Citation Nr: 18141553 Decision Date: 10/11/18 Archive Date: 10/10/18 DOCKET NO. 13-01 009 DATE: October 11, 2018 ORDER 1. Entitlement to service connection for residuals of heat exhaustion is denied. 2. Entitlement to service connection for a traumatic brain injury (TBI) is denied. 3. Entitlement to service connection for vision problems, to include as secondary to headaches or heat exhaustion is denied. 4. Entitlement to service connection for a disability manifested by fatigue (claimed as chronic fatigue syndrome (CFS)), to include as secondary to heat exhaustion is denied. 5. Entitlement to service connection for a right hip disability is denied. 6. Entitlement to service connection for a left hip disability is denied. 7. Entitlement to service connection for a right ankle disability is denied. 8. Entitlement to service connection for a left ankle disability is denied. 9. Entitlement to service connection for a right foot disability is denied. 10. Entitlement to service connection for a left foot disability is denied. 11. Entitlement to service connection for asbestosis is denied. 12. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to heat exhaustion is denied. 13. Entitlement to service connection for a thyroid disability, to include as secondary to heat exhaustion is denied. 14. Entitlement to service connection for restless leg syndrome (RLS), to include as secondary to heat exhaustion is denied. 15. Entitlement to service connection for memory loss, to include as secondary to TBI or heat exhaustion is denied. 16. Entitlement to service connection for erectile dysfunction (ED) is denied. REMANDED 17. Entitlement to service connection for vertigo, to include as secondary to hearing loss, tinnitus, and heat exposure, or as due to exposure to solvents is remanded. 18. Entitlement to service connection for headaches, to include as secondary to hearing loss, tinnitus, or heat exhaustion, or as due to exposure to chemicals and vaccines is remanded. 19. Entitlement to service connection for hypertension, to include as secondary to heat exhaustion, or as due to exposure to diesel fumes, is remanded. 20. Entitlement to service connection for hemorrhoids, to include as secondary to heat exhaustion and psychiatric disability is remanded. 21. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to psychiatric disability or medication for service-connected disability, or as due to exposure to second-hand smoke, is remanded. 22. Entitlement to service connection for a psychiatric disability, to include as secondary to TBI, heat exhaustion, bilateral hearing loss, or tinnitus is remanded. 23. Entitlement to service connection for a back disability is remanded. 24. Entitlement to special monthly compensation (SMC), based on the need for aid and attendance or housebound status is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against a finding that the Veteran has, or at any time during the pendency of the claim has had, any disability that is a residual of heat exhaustion. 2. The Veteran is not shown to have sustained a traumatic brain injury in service, and is not shown to have a current disability that may be a residual of a TBI. 3. The Veteran is not shown to have a vision disability. 4. The Veteran is not shown to have CFS or a disability manifested by chronic fatigue. 5., 6. A right or left hip injury in service is not shown; a right or left hip disability was not manifested in service or for many years thereafter; and any such disability is not shown to be related to the Veteran’s service. 7., 8. A right or left ankle injury in service is not shown; a right or left ankle disability was not manifested in service or for many years thereafter; and any such disability is not shown to be related to the Veteran’s service. 9., 10. The Veteran is not shown to have a right or left foot disability. 11. The Veteran is not shown to have (or have ever had) asbestosis. 12. OSA was not manifested in service, and the preponderance of the evidence is against a finding that the Veteran’s current sleep apnea is related to his service or was caused or aggravated by heat exhaustion. 13. A thyroid disability was not manifested in service, and the preponderance of the evidence is against a finding that such disability is etiologically related to the Veteran’s service (to include heat exhaustion therein). 14. RLS was not manifested in service, and the preponderance of the evidence is against a finding that the Veteran’s current RLS is etiologically related to his service to include as due to heat exhaustion therein. 15. Memory loss was not manifested in service, and the preponderance of the evidence is against a finding that the Veteran’s current memory loss is related to his service, to include as due to heat exhaustion or head injury therein. 16. ED was not manifested in service, and the preponderance of the evidence is against a finding that the Veteran’s current ED is etiologically related to his service, to include as due to heat exhaustion therein. CONCLUSIONS OF LAW 1. Service connection for residuals of heat exhaustion is not warranted. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. Service connection for TBI is not warranted. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. Service connection for a vision disorder is not warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. Service connection for CFS is not warranted. 38 U.S.C. §§ 1110,5107; 38 C.F.R. §§ 3.303, 3.317. 5., 6. Service connection for right and left hip disabilities is not warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304. 7., 8. Service connection for right and left ankle disabilities is not warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304. 9., 10. Service connection for right and left foot disabilities is not warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304. 11. Service connection for asbestosis is not warranted. 38 U.S.C.§§ 1110, 5107; 38 C.F.R. § 3.102, 3.303. 12. Service connection for OSA is not warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 13. Service connection for a thyroid disability is not warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 14. Service connection for RLS is not warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 15. Service connection for memory loss is not warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 16. Service connection for ED is not warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty for training (ACDUTRA) from June 11, 1991 to August 23, 1991 and had additional National Guard service from November 1989 to November 1995 (including a period of federalized active duty from June 12 to June 26, 1993). These matters are before the Board of Veterans’ Appeals (Board) on appeal from February 2012 (finding no new and material evidence to reopen claims of service connection for concussion and psychiatric disability and reopening and denying on the merits a claim of service connection for heat exhaustion); January 2014 (denying all other claims except vertigo); April 2014 (denying service connection for vertigo and continuing the previous denial of headaches); and November 2014 (continuing the previous denial of service connection for vertigo) rating decisions. In March 2016, a videoconference hearing was held before the undersigned; a transcript is associated with the record. In November 2016 the case was remanded for further development. [The November 2016 Board decision remanded an issue pertaining to the rating for bilateral hearing loss for a hearing to be held. In February 2017 a hearing in the matter, and addressing TDIU, was held before a VLJ other than the undersigned. Entitlement to a total disability rating due individual unemployability (TDIU) is intertwined with the issues being decided herein and in a separate decision. The TDIU issue ultimately will be decided by a panel of judges including those who conducted hearings in the matter (after the inextricably intertwined claims are resolved]. While VA examinations have not been conducted in conjunction with the claims seeking service connection for vision, ankle, feet, hip, asbestosis, memory loss, and ED disabilities, because there is no evidence that such disabilities may be etiologically related to the Veteran’s service, the low threshold standard for determining when a VA examination is necessary is not met as to those matters. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may 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. To substantiate a claim of service connection there must be evidence of: (1) a present disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Secondary service connection may be established for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). To substantiate a secondary service connection claim, there must be evidence of: (1) a present disability (for which secondary service connection is sought); (2) an already service-connected disability; and (3) competent evidence that the service connected disability caused or aggravated the disability for which service connection is sought. Service connection is limited to those cases where disease or injury has resulted in a disability. In the absence of proof of a present disability for which service connection is sought, there is no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Court has held the requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or at any time during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007). 1. Service connection for heat exhaustion is denied. The Veteran contends that he has memory loss, a psychiatric disability, a thyroid disability, headaches, vision problems, CFS, hemorrhoids, hypertension, vertigo, OSA, RLS, ED, and a TBI, due to an episode of heat exhaustion during service. The Veteran’s service treatment records (STRs) note that he suffered heat exhaustion during Annual Training with the National Guard during June 1993. A June 15, 1993 STR notes that the Veteran reported weakness, dizziness, nausea and vomiting; he was given IV solution. A June 16, 1993 STR notes that his nausea had dissipated, and he was directed to drink plenty of fluids. It was noted that he appeared to be hydrated well and that the heat exhaustion was resolving. A June 17, 1993 STR notes dizziness, slight weakness, and a blood pressure reading of 128/73, and that saline solution was again administered. A June 19, 1993 STR notes that the Veteran reported headache and light headedness. Salt tablets were provided; and it was noted that he was doing well. A July 10, 1993 report of medical examination notes all systems were normal, and a blood pressure reading of 110/74. A February 1995 annual medical certificate notes that the Veteran was determined fit for duty. A July 2013 private medical opinion notes that the Veteran reported that in July 1993 (June 1993 according to the STRs), he became hot, dizzy, and nauseated and was given IV fluids. He related that since then he has had trouble thinking and concentrating, poor memory, dizziness, weakness, heat sensitivity, headaches, and light sensitivity. The diagnoses were TBI, dizziness and headaches due to TBI, and sleep apnea. He opined that it is as likely as not that the severe heat exhaustion and/or stroke on June 15, 1993 caused severe injury to multiple areas in his brain resulting in brain injury. He explained that elevated core temperature caused severe brain injury and that the Veteran fell and sustained a head injury due to the heat exhaustion. At the March 2016 videoconference hearing, the Veteran testified that he was seeking service connection for headaches, vision problems, CFS, poor memory, and a TBI all as due to heat exhaustion. A December 2017 VA medical opinion notes the Veteran’s June 1993 treatment for heat exhaustion. The provider explained that the clinical criteria for heat exhaustion generally include the following: obvious difficulty continuing with exercise, a core body temperature of 101 to 104ºF at the time of collapse, no significant dysfunction of the central nervous system, extreme weakness, dehydration and electrolyte losses, ataxia and coordination problems, syncope, light-headedness, profuse sweating, pallor, “prickly heat” sensations, headache, abdominal cramps, nausea, vomiting, and diarrhea. The provider further noted that heat injury is defined as an exertional heat illness with evidence of both hyperthermia and end organ damage, but without any significant neurologic manifestations. The two main criteria for diagnosing exertional heat stroke are a core temperature above 104°F, measured immediately following collapse during strenuous activity, and central nervous system dysfunction. The examiner opined that it was less likely than not that the Veteran had any current residuals of heat exhaustion, such as hypertension, a thyroid disability, vertigo, hemorrhoids, ED, headaches, RLS, TBI, vision problems, OSA, or CFS, caused by heat exhaustion that occurred during active duty for training in June of 1993. She noted that at the time of the event, the Veteran had lightheadedness, nausea and vomiting, and four days after the initial event, complained of headache. There was no documentation of collapse at the time. There was no evidence of significant neurological manifestations at the time and no evidence of end organ failure. Thus, noting the presenting symptoms at the time of the incident in June 15, 1993 and in the days following, the diagnosis of heat exhaustion provided by the treating medical doctor in 1993 is consistent with the most recent peer reviewed medical criteria for a diagnosis of heat exhaustion and was not consistent with heat injury or with heat stroke. She explained that a review of the medical literature indicates that heat exhaustion is acute and self-limited, and resolves over time (and that such resolution is supported by the Veteran’s medical record). She indicated that the medical literature does not support that any residuals would occur latently, more than 10 years after the heat exhaustion episode. She also indicated that the disabilities noted are all separate and distinct disorders with distinct etiologies and are not etiologically related to heat exhaustion. The Veteran’s stated theory of entitlement presents a medical question that is beyond the scope of common knowledge or resolution by lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). He alleges that he has multiple disabilities such as memory loss, TBI, vision problems, hemorrhoids, etc., that are residuals of heat exhaustion in service. It is not in dispute that he suffered an episode of heat exhaustion. The threshold question that must be addressed is whether or not he has any current symptoms/pathology that are residuals of the heat exhaustion. The Board finds that the preponderance of the evidence is against a finding that the Veteran’s current symptoms/disabilities are residuals of his heat exhaustion in service. The July 2013 private provider’s opinion is conclusory and lacks adequate rationale. The VA examiner explained the difference between heat exhaustion and heat injury or heat stroke, and found that the Veteran suffered an episode of heat exhaustion in service. She then noted that heat exhaustion was a self-limiting event that had no long-term residuals. She pointed to factual data and medical literature in support of the opinion. The Board finds the VA examiner’s opinion to be more probative and persuasive. In light of the foregoing, the Board concludes that the preponderance of the evidence is against finding that the Veteran has any current disability that is a residual of his heat exhaustion in service. [Because heat exhaustion is not service connected, any claims of service connection for disabilities as secondary to heat exhaustion lack legal merit. See 3.310.] 2. Entitlement to service connection for TBI is denied. The Veteran contends that he has current disability residual from a TBI in service. He reported that during an episode of heat exhaustion in June 1993 he sustained a head injury when he fell. His STRs note treatment for heat exhaustion, but contain no mention of a fall or fall-related head injury/TBI. A July 1993 report of medical examination notes that the Veteran’s head was normal on clinical evaluation. A June 2003 VA treatment record notes that the Veteran reported he did not have weakness, frequent headaches, dizzy spells, difficulty making decisions, or memory problems. A December 2010 statement notes that the Veteran reported that he sustained a concussion after collapsing due to a heat stroke. The Line of Duty (LOD) Determination dated July 15, 1993, notes that he was light headed; there was no mention of a collapse resulting in head injury. A head injury in service is not shown. In a July 2013 private medical opinion, the provider stated that the Veteran’s heat exhaustion episode caused a permanent brain injury due to his elevated core temperature. The provider also noted that he fell and injured his head, but noted that it was more likely that the heat, rather than the fall, caused the brain injury. On August 2014 VA mental disorders examination, it was noted that TBI had not been diagnosed. A December 2017 mental disorders disability benefits questionnaire (DBQ), notes that a TBI diagnosis was not shown in the record. A December 2017 medical opinion notes that a review of current medical research indicates that it is a known medical fact that TBI can happen from a blow or jolt to the head, or from an object penetrating the brain. When the brain is injured, the person who has been injured may experience a change in consciousness that can range from becoming disoriented and confused to slipping into a coma. In review of the Veteran’s history and record, there is no evidence of a TBI during or after active duty. There is mention of a head injury one year prior to his entry into service as documented on his service entrance examination. The examiner notes that though the July 2013 private provider diagnosed a TBI, a TBI results from a blow or jolt to the head, or from an object penetrating the brain but does not occur as the result of heat exhaustion per current peer reviewed medical literature. At the March 2016 videoconference hearing, the Veteran testified that the July 2013 provider diagnosed a brain injury as a result of heat exhaustion in June 1993. There is no competent evidence in the record indicating or supporting that the Veteran suffered a TBI during service. The Veteran has reported in numerous statements that during an episode of heat exhaustion in June 1993 he fell and struck his head repeatedly. There is no documentation of such falls in his STRs. Inasmuch as various other complaints and symptoms are described in detail, it may reasonably be assumed that if a fall resulting in head injury had occurred at the time, it would have also been noted. The July 2013 medical provider notes a diagnosis of TBI based on an elevated core temperature due to heat exhaustion, and not the head trauma reported by the Veteran. To the extent that the opinion suggests that the Veteran suffered a TBI in service, that opinion is based entirely on his own accounts of symptoms which are inconsistent with contemporaneous clinical data and reflects lack of familiarity with the Veteran’s accurate medical history. Given the multiple notations in the STRs of the treatment for heat exhaustion, it is implausible and not credible that a head injury that the Veteran has reported in numerous statements since service would not have been noted in STRs such as the July 1993 report of medical examination (which does not note a head injury) or the July 1993 report of medical history (which notes his report of heat exhaustion, vomiting, and IV administration of fluids but no mention of a head injury). The diagnosis of a TBI is unsupported by, and in opposition with, the factual record. The diagnosis of a TBI is a medical question. While the Veteran and his wife are competent to report symptoms capable of lay observation such as memory loss and psychiatric symptoms, they are not competent to establish by their observations that the Veteran has a specific disability underlying the symptoms observed. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As the Veteran has not presented competent and probative evidence that he suffered a TBI during a period of active service, he has not presented a valid claim of service connection for TBI. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). [And because TBI is not service connected, any claims of service connection for disabilities secondary to TBI lack legal merit. See 3.310.] Accordingly, the appeal in this matter must be denied. 3. Service connection for vision problems, to include as secondary to headaches or heat exhaustion, is denied. The Veteran’s STRs are silent for any complaint, treatment, or diagnosis, of a vision problem. A July 2013 private treatment record notes that the Veteran’s pupils were equal, round, and reactive to light, extraocular movements and visual fields were intact, and there was no nystagmus. A January 2016 private treatment examination found that the Veteran’s eyes were normal. At the March 2016 videoconference hearing, the Veteran testified that he had vision problems after his heat exhaustion episode. He reported that he wore special glasses for light sensitivity and headaches. August 2016 diabetic retinopathy screening showed normal imaging. A November 2017 private treatment record notes that the Veteran had normal vision, no diplopia, no tearing, no scotomata, and no pain. The examination was grossly normal. A review of the Veteran’s file found no clinical diagnosis of a vision disorder during the pendency of the claim. The threshold requirement for substantiating a claim of service connection (whether direct or secondary) is that there must be competent evidence of the disability for which service connection is sought. Here, there is no competent evidence that the Veteran has, or at any time during the pendency of the instant claim has had, a diagnosis of a vision disability. No medical provider has diagnosed such a disability. The diagnosis of a visual impairment disability is a medical question (that requires medical expertise (informed by diagnostic studies)). The Veteran is a layperson and lacks the expertise to provide a competent opinion in the matter. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). He does not cite to supporting clinical data, medical opinion, or treatise evidence, and his opinion in the matter has no probative value. As there is no competent evidence that the Veteran has, or during the pendency of the claim has had, a vision disability, he has not presented a valid claim of service connection for such disability. See 38 U.S.C. § 1110, 1131;38 C.F.R. § 3.310; see also Brammer v. Derwinski, 3 Vet. App. 223 (1992). The preponderance of the evidence is against this claim. Accordingly, the appeal in the matter must be denied. 4. Service connection for a disability manifested by fatigue, claimed as CFS, to include as secondary to heat exhaustion, is denied. The Veteran’s June 1993 STRs note that he reported weakness after an episode of heat exhaustion. A July 1993 STR notes that his vascular system was normal on clinical evaluation. The Veteran submitted numerous statements in 2013 and 2014 in which he claimed fatigue due to heat exhaustion, TBI, and exposure to carbon monoxide. At the March 2016 videoconference hearing, the Veteran testified that after his June 1993 heat exhaustion episode, he had “tremendous amounts of chronic fatigue.” He related that he had trouble getting sufficient rest. A December 2017 VA medical opinion notes that the Veteran does not have CFS. The examiner explained that CFS is a disease of exclusion and that he has reported generalized fatigue in the record. She noted that the Veteran had many diagnoses which could be contributing to his symptoms of fatigue, such as sleep dysfunction secondary to a diagnosed psychiatric disorder, OSA, and other chronic health disorders such as hypothyroidism, obesity, and diabetes. These factors reduce the quality of sleep which in turn causes daytime sleepiness, which is manifesting as fatigue. VA treatment records through December 2017 do not show a diagnosis of CFS and CFS is not listed in the Veteran’s problem listing in medical records. The threshold requirement for substantiating a claim of service connection (whether direct or secondary) is that there must be competent evidence of the disability for which service connection is sought. Here, there is no competent evidence that the Veteran has, or at any time during the pendency of the instant claim has had, CFS. No medical provider has diagnosed such a disability. While the Veteran may be competent to observe that he feels fatigued on occasion, whether he has a diagnosis of an underlying disease for such symptom, such as CFS, is a medical question; he is a layperson and lacks the expertise to provide a competent opinion in the matter. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). He does not cite to supporting clinical data, medical opinion, or treatise evidence, and his opinion in the matter has no probative value. The only competent (medical) evidence in the record that adequately addresses whether or not the Veteran has CFS is in the report of the December 2017 VA examiner, who found that the Veteran did not have such diagnosis. The provider noted that a review of the record did not reveal any findings, signs, or symptoms of CFS. The Board finds the opinion probative evidence, and (without competent evidence to the contrary) persuasive. As there is no competent evidence that the Veteran has, or has had, CFS, he has not presented a valid claim of service connection for such disability. See 38 U.S.C. § 1110; 38 C.F.R. § 3.310; see also Brammer v. Derwinski, 3 Vet. App. 223 (1992). The preponderance of the evidence is against this claim. Accordingly, the appeal in the matter must be denied. 5., 6., 7., 8. Service connection for right and left hip and right and left ankle disabilities is denied. The Veteran’s STRs are silent for complaints or treatment for, or diagnosis of right and left hip and ankle disabilities. His military occupation specialty (MOS) was plumber and quarry man. A July 2013 private treatment record notes that there was no report of injury to the Veteran’s hips during “National Guard drill.” The Veteran reported that he hurt his hips lifting, twisting, and getting into different positions working as a plumber. On examination, the hip joints, trochanteric bursa, and iliotibial tracts were unremarkable. There was tenderness over the ankles consistent with traumatic arthritis. The diagnoses were left and right lumbosacral plexus and sciatic nerve impingement and lumbosacral strain. At the March 2016 videoconference hearing, the Veteran testified that he did not have a diagnosis of an ankle disability. Records of the Veteran’s VA treatment during the pendency of the claim do not show diagnoses of, or treatment for, ankle or hip disabilities. Whether any ankle and hip disabilities may (in the absence of onset in service/continuity since) be related to an event in service that ended more than 20 years earlier is a medical question outside the scope of common knowledge. It requires medical expertise. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). The Veteran is a layperson and has not presented any competent (medical opinion/textual) evidence in support of his theory that his claimed ankle and hip disabilities are etiologically related to his service. His own opinion is not competent evidence in this matter. Regarding the private diagnosis of traumatic ankle arthritis, the Board notes that such diagnosis is not shown to have been based on X-rays. The Veteran did not have 90 days of active duty service, and the chronic disease presumption provisions of 38 U.S.C. § 1112; 38 C.F.R. § 3.309 (c) do not apply. See 38 C.F.R. § 3.307. There is no probative evidence that shows or suggests that any ankle and hip disability may be etiologically related to the Veteran’s service. The preponderance of the evidence is against these claims, and the appeal in the matter must be denied. 9., 10. Service connection for right and left foot disabilities is denied. The Veteran’s STRs are silent for complaints or treatment for, or diagnoses of a foot disability. In testimony at the March 2016 videoconference hearing, the Veteran acknowledged that he does not have a diagnosis of a foot disability. VA treatment records through December 2017 do not show a diagnosis of a foot disability and a foot disability is not listed in the Veteran’s problem listing in medical records. The threshold requirement for substantiating a claim of service connection (whether direct or secondary) is that there must be competent evidence of the disability for which service connection is sought. Here, there is no competent evidence that the Veteran has, or at any time during the pendency of the instant claim has had, a foot disability. No medical provider has diagnosed such a disability. While the Veteran may be competent to observe that he has foot pain on occasion, whether or not he has an underlying foot disability is a medical question; he is a layperson and lacks the expertise to provide a competent opinion in the matter. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). He does not cite to supporting clinical data, medical opinion, or treatise evidence, and his opinion in the matter has no probative value. As there is no competent evidence that the Veteran has, or has had, a foot disability, he has not presented a valid claim of service connection for such disability. See 38 U.S.C. § 1110; 38 C.F.R. § 3.310; see also Brammer v. Derwinski, 3 Vet. App. 223 (1992). The preponderance of the evidence is against the claim. Accordingly, the appeal in the matter must be denied. 11. Service connection for asbestosis is denied. The Veteran’s STRs are silent for complaints, treatments, or diagnosis of a lung disability, to include asbestosis. As noted above, he was a plumber during service, so he had possible exposure to asbestos. An April 2013 chest X-ray found that the soft tissues of the Veteran’s lungs and bony thorax were unremarkable, the lungs were well expanded and clear, and there was no active or acute disease. A July 2013 private treatment record notes that the Veteran reported that he worked around pipes that were wrapped in asbestos, the asbestos was dry and flaky, and he would get the substance on his clothes and hands. The provider opined that it is as likely as not that the Veteran would have inhaled asbestos fibers, and therefore has a diagnosis of asbestosis. He also noted that the Veteran “does not have the fibers in his body. It means he has asbestosis. It does not mean he has any disability or impairment at the present time.” There is no indication that X-rays were performed. At the March 2016 videoconference hearing, the Veteran testified that he was a plumber during service and that asbestosis was diagnosed by his private provider. He reported that the provider did not do a chest CT scan or chest X-ray before he gave the asbestosis diagnosis. VA treatment records through December 2017 do not show a diagnosis of asbestosis, and asbestosis is not listed in the Veteran’s problem listing in medical records. The Board finds that the July 2013 opinion by the private provider assigning the Veteran a diagnosis of asbestosis has no probative value. The provider did not conduct any diagnostic studies, and the explanation that the Veteran” does not have the fiber in his body” and does not have “any disability or impairment at the present time” contradicts (and does not support) that he has such disability. There is no competent evidence that shows or suggests that the Veteran has or has had asbestosis. The preponderance of the evidence is against this claim, and the appeal in the matter must be denied. 12. Service connection for OSA, to include as secondary to heat exhaustion, is denied. The Veteran’s STRs are silent for complaints, diagnoses, or treatment for OSA. A July 2009 sleep study found no evidence of clinically significant sleep apnea. A February 2010 sleep study showed a diagnosis of OSA. A July 2013 private treatment record, notes that the Veteran reported that he snores and stops breathing at night. The provider diagnosed sleep apnea. The provider opined that the Veteran’s brain injury (allegedly incurred in service), sluggishness and decreased mobility contributed to weight gain, and his weight gain resulted in obstruction of the air when he sleeps at night and contributes to sleep apnea. At the March 2016 videoconference hearing, the Veteran related that he thought his OSA was related to heat stroke or CFS. It is not in dispute that the Veteran now has OSA (shown by a February 2010 sleep study). He has presented alternate theories of entitlement to service connection for OSA, direct and secondary. Regarding the direct service connection theory of entitlement, his STRs are silent for complaints, findings, treatment or diagnosis regarding OSA. OSA was not diagnosed until 2010. Accordingly, service connection for OSA on the basis that it became manifest in service and persisted is not warranted. The diagnosis of an insidious disability such as sleep apnea is a medical question. While the Veteran may be able to establish by his own observation that he had symptoms that might be associated with OSA, because he is a layperson he is not competent to establish that such symptoms establish that OSA was then present; that requires medical expertise. The July 2013 private provider’s opinion relating his sleep apnea in part to a brain injury in service is based on an inaccurate factual premise (such injury is not shown) and lacks probative value. The only competent (medical) and probative evidence regarding a nexus between the Veteran’s current OSA and his remote service is in the opinion by the December 2017 VA examiner, who expressed familiarity with record, noted that STRs did not document OSA, and noted that OSA was not diagnosed until 2010 (over 10 years following discharge from service). The Board finds that opinion persuasive evidence in establishing that OSA was not incurred in service. The Board notes that the lengthy postservice interval before the Veteran’s OSA was clinically documented and diagnosed is also probative evidence weighing against the theory that sleep apnea became manifest in service, and has been present ever since. Accordingly, the Board finds that the preponderance on the evidence is against the direct service connection theory of entitlement. The Veteran’s secondary service connection theory of entitlement is premised on an allegation that his OSA was either caused or aggravated by heat exhaustion or CFS. Since heat exhaustion and CFS are not service-connected, the secondary service connection theory of entitlement is legally insufficient. The preponderance of the evidence is against the Veteran’s claim for service connection for OSA, under both direct and secondary service connection theories of entitlement. Accordingly, the appeal in the matter must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 13. Service connection for a thyroid disability, to include as secondary to heat exhaustion, is denied. The Veteran’s STRs are silent for complaints, diagnoses, or treatment for a thyroid disability. January 2014 to November 2017 private treatment record note diagnosis and treatment for a thyroid disability. At the March 2016 videoconference hearing, the Veteran testified that he took medication for a thyroid disability. It is not in dispute that the Veteran has a thyroid disability. He has presented alternate theories of entitlement to service connection for his thyroid disability, direct and secondary. Regarding the direct service connection theory of entitlement, his STRs are silent for complaints, findings, treatment or diagnosis regarding a thyroid disability. A thyroid disability was not diagnosed until 2013. Accordingly, service connection for a thyroid disability on the basis that it became manifest in service and persisted is not warranted. The diagnosis of a thyroid disability is a medical question. While the Veteran may be able to establish by his own observation that he had symptoms that might be associated with a thyroid disability, because he is a layperson he is not competent to establish that such symptoms establish that a thyroid disability was then present; that requires medical expertise. The only competent (medical) evidence regarding a nexus between the Veteran’s current thyroid disability and his remote service is in the opinion by the December 2017 VA examiner, who expressed familiarity with record, noted that STRs do not document a thyroid disability, and that a thyroid disability was not diagnosed until 2013 (over 10 years following discharge from service). The Board finds that opinion persuasive evidence in establishing that a thyroid disability was not incurred in service. Accordingly, the Board finds that the preponderance on the evidence is against the direct service connection theory of entitlement. The Veteran’s secondary service connection theory of entitlement is premised on an allegation that his thyroid disability was either caused or aggravated by heat exhaustion. Since heat exhaustion is not service-connected, the secondary service connection theory of entitlement is without legal merit. The preponderance of the evidence is against the claim of service connection for a thyroid disability, under both direct and secondary service connection theories of entitlement. Accordingly, the appeal in the matter must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 14. Service connection for RLS, to include as secondary to heat exhaustion, is denied. The Veteran’s STRs are silent for complaints, diagnoses, or treatment for RLS. February 2010 private treatment records note treatment for, and a probable diagnosis of, RLS. At the March 2016 videoconference hearing, the Veteran testified that RLS was diagnosed by a private physician. It is not in dispute that the Veteran has RLS. He has presented alternate theories of entitlement to service connection for the RLS, direct and secondary. Regarding the direct service connection theory of entitlement, his STRs are silent for complaints, findings, treatment or diagnosis regarding his RLS. RLS was not diagnosed until 2010. Accordingly, service connection for RLS on the basis that it became manifest in service and persisted is not warranted. The diagnosis of RLS is a medical question. While the Veteran may be able to establish by his own observation that he had symptoms that might be associated with RLS in service, because he is a layperson he is not competent to establish that such symptoms establish that RLS was then present; that requires medical expertise. The only competent (medical) evidence regarding a nexus between the Veteran’s current RLS and his remote service is in the opinion by the December 2017 VA examiner, who expressed familiarity with record and cited to supporting factual data. Accordingly, the Board finds that the preponderance on the evidence is against the direct service connection theory of entitlement. The Veteran’s secondary service connection theory of entitlement is premised on an allegation that his RLS was either caused or aggravated by heat exhaustion. Since heat exhaustion is not service-connected, that theory lacks legal merit. The preponderance of the evidence is against the claim of service connection for RLS, under both direct and secondary service connection theories of entitlement. Accordingly, the appeal in the matter must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 15. Entitlement to service connection for memory loss, to include as secondary to TBI or heat exhaustion, is denied. The Veteran’s STRs are silent for complaints, findings, diagnoses, or treatment of memory loss. A July 2013 private treatment record notes that the Veteran reported trouble with his memory since a heat exhaustion episode in June 1993. At the March 2016 videoconference hearing, the Veteran testified that he had memory loss due to his heat exhaustion episode during service in June 1993. On December 2017 VA psychiatric examination, schizotypal personality disorder was diagnosed. The examination found memory loss to be a symptom of the schizotypal personality disorder. Memory loss was not manifested in service or in the Veteran’s first postservice year. Service connection for this disability on the basis that it was incurred in service is not warranted. Regarding the secondary service-connection theory of entitlement proposed, as TBI and heat exhaustion are not service-connected (and this decision upholds that determination), such theory of entitlement lacks legal merit. 38 C.F.R. § 3.310. There is no competent evidence that the Veteran’s memory loss may be directly related to his service, and his secondary service connection theory of entitlement lacks legal merit. The preponderance of the evidence is against this claim, and the appeal in the matter must be denied. 16. Service connection for ED is denied. The Veteran’s STRs are silent for complaints or diagnosis of, or treatment for, ED. A 2014 VA treatment record notes that the Veteran reported a reduced libido and difficulty gaining and erection and took Sildenafil. At the March 2016 videoconference hearing, the Veteran testified that he took Viagra prescribed by VA. It is not in dispute that the Veteran has ED. He has presented alternate theories of entitlement to service connection for his ED, direct and secondary. Regarding the direct service connection theory of entitlement, his STRs are silent for complaints, findings, treatment or diagnosis regarding his ED. ED was not diagnosed until 2014. Accordingly, service connection for ED on the basis that it became manifest in service and persisted is not warranted. The etiology of ED is a medical question. The only competent (medical) evidence regarding a nexus between the Veteran’s current ED and his remote service is in the opinion by the December 2017 VA examiner, who expressed familiarity with record, noted that STRs did not document ED, and noted that ED was not diagnosed until 2014 (over 10 years following his discharge from service). The Board finds that opinion persuasive evidence in establishing that ED was not incurred in service. The Board notes that the lengthy postservice interval before the Veteran’s ED was clinically documented and diagnosed is also probative evidence weighing against the theory that RLS became manifest in service, and has been present ever since. Accordingly, the preponderance on the evidence is against the direct service connection theory of entitlement. The Veteran’s secondary service connection theory of entitlement is premised on an allegation that his ED was caused or aggravated by heat exhaustion. Since heat exhaustion is not service-connected, the secondary service connection theory of entitlement lacks legal merit. The preponderance of the evidence is against the Veteran’s claim for service connection for ED, under both direct and secondary service connection theories of entitlement. Accordingly, the appeal in the matter must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). REASONS FOR REMAND 17. Entitlement to service connection for vertigo, to include as secondary to hearing loss and tinnitus, or as due to exposure to solvents, is remanded. The December 2017 VA examiner opined that the Veteran’s vertigo was less likely than not proximately due to or the result of hearing loss and/or tinnitus. She explained that a review of the most recent medical literature noted that symptoms of vertigo, hearing loss, and tinnitus may overlap, but the literature did not support an etiological relationship between hearing loss and tinnitus and vertigo. The examiner also noted that there is no current diagnosis of vertigo, (although a private treatment record notes that in 2013 during the pendency of the claim, the Veteran was treated for vertigo). The opinion is inadequate for rating purposes as it does not address aggravation, and it did not address the allegation that such disability may be related to exposure to solvents in service. A further examination for an adequate medical advisory opinion is necessary. 18. Entitlement to service connection for headaches, to include as secondary to hearing loss and tinnitus, or as due to exposure to chemicals and vaccines is remanded. The December 2017 VA examiner opined that the Veteran’s headaches were less likely than not proximately due to or the result of hearing loss and/or tinnitus. She explained that a review of the most recent medical literature noted that symptoms of headaches, hearing loss, and tinnitus may overlap, but the literature did not support an etiological relationship between hearing loss and tinnitus and headaches. The examination is inadequate for rating purposes because it does not address aggravation, and does not address the allegation that the disability may be related to exposure to chemicals and vaccines in service. Therefore, an examination to provide an adequate medical advisory opinion is necessary. 18. Service connection for hypertension, to include as secondary to exposure to diesel fumes is remanded. The December 2017 VA examiner opined that heat exhaustion did not cause the Veteran’s hypertension (and service-connection for heat exhaustion is denied above). However, the examiner did not address whether the hypertension was caused or aggravated by alleged exposure to diesel fumes. An addendum advisory medical opinion addressing that alleged theory of entitlement is necessary. 19. Service connection for hemorrhoids, to include as secondary to a psychiatric disability is remanded. The Board finds that further development of the record remains necessary for proper adjudication of the instant claim. The December 2017 VA examiner opined that heat exhaustion did not cause the Veteran’s hemorrhoids (and service-connection for heat exhaustion was denied). However, the examiner did not address whether his hemorrhoids were caused or aggravated by a psychiatric disability (or medications taken for a psychiatric disability). Therefore, an addendum advisory medical opinion is necessary. 20. Service connection for GERD, to include as secondary to psychiatric disability or medication for service-connected disability, or as due to second-hand smoke exposure is remanded. The claim of service connection for GERD, to include as secondary to a psychiatric disability, is inextricably intertwined with the claim of service connection for a psychiatric disability, and consideration of that claim must be deferred pending resolution of the service connection for GERD claim. 21. Service connection for a psychiatric disability, to include as secondary to TBI, heat exhaustion, bilateral hearing loss, or tinnitus is remanded. In a statement submitted to VA, the Veteran raised an alternate theory of entitlement to service connection (that his claimed psychiatric disability is secondary to his service-connected bilateral hearing loss and/or tinnitus). Such theory has not yet been considered (or addressed in a medical opinion). Therefore, an examination to obtain a medical advisory opinion and adjudication that addresses the secondary service connection theory of entitlement raised is necessary. 22. Service connection for a back disability (arthritis) is remanded. A July 2013 private provider diagnosed lumbosacral strain and bilateral lumbosacral plexus with sciatic nerve impingement. The provider opined that it is more likely than not that the Veteran strained the iliolumbar and sacroiliac ligaments in service. The opinion is inadequate for rating purposes because it does not include adequate rationale. The Veteran’s STRs are silent for complaints, treatment, findings, or diagnosis pertaining to a back injury. He has not been afforded a VA examination to determine the etiology of his back disability. March 2013 VA treatment records note that the Veteran reported chronic back and neck pain, but there does not appear to be a clear diagnosis. In light of his contentions and the state of the medical evidence, an examination to secure a medical opinion regarding the etiology of his back disability is warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 23. Entitlement to SMC, based on the need for aid and attendance or housebound status, is remanded. As an award of service connection for vertigo, hypertension, hemorrhoids, GERD, ED, headaches, and a psychiatric disability may have bearing on the Veteran’s claim for SMC based on the need for regular aid and attendance, the claims are inextricably intertwined, and consideration of the SMC claim must be deferred pending resolution of the remanded service connection claims. The matters are REMANDED for the following: 1. Ask the Veteran to identify the types of solvents to which he was exposed, the installations where he was exposed, and the dates of exposure. Arrange for any necessary verification, and when such development is completed, the make a finding for the regarding the nature of any exposure to solvents the Veteran had during a period of federalized National Guard service. Then arrange for the Veteran to be examined by a neurologist to confirm whether he has a vertigo disability (and if so, determine its nature and etiology). The examiner should: (a) Opine whether if the Veteran has a disability manifested by vertigo. If vertigo is not diagnosed, reconcile that finding with the notations of vertigo (and its private treatment) in the record. (b) Identify the likely etiology of any vertigo disability. Specifically, is it at least as likely as not (a 50% or better probability) that the disability: (i) Is directly related to the Veteran’s period of federalized National Guard service (was incurred therein)? (ii) Was (A) caused or (B) aggravated by his service- connected hearing loss and/or tinnitus disabilities. The opinion must specifically address the concept of aggravation. If aggravation is found, please identify (to the extent possible) the degree of disability (additional manifestations and impairment) due to the aggravation. (iii) If it is conceded that he was exposed to solvents during a verified period of federalized National Guard service, determine whether the vertigo was caused or aggravate by his alleged exposure to solvents in service. (c) If vertigo is determined to be unrelated to the Veteran’s service, and to not have been caused or aggravated by a service connected disability identify (to the extent possible) the etiology considered more likely. (d) Identify the diagnosis (and the etiology)for the Veteran’s headaches. Is it at least as likely as not (a 50% or better probability) that the disability: (i) Is directly related to the Veteran’s service (was incurred therein)? (ii) Was (A) caused or (B) aggravated by his service- connected hearing loss and/or tinnitus disabilities. The opinion must specifically address the concept of aggravation. If aggravation is found, please identify (to the extent possible) the degree of disability (additional manifestations and impairment) due to the aggravation. (iii) Was caused or aggravate by his alleged exposure to chemicals or vaccines in service. (e) If a headache disability is determined to be unrelated to the Veteran’s service, and to not have been caused or aggravated by a service connected disability identify (to the extent possible) the etiology considered more likely. The examiner must include rationale with all opinions. 2. Return the Veteran’s record to the December 2017 VA examiner (or to another appropriate provider if the December 2017 examiner is not available) for further review and an addendum medical opinion regarding the etiology of the Veteran’s hypertension. The examiner should provide responses to the following: (a) Identify the likely etiology for the Veteran’s hypertension. Is it at least as likely as not (a 50% or greater probability) that it is etiologically related to (was incurred in) his service, period of federalized National Guard service in June 1993 when he suffered heat exhaustion? (b) If the Veteran’s hypertension is determined to not be directly related to a (qualifying for VA benefits) period of active duty service, is it at least as likely as not (a 50% or greater probability) that it was caused or aggravated by (increased in severity due to) exposure to diesel fumes? If the hypertension is determined to be unrelated to the Veteran’s service or exposure to diesel fumes, identify the etiology for the hypertension considered to be more likely. The examiner should include rationale with all opinions. 3. Arrange for the Veteran to be examined by a psychologist or psychiatrist to confirm the diagnosis(es) of his psychiatric disability(ies) (and ascertain its/their nature and etiology). The examiner should: (a) Identify (by diagnosis) each psychiatric disability entity found or shown by the record during the pendency of this claim. If none is diagnosed, reconcile that finding with the notations of psychiatric diagnoses in the record. (b) Identify the likely etiology of each psychiatric disability entity diagnosed. Specifically, is it at least as likely as not (a 50% or better probability) that the disability: (i) Is directly related to the Veteran’s service (was incurred therein)? (ii) Was (A) caused or (B) aggravated by service-connected bilateral hearing loss and/or tinnitus. The opinion must specifically address the concept of aggravation. If aggravation is found, please identify (to the extent possible) the degree of disability (additional manifestations and impairment) due to the aggravation. (c) If a diagnosed psychiatric disability is determined to be unrelated to the Veteran’s service, and to not have been caused or aggravated by a service connected disability please identify (to the extent possible) the etiology considered more likely. The examiner must include rationale with all opinions. 4. If (and only if) service connection for a psychiatric disability is established, arrange for the Veteran’s record to be forwarded to an appropriate physician for review and an advisory medical opinion as to whether or not his hemorrhoids have been caused or aggravated (the opinion must address aggravation) by the service-connected psychiatric disability (and its medication). [If further examination of the Veteran is deemed necessary for the opinion sought, such should be arranged]. The consulting physician must explain the rationale for the opinion offered. 5. If (and only if) service connection for a psychiatric disability is established, arrange for the Veteran to be examined by an appropriate physician to determine the most likely etiology for his GERD, and specifically, whether it is caused or aggravated by a psychiatric disability, medications taken for his service-connected disabilities, and/or exposure to second-hand smoke. The Veteran’s claims file must be reviewed by the examiner in conjunction with the examination, and any indicated studies or tests should be completed. Based on review of the record and examination of the Veteran, the examiner should provide opinions that respond to the following: (a) Is it at least as likely as not (a 50% or better probability) that GERD is related to the Veteran’s active military service/injuries therein? (b) If GERD is determined to not be directly related to the Veteran’s service, please opine whether it is at least as likely as not (a 50% or better probability) that the GERD was caused or aggravated by a psychiatric disability, medications the Veteran took for his service-connected disabilities, and/or exposure to second-hand smoke. The examiner must explain the rationale for all opinions. 6. Arrange for an orthopedic examination of the Veteran to determine the likely etiology of his back disability, and specifically whether or not it is directly related to (was incurred during) a federalized period of National Guard service/to include as due to activities/injuries therein. The Veteran’s record must be reviewed by the examiner in conjunction with this examination. On review of the record/examination of the Veteran, the examiner should: (a) Identify (by diagnosis) each back disability entity found/or shown during the pendency of the instant claim. (b) Identify the likely etiology for each back disability diagnosed. Is it at least as likely as not (a 50% or greater probability) that it was incurred during federalized National Guard service, due to his duties as a plumber? (c) If the opinion is that a current back disability was not incurred in service, identify the etiology considered more likely. Include rationale with all opinions. 7. The review the record and readjudicate entitlement to SMC considering the determinations on the other claims remanded. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Bayles, Associate Counsel