of diabetes mellitus at any time after service. In this regard, it is noted that review of the Veteran's STRs as well as a VA general medical examination conducted in June 1968 do not show complaints or manifestations of diabetes mellitus. Post-service private and VA medical evidence is similarly negative. While a 2001 VA outpatient treatment report shows that the Veteran's problem list included impaired fasting glucose, diabetes mellitus was not diagnosed. An April 2013 laboratory test showed a blood glucose level of 94 mg/dl, which is within normal limits. In a November 2013 statement, the Veteran's private physician does not diagnose diabetes mellitus, but "pre-diabetes mellitus" The Veteran was afforded a VA examination in June 2014 specifically to ascertain whether the Veteran manifested diabetes mellitus. After examination, no diagnosis of diabetes mellitus could be made. In the absence of proof of a disability at any time, there is no valid claim of service-connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, service connection for diabetes mellitus, type II, is not warranted. Benign Prostate Hyperplasia The Veteran is claiming service connection for benign prostate hyperplasia. This disability was included among the diagnoses noted by the Veteran's private physician in the November 2013 statement, who stated that he believed it to be related to the Veteran's period of service. After review of the evidence, the Board finds no basis to establish service connection for benign prostate hyperplasia. Review of the Veteran's STRs shows no complaint or manifestation of a prostate disorder. Post-service medical evidence includes a report of a June 1968 VA examination that showed evaluation of the genitourinary system, which includes the prostate, to be negative. Additional post-service medical evidences shows no complaint or manifestation of a prostate disorder until 2013 when benign prostate hypertrophy was noted. Of note are VA outpatient treatment records dated in 2001 and 2002 when screening for prostate cancer was negative. On examination by VA in June 2014, benign prostate hypertrophy was again noted, but prostate cancer was specifically ruled out. Service connection may be presumed for prostate cancer in those veterans who, like the Veteran were exposed to defoliants during service. The Veteran does not, however, manifest prostate cancer, but benign prostate hyperplasia or hypertrophy. This disorder is not one that may be presumed as being the result of defoliant exposure. While the Veteran's private physician has rendered an opinion that this disability is related to service, no rationale to support this opinion has been provided. The Board finds that this opinion is afforded minimal probative value because it lacks any explanation. See Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012) (stating that a medical opinion must "sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion."). In addition it is noted that private treatment records dating from 1995, when the Veteran was receiving treatment for disabilities unrelated to this appeal, do not show complaints of a prostate disability. The Board finds that if the appellant had, in fact, been suffering from a prostate disorder since service, he would have mentioned it at some time prior to his current appeal, when he was seeking treatment for other disabilities. See Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (holding that silence in a medical record can be weighed against lay testimony if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the medical record being evaluated by the fact finder (citing Fed. R. Evid. 803 (7))). For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for benign prostate hyperplasia, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. An Acquired Psychiatric Disorder The Veteran claims service connection for an acquired psychiatric disorder, which he asserts should be diagnosed as PTSD. Review of the record shows that he received the Purple Heart Medal during service and, thus, service connection would likely be appropriate if he were to have a confirmed diagnosis of PTSD and the stressor was related to the injury resulting in the award of the Purple Heart. After review of the record, however, the Board finds that there is no adequate diagnosis of PTSD, but that the Veteran's psychiatric disability is most likely GAD, which was not manifested during service or related to active duty. Review of the Veteran's STRs shows that at the time of entry into service he did give a medical history of nervous trouble. On examination, however, psychiatric clinical evaluation was normal. As no psychiatric abnormality was noted on examination, he is presumed to have been psychiatrically sound at the time of entry into service. See 38 U.S.C.A. § 1111. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). The Veteran's STRs do not show that he had complaints or manifestations of an acquired psychiatric disability while he was in service. On VA examination in June 1968, the Veteran was noted to be psychiatrically within normal limits. Post-service treatment records include a 1995 private treatment report when the Veteran reported a depressed mood. He was placed on the medications Xanax and Prozac. The records do not report a relationship between the Veteran's depression and service. An examination was conducted by a VA psychologist in May 2013 to ascertain if the Veteran had PTSD. At that time, the examiner found that the Veteran did not meet the diagnostic criteria for PTSD. Rather, the diagnosis was of anxiety disorder, not otherwise specified (NOS), which was not found to be related to service. The rationale was that, other than a notation in medical history at induction of nervousness, the Veteran did not have complaints of a psychiatric disability during service. The examiner noted that the Veteran had successfully worked for the U.S. Postal Service until retirement after 30 years. The Veteran did state that he had recollections of his war experiences, but that he did not have a mental disorder that was related to service. A second VA examination was conducted by a VA psychiatrist in August 2013 when again it was found that the Veteran's symptoms did not meet the diagnostic criteria for PTSD. The diagnosis was anxiety disorder NOS. The rationale included that, while the Veteran had experienced traumatic events in service he did not persistently re-experience the events, had no persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness, and no persistent symptoms of increased arousal. Thus, he did not meet the full criteria for a PTSD diagnosis. The examiner concluded that the Veteran had sought psychiatric care many years after his military discharge and that a temporal relationship between the neuropsychiatric disorder and the Veteran's military service was not established. In a November 2013 statement, the Veteran's private physician, who did not indicate a psychiatric specialty, rendered diagnoses of PTSD, MDD, GAD and a sleep disorder. The examiner noted that the Veteran referred anxiety, irritability, impaired impulse control, difficulty in adapting to stressful circumstances, depressed mood, disturbances in motivation, and sleep impairment with nightmares and flashbacks of traumatic experiences during military service in Vietnam. The examiner opined that these conditions were more probably than not related to the Veteran's military service. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140, 146 (1993); Guerrieri, 4 Vet. App. at 470-71. While the Board may not ignore a medical opinion, it is certainly free to discount the relevance of a physician's statement, as it has done in this case. See Sanden v. Derwinski, 2 Vet. App. 97 (1992). In this case, the Board finds the opinions of the VA psychologist and psychiatrist to be more probative than that of the Veteran's private physician. Both specialists, particularly the psychiatrist who rendered the August 2013 report, gave specific rationale regarding why the Veteran did not meet the diagnostic criteria for a PTSD diagnosis. The absence of psychiatric complaints for over 25 years following discharge from service is probative evidence against a service relationship. See Mense v. Derwinski, 1 Vet. App. 354 (1991). The private medical opinion contained no rationale, and the Board affords it much less probative value. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for an acquired psychiatric disability, including PTSD, sleep disorder, MDD, and GAD, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Hiatal Hernia, GERD, PUD, and Chronic Colitis The Veteran claims service connection for a chronic gastrointestinal disorder, including a hiatal hernia, GERD, PUD, and chronic colitis. Review of the Veteran's STRs shows that the Veteran reported frequent indigestion in his medical history report at the time of entry into service and reported stomach trouble on the medical history form at separation. The STRs show no complaint or manifestation of any gastrointestinal disorder during service. On examinations for entrance and separation from service, clinical examination of the abdomen was normal. On examination by VA in June 1968, no chronic gastrointestinal disability was reported. (The June 1968 examination report noted that the Veteran had been treated for hepatitis, a disability unrelated to this appeal, in 1963, prior to service.) Private treatment records dated from 1995 do not show complaints or manifestations of a gastrointestinal disorder. VA outpatient treatment records, dated in 2001, include a notation of hiatal hernia and GERD on the Veteran's problem list. Additional VA and private outpatient treatment records, dated from 2001 to 2015 show and hiatal hernia, GERD, and a colonic polyp. An examination was conducted by VA in May 2013. At that time, the diagnoses were GERD, hiatal hernia, and chronic gastritis with intestinal metaplasia, noted on an upper endoscopy in October 2011. The examiner noted the Veteran's stomach complaints on entry and separation examinations and related that the Veteran said that he had had stomach ache and reflux since he was on active service, which he attributed to the "water and food in Vietnam." He stated that, when he was young, he was able to handle these symptoms by himself using over-the-counter medications. He stated that he saw a private gastroenterologist in 2006, who performed an upper endoscopy that showed gastritis and a hiatal hernia. A 2011 upper endoscopy showed chronic gastritis and a hiatal hernia. In a November 2013 statement, the Veteran's private physician reported that the Veteran had complained of dyspepsia, flatulence, pyrosis, epigastric burning, watery diarrheas with fatty food intolerance episodes. The diagnoses included hiatal hernia, GERD, PUD and chronic colitis. It was assessed that these medical conditions were more probably than not related to military service. No rationale for this opinion was provided. The Board finds that the evidence of record does not demonstrate that any of the Veteran's gastrointestinal disorders, whether diagnosed as GERD, hiatal hernia, PUD or chronic colitis, are related to service. While the Veteran's private physician has rendered an opinion that these disabilities are related to service, no rationale to support the opinion has been provided. The Board finds that this opinion is afforded minimal probative value because it lacks any explanation. Monzingo, 26 Vet. App. at 97. Moreover, it is noted that private treatment records dating from 1995, when the Veteran was receiving treatment for disabilities unrelated to this appeal, do not show complaints of a gastrointestinal disability. The Board finds that if the appellant had, in fact, been suffering from a chronic gastrointestinal disability since service, he would have mentioned it at some time prior to his current appeal, when he was seeking treatment for other disabilities. Kahana, 24 Vet. App. at 428. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a chronic gastrointestinal disability, including hiatal hernia, GERD, PUD or chronic colitis, and the claims must be denied. Because the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Degenerative Joint and Degenerative Disc Disease The Veteran contends that he has degenerative disc disease of his cervical and lumbar spine as well as degenerative joint disease of both hips, knees, and feet. Review of the Veteran's STRs shows no complaints or manifestations of neck, low back, hip, knee, or foot disorders. On examination for separation from service, the Veteran indicated on his medical history form that he did not have back, knee or foot disability. Clinical evaluation of the neck, spine, lower extremities, and feet was normal. On examination by VA in June 1968, examination of the musculoskeletal system showed no fractures or dislocations and no orthopedic problems. Post-service medical records include private medical treatment dated in 1995, when the Veteran had no complaints of neck, back, hip, knee or foot pain; and a report of outpatient treatment in 2001 when the Veteran's problem list included cervical radiculopathy and lumbosacral degenerative disc disease. Additional private treatment records show that the Veteran underwent knee replacement surgery in 2012 and was treated for degenerative disc disease of the cervical and lumbar spine in 2011 and 2012. In a November 2013 report, the Veteran's private physician indicated that the Veteran referred polymyalgias, polyarthralgias with severe pain in the neck and low back areas; numbness, tingling, swelling, and pain in the cervical area radiating to both shoulders and arms; lumbar spine pain radiating to both legs, knees, and feet. The diagnoses included degenerative disc disease of the cervical and lumbar spine as well as degenerative joint disease of the bilateral hips, knees, and feet. The examiner assessed that these medical conditions were more probably than not related to his military service. The Board finds that the evidence of record does not demonstrate that any of the Veteran's musculoskeletal disorders, including degenerative disc disease of the cervical and lumbar spine; or degenerative joint disease of the hips, knees or feet, are related to service. While the Veteran's private physician has rendered an opinion that these disabilities are related to service, no rationale to support the opinion has been provided. The Board finds that this opinion is afforded minimal probative value because it lacks any explanation. Monzingo 26 Vet. App. at 97. Moreover, it is noted that private treatment records dating from 1995, when the Veteran was receiving treatment for disabilities unrelated to this appeal, do not show complaints of a musculoskeletal disability. The Board finds that if the appellant had, in fact, been suffering from a chronic musculoskeletal disability since service, he would have mentioned it at some time prior to his current appeal, when he was seeking treatment for other disabilities. Kahana 24 Vet. App. at 428. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for degenerative disc disease of the cervical or lumbar spine; or degenerative joint disease of the hips, knees or feet, and the claims must be denied on both a direct and chronic disease presumptive basis. Because the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Increased Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2015). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2015). The United States Court of Appeals for Veterans Claims (Court) has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to the appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. Conjunctivitis Service connection for chronic conjunctivitis was granted by the RO in an August 1968 rating decision. The current 10 percent disability rating was awarded under the provisions of Code 6018. The Veteran submitted a claim for increase in September 2012. Under Diagnostic Code 6018, active chronic conjunctivitis (with objective findings, such as red, thick conjunctivae, mucous secretion, etc.) is evaluated as 10 percent disabling. 38 C.F.R. § 4.79, Code 6018. Inactive chronic conjunctivitis is evaluated based on residuals, such as visual impairment and disfigurement. Id. Diagnostic Code 7800 provides ratings for disfigurement of the head, face, or neck. Note (1) to Diagnostic Code 7800 provides that the 8 characteristics of disfigurement, for purposes of rating under 38 C.F.R. § 4.118, are: Scar is 5 or more inches (13 or more cm.) in length. Scar is at least one-quarter inch (0.6 cm.) wide at the widest part. Surface contour of scar is elevated or depressed on palpation. Scar is adherent to underlying tissue. Skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.). Skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.). Underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm.). Skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Diagnostic Code 7800 provides that a skin disability with one characteristic of disfigurement of the head, face, or neck is rated 10 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement, is rated 30 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement, is rated 50 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement, is rated 80 percent disabling. Note (2) to Diagnostic Code 7800 provides that tissue loss of the auricle is to be rated under Diagnostic Code 6207 (loss of auricle), and anatomical loss of the eye under Diagnostic Code 6061 (anatomical loss of both eyes) or Diagnostic Code 6063 (anatomical loss of one eye), as appropriate. Note (3) provides that unretouched color photographs are to be taken into consideration when rating under these criteria. 38 C.F.R. § 4.118. An examination was conducted by VA in June 2013. At that time, the diagnoses were recurrent pterygium of the left eye, chronic conjunctivitis of both eyes and senile cataracts of both eyes. On examination corrected visual acuity was 20/25 in the right eye and 20/25- in the left eye. The lids were within normal limits and the conjunctiva were normal. New refractions were accomplished, with the Veteran's corrected visual acuity remaining 20/25 in the right eye and 20/20 in the left eye. Eyeglasses were planned. On examination, the conjunctiva showed 1+ injection. There was no contraction of visual fields. The Veteran described symptoms of burning that were considered to be partially due to his non-service-connected pterygium as well as his service-connected conjunctivitis. There was no scarring or disfigurement attributable to the Veteran's eye condition. He had no incapacitating episodes attributable to any eye condition. The Veteran's eye disability is active and, as such, based on the rating schedule discussed above, the maximum evaluation for the disability is 10 percent. A review of all additional codes fails to indicate a basis to grant a rating in excess of 10 percent. For example, the Veteran had no disfigurement or visual impairment as a result of the eye disability. As such, the Board finds that an increased evaluation is not warranted. The Board also has considered whether referral for extraschedular consideration is warranted. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2015); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. In this case, comparing the Veteran's disability level and symptomatology to the rating schedule, the degree of disability throughout the appeal period under consideration is contemplated by the rating schedule. The Veteran's conjunctivitis directly corresponds to the schedular criteria for the 10 percent evaluation for this disability. As noted, there is no disfigurement or visual impairment noted on examination. For this reason, the Board finds that the assigned schedular rating is adequate to rate the Veteran's eye disability, and no referral for an extraschedular rating is required. ORDER Service connection for diabetes mellitus, type II, is denied. Service connection for benign prostate hyperplasia is denied. Service connection for an acquired psychiatric disorder, including PTSD, sleep disorder, MDD, and GAD, is denied. Service connection for hiatal hernia is denied. Service connection for GERD is denied . Service connection for PUD is denied. Service connection for chronic colitis is denied. Service connection for degenerative disc disease of the cervical spine is denied. Service connection for degenerative disc disease of the lumbar spine is denied. Service connection for degenerative joint disease of both hips is denied. Service connection for degenerative joint disease of both knees is denied. Service connection for degenerative joint disease of both feet is denied. An increased rating in excess of 10 percent for conjunctivitis is denied. REMAND Regarding the issues of service connection hypertensive cardiovascular disease, the Board finds that further development is necessary prior to further appellate consideration. In this regard, as pointed out, service connection for ischemic heart disease may be presumed as being the result of exposure to defoliants in service. The record shows that the Veteran served in the RVN and, as such, is presumed to have been so exposed. He has claimed service connection for hypertensive heart disease, but it is not clear that he carries a diagnosis of ischemic heart disease. As such, the case should be remanded so that a VA examination may be conducted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (Setting forth the criteria under which VA is required to obtain an examination.) The claim for TDIU must be held in abeyance pending this development. Accordingly, the case is REMANDED for the following action: 1. The AOJ should arrange for the Veteran to undergo a medical examination to ascertain the current nature and etiology of any heart disease. The examiner should specifically state whether the Veteran is diagnosed with ischemic heart disease and, for any other heart disorder, whether it is at least as likely as not (probability 50 percent or more) that such disorder had its onset during active service, within one year of service discharge, or is otherwise related to service. The claims file should be made available for review in connection with this examination. The examiner should provide complete rationale for all conclusions reached. 2. The claims should be readjudicated. If any claim remains denied, the Veteran should be provided a supplemental statement of the case and afforded the opportunity to respond. Thereafter, the case should be returned to the Board for further appellate review, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2015). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court (CONTINUED ON NEXT PAGE) of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs