Citation Nr: 18141510 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 14-31 410A DATE: October 10, 2018 ORDER New and material evidence having been submitted, the Veteran’s previously denied claim for entitlement to service connection for cervical strain is reopened. Entitlement to service connection for a cervical spine disorder is denied. REMANDED Entitlement to service connection for a disorder manifested by difficulty swallowing to include as due to exposure to asbestos, chemicals, and/or ionizing radiation, is remanded. FINDINGS OF FACT 1. In a September 2002 rating decision, the RO denied the Veteran's service connection claim for cervical strain. The Veteran was notified of that decision and his appellate rights, but he did not appeal or submit new and material evidence within the one year period thereafter. 2. The evidence received since the September 2002 rating decision, by itself, or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the Veteran's claim for service connection for cervical strain. 3. A cervical spine disorder did not manifest in active service or within one year of active service and is not otherwise related to the Veteran's active service. CONCLUSIONS OF LAW 1. The September 2002 rating decision that denied the Veteran's service connection claim for cervical strain is final. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. 2. The evidence received since the September 2002 rating decision is new and material, and the claim of entitlement to service connection for cervical strain is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 3. A cervical spine disorder was not incurred during active service and many not be presumed to have been so incurred. 38 U.S.C. §§ 1101, 1110, 1111, 1112, 1113, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from June 1981 to June 2001. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated in July 2013 and July 2015. The Veteran testified at Decision Review Officer (DRO) hearings in August 2014 and January 2017. The Veteran also testified at a Board videoconference hearing before the undersigned Veterans Law Judge in March 2018. Transcripts from these proceedings are associated with the Veterans Benefits Management System (VBMS) folder. As discussed in greater detail below, the Veteran's service connection claim for a cervical spine disorder was previously denied by a final September 2002 rating decision. In the September 2014 statement of the case, the RO reopened the claim and proceeded to consider the issue on its merits. However, the Board must make its own determination as to whether new and material evidence has been received to reopen the claims. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). The Board notes in October 2017 and March 2018, the Veteran submitted additional private treatment records that were not previously considered by the RO. Although the Veteran submitted a waiver of the AOJ's initial consideration of the evidence submitted in March 2018, he did not submit a waiver for the evidence submitted in October 2017. However, the automatic waiver provision applies in this case. See Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, 126 Stat. 1165 (amending 38 U.S.C. § 7105 to provide for an automatic waiver of initial AOJ review of evidence submitted to the AOJ or to the Board at the time of or subsequent to the submission of a substantive appeal filed on or after February 2, 2013, unless the claimant or claimant's representative requests in writing that the AOJ initially review such evidence). I. Duties to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). 1. Whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for cervical strain. The Veteran's service connection claim for cervical strain was initially denied in a September 2002 rating decision. The RO determined that record did not establish that the Veteran had a current disorder. The Veteran was notified of the decision and his appellate rights in a September 2002 letter. However, the Veteran did not file a notice of disagreement. In general, rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. There was also no new and material evidence submitted within one year of the date of mailing of the decision. Therefore, the September 2002 rating decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.200, 20.201, 20.302, 20.1103. Although a decision is final, a claim will be reopened if new and material evidence is presented. 38 U.S.C. § 5108. New and material evidence can be neither cumulative, nor redundant, of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The evidence need not relate specifically to the reason why the claim was last denied; rather it need only relate to any unestablished fact necessary to substantiate the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). Additionally, the phrase "raises a reasonable possibility of substantiating the claim" is meant to create a low threshold that enables, rather than precludes, reopening. Id. at 117. Reopening is required when the newly submitted evidence, combined with VA assistance and considered with the other evidence of record, raises a reasonable possibility of substantiating the claim. Id. at 117. Notwithstanding the foregoing, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim. 38 C.F.R. § 3.156(c)(1). Such official service department records include, but are not limited to, records that are related to a claimed in-service event, injury, or disease, regardless of whether such records mention the Veteran by name. Such records do not include any records that VA could not have obtained when it decided the claim because the records did not exist when VA decided the claim, or because the claimant failed to provide sufficient information for VA to identify and obtain the records from the respective service department, the Joint Services Records Research Center, or from any other official source. 38 C.F.R. § 3.156(c)(2). At the time of the September 2002 rating decision, the evidence of record included the Veteran’s statements, his service treatment records (STRs), and a May 2002 VA examination. The Veteran’s STRs reveal that in his July 1980 enlistment examination, no abnormalities were noted in the clinical examination of the Veteran’s spine or head, face, neck, and scalp. The Veteran also denied having recurrent back pain in the July 1980 Report of Medical History, and he did not report any relevant problems. Later on August 18, 2018, an Emergency Care and Treatment STR from the Naval Regional Medical Center in Philadelphia, Pennsylvania noted that the Veteran reported having a trauma to the lower back. He had been struck by a wooden plank in the low back that knocked the Veteran down. The record indicated that the board had been "8 feet up." An ambulance brought him the emergency room on a back board, and the Veteran reported having low back pain with movement. The physical examination showed that his neck was supple, his lungs were clear, his chest did not have point tenderness, and his abdomen was nontender. The Veteran's back had diffuse tenderness at T12 to L3. In addition, there was a small contusion and laceration at L2. The neurological examination was non-focal. The extremities had a full range of motion with referred pain to the low back. The record noted that an x-ray of the thoracolumbar spine was normal. The assessment was blunt trauma/soft tissue injury. An August 19, 2018 x-ray report noted that a lower thoracic spine series had been requested on August 18, 2018, especially the T12 to L1. The pertinent clinical history section of the x-ray report noted that the Veteran had been struck by a large board on the ship in his back while standing. The radiographic report noted that the thoracic spine demonstrated normal vertebral alignment with no evidence of fracture or subluxation. The lumbosacral spine showed normal vertebral alignment with no evidence of fracture or dislocation. The impression stated that the thoracic and lumbar spine were negative for fracture. On August 22, 1983, an STR reported that the Veteran was coming off 72 hours of no duty. He had back pain in the lower back, and he was post-accident/trauma. The pain was located in the lumbar region of the right side, and he had decreased range of motion. There was pain/discomfort with movement. The impression was strain from trauma. He was given Norgesic and prescribed light duty for 5 days. During a subsequent service examination in October 1985, there continued to be no noted abnormalities in the spine/other musculoskeletal; or the head, face, neck, and scalp. The Veteran also maintained his previous denials of recurrent back pain or any other relevant problem in the October 1985 Report of Medical History. The clinical examination findings were unchanged in a February 1991 service examination. In the associated Report of Medical History, the Veteran denied having recurrent back pain. He did report experiencing swollen or painful joints. The physician's summary stated that he experienced this issue intermittently secondary to an injury. It was not considered disabling. The record did not specify what joints were involved. In December 1993, the Veteran reported having a 2 day history of right side neck and upper back pain. There was no history of an injury or extreme physical exertion. In addition, the Veteran did not have symptoms of numbness, tingling, weakness, or radicular symptoms of the upper extremities. His pain was worse with neck movement. An examination of the neck was positive for tenderness and spasm in the right part of the cervical region. Tenderness was also elevated with palpation of the right shoulder. In the bilateral upper extremities, the Veteran's motor and sensory functioning were within normal limits; and his reflexes were normal (2+) bilaterally. In the back, there was full range of motion without mid-line tenderness. The record also stated that no paravertebral tenderness was noted. The assessment was trapezius strain on the right. The treatment plan noted that that the Veteran was given motrin and Flexeril, as well as instructions to apply heat to the affected region. In addition, the Veteran was refrain from heavy lifting for 5 days. It was noted that he should return if there was no improvement in his symptoms. In October 1996, a service examination reflects that no relevant abnormalities were present upon clinical evaluation. In addition, the Veteran denied having recurrent back pain or swollen or painful joints in the October 1996 Report of Medical History. On October 11, 1998, the Veteran reported having neck pain for three days. He could not recall an injury. He had been taking aspirin and Motrin without relief. The record indicated that the Veteran's pain was located at his left neck and shoulder. Range of motion testing revealed that the Veteran had 10 degrees of forward bending, 10 degrees of extension, 10 degrees of side bending bilaterally, 30 degrees of right turning, and 40 degrees of left turning. The assessment was acute cervical spine sprain. The Veteran's treatment plan included naproxen and Flexeril. The record indicated that he should follow up for physical therapy. On October 13, 1998, the Veteran complained of waking up one week ago with a sore neck. He had been seen over the weekend for cervical strain, and he was given naproxen and Flexeril. The cervical spine x-ray was within normal limits. There was no fever or trauma, but his pain was still present. Upon examination, his neck was supple and without spinous tenderness or deformity. In addition, there was no pain to palpation. There was decreased range of motion in all planes secondary to pain. The record also appeared to indicate that the nervous functioning of the bilateral upper extremities was within normal limits. The assessment was cervical/upper trapezius strain. The plan was for the Veteran to continue his current treatment and wear a soft cervical collar for 2 to 3 days. The record also indicated that he should engage in gentle range of motion exercises and return for persistent symptoms. In the Veteran’s March 2001 separation examination, there were still no abnormalities documented in the spine/other musculoskeletal or the head, face, neck, and scalp. In the March 2001 Report of Medical History, the Veteran reported swollen or painful joints, cramps in his legs, and a trick or locked knee. He denied recurrent back pain. The physician's summary indicated that the reported problems were in relation to intermittent left knee pain. After service, the Veteran was provided with a VA examination related to his service connection claim for a cervical spine disorder in May 2002. During the examination, the Veteran denied having any neck injury. Although he reported that there was an episode of transient neck pain while he in the military years ago, he did not experience any subsequent symptoms. There had also been no reduction in his range of motion, and no complaints relative to his neck. The diagnosis was transient neck pain years ago by history without any current symptoms or sequelae. The Board initially acknowledges that after the September 2002 rating decision, the Veteran’s military personnel records were associated with the claims file. However, these records primarily concern administrative matters such as performance evaluations. Moreover, the STRs in these records are duplicates of the STRs considered by the RO in September 2002. As these records do not contain information that is relevant to the Veteran’s service connection claim for a cervical spine disorder, a reconsideration of the Veteran's claim under 38 C.F.R. § 3.156(c) is not appropriate. The newly received evidence also includes an October 2017 VA examination report. This report reflects that the Veteran has a current diagnosis of degenerative disc disease of the cervical spine, status post anterior cervical discectomy and fusion (ADCF). This evidence is new and material as it is not cumulative or redundant of the previous evidence of record, it relates to the previously unestablished question of a current diagnosis, and it raises the reasonable possibility of substantiating the claim. Therefore, the Board finds that new and material evidence has been submitted, and the claim is reopened. 38 C.F.R. § 3.156(a). As discussed above, the RO has already addressed the merits of the Veteran's service connection claim for a cervical spine disorder. Consequently, there is no prejudice to the Veteran in the Board proceeding to adjudicate this claim on its merits. Bernard v. Brown, 4 Vet. App. 4 Vet. App. 384, 390 (1993). 2. Entitlement to service connection for a cervical spine disorder. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Service connection may also be granted for any disease initially diagnosed after service 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). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of a chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). After the May 2002 VA examination discussed above, private treatment records from 2008 show that the Veteran sought treatment for cervical spine problems. In August 2008, a private treatment record stated that the Veteran had progressive paresthesias in the right arm that now involved the ring and little fingers. He also had an episode where he had numbness in the right anterior thigh. He still had persistent weakness in the right upper extremity. In September 2008, a record stated that the Veteran had progressive neck and radicular arm pain that had been worse over the last couple of months. The Veteran had significant pain radiating into the middle fingers. Although the symptoms initially started on the left, they were now only present on the right. He denied any significant trauma. A cervical spine MRI showed a-focal kyphotic deformity and a broad-based disc herniation at C5-6 with a congenitally narrow spinal canal. He also had T2 changes within the cord at this level. In November 2008, it was noted that the Veteran’s symptoms had worsened despite conservative therapy. The record stated that an MRI of the cervical spine showed C5-6 disc herniation with narrow canal. The treatment plan was a right-sided anterior cervical discectomy and fusion at C5-6. The surgery was conducted later that month. The operative report stated that the pre- and post-operative diagnosis was cervical degenerative disc disease. In December 2008, a private treatment record noted that it was approximately two weeks since the Veteran's cervical discectomy and fusion for right-sided pain. The Veteran was doing well, but he had some postoperative swallowing difficulty that was expected as well as some paresthesias in the right C6 dermatome. The Veteran also had some right-sided tingling and paresthesias in the ulnar nerve distribution, and tenderness over the medial epicondyle on the right. The examining doctor stated that he suspected this complaint was a separate issue for the Veteran's neck. Approximately 6 weeks after the cervical fusion surgery in January 2009, the Veteran's paresthesias in the right C6 dermatome had resolved. He still had right-sided ulnar neuropathy by examination with tenderness over the medial epicondyle. The Veteran stated he felt as though someone was pinching his funny bone. In February 2009, an EMG/nerve conduction study was performed in the right upper extremity. The report stated that the Veteran had experienced pain and tingling in his right hand, with tingling location in the last two digits. There had been no change in symptoms after his cervical spine fusion surgery. The examination was notable for mild intrinsic weakness in the left hand with finger abduction, otherwise strong. Dysesthesias was present when palpating the ulnar groove with decreased sensation in the last digits. The results of the studies suggested that multilevel cervical nerve root irritations were present that were consistent with radiculoapthies at the C6-7, and possibly C8. Despite the pattern of numbness, the EMG findings were more impressive at C6 and 7 than at C8. Notably, there was no focal compression of the ulnar nerve, including at the elbow. In addition, no carpal tunnel was present. In March 2010, the impression from a private cervical spine x-ray showed a prior C5-6 fusion with normal radiographic appearance. The examination was otherwise unremarkable. In August 2011, a cervical spine MRI related to the Veteran's symptoms of right hand and finger numbness noted in the impression that a shallow diffuse disc osteophyte complex at C4-C5 caused mild central canal stenosis and mild bilateral neural foraminal stenosis. In additional, postoperative ADCF changes at C5-C6 appeared to be intact without significant central canal or neural foraminal stenosis. In November 2011, the impression from a CT scan of the cervical spine showed moderate diffuse disc bulging with mild to moderate spinal canal narrowing and minimal symmetric bilateral neural foraminal narrowing at C4-5. The Veteran was status post ADCF at C5-6. This same month, an additional an additional EMG and nerve conduction study was conducted. The summary/interpretation stated that there was no evidence of ulnar neuropathy, plexopathy, or peripheral neuropathy. In addition, the Veteran had chronic C7 > C6 radiculopathy by needle EMG criteria. Later in May 2012, the Veteran underwent a C4-C5 anterior cervical discectomy and fusion. The pre- and post-operative diagnosis was status post C5-C6 anterior cervical discectomy and fusion with C4-5 disc herniation with cord compression. In June 2014, a private treatment record noted that the Veteran had recurrent cervical spondylosis with myelopathy. In addition, VA examinations in April 2013 and October 2014 noted that the Veteran had cervical degenerative disc disease, status post ADCF. Based on the above evidence, the record establishes that the Veteran has a current cervical spine disorder. The Veteran contends that his cervical spine disorder is directly related to service. In contrast to the Veteran’s report from the May 2002 VA examination that there had been no history of a cervical spine injury, the Veteran now asserts that his cervical spine was injured at the time of the in-service accident involving a board falling on him in August 1983. The Veteran has maintained that the Board fell from a height of approximately 10 to 12 feet before hitting him. However, the Veteran has provided different accounts concerning the anatomical region where he was initially struck by the board. During the August 2014 DRO hearing, the Veteran testified that the board fell and hit him in the small of his back, causing him to fall. See August 2014 DRO Hearing Transcript, page 3. The Veteran later stated that the board fell and hit him in the lower neck/upper back. See November 2014 Private treatment record. He subsequently informed A.M., a family nurse practitioner, that the board fell and hit him on the head. See August 2016 Letter from A.M. In a March 2017 private psychological evaluation, the Veteran similarly stated that his cervical spine pain had its onset during service when a heavy board fell and hit him on the head. During an October 2016 VA examination, the Veteran stated that he was hit by the board in the lower neck. During the March 2018 Board Hearing, the Veteran testified that he was hit between the shoulder blades, and then the board came down and hit his low back. See March 2018 Board Hearing Transcript, page 3. The record also shows that after the May 2002 VA examination discussed above, the Veteran had a motor vehicle accident. All the available records have been consistent in reporting that the accident followed the 2002 examination. However, reports of the exact year and nature of the accident have varied. In addition, the record has different reports regarding when the Veteran’s current symptoms began in relation to the accident. In May 2012, a private treatment record noted that the Veteran had a diagnosis of cervical degenerative disc disease, and his chief complaint was neck pain and right hand numbness. The record indicated that these symptoms manifested after a motor vehicle accident in 2005. In August 2012, a private treatment record stated that the Veteran had a motorcycle accident in 2005. In February 2013, a private treatment record indicated that the Veteran’s symptoms of numbness from cervical radiculopathy began in 2006. In November 2014, a private treatment record reported that the motor vehicle accident occurred in 2006. It had been high impact and totaled the car. However, the record indicated that the Veteran’s current complaints began with the neck injury involving the board in the Navy. During an April 2013 VA examination concerning the cervical spine, the examiner stated that per the Veteran’s report, his current symptoms began after the motor vehicle accident in 2005. During the January 2017 DRO hearing, the Veteran stated that he had neck pain prior to the car accident. See January 2017 DRO hearing., page 6. He indicated that the numbness symptoms followed the car wreck. He also stated that testing was performed at the time of the accident, and it was determined that his cervical spine problem had been present for a long time. The Veteran later testified at the March 2018 Board hearing that the accident occurred in 2006. See March 2018 Board Hearing Transcript, page 7-8. He also reported experiencing a sore neck after the 1983 accident as well as problems in his hands with numbness and grasping items. See March 2018 Board Hearing Transcript, page 7-8. However, the Veteran stated that he did not go to sick call for these problems due to his desire to be strong and his fear of any repercussions with his job. The Veteran also reported seeking treatment for his hand problems after service in 2001, 2003, or 2004, and having surgery on his tennis elbow in an attempt to treat the problem. See March 2018 Board Hearing Transcript, page 9. The Board notes that the record also includes conflicting accounts of when this surgery occurred. In December 2011, the Veteran’s neurologist, Dr. H., noted that he had a previous right elbow surgery in 2006. A May 2012 private treatment record later stated that the Veteran’s past surgical history included a right elbow surgery in 2004. However, other aspects of the surgical history provided by this treatment record were incorrect. Although the record stated that the Veteran had a C5-C6 ADCF in 2005, the Veteran’s private treatment records, to include an operative report, reflect that this fusion surgery was conducted in November 2008. Turning to the question of nexus, the Board notes that different medical opinions have been provided. In April 2013, the VA examiner gave a negative nexus opinion. The examiner noted that the Veteran was seen on two occasions during service with complaints of neck pain in 1993 and 1998, which was diagnosed as cervical/right upper trapezius strain. He was treated conservatively with analgesics, heat, and a soft collar for two days. However, he had no recurrence of these symptoms and no mention of any problems on his separation physical in 2001. The examiner highlighted the fact that per the Veteran’s reports, his current symptoms started following a motor vehicle accident in 2005. The Board also notes that the medical history section of the report includes a discussion of the Veteran’s history of treatment and surgeries in 2008 and 2012. The examiner concluded that there was no relationship between the Veteran’s in-service acute muscle strain that resolved and the development of cervical degenerative disc disease with bilateral radiculopathies approximately fifteen years later. Another medical opinion was provided by A.M. in August 2016. A.M., stated that she had reviewed the Veteran’s service medical records, his medical history, and the current examination. A.M. opined that it was at least as likely as not that the Veteran’s current cervical spine with nerve damage was a continuation of the condition first treated on active duty. A.M. noted that the Veteran had been hit by a 2 x 4 piece of lumber in the head in 1983 that fell 12 feet. He had experienced neck problems ever since and had undergone two neck surgeries. The Veteran’s most recent neck surgery was in May 2012. The Veteran had ongoing, chronic C5-6 radiculopathy/myelopathy as a result of the original injury, and his surgery had not improved his radicular and motor issues. Following A.M.’s opinion, the October 2016 VA examiner gave a negative nexus opinion. The examiner indicated that she had reviewed relevant medical evidence, including the Veteran’s tabbed files, multiple VBMS documents, the April 2013 VA examination, and the August 2016 opinion from A.M. Based on this review, she had determined that the Veteran’s current cervical spine disorder was not related to, or caused by, any of the Veteran’s in-service injuries. The examiner acknowledged the opinion from A.M., but stated that it could not have been based on any documentation or other factual knowledge as the documents did not support A.M.’s statements. Her opinion appeared to be based solely on the Veteran’s reported medical history. In contrast, the examiner stated that the documentation supported that the Veteran was seen in the emergency room on August 18, 1983, when he reported being hit by a board in his lower back (not his neck), with no neck complaints at that time. In addition, there were no reported neck complaints three days later when he was seen again for persistent low back pain on August 22, 1983. The Veteran was later seen in service for acute neck muscle strain in 1993 and 1998. The examiner highlighted the fact that there was no reported neck trauma or other sequalae at those times. In addition, the Veteran did not report neck or back problems on March 2001 exit examination. There was also no further mention of neck pain from 1998 until 2011 (possible 2008), which was 25 to 28 years after the Veteran was hit by a board in his back; and 10 to 13 years after his reported neck muscle strain. The examiner added that neck muscle strain is an acute diagnosis that almost always resolves without further sequalae and did not cause arthritis. Furthermore, the examiner explained that her particular medical expertise was in emergency medicine for more than 20 years. In light of this experience, the examiner stated that without a doubt, it was her opinion that the Veteran would have been given a full cervical spine imaging and evaluation if neck trauma was even remotely considered at the time he was hit by the board in the back. The record showed that the Veteran had full back x-rays before he was taken off the backboard. These x-rays would have included neck images, if needed. In reviewing the evidence discussed above, the Board has considered the Veteran’s reported history that his cervical spine was injured when the board fell on him in 1983, and he has continued to have cervical spine complaints since that time. The Veteran is competent to report as to the observable events and symptoms he experiences and their history. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, 6 Vet. App. at 469 (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). In this case, the Board finds that the Veteran's reported history is not credible. The Veteran’s statements have been inconsistent in relaying where he was first hit by the Board. Furthermore, the reports that he was hit in the neck or head conflict with the report he provided immediately after the 1983 accident. The Veteran’s reports from the May 2002 VA examination also provide affirmative evidence that there was no in-service injury or continuity of cervical spine symptoms after service. Moreover, the October 2016 examiner’s opinion reflects that the lack of any evidence of cervical spine x-rays after the accident makes it highly unlikely than any cervical spine injury was indicated. The Board notes the Veteran’s March 2018 testimony that he did not report his neck problems after the 1983 accident to avoid appearing weak or a negative impact on his employment. However, the subsequent STR entries from 1993 and 1998 directly contradict his report and show that he did seek treatment for neck complaints. Notably, the Veteran did not report any prior injury at those times. Moreover, the Veteran reported having other musculoskeletal problems, specifically his left knee complaints, at the time of the March 2001 Report of Medical History. The Veteran also reported having left knee problems during the March 2002 VA examination after service, but he denied any current cervical spine symptoms. Given the report of left knee symptoms, the Board finds it highly unlikely that the Veteran would refrain from reporting any current neck symptoms if they had been present at the time of separation or during the May 2002 VA examination; especially in light of the fact that the Veteran was seeking service connection for a cervical spine disorder at that time. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (citing Fed. R. Evid. 803 (7) for the proposition that "the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded"). The Board also finds that the inconsistencies in the record regarding whether the Veteran’s current cervical spine symptoms began before or after the post-service motorcycle accident is additional evidence that weighs against the credibility of Veteran’s report that his current symptoms manifested during service. In weighing the probative value of the nexus opinions addressing the Veteran’s claim, the Board finds that the October 2016 VA examiner’s opinion carries the greatest probative weight. Although A.M. asserted that she had reviewed the Veteran’s service medical records before providing an opinion, the Veteran later testified that A.M. did not actually review his STRs. See March 2018 Board Hearing Transcript, page 13-14. Her review of the record was limited to the post-service medical evidence, and the Veteran’s reported history that the board hit him in the head in 1983. In addition, as the Board does not find the Veteran's report of the 1983 cervical spine injury to be credible, A.M.’s opinion based on this reported history is not probative. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (providing that a medical opinion based on an inaccurate factual premise is not probative). The April 2013 VA examiner’s opinion provides limited probative value. The examiner provided a rationale for why the Veteran’s current disorder was unrelated to the documented cervical spine complaints during service, but failed to address the Veteran’s contentions regarding the 1983 injury. In contrast, the October 2016 VA examiner’s opinion has great probative value as the examiner provided thorough explanations based on her medical expertise and demonstrated a familiarity with the relevant evidence record. Although the Veteran’s current contentions have focused on the reported 1983 injury, the October 2016 VA examiner explained why the current disorder was also unrelated to the documented cervical spine complaints from 1993 and 1998. The Board also notes that arthritis is one of the chronic diseases listed in 38 C.F.R. § 3.309(a). Consequently, the Board has considered whether service connection may be granted on a presumptive basis. However, arthritis was not documented during the Veteran’s active duty service, and there was no in-service manifestation sufficient to identify this disease entity. The pertinent regulations require that manifestations are "noted" in the service records, and that is not the case in this instance. The Board finds that the most probative evidence of record reflects that this disorder did not manifest until many years after the Veteran’s active duty service. As a result, the Veteran is not entitled to service connection for a cervical spine disorder on a presumptive basis, either as a chronic disease during service or within one year of service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a); Walker, 708 F.3d 1335-37. Therefore, chronicity is not established in service or within a year of separation. Based on the foregoing, the preponderance of the evidence is against the Veteran's service connection claim for a cervical spine disorder. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt provision does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the Board finds that service connection for a cervical spine disorder is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a disorder manifested by difficulty swallowing to include as due to exposure to asbestos, chemicals, and/or ionizing radiation, is remanded. No VA examination or medical opinion has been obtained in connection with the Veteran's service connection claim for a disorder manifested by difficulty swallowing. The Veteran has been assessed to have an impaired swallowing function. See August 2012 VA treatment record. During the March 2018 Board hearing, the Veteran asserted that his disorder was related to his in-service exposure to asbestos, different chemicals, and/or ionizing radiation. See Tr., page 19. Regarding the Veteran's contention that he was exposed to ionizing radiation, the Board notes that the Veteran does not contend, and the record does not show, that he participated in atmospheric nuclear weapons testing or received exposure from the American occupation of Hiroshima or Nagasaki, Japan prior to July 1, 1946. In addition, the Veteran’s difficulty swallowing has not been associated with a radiogenic disease as defined by 38 C.F.R. § 3.311(b)(2). The Veteran also has not submitted or cited to competent medical evidence showing that his disorder is a radiogenic disease. 38 C.F.R. § 3.311(b)(4). Thus, it is unnecessary to conduct additional development involving a request for dose information under 38 C.F.R. § 3.311(a)(2). In terms of his remaining contentions, the Veteran’s DD 214 for the period from June 1981 to November1985 lists his military occupational specialty as boiler technician. The M21-1 reflects that this job title had a high probability of exposure to asbestos. See M21-1, IV.ii.1.3.d. The Veteran’s STRs also contain the Veteran’s reports that he engaged in activities such as chipping paint, and he received exposure to paint fumes and different chemicals. See May 1994 Asbestos Exposure Part II Periodic Medical Questionnaire. The Veteran additionally reported having exposure to asbestos during service, and it was recommended that he be placed in an asbestos medical surveillance program. See March 1983 Asbestos Medical Surveillance Questionnaire. Based on the foregoing, the Board finds that a remand is necessary to provide the Veteran with a VA examination and medical opinion to determine the etiology of the claimed disorder manifested by difficulty swallowing. See McLendon v. Nicholson, 20 Vet. App. 79, 83-86; Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (finding that when the medical evidence is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion, ordering a medical examination, or citing recognized medical treatises that clearly support its ultimate conclusions). The matter is REMANDED for the following action: 1. Request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his disorder manifested by difficulty swallowing. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding, relevant VA medical records, to include records from the Ralph H. Johnson VA Medical Center dated since March 2016. 2. After completing the preceding development in paragraph 1, provide the Veteran with a VA examination in connection with his service connection claim for a disorder manifested by difficulty swallowing. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should provide an opinion as to the following questions: (a) The examiner should clarify whether the Veteran’s difficulty swallowing is a manifestation of any specific disorder. If the difficulty swallowing cannot be associated with any disorder, the examiner should clearly state whether the Veteran has functional impairment due to his difficulty swallowing. In providing an opinion, the examiner should address the following: (1) The August 2012 private treatment record that noted an impression of impaired swallowing function; and (2) the statement from a March 2016 VA treatment record that the Veteran had a history of GERD with associated swallowing difficulties (due to stricture). This record also noted the Veteran’s report that it was thought he had suffered from nerve damage (post-cervical fusion) that contributed to his swallowing problems. (b) For any identified disorder and/or functional impairment, the examiner should opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the disorder/impairment manifested during service or is otherwise related to service, to include the Veteran’s exposure to asbestos and/or chemicals therein. In providing an opinion, the examiner should address the following: (1) the Veteran’s March 2018 Board hearing testimony that his chemical exposure during service included lead paint; and (2) the May 1994 Asbestos Exposure Part II Periodic Medical Questionnaire that noted the Veteran’s report that he engaged in activities such as chipping paint; and he received exposure to paint fumes, H6H, PD-680, Nitric Acid, Hydrazine, Morpholine, TSP, DSP, Caustic Soda, EDTA, and Mercuric Nitrate; (3) the report from a personnel record for the period from July 1995 to November 1995 that the Veteran supervised personnel in the administration, testing, and chemical treatment of the ship’s steam plant water chemistry, lube and fuel oil management, potable water service and transfer, reserve feed and transfer system, fuel transfer, and stripping and ballast systems; and (4) the report from a personnel record for the period from March 1989 to March 1990 noting that the Veteran was a laboratory technician in the chemical laboratory responsible for the quantitative analysis of hydraulic oils, black oils, fuel oils, and lubricating oils; and he maintained and prepared numerous acids and chemicals used in laboratory operations. Gayle Strommen Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.C. Spragins