Citation Nr: 1624045 Decision Date: 06/15/16 Archive Date: 06/29/16 DOCKET NO. 12-30 440 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to an initial compensable rating for migraines. 2. Entitlement to service connection for peripheral vascular disease of the right leg, including as due to herbicide or other chemical exposure. 3. Entitlement to service connection for peripheral vascular disease of the left leg. 4. Entitlement to service connection for residuals of Q fever, other than heart disease or peripheral neuropathy of the bilateral lower extremities. 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to service connection for Peyronie's disease. 7. Entitlement to a total disability rating based on individual unemployability (TDIU) due exclusively to service-connected chronic obstructive pulmonary disease (COPD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from September 1951 to May 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas, which granted, in pertinent part, the Veteran's claim of service connection for migraine headaches, assigning a zero percent (non-compensable) rating effective November 12, 2010. The Veteran disagreed with this decision in September 2011, seeking an initial compensable rating for his service-connected migraines. He perfected a timely appeal in October 2012. This matter also is on appeal from a March 2012 rating decision in which the RO denied, in pertinent part, the Veteran's claims of service connection for peripheral vascular disease of the right leg, including as due to herbicide or other chemical exposure (which was characterized as right lower extremity pain (also claimed as peripheral arterial disease, sciatica pain, knee, hip and toes)), peripheral vascular disease of the left leg (which was characterized as left lower extremity pain (also claimed as vascular disease, residuals of insect bite, knee, hip, and toes)), residuals of Q fever, other than heart disease or peripheral neuropathy of the bilateral lower extremities (which was characterized as residuals of Q fever), bilateral hearing loss, and for Peyronie's disease. The RO also denied the Veteran's claim of entitlement to a TDIU due exclusively to service-connected chronic obstructive pulmonary disease (COPD). The Veteran disagreed with this decision in May 2012. He subsequently perfected a timely appeal on these claims. The Board notes in this regard that it has jurisdiction over these claims even though a copy of the Veteran's timely filed substantive appeal (VA Form 9) is not included in his claims file. See Percy v. Shinseki, 23 Vet. App. 37, 45 (2009) (finding that VA may waive timely filing of substantive appeal implicitly or explicitly and as to any issue or claim raised in substantive appeal). Having reviewed the record evidence, the Board finds that the issues on appeal should be characterized as stated on the title page of this decision. In May 2015, the Board remanded this matter to the Agency of Original Jurisdiction (AOJ) for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board directed the AOJ to attempt to obtain the Veteran's complete service treatment records from the National Personnel Records Center in St. Louis, Missouri (NPRC). The AOJ's efforts to obtain these records are documented in the Veteran's claims file. The Board also directed the AOJ to obtain an addendum opinion concerning the nature and etiology of the Veteran's bilateral hearing loss and to schedule him for appropriate VA examinations to determine the nature and etiology of his residuals of Q fever and the current nature and severity of his service-connected migraines. The requested opinion was obtained in January 2016. The requested examinations occurred in October 2015 and in January 2016. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The issue of entitlement to service connection for posttraumatic stress disorder (PTSD) has been raised by the record in an April 2015 statement but has not been adjudicated by the AOJ. The Board notes that it previously referred this claim to the AOJ in its May 2015 remand; to date, it does not appear that the AOJ has taken any action on this claim. Therefore, the Board does not have jurisdiction over this claim and it is referred again to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). 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). This appeal was processed using the Virtual VA (VVA) and Virtual Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this appellant's case should take into consideration the existence of these electronic records. The issues of entitlement to service connection for Peyronie's disease and entitlement to a TDIU due exclusively to service-connected COPD are addressed in the REMAND portion of the decision below and are REMANDED again to the AOJ. VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. The record evidence shows that the Veteran's service-connected migraines are manifested by, at worst, complaints of daily headaches, pain in both temples and less frequent characteristic prostrating attacks. 2. The record evidence shows that the Veteran only reported serving in Thailand during active service; thus, his in-service herbicide exposure cannot be presumed. 3. The record evidence indicates that the Veteran reported serving at Don Muang Royal Thai Air Force Base in Thailand from April 1967 to July 1969; although this location was one of the facilities where herbicides were sprayed in Thailand, because the Veteran's in-service duties were in inventory and supply management, his alleged in-service exposure to herbicides while on active service in Thailand cannot be conceded. 4. The record evidence indicates that the Veteran was not exposed other harmful chemicals while on active service, including while in Thailand. 5. The record evidence shows that both the Veteran's peripheral vascular disease of the right leg and peripheral vascular disease of the left leg are not related to active service. 6. The record evidence shows that the Veteran does not experience any residuals of Q fever other than heart disease or peripheral neuropathy of the bilateral lower extremities which could be attributed to active service which were previously denied by the Board in May 28, 2015. 7. The record evidence shows that the Veteran's current bilateral hearing loss is not related to active service. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for migraines have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, Diagnostic Code (DC) 8100 (2015). 2. Peripheral vascular disease of the right leg was not incurred in or aggravated by active service, including as due to herbicide or other chemical exposure. 38 U.S.C.A. §§ 1110, 1116, 1117, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2015). 3. Peripheral vascular disease of the left leg was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2015). 3. Residuals of Q fever, other than heart disease or peripheral neuropathy of the bilateral lower extremities, were not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2015). 4. Bilateral hearing loss was not incurred in or aggravated by active service nor may it be so presumed. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his or her claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. In letters issued in March, July, August, and December 2010, and in April 2011, VA notified the Veteran of the information and evidence needed to substantiate and complete his claims, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). These letters informed the Veteran to submit medical evidence relating the claimed disabilities to active service and noted other types of evidence the Veteran could submit in support of his claims. The Veteran also was informed of when and where to send the evidence. After consideration of the contents of these letters, the Board finds that VA has satisfied substantially the requirement that the Veteran be advised to submit any additional information in support of his claims. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Additional notice of the five elements of a service-connection claim was provided in the March, July, and December 2010 VCAA notice letters, as is required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's higher initial rating claim for migraines is a "downstream" element of the AOJ's grant of service connection for this disability in the currently appealed rating decision. For such downstream issues, notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159 is not required in cases where such notice was afforded for the originating issue of service connection. See VAOPGCPREC 8-2003 (Dec. 22, 2003). Courts have held that once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d. 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). As noted above, in March, July, August, and December 2010, and in April 2011, VA notified the Veteran of the information and evidence needed to substantiate and complete the service connection claim for migraines, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. at 187. As will be explained below in greater detail, the evidence does not support granting service connection for peripheral vascular disease of the right leg, peripheral vascular disease of the left leg, residuals of Q fever, other than heart disease or peripheral neuropathy of the bilateral lower extremities, or for bilateral hearing loss. The evidence also does not support granting an initial compensable rating for migraines. Because the Veteran was fully informed of the evidence needed to substantiate these claims, any failure of the AOJ to notify the Veteran under the VCAA cannot be considered prejudicial. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Veteran also has had the opportunity to submit additional argument and evidence and to participate meaningfully in the adjudication process. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With respect to the timing of the notice, the Board points out that the Court has held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a Veteran before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. See Pelegrini, 18 Vet. App. at 112. Here, all relevant notice was issued prior to the currently appealed rating decisions; thus, this notice was timely. Because the Veteran's claims are being denied in this decision, any question as to the appropriate disability rating or effective date is moot. See Dingess, 19 Vet. App. at 473. And any defect in the timing or content of the notice provided to the Veteran and his service representative has not affected the fairness of the adjudication. See Mayfield, 444 F.3d at 1328. The Board is aware of the decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) in which the Court held that, for an increased-compensation claim, section § 5103(a) requires, at a minimum, VA notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Relying on the informal guidance from VA's Office of General Counsel (OGC) and a VA Fast Letter issued in June 2008 (Fast Letter 08-16; June 2, 2008), the Board finds that Vazquez-Flores is not applicable to the Veteran's higher initial rating claim for migraines. According to OGC, because this appeal arises from an initial rating decision, VCAA notice obligations are satisfied fully once service connection has been granted. Any further notice and assistance requirements are covered by 38 U.S.C. §§ 5104(a), 7105(d)(1), and 5103A as part of the appeals process, upon the filing of a timely NOD with respect to the initial rating or effective date assigned following the grant of service connection. In Dingess, the Court held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess, 19 Vet. App. at 490-91. To the extent that Dingess requires more extensive notice as to potential downstream issues such as disability rating and effective date, because the currently appealed rating decision was fully favorable to the Veteran on the issue of service connection for migraines, and because the Veteran was fully informed of the evidence needed to substantiate this claim, the Board finds no prejudice to the Veteran in proceeding with the present decision. See also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the AOJ and the Board, although he declined to do so. It appears that all known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Veteran's electronic paperless claims files in Virtual VA and in VBMS have been reviewed. The Veteran also does not contend, and the evidence does not show, that he is in receipt of Social Security Administration (SSA) disability benefits such that a remand to obtain his SSA records is required. The Veteran contends that he was treated for his claimed disabilities at a medical clinic at the U.S. Embassy in Thailand while on active service in 1968. In response to a request for records, embassy personnel notified the AOJ in November 2011 that it had no treatment records for the Veteran. Embassy personnel also notified the AOJ that any treatment for the Veteran would have been entered in to his service treatment records at the time of treatment in 1968 and any other medical treatment records would have been destroyed pursuant to a records retention schedule. In September 2015, the National Personnel Records Center in St. Louis, Missouri (NPRC), notified VA that the Veteran's service treatment records and service personnel records were missing and further efforts to attempt to obtain them would be futile. In cases where the Veteran's service treatment records (or other pertinent records, for that matter) are unavailable through no fault of the claimant, there is a heightened obligation to assist the claimant in the development of his or her case. O'Hare v. Derwinski, 1 Vet. App. 365 (1991). VA must provide an explanation to the Veteran regarding VA's inability to obtain his or her service treatment records. Dixon v. Derwinski, 3 Vet. App. 261 (1992). The Court also has held that VA's efforts to obtain service department records shall continue until the records are obtained or unless it is reasonably certain that such records do not exist or that further efforts to obtain those records would be futile. Hayre v. West, 188 F.3d 1327 (Fed. Cir. 1999); see also McCormick v. Gober, 14 Vet. App. 39 (2000). The Veteran also informed VA in September 2015 that he did not have any of his service treatment records in his possession, although he provided copies of a few of his service personnel records denoting awards of the Meritorious Service Medal and the Joint Service Commendation Medal. A review of the Veteran's VBMS eFolder shows that copies of selected service treatment records, to include his separation physical examination, have been associated with the claims file. The AOJ formally concluded on several occasions during the appeal period that no service treatment records were available for the Veteran. Given the foregoing, the Board concludes that all available service treatment records and service personnel records for the Veteran have been obtained. The Board also concludes that it is reasonably certain that additional records do not exist and further efforts to attempt to obtain them would be futile. The Veteran has been provided with VA examinations which address the contended causal relationship between the claimed disabilities and active service. He also has been provided with VA examinations which address the current nature and severity of his service-connected migraines. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Given that the pertinent medical history was noted by the examiners, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the claims adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. Higher Initial Rating for Migraines The Veteran contends that his service-connected migraine headaches are more disabling than currently evaluated. He specifically contends that he experiences daily migraines. Laws and Regulations In general, disability evaluations are assigned by applying a schedule of ratings that represent, as far as can be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria that must be met for specific ratings. The regulations require that, in evaluating a given disability, the disability be viewed in relation to its whole recorded history. 38 C.F.R. § 4.2; see Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, as in this case, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). In Johnson, the Federal Circuit held that 38 C.F.R. § 3.321 required consideration of whether a Veteran is entitled to referral to the Director, Compensation Service, for consideration of the assignment of an extraschedular rating based on the impact of his or her service-connected disabilities, individually or collectively, on the Veteran's "average earning capacity impairment" due to such factors as marked interference with employment or frequent periods of hospitalization. See Johnson v. McDonald, 762 F.3d 1362 (2014); see also 38 C.F.R. § 3.321(b)(1). As is explained below in greater detail, following a review of the record evidence, the Board concludes that the symptomatology experienced by the Veteran as a result of his service-connected disabilities, individually or collectively, does not merit referral to the Director, Compensation Service, for consideration of the assignment of extraschedular ratings. In other words, the record evidence does not indicate that these service-connected disabilities, individually or collectively, show marked interference with employment or frequent periods of hospitalization or otherwise indicate that the symptomatology associated with them is not contemplated within the relevant rating criteria found in the Rating Schedule. VA recently proposed amending 38 C.F.R. § 3.321(b)(1) to limit extraschedular consideration based on the impact of an individual service-connected disability. This proposed regulation is consistent with VA's longstanding practice of interpreting this regulation to provide an extraschedular rating for a single disability and not the combined effect of two or more disabilities. The proposed changes will clarify the regulation so that an extraschedular rating is available only for an individual service-connected disability but not for the combined effect of more than one service-connected disability. See 81 Fed. Reg. 23228-23232 (Apr. 20, 2016) to be codified at 38 C.F.R. § 3.321(b)(1). Until this proposed regulation becomes final, however, the requirement of extraschedular consideration for a Veteran's service-connected disabilities, individually or collectively, set out by the Federal Circuit in Johnson remains applicable. The Veteran's service-connected migraines currently are evaluated as zero percent disabling (non-compensable) effective November 12, 2010, under 38 C.F.R. § 4.124a, DC 8100. See 38 C.F.R. § 4.124a, DC 8100 (2015). A 10 percent rating is assigned under DC 8100 for migraines with characterized prostrating attacks averaging 1 in 2 months over the previous several months. A 30 percent rating is assigned for migraines with characteristic prostrating attacks occurring on an average once a month over the previous several months. A maximum 50 percent rating is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. See 38 C.F.R. § 4.124a, DC 8100 (2015). Factual Background and Analysis The Board finds that the preponderance of the evidence is against granting the Veteran's claim for an initial compensable rating for migraines. The Veteran contends that his service-connected migraines are more disabling than currently evaluated. The record evidence does not support his assertions. It shows instead that the Veteran's service-connected migraines are manifested by, at worst, complaints of daily headaches, pain in both temples and less frequent characteristic prostrating attacks throughout the appeal period. For example, although not all of the Veteran's service treatment records are available for review, his separation physical examination in February 1974 shows that he had a diagnosis of migraine headaches which were treated with Fiorinal. The post-service evidence shows that, although the Veteran continues to complain of migraine headaches, they are not manifested by at least characteristic prostrating attacks averaging 1 in 2 months over the past several months (i.e., at least a 10 percent rating under DC 8100) such that an initial compensable rating is warranted at any time during the appeal period. See 38 C.F.R. § 4.124a, DC 8100 (2015). For example, on VA neurological disorders examination in April 2011, the Veteran complained of weekly headaches. He denied experiencing prostrating attacks of migraines or needing to take continuous medication to treat them. He reported that "ordinary activity is possible" during a migraine. The VA examiner reviewed the Veteran's claims file. He reported being given Fiorinal during service to treat his migraines. "Since then [he] continues to take Fiorinal as needed and when he takes it at the onset of headache, it ceases/eases up." Physical examination of the Veteran in April 2011 showed normal funduscopic exam, normal mental status, intact cranial nerves, normal cerebellar exam, and no evidence of chorea or carotid bruits. The Veteran stated that he retired in January 2001 because he was eligible by age or duration of work. The diagnosis was migraine headaches. On VA headaches Disability Benefits Questionnaire (DBQ) in September 2015, the Veteran's complaints included daily headaches which lasted an hour or longer. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran took Fiorinal and Fioricet to treat his migraines. The Veteran experienced headache pain which was pulsating or throbbing in both temples. His pain lasted for less than 1 day. He did not experience non-headache symptoms. Although he reported characteristic prostrating attacks of migraine pain, these attacks were less frequent. He did not have very prostrating and prolonged attacks of migraine pain productive of severe economic inadaptability. The diagnosis was migraine including migraine variants. The Veteran contends that his service-connected migraines are more disabling than currently evaluated. The record evidence does not support his assertions. It shows instead that, although he continues to complain of migraine headaches, they are manifested by, at worst, less frequent attacks of migraine pain (i.e., a zero percent rating under DC 8100) throughout the appeal period. Id. The Board finds it highly significant that the Veteran reported at his April 2011 VA examination for migraines that "ordinary activity is possible" during one of his migraine attacks. This persuasively suggests that the Veteran experienced no prostrating attacks of migraine headaches at that time. The Board acknowledges that, at his most recent VA examination for migraines in October 2015, the Veteran reported experiencing daily headaches and taking 2 different medications to treat them. There is no indication, however, that the Veteran experiences migraines with at least characteristic prostrating attacks averaging one in 2 months over the past several months (i.e., at least a 10 percent rating under DC 8100) such that an initial compensable rating is warranted for this disability at any time during the appeal period. Id. In fact, the Veteran reported at his October 2015 VA examination that his migraine headache pain lasted for less than 1 day. The Veteran also has not identified or submitted any evidence, to include a medical nexus, demonstrating his entitlement to an initial compensable rating for migraines. Thus, the Board finds that the criteria for an initial compensable rating for migraines have not been met. Extraschedular The Board must consider whether the Veteran is entitled to consideration for referral for the assignment of an extraschedular rating for his service-connected migraines. 38 C.F.R. § 3.321; Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record). An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that schedular evaluation assigned for the Veteran's service-connected migraines is not inadequate in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's service-connected migraines. This is especially true because the zero percent rating currently assigned for the Veteran's migraines effective November 12, 2010, contemplates minimal to no disability. Moreover, the evidence does not demonstrate other related factors such as marked interference with employment and frequent hospitalization. The Veteran reported at his April 2011 VA examination that he had retired in 2001 because he was eligible by his age or duration of work. A different VA examiner noted in October 2015 that the Veteran's migraines had not interfered with his ability to work while he was employed. The Veteran also has not been hospitalized at any time during the appeal period for treatment of his service-connected migraines. As noted elsewhere, the record evidence does not indicate that these service-connected disabilities, individually or collectively, show marked interference with employment or frequent periods of hospitalization or otherwise indicate that the symptomatology associated with them is not contemplated within the relevant rating criteria found in the Rating Schedule such that he is entitled to extraschedular consideration under Johnson. As also noted elsewhere, the Veteran's TDIU claim is being remanded for additional development. In light of the above, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Service Connection Claims The Veteran contends that he incurred peripheral vascular disease of the right leg and of the left leg, residuals of Q fever, other than heart disease and peripheral neuropathy of the bilateral lower extremities, and bilateral hearing loss during active service. He specifically contends that in-service exposure to herbicides (Agent Orange) or other chemicals while on active service in Thailand caused or contributed to his peripheral vascular disease of the right leg. He also contends that he experiences currently residuals of Q fever that are attributable to service. He finally contends that in-service exposure to significant acoustic trauma while in Thailand caused or contributed to his current bilateral hearing loss. Laws and Regulations Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection also may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including sensorineural hearing loss (as an organic disease of the nervous system), are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Establishing service connection generally requires (1) medical evidence of a presently existing disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); Hickson v. West, 12 Vet. App. 247, 253 (1999). VA regulations provide that a Veteran who had active military, naval, or air service 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 the Veteran was not exposed to any such agent during that service. See 38 C.F.R. § 3.307(a)(6)(iii). In such circumstances, service connection may be granted on a presumptive basis for the diseases listed in 38 C.F.R. § 3.309(e). Peripheral vascular disease of the right leg is not among the diseases listed in § 3.309 for which presumptive service connection is available based on in-service herbicide exposure. The Secretary of Veterans Affairs also has determined that there is no positive association between exposure to herbicides and any other condition for which he has not specifically determined a presumption of service connection is warranted. See Diseases Not Associated with Exposure to Certain Herbicide Agents, 67 Fed. Reg. 42,600 (June 24, 2002). Notwithstanding the foregoing, the Federal Circuit has determined that the Veteran's Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984) does not preclude a Veteran from establishing service connection with proof of direct causation. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The rationale employed in Combee also applies to claims based on exposure to Agent Orange. See Brock v. Brown, 10 Vet. App. 155 (1997). Clinically, the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For compensation purposes, however, impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels (dB) or greater or where the auditory thresholds for at least three of these frequencies are 26 dB or greater or when speech recognition scores are less than 94 percent. 38 C.F.R. § 3.385. If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-498. In Walker, the Federal Circuit overruled Savage and limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also Fountain v. McDonald, 27 Vet. App. 258 (2015) (adding tinnitus as an "organic disease of the nervous system" to the list of disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a)). Because peripheral vascular disease of the right leg and of the left leg and residuals of Q fever are not recognized explicitly as "chronic" in 38 C.F.R. § 3.309(a), the Board finds that Savage and the theory of continuity of symptomatology in service connection claims is inapplicable to these claims. In contrast, because sensorineural hearing loss (as an organic disease of the nervous system) is considered a "chronic" disability under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology remains valid in adjudicating the Veteran's claim of service connection for bilateral hearing loss to the extent that it includes a claim for sensorineural hearing loss. It is VA policy to administer the laws and regulations governing disability claims under a broad interpretation and consistent with the facts shown in every case. When a reasonable doubt arises regarding service origin, the degree of disability, or any other point, after careful consideration of all procurable and assembled data, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not prove or disprove the claim satisfactorily. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. Factual Background and Analysis The Board finds that the preponderance of the evidence is against granting the Veteran's claims of service connection for peripheral vascular disease of the right leg, including as due to herbicide or other chemical exposure, and for peripheral vascular disease of the left leg. The Veteran contends that in-service exposure to herbicides (Agent Orange) or other harmful chemicals while he was on active service in Thailand caused or contributed to his peripheral vascular disease of the right leg. He also contends that his current peripheral vascular disease of the left leg is related to active service. The record evidence does not support his assertions regarding in-service incurrence of peripheral vascular disease of the right leg or of the left leg, in-service exposure to herbicides or other harmful chemicals, or a nexus between his current peripheral vascular disease of the right leg and of the left leg and active service or any incident of service. For example, although the Veteran's complete service treatment records are not available for review, on a consult dated in July 1973, the Veteran's complaints included "numbness in the stocking area of both feet since about 1966, this tends to be persistent unaffected by sleep or activity." Physical examination showed no atrophy in the extremities, "good grade 5 strength in his legs," and neurological exam was normal except for decreased vibration sensation in the toes relative to the ankles and knees. The diagnoses included chemical diabetes with postprandial hypoglycemia and peripheral neuropathy "probably on a vascular basis perhaps related to" chemical diabetes with postprandial hypoglycemia. The Veteran "was reassured about his stable status." He was advised to take 100 mg of Darvon at 6 hour intervals "for leg discomfort." At the Veteran's separation physical examination in February 1974, clinical evaluation showed that his lower extremities were abnormal because he had peripheral neuropathy. An in-service history of swollen, painful joints with cramps in legs and foot trouble was noted. The in-service examiner stated, "All these items pertain to [a] condition involving both legs from [the] knees down. Examined on numerous occasions, diagnoses - etiology unknown." The in-service examiner referred to a consult dated in July 1973. With respect to the Veteran's assertion that he was exposed to herbicides while on active service in Thailand, the Board acknowledges that the Veteran's DD Form 214 indicates that he was awarded the Vietnam Service Medal with 2 Bronze Service Stars and the Republic of Vietnam Campaign Medal. More importantly, the evidence does not suggest, nor does the Veteran contend, that he actually had in-country duty in Vietnam. Although it is unfortunate that the Veteran's complete service personnel records are missing and not available for review, because the available records do not show that he had in-country duty in Vietnam, his active service does not meet the regulatory definition of Vietnam service found in 38 C.F.R. § 3.307(a)(6)(iii) and upheld by the Federal Circuit in Haas. See Haas v. Peake, 525 F.3d. 1168 (Fed. Cir. 2008) cert. denied 129 S. Ct. 1002 (2009) (upholding as permissible VA's regulatory interpretation of "service in Vietnam" as requiring in-country duty or visitation in Vietnam). Accordingly, because the Veteran did not have active service in Vietnam, his in-service herbicide exposure cannot be presumed. See 38 C.F.R. §§ 3.307, 3.309. Pursuant to the M21-1, the AOJ concluded in a formal finding in October 2012 that there was insufficient evidence to corroborate the Veteran's assertion regarding in-service herbicide exposure while in Thailand by referring this matter to the Joint Services Records Research Center (JSRRC). The AOJ noted that the National Personnel Records Center in St. Louis, Missouri (NPRC) had notified VA in September 2010 that there were no records of in-service herbicide exposure for the Veteran. Although the Board is not bound by the provisions of the M21-1, it is noted that, under M21-1, Part IV, Subpart ii, 1.H.5.b, herbicide exposure in Thailand will be conceded by VA only where a Veteran served at a specific Royal Thai Air Force Base (RTAFB) and served as a U.S. Air Force security policeman, security patrol dog handler, member of the security police squadron, or otherwise served near the air base perimeter as shown by evidence of daily work duties, performance evaluation reports, or other credible evidence. See M21-1, Part IV, Subpart ii, 1.H.5.b. In this case, the AOJ noted in its October 2012 formal finding that the Veteran had alleged in-service herbicide exposure while assigned to Don Muang RTAFB from April 7, 1967, through July 29, 1969. The Board acknowledges that Don Muang RTAFB is one of the locations where herbicides were used in Thailand during the Vietnam Era. Id. A review of the Veteran's DD Form 214s for his 23-year U.S. Air Force career does not indicate that he served as a security policeman, security patrol dog handler, member of the security police squadron, or otherwise served near the air base perimeter at any time during active service, including while on active service in Thailand. These records show instead that the Veteran's in-service duties were in inventory and supply management. Unfortunately, it appears that a copy of VA Compensation Service's "Memorandum For The Record" concerning herbicide use in Thailand was not placed in the Veteran's claims file pursuant to M21-1MR, Part IV, Subpart ii, 2.C.10.r. See M21-1MR, Part IV, Subpart ii, 2.C.10.r. Nevertheless, comparing the facts and circumstances of the Veteran's reported active service in Thailand with the M21-1, Part IV, Subpart ii, 1.H.5.b, the Board finds that the Veteran was not assigned to areas where herbicides were used when he was on active service in Thailand. Thus, the Board concludes that any argument concerning the Veteran's alleged in-service herbicide exposure while on active service in Thailand to be without merit. The Board also finds that, although the Veteran was not exposed to herbicides during active service, and although peripheral vascular disease of the right leg and of the left leg are not among the diseases for which service connection is available on a presumptive basis due to in-service herbicide exposure, the record evidence also does not show that any current peripheral vascular disease of the right leg or of the left leg is related to active service. For example, the post-service evidence shows that, on outpatient treatment in March 1979, the Veteran complained of leg cramps and numbness below both knees. The assessment was peripheral vascular disease. In January 1987, the Veteran complained of "leg cramps at night." Objective examination showed no hair on the distal lower extremities and feet and dorsal pedis pulses were not palpable bilaterally. The assessment was early peripheral vascular disease which was not the etiology of his reported leg cramps. In July 2001, the Veteran's complaints included bilateral foot pain. The assessment included peripheral vascular disease. On private outpatient treatment in October 2009, it was noted that the Veteran's chronic problems included peripheral vascular disease. "He has a history of peripheral neuropathy. This is currently well controlled with his Neurontin and is probably related to his vascular disease." Physical examination was unremarkable. The assessment included peripheral vascular disease. In February 2010, S.A.G., M.D., noted that the Veteran "also had a question about an old disability claim that he has related to his military service and possible chemical exposures there and whether or not these are related to a multitude of chronic problems that he has. I discussed this with him in the office at length and told him that certainly I cannot say with any definitive opinion that these problems are related to his chemical exposure. In fact, I suspect that they are probably not [related]." In October 2010, a history of peripheral vascular disease was noted. Physical examination was unchanged. The assessment included peripheral vascular disease "being treated with aspirin and Plavix." Dr. S.A.G. stated, "I do not really suspect this is a significant problem for him." On VA artery and vein conditions DBQ in January 2012, it was noted that the Veteran's peripheral vascular disease symptoms including claudication of the bilateral lower extremities on walking between 25-100 yards on a level surface at 2 miles per hour, persistent coldness of the bilateral lower extremities, and ischemic limb pain at rest of the bilateral lower extremities. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran regularly used a cane and a cart at a grocery store or Walmart. The Veteran's right ankle brachial index was 1.01 which was within normal limits "but with abnormal toe brachial index suggestive of at least moderate small vessel disease" and his left ankle brachial index was 1.07 which was within normal limits. The VA examiner opined that it was less likely than not that the Veteran's peripheral vascular disease was related to active service. The rationale for this opinion was that a review of the Veteran's service treatment records showed that, although he experienced leg pain and cramps, there was no indication of decreased pulse. The rationale also was that a July 1973 consult diagnosed the Veteran as having peripheral neuropathy due to chemical diabetes. "This is a nerve condition and not due to vascular disease." The diagnoses included peripheral vascular disease. The Veteran contends that he incurred peripheral vascular disease of the right leg, including as due to in-service herbicide or chemical exposure, and of the left leg during active service. As noted, the Veteran's assertion that he was exposed to herbicides or other chemicals during active service and such exposure caused or contributed to his current peripheral vascular disease of the right leg is without merit. The Board finds it highly significant that the Veteran denied being exposed to herbicides on an October 2006 VA Form 21-526 when he filed a claim of service connection for peripheral neuropathy of the bilateral lower extremities. He also has not identified or submitted any evidence, to include a medical nexus, which relates his peripheral vascular disease to his alleged in-service herbicide exposure. Thus, the Board finds that service connection for peripheral vascular disease of the right leg is not warranted on a presumptive service connection basis as due to herbicide exposure. See 38 C.F.R. §§ 3.307, 3.309. The Veteran further is not entitled to service connection for either peripheral vascular disease of the right leg or of the left leg on a direct service connection basis. See also 38 C.F.R. §§ 3.303, 3.304. The record evidence does not show that the Veteran's current peripheral vascular disease of the right leg and of the left leg are related to active service. The January 2012 VA examiner specifically found that it was less likely than not that the Veteran's peripheral vascular disease was related to active service. This opinion was fully supported. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Veteran has not identified or submitted any evidence, to include a medical nexus, demonstrating his entitlement to service connection for peripheral vascular disease of the right leg, including as due to herbicide or chemical exposure, or for peripheral vascular disease of the left leg. Accordingly, the Board finds that service connection for peripheral vascular disease of the right leg, including as due to herbicide or chemical exposure, and for peripheral vascular disease of the left leg is not warranted. The Board next finds that the preponderance of the evidence is against granting the Veteran's claim of service connection for residuals of Q fever other than heart disease or peripheral neuropathy of the bilateral lower extremities. The Veteran contends that, following in-service treatment for Q fever, he experienced residuals of this disability that are related to active service. As the Board noted in its May 2015 remand, because service connection for heart disease and peripheral neuropathy of the bilateral lower extremities had been denied in October 2013, and because that Board decision had considered the possibility that heart disease and peripheral neuropathy of the bilateral lower extremities were residuals of Q fever, neither of those disabilities would not be considered residuals of Q fever when that claim was adjudicated on the merits. See Board decision dated May 28, 2015, at pp. 2. The record evidence shows that the Veteran does not experience any residuals of Q fever other than heart disease or peripheral neuropathy of the bilateral lower extremities which could be attributed to active service. The Board recognizes here that the Veteran's February 1974 separation physical examination indicates that he was hospitalized in April 1972 for Q fever during active service. The post-service evidence shows that, on VA infectious diseases DBQ in October 2015, the Veteran reported that he had been hospitalized for 10 days "with a high fever of 104" and had been treated with antibiotics during active service. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. This examiner stated that the Veteran's Q fever became inactive in 1972 and he had no symptoms or residuals attributable to this diagnosis. The VA examiner opined that it was less likely than not that the Veteran's claimed residuals of Q fever were related to active service. The rationale for this opinion was that, although the Veteran was diagnosed and treated for Q fever during active service, no residuals were reported at that time or following this treatment. This examiner also stated in her rationale that: Q fever usually is asymptomatic or acute and transitory and treated with antibiotics. For the few that have recurrent infections, it affects heart valves, lungs, liver - causing hepatitis, pregnancy problems, and meningitis infections. The Veteran has had none of these complications except [chronic obstructive pulmonary disease] which is caused from his chronic smoking. Therefore it is less likely that the Veteran has any residuals including [peripheral neuropathy] or headaches caused from his...Q fever. The diagnosis was Q fever. The Board acknowledges the Veteran's assertions that he experiences current residuals of Q fever other than heart disease or peripheral neuropathy of the bilateral lower extremities which he attributes to active service. A service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability. Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection is not warranted in the absence of proof of current disability. The Board has considered whether the Veteran experienced any residuals of Q fever at any time during the pendency of this appeal. Service connection may be granted if there is a disability at some point during the claim even if it later resolves or becomes asymptomatic. McClain v. Nicholson, 21 Vet. App. 319 (2007). In this case, although the Board again acknowledges that the Veteran was hospitalized for treatment of Q fever during active service, there is no evidence that he experienced any residuals of Q fever at any time during the pendency of this appeal which could be attributed to service. In summary, the Board finds that service connection for residuals of Q fever other than heart disease or peripheral neuropathy of the bilateral lower extremities is not warranted. The Board finally finds that the preponderance of the evidence is against granting the Veteran's claim of service connection for bilateral hearing loss. The Veteran contends that he incurred bilateral hearing loss during active service or, alternatively, his current bilateral hearing loss is related to active service. The record evidence does not support the Veteran's assertions regarding in-service incurrence of bilateral hearing loss or an etiological link between his current bilateral hearing loss and service. For example, although the Board again notes that the Veteran's complete service treatment records are missing and not available for review, his separation physical examination in February 1974 shows that his pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 5 0 0 0 LEFT 15 5 0 0 15 The post-service evidence indicates that, although the Veteran currently experiences bilateral hearing loss, it is not related to active service. For example, on VA hearing loss and tinnitus DBQ in February 2012, the Veteran complained of difficulty hearing "in some situations." His pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 25 30 60 LEFT 15 20 50 55 65 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and 80 percent in the left ear. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. This examiner opined that it was less likely than not that the Veteran's bilateral hearing loss was related to active service. The rationale for this opinion was that the Veteran's hearing sensitivity was normal in both ears at his February 1974 separation physical examination. The diagnosis was bilateral sensorineural hearing loss. The Board finds that the February 2012 VA hearing loss and tinnitus DBQ is not probative on the issue of whether the Veteran's bilateral hearing loss is related to active service. It is well-settled that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). It appears that the February 2012 VA examiner relied on the absence of hearing loss at the Veteran's separation physical examination in February 1974 as support for his negative nexus opinion concerning the contended etiological relationship between bilateral hearing loss and active service. Because this opinion rationale violates the Court's holdings in Buchanan and Barr, the Board finds that the February 2012 examination is entitled to no probative value. In contrast, a different VA audiologist opined in December 2015 that it was less likely than not that the Veteran's bilateral hearing loss was related to active service. The rationale for this opinion was, "The Veteran had normal hearing at the time of retirement. Scientific research has shown that if there is no hearing loss immediately following exposure, it will not then be displayed later as a delayed onset." After citing to relevant medical literature, this VA audiologist concluded: [B]ased on the clear-cut evidence and scientific research, it is this examiner's opinion that the Veteran's current hearing loss is less likely as not caused by military service noise exposure. Had the Veteran been exposed to acoustic trauma excessive enough to damage his hearing, it would have most likely been present and documented at the time of retirement. The Board finds that the December 2015 VA audiologist's opinion is highly probative on the issue of whether the Veteran's bilateral hearing loss is related to active service. It was based on a review of the Veteran's claims file and cited and discussed relevant medical literature before offering a medical conclusion. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (finding that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). The December 2015 VA audiologist's opinion also was fully supported. See Stefl, 21 Vet. App. at 124 (2007). The Veteran further has not identified or submitted any evidence, to include a medical nexus, demonstrating his entitlement to service connection for bilateral hearing loss. In summary, the Board finds that service connection for bilateral hearing loss is not warranted. The Board finally finds that the preponderance of the evidence is against granting service connection for bilateral sensorineural hearing loss on a presumptive basis. See 38 C.F.R. §§ 3.307, 3.309. The Board acknowledges here that sensorineural hearing loss (as an organic disease of the nervous system) is considered a disability for which service connection is available on a presumptive basis. Id. The record evidence does not show that the Veteran was diagnosed as having or treated for bilateral sensorineural hearing loss during active service or within the first post-service year (i.e., by May 1975) such that service connection is warranted on a presumptive basis. Thus, the Board finds service connection for bilateral hearing loss is not warranted on a presumptive basis. In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"); 38 C.F.R. § 3.303(a) (service connection claims "must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown,6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A Veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr, 21 Vet. App. at 309 (holding that, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan, 451 F.3d at 1337; Barr, 21 Vet. App. at 303. In determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). As part of the current VA disability compensation claims, in recent statements, the Veteran has asserted that his symptoms of peripheral vascular disease in both legs, residuals of Q fever other than heart disease or peripheral neuropathy of the bilateral lower extremities, and bilateral hearing loss have been continuous since service. He asserts that he continued to experience symptoms relating to peripheral vascular disease in both legs (swelling, cramping, coldness, or numbness), residuals of Q fever (lethargy), and bilateral hearing loss (difficulty hearing) after he was discharged from service. In this case, after a review of all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of any of these claimed disabilities after service separation. Further, the Board concludes that his assertion of continued symptomatology since active service, while competent, is not credible. The Board finds that the Veteran's more recently-reported history of continued symptoms of peripheral vascular disease in both legs, residuals of Q fever other than heart disease or peripheral neuropathy of the bilateral lower extremities, and bilateral hearing loss since active service is inconsistent with the other lay and medical evidence of record. Indeed, while he now asserts that his disorders began in service, in the more contemporaneous medical history he gave at the service separation examination, he denied any history or complaints of symptoms of peripheral vascular disease in both legs, residuals of Q fever other than heart disease or peripheral neuropathy of the bilateral lower extremities, and bilateral hearing loss. Specifically, the service separation examination report reflects that the Veteran was examined and only peripheral neuropathy was noted in the lower extremities, no residuals of Q fever were identified, and his hearing was found to be normal clinically. His in-service history of symptoms at the time of service separation is more contemporaneous to service so it is of more probative value than the more recent assertions made many years after service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding 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). The post-service medical evidence does not reflect complaints or treatment related to any of the Veteran's claimed disabilities for many years following active service. The Board emphasizes the multi-year gap between discharge from active service (1974) and initial reported symptoms related to peripheral vascular disease in May 1979 (a 5-year gap). The Board also emphasizes that the record evidence shows that the Veteran did not experience any residuals of Q fever following his in-service hospitalization and treatment for this disease. The Board further emphasizes the multi-year gap between discharge from active service (1974) and bilateral sensorineural hearing loss which was diagnosed on VA examination in February 2012 (a 38-year gap). See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (finding lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where Veteran failed to account for lengthy time period between service and initial symptoms of disability). The Veteran filed a VA disability compensation claim for service connection for a peripheral neuropathy of the bilateral lower extremities in October 2006 but did not claim service connection for peripheral vascular disease in both legs, residuals of Q fever other than heart disease or peripheral neuropathy of the bilateral lower extremities, and bilateral hearing loss or make any mention of any relevant symptomatology. As noted elsewhere, the Veteran specifically denied any in-service herbicide exposure when he filed his service connection claim for peripheral neuropathy of the bilateral lower extremities in October 2006. He did not claim that symptoms of his disorders began in (or soon after) service until he filed his current VA disability compensation claims in February 2010. Such statements made for VA disability compensation purposes are of lesser probative value than his previous more contemporaneous in-service histories. See Pond v. West, 12 Vet. App. 341 (1999) (finding that, although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). These inconsistencies in the record weigh against the Veteran's credibility as to the assertion of continuity of symptomatology since service. See Madden, 125 F.3d at 1481 (finding Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a Veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service). The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation, the absence of complaints or treatment for years after service, and the record evidence showing no etiological link between peripheral vascular disease of the right leg and of the left leg, claimed residuals of Q fever other than heart disease or peripheral neuropathy of the bilateral lower extremities, or bilateral hearing loss and active service. For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of continuity of symptoms since service separation. ORDER Entitlement to an initial compensable rating for migraines is denied. Entitlement to service connection for peripheral vascular disease of the right leg, including as due to herbicide or other chemical exposure, is denied. Entitlement to service connection for peripheral vascular disease of the left leg is denied. Entitlement to service connection for residuals of Q fever, other than heart disease or peripheral neuropathy of the bilateral lower extremities (which were denied by the Board in a decision of May 28, 2015), is denied. Entitlement to service connection for bilateral hearing loss is denied. REMAND The Veteran contends that he incurred Peyronie's disease during active service or, alternatively, his current Peyronie's disease is related to service. He also contends that his service-connected COPD, alone or in combination with his other service-connected disabilities, preclude his employability and entitle him to a TDIU. The Board acknowledges that these claims previously was remanded to the AOJ in May 2015. Having reviewed the record evidence, and although the Board is reluctant to contribute to "the hamster-wheel reputation of Veterans law" by remanding these claims again, additional development is required before the underlying claims can be adjudicated on the merits. Cf. Coburn v. Nicholson, 19 Vet. App. 427, 434 (2006) (Lance, J., dissenting) (finding that repeated remands "perpetuate the hamster-wheel reputation of Veterans law"). With respect to the Veteran's service connection claim for Peyronie's disease, the voluminous record evidence shows that, following private outpatient treatment in July 2011, he was diagnosed as having Peyronie's disease. To date, however, the AOJ has not scheduled the Veteran for an examination to determine the nature and etiology of this disability. The Board observes in this regard that VA's duty to assist includes obtaining an examination where necessary. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon, 20 Vet. App. at 79. Thus, the Board finds that, on remand, the Veteran should be scheduled for appropriate examination to determine the nature and etiology of his Peyronie's disease. With respect to the Veteran's TDIU claim, the Board notes that, although the Veteran currently does not meet the scheduler criteria for a TDIU, entitlement to a TDIU may be established on an extraschedular basis, in exceptional cases, when the Veteran is unable to secure and follow a substantially gainful occupation by reason of a service-connected disability. See 38 C.F.R. §§ 4.16(a), (b) (2015). Service connection is in effect for COPD, evaluated as 30 percent disabling effective April 8, 2008, insomnia disorder, evaluated as 30 percent disabling effective March 11, 2014, restless leg syndrome, evaluated as zero percent disabling effective April 8, 2008, and for migraines, evaluated as zero percent disabling effective November 12, 2010. The Veteran's combined disability rating for compensation is 50 percent effective March 11, 2014. See 38 C.F.R. § 4.25 (2015). The Board next notes that the medical evidence of record does not address the impact of the Veteran's service-connected COPD, alone or in combination with his other service-connected disabilities, on his employability. The Board acknowledges that the VA clinicians who conducted the Veteran's most recent VA examinations in October 2015 and in January 2016 provided some limited information concerning the impact of his service-connected disabilities on his employment but did not address whether these disabilities, alone or in combination, precluded the Veteran's employability. The Board observes in this regard that VA's duty to assist includes obtaining an examination where necessary. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon, 20 Vet. App. at 79. Thus, the Board finds that, on remand, the Veteran should be scheduled for appropriate examination to determine the impact of his service-connected disabilities, alone or in combination, on his employability. Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Contact the Veteran and/or his service representative and ask him to identify all VA and non-VA clinicians who have treated him for Peyronie's disease since his service separation. Obtain all VA treatment records which have not been obtained already. Once signed releases are received from the Veteran, obtain all private treatment records which have not been obtained already. A copy of any records obtained, to include a negative reply, should be included in the claims file. 2. Thereafter, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his Peyronie's disease. The claims file and a copy of this remand must be provided to the examiner for review. All appropriate testing should be conducted. The Veteran should be asked to provide a complete medical history, if possible. Based on a review of the claims file and the results of the Veteran's physical examination, and the Veteran's statements regarding the development and treatment of her claimed disorder, the examiner is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that Peyronie's disease, if diagnosed, is related to active service or any incident of service. A complete rationale must be provided for any opinions expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the examiner must explain why this is so. 3. Schedule the Veteran for appropriate examination to determine whether his service-connected disabilities, alone or in combination, render him unable to secure or follow a substantially gainful occupation. The claims file and a copy of this remand must be provided to the examiner for review. All appropriate testing should be conducted. The Veteran should be asked to provide a complete medical and employment history, if possible. Based on a review of the claims file and the results of the Veteran's physical examination, the examiner is asked to specify the occupational limitations associated with the service-connected disabilities. A complete rationale must be provided for any opinions expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the examiner must explain why this is so. The examiner is advised that service connection is in effect for COPD, insomnia disorder, restless leg syndrome, and for migraines. 4. The Veteran should be given adequate notice of the requested examinations which includes advising him of the consequences of his failure to report to the examinations. If he fails to report to the examinations, then this fact should be noted in the claims file and a copy of the scheduling of examination notification or refusal to report notice, whichever is applicable, should be obtained by the RO and associated with the claims file. 5. Review all evidence received since the last prior adjudication and readjudicate the Veteran's claims. If the determination remains unfavorable to the Veteran, then the RO should issue a supplemental statement of the case that contains notice of all relevant actions taken, including a summary of the evidence and applicable law and regulations considered pertinent to the issues. An appropriate period of time should be allowed for response by the Veteran and his service representative. Thereafter, the case should be returned to the Board for further appellate consideration, 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). 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 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). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs