Citation Nr: 1617475 Decision Date: 05/02/16 Archive Date: 05/13/16 DOCKET NO. 09-41 977A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to service connection for a blood disorder, to include neutropenia, dyslipidemia, leukopenia, and anemia, including as due to a qualifying chronic disability to include undiagnosed illness. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from July 1981 to July 1985, and from December 1990 to June 1991, as well as service in the Army National Guard. This appeal comes to the Board of Veterans' Appeals (Board) from a February 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana, which, in pertinent part, denied service connection for a blood disorder, to include, unspecified neutropenia, dyslipidemia, leukopenia, and mild anemia, including presumptively as due to a qualifying chronic disability (undiagnosed illness). In April 2008, the Veteran entered a notice of disagreement with the February 2008 rating decision denial of service connection for a claimed blood disorder. A statement of case was issued in November 2009. The Veteran entered a substantive appeal in November 2009 (VA Form 9 indicating desire to appeal all issues listed in a statement of the case). This appeal is derived from a claim for service connection for a blood disorder that was received in August 2007. In August 2014, the Board, in pertinent part, remanded the issue on appeal for additional development. Pursuant to the remand instructions, correspondence was sent to the Veteran in September 2014 asking him to submit any outstanding private treatment records with respect to treatment for blood disorders or the appropriate authorizations for VA to obtain the records on his behalf. No response to the September 2014 correspondence or additional private treatment records has been received. The Veteran was afforded a VA examination in September 2014 to assist in determining the nature and etiology of the claimed blood disorders. The Board finds that the September 2014 VA examination report was thorough and adequate and in compliance with the Board's remand instructions. As such, the Board finds there has been substantial compliance with the August 2014 Board remand orders. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders); D'Aries v. Peake, 22 Vet. App. 97 (2008). The issues of additional dependency benefits based on school attendance and entitlement to vocational rehabilitation benefits have been raised by the record (see request for approval of school attendance (on a VA Form 21-674) and disabled veterans application for vocational rehabilitation (on a VA Form 28-1900)), but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). FINDINGS OF FACT 1. The Veteran had service in the Southwest Asian Theater of operations during the Persian Gulf War. 2. Leukopenia, neutropenia, and dyslipidemia are laboratory findings without underlying or resulting disability and are not disabilities for VA compensation purposes. 3. The Veteran's leukopenia, neutropenia, and dyslipidemia have not manifested to a compensable degree during a six month period since service, and are not manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness. 4. The Veteran has currently diagnosed borderline anemia. 5. A blood disease or disorder was not sustained in service. 6. Symptoms of anemia were not chronic in service, were not continuous since service, were not shown to a compensable degree within one year of service, and have not been manifested to a compensable degree at any time after service separation. 7. The Veteran's anemia first manifested many years after service separation and is not causally or etiologically related to active service. CONCLUSION OF LAW A blood disorder, to include neutropenia, dyslipidemia, leukopenia, and anemia, was not incurred in active service, and may not be presumed to have been incurred therein, including as due to a qualifying chronic disability to include undiagnosed illness. 38 U.S.C.A. §§ 1101, 1110, 1117, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.317 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159 (2015). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2015). Such notice should also address VA's practices in assigning disability ratings and effective dates for those ratings. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice should be provided to a claimant before the initial unfavorable AOJ decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In this case, notice was provided to the Veteran in September 2007, prior to the initial adjudication of the claim in February 2008. The Veteran was notified of the evidence not of record that was necessary to substantiate the claim, VA and the Veteran's respective duties for obtaining evidence, and VA's practices in assigning disability ratings and effective dates. Thus, the Board concludes that VA satisfied its duties to notify the Veteran. VA satisfied its duty to assist the Veteran in the development of the claim. First, VA satisfied its duty to seek, and assist in the procurement of, relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Specifically, the information and evidence that have been associated with the claims file include service treatment records, VA treatment records, VA examination reports, and lay statements. Second, VA satisfied its duty to obtain a medical opinion when required. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran was provided with a VA examination (the report of which has been associated with the claims file) in September 2014. The Board finds that the VA examination report is thorough and adequate and provides a sound basis upon which to base a decision with regard to the issue on appeal. The VA examiner personally interviewed and examined the Veteran, including eliciting a history, and provided opinions with supporting rationale. Finally, the Veteran was offered the opportunity to testify at a Board hearing, but declined. As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 C.F.R. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Service Connection for a Blood Disorder Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a) (2015). Generally, service connection for a disability requires evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). In this case, as discussed below, the Board finds that the leukopenia, neutropenia, and dyslipidemia are abnormal laboratory findings and not in and of themselves "disabilities" for VA purposes. Nor does the weight of the evidence reflect that the Veteran has a causal or resultant disability associated these laboratory findings. As such, the leukopenia, neutropenia, and dyslipidemia cannot be "chronic diseases" under 38 C.F.R. § 3.309(a) (2015) and the presumptive provisions based on "chronic" symptoms in service and "continuous" symptoms since service at 38 C.F.R. § 3.303(b) or manifesting within one year of service separation at 38 C.F.R. § 3.307 (2015) do not apply. In this case, the Veteran has been diagnosed with amenia. See September 2014 VA examination report. Primary anemia is listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions at 38 C.F.R. § 3.303(b) and 38 C.F.R. § 3.307 apply. For a chronic disease such as anemia, service connection may be established under 38 C.F.R. § 3.303(b) if a chronic disease or injury is shown in service, and subsequent manifestations of the same chronic disease or injury at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Continuity of symptomatology after service is required where a condition noted during service is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). The presumptive service connection provisions based on "chronic" in-service symptoms and "continuity of symptomatology" after service under 38 C.F.R. § 3.303(b) have been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013) (holding that the "chronic" in service and "continuous" post-service symptom presumptive provisions of 38 C.F.R. § 3.303(b) only apply to "chronic" diseases at 3.309(a)). Service connection may also be established with certain chronic diseases, including anemia, based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Service connection may also be granted on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 21, 2016, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on qualifying chronic disability, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Laypersons are competent to report objective signs of illness. The term "Persian Gulf veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). The DD Form 214 reflects that the Veteran served in Southwest Asia from February to May 1991; therefore, he is a "Persian Gulf veteran" as defined by 38 C.F.R. § 3.317. A "qualifying chronic disability" for VA purposes is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C.A. § 1117(d) warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; and (12) abnormal weight loss. 38 C.F.R. § 3.317(b). The Veteran has clinically diagnosed anemia. See e.g., September 2014 VA examination report (noting that VA laboratory results indicate borderline anemia/an ongoing anemic condition). Because the anemia is clinically diagnosed and anemia is not a chronic multisymptom illness, the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 are not for application with respect to this aspect of the appeal for service connection for a blood disorder. The Board will discuss whether the leukopenia, neutropenia, and dyslipidemia, which, as discussed below, the Board finds are laboratory findings and not clinically diagnosed "disabilities," are symptoms of a qualifying chronic disability to include undiagnosed illness or chronic multisymptom illness. The Veteran essentially contends that the claimed blood disorders are related to active service, specifically environmental and chemical exposures during the Persian Gulf War. See generally August 2007 service connection claim. In a September 2007 written statement, the Veteran reported that, while transporting equipment in Southwest Asia, the "sky turned orange" and he had to put on a protective chemical suit. The Veteran contended that this may explain why he has a blood disorder. See also April 2010 and March 2016 written statements from the representative. In a July 2015 written statement, through the representative, the Veteran contended that his exposure to hazardous chemicals and environment during the Gulf War is the direct cause of his blood disorder, to include neutropenia, dyslipidemia, leukopenia, and anemia. Leukopenia, Neutropenia, Dyslipidemia Initially, to the extent that the claimed blood disorders are manifested by leukopenia, neutropenia, and dyslipidemia, the Board finds that, in this case, each is an abnormal laboratory finding, not a "disability" for which service connection may be granted, and there is no evidence showing a causal or resultant disability due to the leukopenia, neutropenia, or dyslipidemia. A symptom (to include abnormal laboratory study or pain), without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a "disability" for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). October 2005 VA laboratory results note leukopenia with white blood cell count of 3.2 K/cmmm. An April 2007 VA treatment record notes leukopenia and dyslipidemia. A May 2007 hematology/oncology VA treatment record notes that the Veteran was referred for low white blood cell count "since some time." The Veteran reported generally feeling good, but occasional lightheadedness and dizziness. Leukopenia and mild anemia, rule out drug effect, rule out splenomegaly, rule out deficiency disease, rule out myelodysplastic syndromes, and rule out autoimmune disease was assessed. An August 2007 hematology/oncology VA treatment record notes that the Veteran reported dizziness, nose bleeds, cold sweats, occasional abdominal pain, radiating chest pain, nausea, shortness of breath at times, lack of energy, swelling to the hands, and numbness to the feet (though it is unclear from the treatment record whether the Veteran reported all these symptoms in connection with leukopenia). An assessment of leukopenia was rendered. At an October 2007 Persian Gulf War registry examination, the Veteran reported exposure to burning oil, petrochemicals, trash, feces, tent heaters, cigarette smoke, diesel and petrochemical fumes, and pesticides as well as unknown exposure to chemical and/or biological weapons. The examiner reviewed July 2007 laboratory test results and noted an impression of neutropenia. Subsequent VA treatment records dated through September 2014 note leukopenia, neutropenia, and dyslipidemia. September 2008 and January 2009 VA treatment records note that the Veteran reported generally feeling well and an assessment of leukopenia was noted. A November 2009 VA treatment record notes leukopenia without lack of energy and occasional shortness of breath that was stable for the previous six years. A November 2012 hematology/oncology VA treatment record notes that the Veteran reported "generally feel[ing] good but sometimes tired." The treatment record notes that the Veteran had served in the first Gulf War, was exposed to chemicals, and "apparently all his problem[s] . . . started since that time i.e. fatigue etc. and ?? low wbc." See also July 2009 VA treatment record. An assessment of stable leukopenia was rendered. A January 2013 VA treatment record notes assessments of hyperlipidemia and leukopenia. Dyslipidemia is "abnormality in, or abnormal amounts of, lipids and lipoproteins in the blood" also referred to as hyperlipidemia. Dorland's Illustrated Medical Dictionary 586 (31st ed. 2012). Hyperlipidemia is a "general term for elevated concentrations of any or all of the lipids in the plasm." Id. at 903. VA has determined that dyslipidemia is a laboratory finding and not a disability in and of itself for which VA compensation benefits are payable. See Schedule for Rating Disabilities; Endocrine System Disabilities, 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (noting that diagnoses of dyslipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities). The record does not identify or suggest and the Veteran has not alleged an underlying disease to which the dyslipidemia may be related. Leukopenia is a "condition involving abnormally fewer white blood cells." See Watson v. Brown, 4 Vet. App. 189, 191 (1993); see also Dorland's Illustrated Medical Dictionary at 1044 (leukopenia is the "reduction in the number of leukocytes in the blood"). Neutropenia is a decrease in the number of neutrophils in the blood. See id. at 1290. Neutropenia is a type of leukopenia. See id. at 1044 (noting that types of leukopenia are named for the type of cell, such as neutropenia). Leukopenia by itself is not a "disability" for which service connection may be granted. Leukopenia (low white blood cell counts) is a finding from blood panel counts; it does not represent a disability. See generally 38 C.F.R. § 4.117 (Schedule of Ratings for the Hemic and Lymphatic Systems) (2015). At the September 2014 VA examination, the Veteran reported that he has not been treated for a blood disorder, either with medication or transfusion. The VA examiner noted no history of chronic infection, including those associated with Southwest Asia deployment, chronic fatigue syndrome, or fibromyalgia. The VA examiner noted that VA laboratory results indicate decrease in total white blood cells with persistent mild decrease in the neutrophil portion of differential. The VA examiner noted that the VA treatment record do not indicate treatment with antibiotic prescription for systemic infection. The September 2014 VA examiner assessed that the Veteran has mild leukopenia and neutropenia. The VA examiner noted that neutropenia may be congenital or acquired and the primary causes of neutropenia include benign familial neutropenia, infection, congenital disorder, immune disorders, hypersplenism, nutritional deficiency, infection including HIV, and chemotherapy. The VA examiner noted that there was no evidence of record of when the Veteran's neutropenia started, only that it was noted in October 2005, the Veteran did not provide a family history of a similar condition, and the other causes of neutropenia were not identified in the medical records or upon examination or laboratory testing. The VA examiner noted that bone marrow evaluation had not been deemed necessary by the Veteran's treating hematologist and, as such, a definitive diagnosis had not been determined. The September 2014 VA examiner opined that it is more likely that the neutropenia is a normal lab result for the Veteran because the decrease in white blood cells has not resulted in symptoms, illness, or treatment. The VA examiner opined that it is more likely that the neutropenia does not rise of the level of disability. The September 2014 VA examiner reviewed the claims file, interviewed the Veteran, and conducted a physical examination and laboratory testing in coming to the conclusion that the leukopenia and neutropenia did not rise of the level of a disability, but rather were laboratory findings. The VA examiner had the requisite medical expertise to render this conclusion. As such, the Board finds the September 2014 VA examination report to be highly probative. The Board finds that the weight of the evidence in this case demonstrates that leukopenia, neutropenia, and dyslipidemia are laboratory findings and are not disabilities in and of themselves for which VA compensation benefits are payable. See Waters v. Shinseki, 601 F.3d 1274, 1277 (Fed. Cir. 2010) (stating that there must be "medically competent" evidence of a current disability). The VA examiner's opinion provides strong rationale as to why the Veteran's leukopenia and neutropenia do not rise to the level of a disability. While, as a lay person, the Veteran is competent to relate treatment or some symptoms that may be associated with neutropenia, leukopenia, and dyslipidemia, such as some dizziness and lightheadedness, under the facts of this case any actual diagnosis of a disability caused by or stemming from neutropenia, leukopenia, or dyslipidemia requires objective testing to diagnose, and can have many causes. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). To the extent that the Veteran believes that he has neutropenia, leukopenia, and dyslipidemia rising to the level of disability that are due to service, to include exposure to environmental hazards, or as due to an undiagnosed illness, as a lay person, he has not been shown to have such knowledge, training, or experience. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis). Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C.A. §§ 1110, 1131; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). "In the absence of proof of a present disability there can be no valid claim." See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). See also McClain v. Nicholson, 21 Vet. App. 319 (2007) (holding that service connection can also be warranted if there was a disability present at any point during the claim period, even if it is not currently present); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (holding that a current disability may include a diagnosis at the time the claim was filed or during its pendency). As such, the Board finds that the leukopenia, neutropenia, and dyslipidemia are laboratory findings and are not disabilities in and of themselves for which VA compensation benefits are payable. However, as noted above, because the Veteran is a Persian Gulf veteran, the provisions of 38 C.F.R. § 3.317 apply. Signs and symptoms listed that may be manifestations of undiagnosed illness do not include abnormal laboratory findings. 38 C.F.R. § 3.317(b). The VA examiner opined that it is unlikely that the neutropenia is a Gulf War-related illness because there was no history of chronic fatigue syndrome, fibromyalgia, functional gastrointestinal disorders, chronic infection, or other undiagnosed illness consistent with environmental exposures during the Veteran's deployment in Southwest Asia. Further, because there is no specific diagnostic code for leukopenia, the Board finds that leukopenia is most closely analogous to anemia under 38 C.F.R. § 4.117, Diagnostic Code 7700. The criteria for a compensable (10 percent) rating are hemoglobin of 10gm/100ml or less with findings such as weakness, easy fatigability, or headaches. At the September 2014 VA examiner noted that the Veteran's occasional fatigability was related to a (service-connected) psychiatric disorder and not the laboratory findings of leukopenia or neutropenia. The VA examiner noted no weakness, light headedness, dyspnea, tachycardia, syncope/dizziness, cardiomegaly, congestive heart failure, recurring infections, transfusions, neuropathy, renal dysfunction, chronic fevers, or HIV. While May and August 2007 VA treatment records note that the Veteran reported occasional lightheadedness and dizziness (that were never directly attributed to leukopenia or neutropenia), subsequent VA treatment records and the September 2014 VA examination report do not note any symptoms or treatment associated with the neutropenia or leukopenia. Based on the above, the Board finds that the leukopenia and neutropenia have not warranted, rating by analogy to Diagnostic Code 7700, a compensable (10 percent) disability rating during a six month period since service. Additionally, because VA has determined that dyslipidemia is a laboratory finding and not a disability in and of itself for which VA compensation benefits are payable, it inherently has not risen to the level of a compensable (10 percent) disability rating during a six month period since service. See 61 Fed. Reg. 20,440, 20,445; see generally 38 C.F.R. § 4.119. Based on the above, the Board finds that presumptive service connection for an undiagnosed illness as due to a qualifying chronic disability or chronic multisymptom illness, manifested by leukopenia, neutropenia, and dyslipidemia, is not warranted. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. Anemia To the extent that the claimed blood disorder has been manifested by anemia, first, the evidence of record demonstrates that the Veteran has currently diagnosed anemia. See e.g., September 2014 VA examination report (noting that VA laboratory results indicate borderline anemia/an ongoing anemic condition). As noted above, because the anemia is clinically diagnosed and anemia is not a chronic multisymptom illness, the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 are not for application. In this case, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience an in-service injury or disease related to the blood. Service treatment records do not reflect diagnoses of, treatment for, or complaint of any blood disorders or disease derivative of a blood disorder, to include anemia. An August 1986 physical examination report and associated report of medical history (dated shortly after the first period of active service) do not reflect any blood disorders, diseases derivative of a blood disorder, blood dyscrasia, or anemia. A March 1990 periodic examination report and May 1991 service separation physical examination (from the second period of active service) report do not reflect any blood disorders, diseases derivative of a blood disorder, blood dyscrasia, or anemia. Nor did the Veteran endorse any such symptoms on the associated reports of medical history. Further, the Veteran has not contended that he suffered from anemia or other blood disorder during service, but rather more generally that environmental and chemical exposures during service caused the current blood disorders, to include anemia. At the September 2014 VA examination, the Veteran reported that he had never been treated for a blood condition, either with medication or transfusion. As the Veteran's current anemia is a chronic disease under 38 C.F.R. § 3.309(a), the Board will consider whether chronic symptoms in service or continuity of symptomatology since service have been shown. In this case, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience chronic symptoms of anemia in service or continuous symptoms since service to warrant presumptive service connection under 38 C.F.R. § 3.303(b). First, as detailed above, regarding chronic symptoms in service, service treatment records are negative for complaints, treatment, findings, or diagnoses of a blood disorder, to include anemia. Nor has the Veteran alleged otherwise. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the veteran wrote during treatment than to his subsequent assertion years later). As such, the Board finds that the Veteran did not experience chronic symptoms of a blood disorder, to include anemia, during service. 38 C.F.R. § 3.303(b). Next, on the question of continuous symptoms since service, the Board also finds that the weight of the lay and medical evidence demonstrates that the Veteran did not experience continuous symptoms of a blood disorder, to include anemia, after service separation. January 1996 and February 2003 Army National Guard periodic physical examination reports do not reflect any blood disorders, diseases derivative of a blood disorder, blood dyscrasia, or anemia. Nor did the Veteran report otherwise on associated reports of medical history. The first record related to anemia is found in VA laboratory results conducted in May 2007. October 2005 VA laboratory results note normal hemoglobin and hematocrit levels. A May 2007 hematology/oncology VA treatment record notes mild amenia, rule out drug effect, rule out splenomegaly, rule out deficiency disease, rule out myelodysplastic syndromes, and rule out autoimmune disease was assessed. VA treatment records dated throughout the appeal period note low hemoglobin and hematocrit levels resulting in mild anemia. The May 2007 diagnosis of anemia comes over 16 years after service separation. At the September 2014 VA examination, the Veteran reported that he did not know if his complete blood count (CBC) test was normal before the October 2005 VA laboratory results. The Veteran has not alleged he sought treatment for a blood disorder, to include anemia, during this period nor has the Veteran asserted continuity of symptoms or that he experienced anemia symptoms shortly after service separation. At the September 2014 VA examination, the Veteran reported that he had never been treated for a blood condition, either with medication or transfusion. This multi-year gap between treatments is one factor, among others, weighing against a finding of continual symptoms since service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as one factor in resolving a claim). The Board acknowledges that symptoms, not treatment, are the essence of any evidence of continuity of symptomatology; however, the Veteran has not asserted, or even alleged, experiencing symptoms of anemia in-service, continuous symptoms since service separation, or anemia to a compensable degree within one year of service. Rather the Veteran has only generally alleged that he is entitled to service connection for the anemia as due to in-service environmental exposures during service in Southwest Asia during the Persian Gulf War without providing any specifics about the onset of symptoms. For these reasons, the Board finds that the weight of the evidence is against a finding of continuity of symptomatology after service. 38 C.F.R. § 3.303(b). In addition, as shown above, the first notation of anemia was in May 2007, over 16 year following service separation. Therefore, anemia not shown within the first year of discharge and the presumptions under 38 U.S.C.A. § 1112 and 38 C.F.R. § 3.309 do not apply. Finally, anemia has not been shown to have manifested to a compensable degree at any time during the appeal period. Under Diagnostic Code 7700, a compensable (10) percent disability is warranted for hemoglobin of 10gm/100ml or less with findings such as weakness, easy fatigability, or headaches. At no point during the appeal period have laboratory results reflected hemoglobin levels of 10gm/100ml or less. See May 2007 to September 2014 VA treatment records; September 2014 VA examination reported. Based on the above, the Board finds that the criteria for presumptive service connection based on "chronic" symptoms in service and "continuous" symptoms since service at 38 C.F.R. § 3.303(b) or manifesting within one year of service separation at 38 C.F.R. § 3.307 have not been met. The Board further finds that the weight of the evidence demonstrates that the Veteran's current anemia is not otherwise related to service. At the September 2014 VA examination, the Veteran reported that he has not been treated for a blood disorder, either with medication or transfusion. The VA examiner noted that current VA laboratory results indicated borderline anemia or an ongoing anemic condition, but that previous evaluations did not indicate a source of blood loss or lab indices to indicate a chronic condition, including liver or spleen disorders, cancer, chronic infection, or hemoglobinopathy. The VA examiner noted that there had been no bone marrow biopsy to indicate a diagnosis of a myeloproliferative disorder. The September 2014 VA examiner opined that it is less than likely that the Veteran has a blood disorder attributable to a period of active service because the Veteran did not have any symptoms attributable to or treatment for anemia, including medications or transfusions, and the service treatment records did not indicate blood loss or an anemic condition. The reasonable and necessary inference to be drawn from the VA examiner's opinion is that the anemia is less likely than not caused by the in-service environmental exposures. The September 2014 VA examiner reviewed the claims file, interviewed the Veteran, and conducted a physical examination and laboratory testing. The VA examiner has the requisite medical expertise to render a medical opinion regarding the etiology of the anemia and had sufficient facts and data on which to base the conclusion that the currently diagnosed anemia is less likely as not caused by a period of active service. The Board finds the September 2014 VA examination report to be highly probative. Regarding the Veteran's statements as to the cause of the current anemia, generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence can be competent and sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau, 492 F.3d at 1376-77. Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert, 21 Vet. App. at 462 (concerning rheumatic fever); Jandreau, at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"); see 38 C.F.R. § 3.159(a)(2). In this case, the Board finds that the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the current anemia. The etiology of the Veteran's current anemia involves a complex medical etiological question because it deals with the origin and progression of the anemia and because such internal process is diagnosed primarily on clinical findings. The Veteran is competent to relate symptoms of anemia that he experienced at any time, but is not competent to opine on whether there is a link between the current anemia and active service because such diagnosis requires specific medical knowledge and training. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service); see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). The Board does not find the Veteran competent to provide evidence of an etiological nexus between the claimed anemia and service, to include in-service environmental exposures, especially in this case where there is no favorable factual support in the form of an in-service blood disease or symptoms of anemia, or chronic or continuous symptoms in and since service separation, or diagnosis or treatment for symptoms for many years after service. For the reasons discussed above, the Board finds that the weight of the evidence demonstrates that the Veteran's anemia was not incurred in active service, and may not be presumed to have been incurred therein. Further, the Board finds also that the weight of the evidence demonstrates that the Veteran's leukopenia, neutropenia, and dyslipidemia are laboratory findings without underlying or resulting disability and are not disabilities for VA compensation purposes, have not manifested to a compensable degree during a six month period since service, and are not manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness. Service connection for a blood disorder, to include anemia, leukopenia, neutropenia, and dyslipidemia, is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for a blood disorder, to include neutropenia, dyslipidemia, leukopenia, and anemia, is denied. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs