Citation Nr: 1645867 Decision Date: 12/07/16 Archive Date: 12/19/16 DOCKET NO. 13-19 094 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to a compensable rating for bilateral hearing loss (formerly claimed as left ear hearing loss). 2. Entitlement to service connection for residuals of acid burns to the eyes, to include as secondary to herbicide exposure. 3. Entitlement to service connection for a disability characterized by blood in the urine, to include as secondary to herbicide and/or asbestos exposure. 4. Entitlement to service connection for a sinus disability, to include as secondary to asbestos exposure. 5. Entitlement to service connection for a skin disability, to include as secondary to herbicide exposure. 6. Entitlement to service connection for peripheral neuropathy, left upper extremity, to include as secondary to herbicide exposure. 7. Entitlement to service connection for peripheral neuropathy, left lower extremity, to include as secondary to herbicide exposure. 8. Entitlement to service connection for peripheral neuropathy, right upper extremity, to include as secondary to herbicide exposure. 9. Entitlement to service connection for peripheral neuropathy, right upper extremity, to include as secondary to herbicide exposure. 10. Entitlement to service connection for a cervical spine disorder. 11. Entitlement to service connection for a lumbar spine disorder. 12. Entitlement to service connection for a bilateral knee disorder. 13. Entitlement to service connection for a heart disability to include as secondary to herbicide exposure. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served on active duty from December 1968 to November 1972, and was awarded, among other medals and decorations, the Purple Heart Medal and the Combat Action Ribbon. These matters come on appeal before the Board of Veterans' Appeals (Board) from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). A June 2011 rating decision denied a compensable rating for service-connected left ear hearing loss, and reopened and denied previously denied claims for service connection for right ear hearing loss, residuals of acid burns to the eyes, and a sinus disability. The June 2011 rating decision also denied reopening previously denied claims for service connection for bilateral perforation of the tympanic membrane, and a skin disability, and denied claims for service connection for peripheral neuropathy of the bilateral upper and lower extremities. A February 2013 rating decision denied service connection for blood in the urine, a kidney disability, and an adrenal gland disability. A December 2013 rating decision denied the Veteran's claims for service connection for a heart disability and degenerative arthritis of the bilateral knees, cervical spine, and lumbar spine. The Veteran has perfected an appeal as to these issues, but he perfected the appeal subsequent to a September 2015 Board decision. The September 2015 Board decision granted service connection for right ear hearing loss; declined to reopen service connection for bilateral perforation of the tympanic membrane; denied service connection for a kidney disability and an adrenal gland disability; and reopened and remanded the issues of service connection for a sinus disability, residuals of acid burns to the eyes, a disability characterized by blood in the urine, and for a skin disability; and remanded the issue of service connection for peripheral neuropathy of all four extremities. The issues of service connection for peripheral neuropathy of all four extremities, a cervical spine disability, a back disability, a bilateral knee disability, and a heart disability, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. At worse, the Veteran has Level I hearing in his right ear and Level I hearing in his left ear. 2. The Veteran does not have an eye disability that is attributable to service to include presumed herbicide exposure; there was no superimposed injury to the Veteran's refractive error during service. 3. The Veteran does not have an underlying disability characterized by blood in the urine, to include as secondary to herbicide and/or asbestos exposure, which is attributable to service. . 4. The Veteran's rhinitis is attributable to service, but he does not have a diagnosis of sinusitis. 5. The Veteran's recurrent folliculitis and acne are attributable to service. CONCLUSIONS OF LAW 1. The criteria for a compensable evaluation for bilateral hearing loss are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.85, Part 4, Diagnostic Code 6100 (2015). 2. An eye disability was not incurred or aggravated in active service and may not be presumed to be the result of herbicide exposure during active military service in Vietnam. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1137, 1154, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307, 3.309, 4.9 (2015). 3. A disability characterized by blood in the urine was not incurred or aggravated in active service to include as due to asbestos exposure and may be not presumed to be the result of herbicide exposure during active military service in Vietnam. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1173, 1154, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307, 3.309 (2015). 4. Rhinitis was incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1154, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304. 3.306 (2015). 5. Folliculitis and acne were incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1154, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304. 3.306 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) Under the VCAA, when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159. Here, the Veteran was provided with the relevant notice and information in January 2011 and June 2012 letters prior to the initial adjudication of the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). The Veteran has not alleged any notice deficiency during the adjudication of the claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). VA also has a duty to assist the Veteran in obtaining potentially relevant records, and providing an examination or medical opinion when necessary to make a decision on the claim. Here, the Veteran's service treatment records (STRs), VA records, and identified private treatment records have been obtained and associated with the record. The Social Security Administration (SSA) records are unavailable. The Veteran was also provided with VA examinations which, collectively, are adequate as the record was reviewed, the examiner reviewed the pertinent history, examined the Veteran provided findings in sufficient detail, and provided rationale. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Veteran was specifically examined to assess and then reassess the severity of this disability in question. See Caffrey v. Brown, 6 Vet. App. 377 (1994); Olsen v. Principi, 3 Vet. App. 480, 482 (1992); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992); and Allday v. Brown, 7 Vet. App. 517, 526 (1995). The records satisfy 38 C.F.R. § 3.326. In summary, the Board finds that it is difficult to discern what additional guidance VA could have provided to the Veteran regarding what further evidence should be submitted to substantiate the claims. Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004); see also Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances as to when a remand would not result in any significant benefit to the Veteran). Rating for Bilateral Hearing Loss In a June 2004 rating decision, service connection for left ear hearing loss was granted and was assigned a noncompensable rating. As noted above, the September 2015 Board decision granted service connection for right ear hearing loss. In a December 2015 rating decision, the RO implemented the Board's decision and granted service connection for right ear hearing loss effective December 21, 2010, and rated that disability with the already service connected left ear hearing loss. The rating for bilateral hearing loss was noncompensable. Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, a Veteran appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Where factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). In evaluating service connected hearing impairment, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Acevedo-Escobar v. West, 12 Vet. App. 9, 10 (1998); Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The schedule provides a table (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment. Testing for hearing loss is conducted by a state-licensed audiologist, including a controlled speech discrimination test (Maryland CNC). The evaluation is based upon a combination of the percent of speech discrimination and the puretone threshold average which is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by four. See 38 C.F.R. § 4.85. Table VII in the schedule is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear, the horizontal rows representing the ear having better hearing and the vertical columns the ear having the poorer hearing. The percentage evaluation is indicated where the row and column intersect. Table VIa is used when the examiner certifies that the use of speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of 38 C.F.R. § 4.86. See 38 C.F.R. § 4.85(c). When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. See 38 C.F.R. § 4.86(a). When the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. See 38 C.F.R. § 4.86(b). A February 2011 private evaluation revealed that on the audiological evaluation, puretone thresholds, in decibels, were as follows: HERTZ \ 1000 2000 3000 4000 average RIGHT 25 20 25 40 27.50 LEFT 20 20 25 50 28.75 The examiner indicated that the Veteran had a bilateral mild to moderate sloping high frequency sensorineural hearing loss beginning at 4000 Hertz. The speech discrimination was 92 percent in each ear and tympanometry was completely normal. There was a very slight suggestion of a mild conductive component to the hearing loss in the low frequencies of no clinical significance. Under the rating criteria, assuming that the speech discrimination test was the Maryland CNC test which the Board will do at this juncture, the examination results constitute Level I hearing on the right and Level I hearing on the left. When combined, the result is a noncompensable or 0 percent disability evaluation. Further, the Board finds that 38 C.F.R. § 4.86(a) is not for application because the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is not 55 decibels or more. The Board further finds that 38 C.F.R. § 4.86(b) is not for application as the puretone threshold is not 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz. In April 2011, the Veteran was afforded a VA examination. On the audiological evaluation, puretone thresholds, in decibels, were as follows: HERTZ \ 1000 2000 3000 4000 average RIGHT 15 15 25 30 21.25 LEFT 20 20 30 55 31.25 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 96 percent in the left ear. Under the rating criteria, the examination results constitute Level I hearing on the right and Level I hearing on the left. When combined, the result is a noncompensable or 0 percent disability evaluation. Further, the Board finds that 38 C.F.R. § 4.86(a) is not for application because the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is not 55 decibels or more. The Board further finds that 38 C.F.R. § 4.86(b) is not for application as the puretone threshold is not 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz. In December 2015, the Veteran was afforded a VA examination. On the audiological evaluation, puretone thresholds, in decibels, were as follows: HERTZ \ 1000 2000 3000 4000 average RIGHT 15 15 25 35 23 LEFT 20 20 30 55 31.25 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 100 percent in the left ear. With regard to functional impairment as to the impact of the ordinary conditions of daily life including ability to work, the Veteran's bilateral sensorineural hearing loss caused the Veteran to have difficulty hearing his grandchildren and his wife. Under the rating criteria, the examination results constitute Level I hearing on the right and Level I hearing on the left. When combined, the result is a noncompensable or 0 percent disability evaluation. Further, the Board finds that 38 C.F.R. § 4.86(a) is not for application because the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is not 55 decibels or more. The Board further finds that 38 C.F.R. § 4.86(b) is not for application as the puretone threshold is not 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz. The Board acknowledges the Veteran's contentions regarding his difficulty hearing, especially his wife and grandchildren; however, the audiology examinations yielded results warranting a noncompensable rating throughout the appeal period. Thus, while the Board has considered the Veteran's assertions as to worsening hearing loss, the Board must accord greater weight to the objective clinical findings that continue to show that the Veteran's hearing remains in the range of a noncompensable hearing loss under the Rating Schedule. In Martinak v. Nicholson, 21 Vet. App. 447 (2007) the United States Court of Appeals for Veterans Claims (Court) held that in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak, 21 Vet. App. at 455. The Court also noted, however, that even if an audiologist's description of the functional effects of the Veteran's hearing disability was somehow defective, the Veteran bears the burden of demonstrating any prejudice caused by a deficiency in the examination. In this case, VA examiner in 2015 noted that the functional impact of the Veteran's hearing loss was that the Veteran has difficulty understanding speech in certain circumstances; however, this alone does not prohibit his ability to work in his given field. The Board in no way discounts the difficulties that the Veteran experiences as a result of his hearing loss. However, as was explained above, the assignment of disability ratings for hearing impairment is derived by a mechanical application of the rating schedule to the numeric designation assigned after audiometry results are obtained. Hence, the Board has no discretion in this matter and must predicate its determination on the basis of the results of the audiology results of record. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). In other words, the Board is bound by law to apply VA's rating schedule based on the Veteran's audiometry results. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In determining whether a higher rating is warranted for service-connected disability, VA must determine whether the evidence supports the Veteran's claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the preponderance of the evidence is against a compensable rating. In considering the claim for a higher rating, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). The Court has clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The symptoms associated with the Veteran's hearing loss disability are not shown to cause any impairment that is not already contemplated by the relevant diagnostic code, as cited above, and the Board finds that the rating criteria reasonably describe his disability. There have not been any hospitalizations or marked interference with employment. Therefore, referral for consideration of an extraschedular rating is not warranted. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran served in combat during the Vietnam era. In cases where a Veteran asserts service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C.A. § 1154(b) and its implementing regulation, 38 C.F.R. § 3.304(d), are applicable. This statute and regulation ease the evidentiary burden of a combat Veteran by permitting the use, under certain circumstances, of lay evidence. If the Veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The United States Court of Appeals for the Federal Circuit (Federal Circuit Court) has held that, in the case of a combat Veteran, not only is the combat injury presumed, but so, too, is the disability due to the in-service combat injury. Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). To establish entitlement to service connection, however, there still must be evidence of a current disability and a causal relationship between the current disability and the combat injury. Id. VA law and regulations further provide that a chronic, tropical, or prisoner-of-war related disease, or a disease associated with exposure to certain herbicide agents, listed in 38 C.F.R. § 3.309 will be considered to have been incurred in or aggravated by service under the circumstances outlined in this section even though there is no evidence of such disease during the period of service. No condition other than the ones listed in 38 C.F.R. § 3.309(a) will be considered chronic. 38 U.S.C.A. §§ 1101, 1112, 1113, 1116; 38 C.F.R. § 3.307(a). A veteran, who had active service in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975 will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. See 38 U.S.C.A. § 1116(f) (West 2014); 38 C.F.R. § 3.307(a)(6)(iii). In addition, in certain circumstances, a veteran may have been exposed to herbicides while serving in Thailand and Korea. Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne or other acneform disease consistent with chloracne, non-Hodgkin's lymphoma, soft tissue sarcoma, Hodgkin's disease, porphyria cutanea tarda (PCT), multiple myeloma, early onset peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson's disease, ischemic heart disease, and B-cell leukemias, such as hairy cell leukemia. See 38 C.F.R. § 3.309(e). For purposes of 38 C.F.R. § 3.309(e), the term "ischemic heart disease" includes acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease and coronary bypass surgery; and stable, unstable and Prinzmetal's angina. However, "ischemic heart disease" does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. 38 C.F.R. § 3.309, note 3. Effective for claims pending on September 6, 2013, VA replaced the term "acute and subacute peripheral neuropathy" with the term "early-onset peripheral neuropathy." VA also removed Note 2 to 38 C.F.R. § 3.309(e), which had required, in order for the presumption to apply, that the neuropathy be transient, appear within weeks or months of exposure to an herbicide agent, and resolve within two years of the date of onset. Under the amendments, peripheral neuropathy will still need to become manifest to a degree of 10 percent or more within one year after the date of last exposure to herbicides in order to qualify for the presumption of service connection, but it no longer needs to be transient. Id. VA's Secretary has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See 68 Fed. Reg. 27,630 (May 20, 2003). In this regard, the Board observes that VA has issued several notices in which it was determined that a presumption of service connection based upon exposure to herbicides used in Vietnam should not be extended to certain specific disorders, based upon extensive scientific research. See, e.g., Notices, 68 Fed. Reg. 27,630 -41 (2003); 64 Fed. Reg. 59,232 -243 (1999); 61 Fed. Reg. 57,586 -589 (1996). However, the Federal Circuit has determined that an appellant is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom, Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). The Court has specifically held that the provisions of Combee are applicable in cases involving Agent Orange exposure. McCartt v. West, 12 Vet. App. 164, 167 (1999). There is no specific statutory or regulatory guidance with regard to claims for service connection for asbestosis or other asbestos-related diseases. However, in 1988, VA issued a circular on asbestos-related diseases which provided guidelines for considering asbestos compensation claims. See Department of Veterans Benefits, Veterans' Administration, DVB Circular 21-88- 8, Asbestos Related Diseases (May 11, 1988). The information and instructions contained in the DVB Circular have been included in VA Adjudication Procedure Manual, M21-1, Part IV, Subpart ii, Chap. 1, Sec. I., Para. 3 (August 7, 2015) (M21-1). Also, an opinion by VA's Office of General Counsel discussed the development of asbestos claims. VAOPGCPREC 4-00 (April 13, 2000). The aforementioned provisions of M21-1 have been rescinded and reissued as amended in 2015. See M21-1, Part IV, Subpart ii, Chap. 2, Sec. C, entitled "Service Connection for Disabilities Resulting from Exposure to Environmental Hazards or Service in the Republic of Vietnam (RVN)." The latency period for asbestos -related diseases varies from 10 to 45 or more years between first exposure and development of disease. The exposure may have been direct or indirect, and the extent or duration of exposure is not a factor. M21-1, Part IV, Subpart ii, Chap. 2, Sec. C, Para. 2f. The manual provisions acknowledge that inhalation of asbestos fibers and/or particles can result in fibrosis and tumors, and produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of the pleura and peritoneum, and cancer of the lung, gastrointestinal tract, larynx, pharynx and urogenital system (except the prostate), with the most common resulting disease being interstitial pulmonary fibrosis (asbestosis). Also noted is the increased risk of bronchial cancer in individuals who smoke cigarettes and have had prior asbestos exposure. With regard to occupational exposure, exposure to asbestos has been shown in insulation, mining, milling, demolition of old buildings, carpentry and construction, and shipyard workers, and others including workers involved in the manufacture and servicing of friction products such as clutch facings and brake linings. The clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. M21-1, Part IV, Subpart ii, Chap. 2, Sec. C, Para. 2a-g. Further, asbestosis is a pneumoconiosis due to asbestos particles; pneumoconiosis is a disease of the lungs caused by the habitual inhalation of irritant mineral or metallic particles." See McGinty. Neither the M21-1 provisions nor the DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988) create a presumption of exposure to asbestos solely from shipboard service. Rather, they are guidelines that serve to inform and educate adjudicators as to the high exposure of asbestos and the prevalence of disease found in insulation and shipyard workers, and they direct that the raters develop the record, ascertain whether there is evidence of exposure before, during, or after service, and determine whether the disease is related to the putative exposure. Thus, with respect to claims involving asbestos exposure, VA must determine whether or not military records demonstrate evidence of asbestos exposure during service, develop whether or not there was pre-service and/or post-service occupational or other asbestos exposure, and determine whether there is a relationship between asbestos exposure and the claimed disease. In this case, even assuming the Veteran had such exposure during service, he does not have on appeal a disability that is a lung disorder such as asbestosis (or other noted asbestos-related disorders) or one of the cancers noted above. Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. Eyes The Veteran asserts that his bilateral eye disabilities are related to service. On general VA examination conducted to evaluate any disabilities related to exposure to herbicide in June 1983, the Veteran complained about his eyes and stated that they would become red and itchy, and burn when exposed to bright lights and chlorine. He claimed that such was a residual of exposure to herbicides, and also reported that on one occasion during service drain cleaner got in his eyes. In his July 2013 Substantive Appeal, the Veteran asserted that he believed that his problems with his eyes were a result of a traumatic brain injury (TBI) from the explosions to which he was exposed while under attack in Vietnam. He also asserted that his light sensitivity was the result of the inservice acid burns to his eyes and snow blindness while he served in Alaska. The Veteran's STRs dated in January 1969 reflected complaints of burning and itching eyes. The Veteran reported no relief related to his eyes and he presented with eyes that appeared very large and "eerie." Physical examination of the eyes was negative for conjunctivitis or exudate, and his irises and corneas were clear. He was treated with artificial tears. In January 1969, the Veteran's vision was 20/20, bilaterally, and he was qualified for diving. STRs dated in May 1970 indicated that the Veteran complained that he had possible burns to both eyes as he got some drain dissolvent in his eyes. Physical examination revealed that the conjunctiva was red and irritated, bilaterally. The medical provider noted the specific active ingredient in the cleaner used by the Veteran and washed his eyes with saline. Slit lamp evaluation revealed a rather large ulceration at the inferior limbus in the right eye and a very small ulceration at the inferior limbus in the left eye. The treatment provider reported that both injuries appeared to be superficial and treated the Veteran with lavage and boric acid paste. On two occasions in May 1970, the Veteran presented for follow-up treatment and was treated with ointment and his eyes were redressed. The Veteran's October 1972 service separation examination was silent for any bilateral eye disabilities and indicates that his vision was 20/20, bilaterally. Post-service, in June 1983, the Veteran was afforded a VA examination. At that time, the Veteran complained about his eyes and stated that they would become red, itchy and burn when exposed to bright lights and chlorine. The Veteran claimed that his eye problems were residuals of Agent Orange, but also stated that on one occasion in Alaska in 1969, drain cleaner got into his eyes. The subsequent July 1983 eye examination yielded normal findings. In November 1995, the Veteran was hit in the left cornea with a branch and was diagnosed as having a contusion of the left eye. Subsequent VA medical records dated in February 2006 reflected a diagnosis of vitreal hemorrhage of the left eye caused by a posterior vitreal detachment (PVD). March 2006 showed that the Veteran underwent surgical repair (pars plana vitrectomy) of a vitreous hemorrhage of the left eye. VA treatment records dated in January 2009 indicated that the Veteran underwent surgical repair of a visually significant cataract, left eye. VA treatment records dated in February 2010 indicated that the Veteran presented for optometric treatment and was diagnosed with pseudophakia of the left eye, non-significant cataract of the right eye, epiretinal membrane of the left eye, and compound hyperopia and astigmatism with presbyopia, bilaterally. The Veteran was afforded a VA examination in April 2011. The examiner opined that the Veteran's bilateral eye disabilities were less likely related to inservice ulcerations in the cornea. The examiner indicated that there were no residual eye problems noted from drain dissolvent splashed into both eyes during service. The eyes healed and vision was correctable back to 20/20 in each eye with no corneal scarring. The examiner further specified that the Veteran had drain dissolvent splashed into both eyes causing a chemical burn resulting in superficial ulcerations of the cornea in both eyes. The cornea healed without scarring and vision was and is still correctable to 20/20 in each eye. The Veteran's current vision changes were all due to changes inside the eye (retina and lens) which were not caused by the drain solvent being splashed onto the outside (cornea) of each eye. The drain solvent never got into the eye to cause any changes to the retina, lens or any internal eye structures. This examiner, however, did not render an etiological opinion that considered the Veteran's assertions that his bilateral eye disabilities were related to inservice exposure to herbicides or inservice snow blindness. The examiner did not have the opportunity to consider the Veteran's assertion that his bilateral eye disabilities were a result of his claimed in-service TBI. Thus, the claim was remanded for an additional medical assessment. The requested examination was conducted in November 2015. The examiner noted that the Veteran was treated for irritated dry eyes with artificial tears. He was treated without any complications. He had drain dissolvent splashed into both eyes causing a chemical burn resulting in superficial ulcerations of the cornea in both eyes. The cornea healed without scarring and vision was and is still correctable to 20/20 in each eye. He was struck in the left cornea with a thorn apple branch and treated for a corneal abrasion in 1995. The cornea healed without scarring and vision was correctable to 20/20 in each eye. The vitreal hemorrhage he had in 2006 was caused by a PVD as no other injury or retinal pathology was found per the eye records from the Madison VA ophthalmology department. The examiner stated that a PVD happens as a normal part of aging. The vitreous gel shrinks and separates from the retina. PVD normally happens over a period of time and it happens because the vitreous gel in the middle of the eye begins to change by the time a person is 40 or 50 years old. The gel's normal structure breaks down in a process called syneresis. Parts of the gel shrink and lose fluid. The fluid collects in pockets in the middle of the eye, and thick strands of the gel form and drift through the eye. These strands appear as floaters. Most PVD usually do not cause any problems, but if the vitreous gel is strongly attached to the retina, the gel can pull so hard on the retina, a process called traction, that it pulls on the retina blood vessels and can cause a vitreal bleed. PVDs account for 3.7-11.7 percent of vitreous hemorrhage cases. Since the PVD is a normal aging process, the examiner concluded that it was not caused by any injury to the eye. The examiner indicated that the Veteran had complications from the PVD and had a vitreal hemorrhage resulting in his needing surgery to remove the hemorrhage. The cataract in the left eye and epiretinal membrane in the left eye were a direct complication of the surgery (pars plana vitrectomy). The examiner explained that these are common complications of the pars plana vitrectomy. Most often a lens replacement surgery (cataract surgery) is done at the same time as the pars plana vitrectomy because cataracts are eminent after this surgery, but was not done in the Veteran's case. An epiretinal membrane occurs due to the manipulation of the vitreous and retina during the pars plana vitrectomy. The nonsignificant cataract of the right eye was a normal aging cataract and was appropriate for the Veteran's age. The examiner concluded that none of the injuries sustained in the service, exposure to herbicides, snowy conditions in Alaska, or the claimed TBI caused the vitreal hemorrhage, surgical repair of the vitreal hemorrhage, cataract of the left eye, pseudophakia of the left eye, non-significant cataract of the right eye or epiretinal membrane of the left eye. The examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's refractive errors, including, but not limited to, bilateral compound hyperopia and astigmatism with presbyopia, were subject to, or aggravated by, a superimposed disease or injury during service, specifically, his inservice: (1) exposure to herbicides; (2) service in snowy conditions in Alaska; (3) January 1969 eye complaints; (4) May 1970 eye injury; (5) claimed TBI; or (6) the Veteran's November 1995 intercurrent injury wherein he was hit in the left eye with a branch and was diagnosed with a contusion of the left eye. The examiner stated that his refractive errors were normal and appropriate for his age. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In this case, the November 2015 examiner was aware of the Veteran's medical history, provided a fully articulated opinion, and also furnished a reasoned analysis. The Board therefore attaches significant probative value to this opinion, and the most probative value in this case, as it is well reasoned, detailed, consistent with other evidence of record, included an access to the accurate background of the Veteran, including his claimed contentions. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The earlier April 2011 opinion also supports this opinion. At the outset, as discussed above, the Veteran had presumed inservice herbicides exposure. However, the Veteran's claimed eye disabilities are not presumptive disorders for herbicide exposure. As noted, service connection may also be granted on a direct basis. See Combee. The Veteran's inservice eye incidents as documented in the STRs were not incurred in combat. The inservice solvent-related eye injury apparently resulted in eye ulcerations. However, the Veteran was treated for the injuries and had no abnormality on his October 1972 service separation examination. His vision was 20/20, bilaterally, when he left service. The April 2011 VA examiner opined that there were no residual eye problems noted from drain dissolvent splashed into both of the Veteran's eyes during service. The eyes healed and vision was correctable back to 20/20 in each eye with no corneal scarring. The November 2015 examination opinion also concluded that the cornea healed without scarring and vision was and is still correctable to 20/20 in each eye. With regard to a TBI combat-related injury, although the Board accepts that the Veteran experienced visual problems after a TBI since he served in combat as well as exposure to snowy conditions, the Veteran's vision was normal at discharge. The Veteran also suffered a post-service intercurrent injury. Further, the examiner explained why the post-service PVD was not related to service, but rather had an etiology due to aging and which in turn caused other eye problems including cataracts. The examiner provided thorough rationale regarding why the vitreal hemorrhage, surgical repair of the vitreal hemorrhage, cataract of the left eye, pseudophakia of the left eye, non-significant cataract of the right eye or epiretinal membrane of the left eye, were not etiologically related to service. As noted, this opinion is the most probative of record. The Board has considered the Veteran's own opinion. However, as a lay person in the field of medicine, the Veteran's opinion is less probative than the opinion of the optometrist. Thus, the Veteran's opinion is outweighed by the findings to the contrary by the VA examiner, a medical professional who considered the pertinent evidence of record and found against such a relationship. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). The Board notes that the Veteran has been diagnosed as having presbyopia and hyperopia. However, neither of these findings is attributable to the Veteran's service as noted by the 2016 opinion. Presbyopia is associated with aging. See Dorland's Illustrated Medical Dictionary, 545, 1349 (28th ed. 1994) (noting that presbyopia is defined as hyperopia and impairment of vision due to advancing years or to old age). For purposes of entitlement to benefits, the law provides that refractive errors of the eyes are developmental defects and not disease or injury within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9. In the absence of superimposed disease or injury, service connection may not be allowed for refractive error of the eyes (including presbyopia/hyperopia) even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. 38 C.F.R. §§ 3.303(c), 4.9. Thus, VA regulations specifically prohibit service connection for refractory errors of the eyes unless such defect was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90, 55 Fed. Reg. 45711 (1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). In this regard, the most probative evidence of record establishes that there was no superimposed disease or injury which created additional disability. Accordingly, the preponderance is therefore against the Veteran's claim and the benefit-of-the-doubt rule does not apply; the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Disability Characterized by Blood in the Urine The Veteran asserts, in his June 2012 claim, that he has a disability manifested by blood in the urine which is related to service, specifically, to his exposure to herbicides and/or asbestos. The Veteran later, in his April 2013 NOD, indicated that his urine in the blood was part of his kidney and adrenal gland disabilities. The Board notes that in the September 2015 Board decision, as noted in the introductory portion of this decision, denied service connection for a kidney disability and an adrenal gland disability and will not be revisited herein. As noted, even if the Veteran was exposed to asbestos, the disability claimed by the Veteran, blood in the urine, is not the result of an asbestos-related lung or cancer disability. Moreover, with regard to his presumed herbicide exposure, the Veteran's claimed disability is not one of the identified disabilities subject to presumptive service connection on that basis. As noted, direct service connection may still be established. Combee. The Veteran has been afforded pertinent VA examinations. On VA examination in January 2013, the Veteran was diagnosed with a renocortical cyst and benign small bilateral adrenal lesions with the appearance of adenomas, and noted a history of VA treatment records demonstrating microhematuria, or blood in the urine. The examiner, however, did not opine that the Veteran's microhematuria, or blood in the urine, was indeed a laboratory finding related to his kidney and adrenal gland disabilities, or a symptom of a separate disability. Thus, the Board remanded this case to determine whether the Veteran has a disability characterized by blood in the urine, apart from his renocortical cyst and benign small bilateral adrenal lesions with the appearance of adenomas, and if so, whether such is related to service. In November 2015, the Veteran was afforded a VA examination. Microhematuria was not diagnosed at this time. The examiner indicated that the finding of microhematuria in the past was not caused by or the result of service including exposure to herbicides and/or asbestos. The examiner noted that a September 2015 urinalysis did not show blood. Urinalyses in the past had shown microhematuria, which led to a complete medical evaluation and testing including cystoscopy, ultrasound, and culture. A June 2012 cystoscopy showed coapting prostatic lateral lobes and a moderate size intravesical lobe. Evaluation otherwise was unremarkable and microhematuria likely resulted from the prostatic coaptation on the prostatic urethra. The examiner noted that the Veteran took cranberry extract supplement, which is said to help prevent urinary infections which may have helped the microhematuria, which he does not currently have on urinalysis. The examiner indicated that medical literature does not indicate a nexus, or link, between exposure to herbicides or asbestos to microhematuria. The examiner stated that renal cortical cysts might cause hematuria, but again the hematuria is no longer present, and the left renal cyst was unchanged from June 28, 2013. The examiner stated that medical literature indicates kidney cysts occur when the tube of a nephron begins to get bigger and fill with fluid. Researchers do not know what causes this to occur, but they do know that simple cysts are not inherited. It is believed that injury or microscopic blockages in the tubules may lead to the development of some simple kidney cysts. Adrenal conditions do not cause microhematuria as the adrenal glands are not connected to the urinary system. As noted, service connection has been denied for kidney/adrenal gland disabilities. The VA examiner's opinion, rendered by a medical professional, is afforded significant probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (holding that the probative value of medical opinion evidence is based on the personal examination of the patient, the knowledge and skill in analyzing the data, and the medical conclusion reached); see also Nieves- Rodriguez. The Board affords more probative weight to this opinion than the Veteran's opinion VA examiner has the requisite medical expertise to answer complex medical questions while the Veteran does not have such expertise. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In determining the weight assigned to the evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data. See Black v. Brown, 10 Vet. App. 279, 284 (1997). The Board notes that there is no definitive diagnosis of a current disability which results in blood in the urine. To the extent that past findings of blood in the urine may have been related to kidney problems, service connection has been denied by the Board for kidney disability. To the extent that the blood in the urine was an incidental or laboratory findings, Congress specifically limits entitlement for a service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110, 1131; see also Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Court also consistently has held that, under the law, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). This principle has been repeatedly reaffirmed by the Federal Circuit Court, which has stated, "a Veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the Veteran's service and the disability." Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed). Accordingly, because the Veteran does not have a current disability for which service connection may be granted, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a disability characterized by blood in the urine. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert. A Sinus Disability In a January 2011 statement, the Veteran asserted that he has a sinus disability which is related to service. He has reported inservice exposures, including dust from concrete, asbestos, sand, road dirt, septic systems, waste chemicals, lead, solder, flux, fumes from cutting oil, Freon, ammonia, solvents, and gunpowder. At the time of the Veteran's July 2013 Substantive Appeal, he asserted that he experienced sinus problems after he quit smoking. The Veteran's STRs dated in January 1969 indicated that he was treated for an upper respiratory infection. In April 1969, the Veteran complained of a sore throat. In September 1970 and October 1971, he again complained of a sore throat. In March 1972, the Veteran complained of a sore throat and a head cold and was diagnosed with an upper respiratory infection. In March 1972, he complained of a sore throat. In April 1972, the Veteran underwent a tonsillectomy. In October 1971 and May 1972, the Veteran complained of a sore throat. His October 1972 service separation examination was silent for a sinus disability. Post-service a private occupational examination in April 1976 reflected that the Veteran had a smoking history. On VA examination in October 1980, the Veteran's sinuses were unremarkable. On the June 1983 VA examination, the Veteran reported that he had smoked for four years. Physical examination revealed that the Veteran's nose was blocked on both sides. On VA psychiatric examination in April 1985, the Veteran reported a history of inservice recurrent upper respiratory infections, tonsillectomy and adenoidectomy. On VA examination in November 1987, the Veteran reported sinus problems. In March 1988, the Veteran was hospitalized for an unrelated condition and reported sinus problems since 1985 as well as a smoking history. VA treatment records dated in May 1988 indicated that the Veteran was a heavy smoker and he also complained of sinus congestion. Chest and sinus x-rays were negative, and there was a negative examination of the sinus, without active pulmonary disease. During VA hospitalization for an unrelated condition in November 1988, the Veteran was given medication for an upper respiratory infection and sinus congestion. VA treatment records dated in March 1989 indicated that the Veteran complained of chronic sinus problems, and the treatment provider noted that prior sinus X-ray examination was within normal limits. The Veteran was diagnosed with possible allergy versus stress versus sinus infection, although mucus was clear. In June 1989, the Veteran's nasal drainage was still present. During VA psychiatric treatment in September 1994, a diagnosis of chronic sinusitis was entered as an Axis III diagnosis. During VA treatment in February 1995, the Veteran reported one week of nasal congestion, and reported inservice asbestos exposure. The provider noted a prior history of frontal sinusitis by x-ray examination and diagnosed the Veteran with probable recurrent sinusitis. In June 1995, the Veteran presented for VA treatment with a history of allergic rhinitis and complained of constant congestion and clear drainage. He was diagnosed with nasal congestion, sinusitis by history. During VA treatment in September 1995, the Veteran was diagnosed with chronic sinusitis/rhinitis, which was likely second to vasomotor rhinitis. The Veteran's smoking history and report of inservice exposure to asbestos and herbicide was noted. During private treatment in February 2011, the Veteran reported a nine-pack year smoking history and physical examination was silent for sinus tenderness. On VA examination in April 2011, the examiner noted the Veteran's assertion that his sinus condition was related to asbestosis as well as his history of comorbid chronic tobacco use. The examiner noted that the Veteran's STRs were silent for evidence of chronic treatment, as he underwent acute treatments only; and normal x-ray examination results were of record through 1996. The examiner noted a 2005 diagnosis of chronic allergic rhinitis with steroid inhaler prescribed. The examiner opined that no service-related cause of the Veteran's sinus disability could be posited, as his service treatment records were unremarkable and there was no evidence of sinus infection in years. The Veteran currently complained of some drainage issues, without current sinus pressure. The examiner noted a current normal nose and sinus exam, without x-ray examination needed. The examiner concluded that the Veteran's current symptoms were more likely than not related to his continued and many years of smoking, as no chronic sinus condition had even been treated in the past, just allergic irritant rhinitis; and his current symptoms were less likely than not related to any inservice service complaints or asbestos exposure. In the Board prior remand decision, it was noted that the April 2011 examiner's opinion appeared to have based the negative etiological opinion, at least in part, on the conclusion that the Veteran has only been treated for allergic rhinitis post-service. However, the record showed that the Veteran was diagnosed with sinusitis during VA treatment in September 1995, and such was included in his Axis III diagnoses during psychiatric treatment in September 1994. Also, the examiner did not render an opinion, with rationale, as to whether the Veteran's sinus disability was related to inservice asbestos exposure. The examiner simply concluded that the Veteran's current symptoms were more likely related to his history of smoking. Further, the examiner did not render an opinion as to whether the Veteran's sinus disability was related to the other inservice exposure reported by the Veteran, to include dust from concrete, asbestos, sand, road dirt, septic systems, waste chemicals, lead, solder, flux, fumes from cutting oil, Freon, ammonia, solvents, and gunpowder. As such, the claim was remanded for another medical opinion. This requested medical examination and opinion was furnished in November 2015. The examiner indicated that the Veteran did not have sinusitis, whether acute or chronic. With regard to allergic rhinitis, the examiner noted that while it was not being treated according to current medical records, it may be self-treated with over-the-counter (OTC) medications. However, the examiner opined that allergic rhinitis was not incurred inservice, and was not related to: (1) exposure to asbestos; (2) claimed exposure to dust from concrete asbestos, sand, road dirt, septic systems, waste chemicals, lead, solder, flux, fumes from cutting oil, Freon, ammonia, solvents, and gunpowder; (3) treatment for upper respiratory infections in January 1969 and March 1972; and (5) tonsillectomy in April 1972. The examiner indicated that sinusitis was medically defined by purulent or discolored anterior or posterior nasal discharge, nasal congestion, facial pain/pressure, with possible secondary symptoms of hyposmia, ear or dental pain, fever, headache, or acute fatigue. X-rays or computerized tomography (CT) scan may show abnormalities confirming a sinus condition. "Sinus symptoms" may be described differently by different persons. Nasal congestion, from whatever cause, may be called "sinus" by lay persons. The examiner indicated that the evidence did not confirm a diagnosis of a sinus condition, as medically defined. Rather, there was evidence of rhinitis, which had been considered of allergic etiology. The examiner indicated that rhinitis and purported "sinus condition" were not caused by or the result of asbestos exposure or the exposures listed above. The examiner noted that smoking abatement would not be expected to cure allergic rhinitis. The Board notes that the Veteran apparently does not have sinusitis and has not had this diagnosis at all during the appeal period nor does the evidence reflect a diagnosis of recurrent sinusitis. Thus, service connection for sinusitis is not warranted because in the absence of proof of a present disability, there can be no valid claim. Rabideau v. Derwinski, 2 Vet. App. 141, 143- 44 (1992). The Veteran is competent to report sinus complaints, but they have been specifically attributed to rhinitis. Rhinitis (allergic or vasomotor rhinitis) is considered a disability for VA purposes as it is compensated in VA's Rating Schedule. See Diagnostic Code 6522. The VA examiner did not provide adequate rationale explaining why rhinitis is not etiologically related to service. The explanation provided by the examiner focused on sinusitis. The evidence does not show that rhinitis is related to asbestos as the VA examiner opined otherwise, but the Board accepts that the Veteran has experienced allergic rhinitis symptoms during service, including combat service, based on the various exposures advanced by the Veteran. See 38 U.S.C.A. § 1154(a) and (b). The Board finds the Veteran competent to report inservice allergy type symptoms as well as credible. See generally Reeves. The STRs document various nasal/throat complaints and the Board also accepts that there were symptoms of rhinitis prior to the Veteran's commencement of smoking and after the cessation thereof. Accordingly, service connection for rhinitis is warranted, especially with resolution of all reasonable doubt in the Veteran's favor. 38 U.S.C.A. § 5107(b), 38 C.F.R. § 3.102. A Skin Disability The Veteran asserts that his skin disability is related to service. In an August 2004 statement, the Veteran reported that he was first treated for his skin disability during service in Vietnam. In a January 2005 statement, the Veteran reported that he had skin problems in Vietnam, living in dirt without showers, and being bitten by insects and sand fleas. He reported that he had infected pores, and lanced boils and cysts during service and reported the same to VA in 1973. In a January 2005 statement, one of the Veteran's fellow service members reported that during service in Vietnam, they were exposed to insect bites and had to bathe in salt water from rivers; and that they had open sores that were slow to heal in the tropical climate. His STRs dated in May 1969 indicate that the Veteran presented with skin irritation under the left arm and the toes of both feet and was diagnosed with tinea pedis. In August 1971, the Veteran presented with clear fluid-filled vesicles on the legs, the onset of which was one or two days prior. He complained of slight itching and dry skin over the area. The treatment provider reported that the Veteran was a student diver and used communal wool socks in diving school, however, no other students complained of similar symptoms. His STRs dated in February 1972 indicated that the Veteran presented with pain and swelling from an insect bite, and was diagnosed with possible lymphangitis and cellulitis. The Veteran sought treatment on two occasions in April 1972 for dog bites on the lower legs. In May 1972, the Veteran reported itching at the site of a dog bite on the left lower extremity and was diagnosed with irritation/reaction to a dog bite. His October 1972 service separation examination was silent for a skin disability. On VA examination in October 1980, the Veteran presented without dystrophic changes to skin and nails, tinea pedis, or hair pattern problems. VA treatment records dated in January 1981 indicated that the Veteran reported a history of pruritic papular rash on the buttocks, with heat. Physical examination revealed a few papules and open comedones on the back, and a clear face and chest. There were hyperpigmented plaques on the foot. The treatment provider determined that there was no evidence of conglobata acne. On VA examination in June 1983, the Veteran reported that he developed a generalized skin eruption during service in Vietnam, and reported that he had been treated since. He reported that he had since developed some eruptions on the arms, gluteus, and groin. Physical examination revealed very minimal follicular eruption on the lower gluteus, minimal folliculitis on the upper inner thighs and upper arms. The Veteran was diagnosed with minimal folliculitis, not due to herbicide exposure. During VA treatment in April 1989, the Veteran presented with folliculitis, and in June 1989, he reported taking medication for the same. In August 1989, the Veteran reported chronic folliculitis since service in Vietnam, now under good control, and was diagnosed with chronic folliculitis. VA treatment records dated in October 1989 indicate that the Veteran had continued skin problems on his buttocks and legs, with a total of 20 or 30 pustules perifollicular. VA treatment records dated in January 2004 showed that the Veteran presented with a 30+ year history of acneform lesions on the buttocks and legs, without family history, as indicated by the examiner. Physical examination revealed rare inflammatory papules, mostly deep, with numerous post inflammatory hyperpigmentation of the back, buttocks, and legs from prior inflamed lesions. He was diagnosed with symptoms consistent with recurrent acneform eruption and suggestion of hidradenitis/conglobata. VA treatment records dated in March 2011 indicate that the Veteran presented with lipomata, growing lesions, a possible lipoma on back, a history of folliculitis in Vietnam, and was diagnosed with folliculitis, mild to focally moderate on the buttocks and thighs, a probable lipoma on the lower abdomen, and multiple benign cysts on the back, most with overlying puncta. In April 2011, he presented with multiple cysts on the back, with a history of persistent folliculitis previously treated with medications with positive results, but no resolution. Physical examination revealed a healing lesion on the middle of the low back, without clinical evidence of recurrence, folliculitis, mild to focally moderated on the buttocks and thighs, a probable lipoma on the abdomen, and multiple benign cysts on the back, most with overlying puncta. On VA examination in April 2013, the examiner noted a diagnosis of folliculitis as of March 2011 and perhaps earlier. The Veteran complained of skin problems since service, and referred to such as chloracne, infected cysts, and plugged pores, and he attributed such to poor hygiene in Vietnam and exposure to chemicals, including herbicides. The examiner noted that the Veteran's dermatological treatment began in 2004, and has been constant over the years, with a pilonidal cyst excised in the early 1980's. Physical examination revealed dermatitis, on the back there were scattered, well demarcated nevi, lentigo, cherry hemangiomas, two small black comedones, and seborrheic keratosis in the midline of the lower back. No active lesions were seen on the back. No folliculitis was seen. There were prominent sebaceous glands visualized about the anus and on the anoderm, none inflamed or draining, and there were no active lesions on the buttocks or perianal area. There were prominent sebaceous glands present on the scrotum, none draining or inflamed, and there were no active scrotal lesions. No folliculitis was seen in the groin or perineum. No lesions were seen on the thighs or lower legs. No lesions were seen on the face, neck, or hands. There was a well-healed uncomplicated surgical scar left posterior shoulder from a recent sebaceous cyst excision. The examiner provided a negative etiological opinion, indicating that the Veteran's inservice vesicles in the shins were a minor self-limited condition, likely related to some irritant scuba training, and the various lesions present were common, benign, and generally asymptomatic, and there were no lesions suggestive of folliculitis found. The examiner noted that the folliculitis found present in June 1983 was related to pressure from leather items in the Veteran's pockets. The examiner did not offer an opinion as to whether the Veteran's skin disability was related to inservice exposure to herbicides. While a VA examiner opined that the Veteran's folliculitis in June 1983 was not related to herbicides, that opinion was not adequate, as the examiner did not provide a rationale. It also appeared that the VA examiner considered the Veteran's inservice vesicles in the shins and did not consider the Veteran's recorded inservice complaints related to dog and insect bites, tinea pedis, or his lay statements, and those of his fellow service member, as to unhygienic conditions in Vietnam and sores, infected pores, and lanced boils and cysts. Thus, the Board remanded for another medical examination and opinion. The requested examination was furnished in November 2015. The examiner opined that the Veteran's skin disabilities are not caused by or the result of (1) exposure to herbicides; (2) unhygienic conditions in Vietnam, including bathing in river water; (3) May 1969 diagnosis of tinea pedis and presentation with skin irritation under the left arm and the toes of both feet; (4) his August 1971 complaint of clear fluid-filled vesicles with slight itching and dry skin over the area; (5) his February 1972 possible lymphangitis and cellulitis related to pain and swelling from an insect bite; and (6) his April 1972 and May 1972 treatment for skin irritation related to dog bites. The examiner indicated that the Veteran's skin disabilities have not been diagnosed to include chloracne or other acneform disease consistent with chloracne, recurrent acneform eruption, or hidradenitis/conglobate. Currently, no current skin disabilities were diagnosed. The Veteran was not receiving medical treatment for any skin condition now. None of the past diagnoses were currently active. The Veteran stated that all recent treatment for skin conditions has been from VA and none is shown since November 2008 when diffuse calluses of feet (keratomas) were treated. Podiatry examination in April 2015 did not indicate an ongoing problem with calluses. There was a past history of acne, lipomas, tinea pedis, insect bite reaction, skin irritation from wet woolen socks worn as scuba diving clothing, and folliculitis, but none of these conditions are currently active or symptomatic. The suggestion of hidradenitis/conglobate was mentioned as a possible past, and not current, diagnosis. The Veteran was then seen In March 2011 for atypical nevus, 5 mm; folliculitis; probable lipoma; and cysts. The suggestion of past hidradenitis/conglobate was not revisited, and had not been (and was not currently) diagnosed. There was no record of chloracne at any time, even though the Veteran claimed having this condition. At the outset, the Board notes that the Veteran has not been diagnosed as having a skin disorder subject to presumptive service connection for exposure to herbicides. Although he was diagnosed with acne, he has never been diagnosed with chloracne or other acneform disease consistent with chloracne. The exact type of acne is a very specific medical determination. The Veteran is competent in this case to report his symptoms of skin eruptions and to indicate that he had acne papules, but nothing in the record demonstrated that he has received any special training or acquired any medical expertise in evaluating the specific type of acne. Therefore, a medical expert opinion is more probative in that regard. See Woehlaert. However, service connection for a skin condition may be established on a direct basis. Combee. The VA examiner who provided the November 2015 opinion indicated that the various diagnoses of skin disorders, were not related to service. However, the Board notes that the record establishes complaints and reports of folliculitis and acne over the years. The other diagnoses were not continuously shown with periods of waxing and waning. Thus, even though the VA examiner indicated that folliculitis and acne were not service-related, the Board finds credible the Veteran's report of having these continuous skin problems over the years, with period of flare-ups and periods where they were inactive. In Ardison v. Brown, 6 Vet. App. 405 (1994), the Court held that VA was obligated to evaluate a skin condition, while in an "active stage" of the disease in order to fulfill the duty to assist. The Board recognizes that the skin disorders were not active on the November 2015 examination and the Veteran therefore made his assessment with no current disability. However, prior VA records included active evaluations, showing that these diagnoses of folliculitis and acne were recurrent. In fact, evidence of prior inflamed lesions was present on one evaluation. It appears clear that the lesions flare up, resolve, may leave residual hyperpigmentation, and then recur. In affording the Veteran's all reasonable doubt and in affording probative value to the lay evidence that the folliculitis and acne are recurrent conditions consistent with their nature as substantiated in the record, the Board finds that service connection for folliculitis and acne is warranted. 38 U.S.C.A. § 5107(b), 38 C.F.R. § 3.102. ORDER An increased (compensable) rating for bilateral hearing loss is denied. Service connection for an eye disability is denied Service connection for a disability characterized by blood in the urine is denied. Service connection for rhinitis is granted. Service connection for folliculitis and acne is granted. REMAND Peripheral Neuropathy of the Bilateral Upper and Lower Extremities The Veteran asserts that his peripheral neuropathy of the bilateral upper and lower extremities is related to service. In a December 2010 statement, the Veteran asserted that his peripheral neuropathy of the bilateral upper and lower extremities was related to his inservice exposure to herbicides. In his July 2013 Substantive Appeal, the Veteran asserted that his peripheral neuropathy was not related to alcohol dependence, as he had not had alcohol in nine to ten years and still has symptoms of peripheral neuropathy. He reported that he drank off and on during service, but that mainly, he did not drink. There are several recent evaluations. VA treatment records dated in February 2011 indicate that the Veteran had symptoms compatible with peripheral neuropathy and he was diagnosed with neuropathy of the hands and feet. Later VA treatment records in February 2011 indicate that the Veteran reported the presence of his symptoms for six to seven years or possibly longer. Electromyography (EMG) was non-diagnostic but suggestive of early peripheral neuropathy of mixed type. The VA examiner diagnosed the Veteran with the same and noted that the cause of such was unclear, and that the risk factors included a history of alcohol dependence and herbicide exposure. The examiner indicated that the neurodiagnostic studies were "suggestive" and the physician indicated the diagnosis remained obscure and offered to repeat the studies in 1 to 2 years to assess for change in the borderline abnormalities noted the studies. On VA examination in April 2011, the examiner reported that there was no evidence of peripheral neuropathy within one year of herbicide exposure and no resolution of the same within two years of its onset. This assessment was made under the old regulations for peripheral neuropathy. The examiner reported that the onset of the Veteran's disability was six to seven years ago, with numb and burning hands and feet and that the etiology of such was unclear, and there was a long prior history of alcohol dependence. The examiner concluded that the Veteran's peripheral neuropathy was less likely related to service and more likely related to an idiopathic cause or an alcohol-related cause. In an April 2013 opinion, a VA examiner opined that the Veteran's peripheral neuropathy was also not related to his in-service dog bites and provided rationale. In November 2015, the Veteran was afforded another VA examination which considered the new provisions for herbicide-related peripheral neuropathy. The examiner opined that the criteria for the onset of peripheral neuropathy due to herbicide exposure were not met. The examiner stated that late onset peripheral neuropathy was less likely as not caused by herbicide exposure many years previously. The examiner noted that VA presumes early-onset peripheral neuropathy is related to exposure to Agent Orange or other herbicides during service when the disease appears within one year of exposure to a degree of at least 10 percent disabling by VA's rating regulations. The examiner noted that there was limited or suggestive evidence of an association between herbicide exposure and early-onset peripheral neuropathy that may be persistent. The examiner noted that electrodiagnostic studies in February 2011 indicated a span of about 32 years, perhaps somewhat less, but no evidence was found to shorten the span. As such, it was very unlikely that peripheral neuropathy developed within two years of herbicide exposure. The examiner stated that late onset peripheral neuropathy purported to be caused by exposure was also unlikely. In Update 2010, NAS [National Academy of Science] found that evidence did not support an association between herbicide exposure and delayed-onset peripheral neuropathy, which NAS defined as having its onset more than one year after exposure. The examiner opined that the putative peripheral neuropathy, if present, was not caused by or the result of herbicide exposure in Viet Nam, prior to November 1972. The cause was otherwise is unknown. Alcohol toxicity remained a risk factor because even if the Veteran stopped alcohol use, the damage would already be permanent. The Board notes that although the February 2011 examiner suggested repeating the EMG studies in order to verify a diagnosis of early onset peripheral neuropathy, there is no evidence this testing was ever completed. The Board finds that without a confirmed diagnosis, a medical opinion on direct or presumptive service connection is premature until the exact diagnosis is known, particularly given the restrictions of presumptive service connection, but which do not apply for direct service connection. In addition, the November 2015 examiner basically relied on a report by the Veteran that he had experienced symptoms for the past 6-7 years; however, it was initially noted that the Veteran's symptoms were possibly longer as he asserts. There is no evidence that the Veteran was requested to confirm this matter. Thus, an addendum should be obtained. Knees A November 2015 examination concluded that the Veteran's knee condition is not at least as likely as not proximately due to or the result of his service connected bilateral pes cavus with arthritis, claw-like toes, tender calluses, and/or skin thickening. The examiner provided no rationale and did not discuss any altered gait caused by the service-connected bilateral feet disabilities (which are rated as 50 percent disabling). Thus, an addendum should be obtained. Neck and Back In November 2015, it was noted that Veteran's cervical spine and thoracolumbar conditions were not at least as likely as not proximately due to or the result of his service connected bilateral pes cavus with arthritis, claw-like toes, tender calluses, and/or skin thickening. The examiner stated that the cervical spine condition was not caused by or result of service or service connected conditions and was not permanently aggravated by service or service connected conditions. The Board notes that there is insufficient rationale. Thus, an addendum should be obtained. Heart In November 2015, an opinion was obtained regarding the claimed heart disability. As noted above, ischemic heart disease is a presumptive disorder for herbicides exposure. However, the examiner indicated that the current diagnosis is atrial fibrillation which the examiner indicated that not caused by or result of Agent Orange and that the Veteran has not been diagnosed with ischemic heart disease. The examiner; however, did not provide a direct service connection medical opinion per Combee. Thus, an addendum should be obtained. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran updated VCAA notice as to the issues remaining on appeal. 2. Afford the Veteran an opportunity to undergo EMG testing by a VA examiner. The Veteran should indicate how long symptoms have been present. The examiner should report all findings in detail. 3. Then, obtain a medical addendum to the peripheral nerves examination conducted in November 2015, taking into consideration the results of the requested EMG studies, as well as the rest of the record. The examiner should address the Veteran's exact diagnosis and should clarify if the Veteran has peripheral neuropathy of the extremities (early or late onset) or some other diagnosis. It should be noted that the Veteran expressed that he has at least a 7 year history of peripheral neuropathy symptoms, or longer. The examiner should opine whether the Veteran has early onset peripheral neuropathy as contemplated as a presumptive disorder, and if so, was it manifest to a degree of 10 percent or more within one year after the date of last exposure to herbicides. If the examiner concludes that the Veteran does not have peripheral neuropathy as contemplated as a presumptive disorder, the examiner should opine as to whether current neurological impairment had its clinical onset during service, or is related to any in-service disease, event, or injury, including presumed inservice herbicide exposure. 3. Obtain a medical addendum to the orthopedic examinations of the neck, back, and knees. The examiner should review the record. The examiner should consider and address the Veteran's altered gait due to his service-connected feet disabilities. The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any neck, back, and knee disabilities are proximately due to, or the result of, the service-connected feet disabilities. The examiner should also provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current neck, back, and knee disabilities are permanently aggravated by the Veteran's service-connected feet disabilities. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 4. Obtain a medical addendum to the heart examination. The examiner should review the record. The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that the Veteran's heart disability to include atrial fibrillation had its clinical onset during service, within one year of service, or is related to any in-service disease, event, or injury, including presumed inservice herbicide exposure. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 5. Readjudicate the claims on appeal in light of all of the evidence of record. If any issue remains denied, the Veteran should be provided with a supplemental statement of the case as to any issue remaining on appeal, and afforded a reasonable period of time within which to respond thereto. The Veteran 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). ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs