Citation Nr: 18142085 Decision Date: 10/12/18 Archive Date: 10/12/18 DOCKET NO. 13-15 247 DATE: October 12, 2018 ORDER Entitlement to service connection for headaches is granted. Entitlement to service connection for a psychiatric disorder, diagnosed as posttraumatic stress disorder (PTSD), is granted. Entitlement to service connection for hypertension is granted. Entitlement to service connection for a chronic diarrhea as a qualifying chronic disability under 38 C.F.R. § 3.317 is granted. Entitlement to service connection for diverticulitis is denied. Entitlement to service connection for fibromyalgia is denied. Entitlement to service connection for symptoms involving the respiratory system, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is denied. REMANDED Entitlement to service connection for obstructive sleep apnea is remanded. Entitlement to service connection for a thyroid disability is remanded. Entitlement to service connection for a skin disability is remanded. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran’s headaches are related his military service. 2. The evidence is at least evenly balanced as to whether the Veteran’s PTSD are due to his combat stressors. 3. The evidence is in equipoise as to whether the Veteran’s hypertension is related to his military service. 4. The Veteran’s chronic diarrhea is a medically unexplained chronic multi symptom illness of unknown etiology. 5. The Veteran’s diverticulitis did not have its onset in service and is not otherwise related to active duty. 6. The Veteran has not had a current disability of fibromyalgia or symptoms thereof during the appeal period or at any time approximate thereto. 7. The Veteran does not have a disability, separate from his nonservice-connected obesity, manifested by shortness of breath, dyspnea, and wheezing and does not have other related symptoms that have not been attributed to a known clinical diagnosis. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for headaches are met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 2. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for PTSD are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.303, 3.304. 3. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for hypertension are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for chronic diarrhea are met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 5. The criteria for entitlement to service connection for diverticulitis are not met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. 6. The criteria for entitlement to service connection for fibromyalgia are not met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. 7. The criteria for entitlement service connection for symptoms involving the respiratory system, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, are not met. 38 U.S.C. §§ 1110, 1117, 5107(b); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1970 to October 1970 and November 1990 to June 1991, including service in the Southwest Theater of Operations during the Persian Gulf War. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In that decision, the RO denied service connection for acquired psychiatric disorder, hypertension (then characterized as cardiovascular symptom), headaches (characterized as cephalgia), fibromyalgia, gastrointestinal disorder (characterized as diverticulosis), sleep disturbance, respiratory system, thyroid disability (characterized as thyromegaly) and a skin disability (characterized as scabies). The issues on appeal have been recharacterized to more accurately reflect the nature and scope of the claimed disabilities. In March 2015, the Veteran testified at a Board hearing before a Veterans Law Judge (VLJ) who is unavailable to participate in the present decision. The Veteran elected to have a new hearing. In May 2016, the Board remanded the Veteran’s claims to schedule him for a Board hearing. In July 2016, the Veteran testified at a Board hearing before the undersigned VLJ. During the hearing, the Veteran to submitted additional evidence with a waiver. In November 2016, the Board remanded the Veteran’s claims to the agency of original jurisdiction (AOJ) for additional development. For the reasons indicated below, the AOJ complied with the Board’s remand instructions as to the service connection claims for PTSD, headaches, hypertension, gastrointestinal disorder (which has been bifurcated into to separate service connection claims for chronic diarrhea and diverticulitis herein) fibromyalgia, and symptoms involving the respiratory system. Stegall v. West, 11 Vet. App. 268, 271 (1998). In May 2017, the Decision Review Officer(DRO) granted service connection for chronic fatigue syndrome, assigned a 60 percent disability rating, effective March 5, 2010, which had previously been on appeal after being denied by the RO’s June 2011 rating decision. As the Veteran has not appealed either the evaluation or effective date assigned to this disability, this matter is not before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from a disease or injury incurred in active military service. 38 U.S.C.§ 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service incurrence of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The existence of current disability is the cornerstone of a service connection claim. Degmetich v. Brown, 104 F. 3d 1328 (1997) (interpretation of 38 U.S.C. § 1110 and 38 U.S.C. § 1131 as requiring the existence of a present disorder for VA compensation purposes cannot be considered arbitrary and decision based on that interpretation must be affirmed); Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). That a disease or injury occurred in service alone is not enough. There must be disability resulting from that disease or injury. In the absence of proof of a present disability, there can be no valid claim or the grant of the benefit. Rabideau, supra. A current disability encompasses includes one that exists proximately to filing the claim or during the claims period, even if it later resolves. McClain v. Nicholson, 21 Vet. App. 319 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 303 (2013) (to the effect that where a disease or disability is diagnosed proximate to the current appeal period, but not currently, the Board is required to determine whether the earlier diagnosis was inaccurate or the previously diagnosed condition had gone into remission). Applicable Law for Veterans with Service in the Southwest Asia Theater of Operations during the Persian Gulf War. Under 38 U.S.C. § 1117 (a)(1), compensation is warranted for a Persian Gulf veteran who exhibits objective indications of a “qualifying chronic disability” that became manifest during service on active duty in the Armed Forces in the Southwest Asia Theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the Secretary. Effective October 16, 2012, VA extended the presumptive period in 38 C.F.R. § 3.317 (a)(1)(i) through December 31, 2021 (for qualifying chronic disabilities that become manifest to a degree of 10 percent or more after active duty in the Southwest Asia Theater of operations). See 77 Fed. Reg. 71382 (2016). Furthermore, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a), (b) (2016). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. 1117 (d) warrants a presumption of service-connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117; 38 C.F.R. § 3.117, unlike those for “direct service connection,” there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. A medically unexplained chronic multi symptom illnesses is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and, functional gastrointestinal disorders, as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi symptom illness. A “medically unexplained chronic multi symptom illness” means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317 (b). 1. Entitlement to service connection for headaches. The Veteran seeks service connection for headaches, which he attributes to his in-service exposure to environmental hazards, such as inhaling burning oil and consistently surround by smoke, while stationed in Southwest Asia. See Veteran’s statement date June 2010. At the outset, the Veteran served four months in the Southwest Asia Theater of Operations during his second period of active duty; therefore, he is a Persian Gulf veteran within the meaning of the applicable statute and regulation. However, here, the Veteran has been diagnosed with current headaches during a January 2017 VA examination. As such, the Veteran’s diagnosed headaches are, therefore, not a medically unexplained chronic multi symptom illness and 38 U.S.C. § 1117 is not applicable. Nevertheless, the Veteran may still establish service connection on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994); 38 U.S.C. § 1113 (b). For the following reasons, entitlement to service connection for headaches is warranted. As illustrated above, the Veteran has a current diagnosis of headaches. See, e.g., VA examination reports dated January 2017. The Veteran’s DD Form 214 and service records demonstrate that he served in the operation of Dessert Shield/ Desert Storm in Southwest Asia as a motor transport operator. The Veteran’s service treatment records (STRs) do not show that he reported headaches during service. However, the Veteran has reported that prior to military service, he did not have headaches and that he began experiencing headaches during his military service. See Veteran’ statement dated June 2010. The Veteran is competent to report matters within his personal knowledge-such as events that occurred in service, as well as the nature, onset, and continuity of his headaches symptoms. See, e.g., Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); Charles v. Principi, 16 Vet. App 370, 374 (2002). As the Veteran’s reports concerning the onset of headaches are competent and there is no evidence to find that the Veteran is not credible. The in-service disease or injury element has been met. This case turns on the remaining element of service connection, which is whether the Veteran’s headaches are related to or had their onset during service. Here, there are two opinions that address the etiology of the Veteran’s headaches. In June 2010, the Veteran was afforded a VA examination; the examiner documented the Veteran’s reports of headaches. In a February 2011 VA opinion, the examiner who examined the Veteran in June 2010 opined that the Veteran’s headaches are less likely than not caused by his military service. The examiner reasoned that the Veteran reported that his onset of headaches began in 2008, which is 17 years after his military service. The examiner indicated that the Veteran’s STRs were not reviewed. In January 2017, a VA examiner opined that it is at least as likely as not (50% or greater probability) that the Veteran’s current headaches are related to service. The examiner reasoned the Veteran served in Saudi Arabia, UAE, and Kuwait and was exposed to burn pit fires and oil well fires, which can contribute to Gulf war syndrome. The examiner noted that the headaches “could be” a component of his service-connected chronic fatigue syndrome. The February 2011 opinion is predicated on the fact that the Veteran’s headaches did not persist in and since service, without regard to whether they were related to exposure to environmental hazards. Furthermore, the examiner did not review of the service treatment records. Therefore, the February 2011 VA opinion is afforded no probative value as it was based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative). As to the January 2017 opinion, the portion of the opinion that stated the Veteran’s headaches “could be” a component of his service-connected chronic fatigue syndrome are afforded no probative value as the examiner’s use of the phrase “could be” is speculative, and thus, neither supports nor opposes his claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions that are speculative, general, or inconclusive in nature cannot support a claim). The portion of the January 2017 opinion that found that the Veteran’s headaches are due to his military service is afforded probative value, as the VA examiner explained the reasons for his conclusions based on an accurate characterization of the evidence of record, and the opinion is entitled to significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). In sum, the evidence is at least evenly balanced as to whether the Veteran’s current headaches are related to service, specifically, exposure to environmental hazards in Southwest Asia. As the reasonable doubt created by this approximate balance in the evidence must be resolved in favor of the Veteran, entitlement to service connection for headaches is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for PTSD. There are particular requirements for establishing PTSD found in 38 C.F.R. §3.304 (f), which are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD, requires a medical evidence of PTSD, medical evidence that establishes a link between current symptoms and an in-service stressor, and credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. §3.304 (f). If a veteran engaged in combat and the claimed stressor is related to combat, the veteran’s lay testimony alone generally is sufficient to establish the occurrence of the claimed in-service stressor, absent clear and convincing evidence to the contrary and provided that the claimed stressor is consistent with the circumstances of the Veteran’s service. 38 C.F.R. § 3.304(f)(2). The Veteran claims that his PTSD is due to his in-service stressors. See P.R. Ludwig, Ph. D, LPC-S, NCC, report dated June 2017. He has reported several in-service stressors that caused his PTSD. For instances, he contends that his PTSD is the result of fear from SCUD missile attacks while stationed in the Persian Gulf during Desert Storm. See, e.g., Veteran’s statement dated June 2010 and VA PTSD examination report dated November 2010. The Veteran indicated that during service, he consistently observed SCUD missiles intercepted from attacking his military base; however, some SCUD missiles penetrated and exploded with his post parameters. Id. He also reported that on one occasion, the enemy surrounded himself and his sergeant, his sergeant loaded his handguns, and aimed the gun at the enemy, which then the enemy dispersed thereafter. See VA PTSD examination report dated January 2017. He also claims that while stationed in Saudi Arabia he was consistently surround by heavy smoke and that at time he was unable differentiate between day and night. See VA PTSD examination report dated November 2010. For the following reasons, entitlement to service connection for PTSD is warranted. The evidence shows that the Veteran has a current diagnosis of PTSD. Although the January 2017 VA examiner found that the Veteran did not have a diagnosis of PTSD that conforms to the DSM-5 criteria, in a May 2012 VA initial psychological assessment, a VA psychologist interviewed the Veteran and diagnosed PTSD. Additionally, the Veteran’s treating mental health care, P.R. Ludwig, Ph.D., LPC-S, NCC, provider also diagnosed PTSD. See P.R. Ludwig, Ph.D., LPC-S,NCC,’s statement dated June 2017 and undated statement. Therefore, a current diagnosis element is met. The credible evidence supports the Veteran’s reported in-service stressors. The Veteran’s DD Form 214 and service records demonstrate that he served in the operation of Dessert Shield/ Desert Storm in Southwest Asia as a motor transport operator. Although, the Veteran did not receive any medals indicative of combat, the evidence in the record supports a finding that the Veteran engaged in combat with the enemy and the claimed stressor is related to that experience. VAOPGCPREC 12-99 (October 18, 1999) (combat determination should be made on a case by case basis where there is no medal specifically indicating combat service). To this end, the Veteran reports several stressors related to traumatic experiences that occurred while serving in combat in the Gulf War. While not documented, the Veteran’s reported stressors are credible as they appear consistent with nature of his service in Southwest Asia as a motor transport operator. In May 2012, a VA psychologist determined that the Veteran’s reported in-stressors were sufficient to support a current diagnosis of PTSD due to the Veteran’s combat military service. Additionally, in an undated treatment note from P.R. Ludwig, Ph.D., LPC-S, NCC, the Veteran’s private mental health care treatment provider, also determined that the Veteran’s reported Gulf War experiences were sufficient to support a current diagnosis of PTSD. Furthermore, the January 2017 VA examined noted that during the Veteran’s service in the Persian Gulf “[h]e was exposed to war zone experiences. Therefore, the evidence supports that the Veteran engaged in combat. See Gaines v. West, 11 Vet. App. 353, 359 (1998) (holding that evidence submitted to support a claim that a veteran engaged in combat may include the veteran’s own statements and an “almost unlimited” variety of other types of evidence.) Given that the Veteran’s in-service stressors (namely trauma he endured during SCUD missile attacks and his engagement with the enemy when he was with his sergeant) is consistent with the circumstances of his service and the absence of clear and convincing evidence to the contrary, the Veteran’s statements establish the occurrence of his in-service stressors. Therefore, the remaining question is whether there is a relationship between PTSD and his in-service stressors. There are two opinions that address the etiology of the Veteran’s PTSD. In a May 2012 VA initial psychological assessment, a VA psychologist interviewed the Veteran and documented his reported military trauma. For instance, the VA psychologist noted the Veteran’s reports of SCUD missile attacks and burning fuel “for the original assault which last approximately 2 weeks in the theater of combat.” The VA psychologist diagnosed PTSD and related it to the Veteran’s combat military service while service in the Gulf war. The VA psychologist reasoned that the Veteran’s response to his military combat trauma has resulted in his current PTSD symptoms such as re-experiencing and hyperarousal symptoms. Two statements from P.R. Ludwig, Ph.D., LPC-S, NCC, indicated that he was providing a follow-up report of the Veteran since P.R. Ludwig’s last assessment of him in July 2016. P.R. Ludwig indicated that he diagnosed the Veteran with PTSD since July 2016 and that his psychiatric symptoms had improved as he is able to diffuse his thoughts concerning his military trauma. P.R. Ludwig also stated that the Veteran’s PTSD “is more likely than not service connect[ed].” The opinions above, taken as whole, that attributed the Veteran’s PTSD symptoms to his military experience are afforded probative value as to whether there is a link between the Veteran’s PTSD and his in-service combat stressors. The May 2012 VA psychologist explained the reasons for her conclusion based on an interview of the Veteran, his reported history, and his current PTSD symptoms. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Furthermore, although P.R. Ludwig, Ph.D., LPC-S, NCC, did not offer an explicit opinion with a rationale, it is readily apparent that the PTSD diagnosis was a result of the Veteran’s military service in the Persian Gulf based on exposure to traumatic events in service. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner “did not explicitly lay out the examiner’s journey from the facts to a conclusion,” did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). The evidence is thus at least evenly balanced as to whether the Veteran’s PTSD is related to his in-service stressors. As the reasonable doubt created by this approximate balance in the evidence must be resolved in favor of the Veteran, entitlement to service connection for PTSD is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. To the extent that other psychiatric disorders have been diagnosed, there is no indication that there are distinct psychiatric symptoms attributable to such disorders, and all psychiatric symptoms will therefore be attributed to the now service-connected PTSD. See Howell v. Nicholson, 19 Vet. App. 535, 540 (2006); Mittleider v. West, 11 Vet. App. 181, 182 (1998) (VA must apply the benefit of the doubt doctrine and attribute the inseparable effects of a disability to the claimant’s service-connected disability). Consequently, consideration of whether other psychiatric disorders are related to service is unnecessary. 3. Entitlement to service connection for hypertension. The Veteran claims that his hypertension is due to his military service and that he has had symptoms of hypertension, such as increased heart rate and shortness of breath, in and since service. See, e.g., Veteran’s statement dated June 2010 and VA examination report dated January 2017. The Veteran explained that while serving in Southwest Asia, he was consistently exposed to burning oil wells, smoke, and that he inhaled such toxics. See Veteran’s statement dated June 2010. For the following reasons, entitlement to service connection for hypertension is warranted. The evidence, most recently in a January 2017 VA examination report, shows that the Veteran has a current diagnosis of hypertension. As to whether the Veteran’s current hypertension is related to service, the evidence shows that in-service blood pressure readings nearly meet the criteria for hypertension for VA compensation purposes, which is defined, in pertinent part, as diastolic blood pressure is predominantly 90mm. or greater. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1; STRs (120/80 in March 1991; 120/86 in January 1991; 118/82 in February 1991). Additionally, the Veteran credibly testified that he has experienced symptoms of hypertension, such as increased heart rate and shortness of breath, in and since service. In a January 2017 VA examination report, in response to an inquiry as to whether the Veteran’s current hypertension is related to service, a VA examiner opined that it is at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner reasoned that when the Veteran served in Saudi Arabia, UAE, and Kuwait and that he was exposed to burn pit fires and oil well fires which can contribute to Gulf war syndrome. In a separate portion of the opinion, the examiner opined, without rationale, that the Veteran’s current hypertension is not related to service. Despite the apparent internal inconsistency of the examiner’s opinions, the evidence of record, namely credible reports of symptoms in and since service coupled with incidents of elevated blood pressure readings in service, supports the Veteran’s service connection claim for hypertension. Indeed, to the extent that the January 2017 VA examiner’s negative opinion lacks rationale, it carries not probative value. In sum, the evidence is at least evenly balanced as to whether the Veteran’s current hypertension is related to service. As the reasonable doubt created by this approximate balance in the evidence must be resolved in favor of the Veteran, entitlement to service connection for hypertension is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for chronic diarrhea. The Veteran seeks service connection for gastrointestinal problems, which has been diagnosed as chronic diarrhea and diverticulitis. See, e.g., VA examinations (February 2011 and January 2017). For the reasons below, entitlement to service connection for chronic diarrhea is warranted and entitlement to service connection for diverticulitis is not warranted. As to chronic diarrhea, the January 2017 VA examiner explained that the Veteran’s chronic diarrhea is a medically unexplained chronic multi symptom illness of unknown etiology. The examiner further stated that the Veteran’s diarrhea could be related to exposure to environmental hazards in Southwest Asia. Pursuant to 38 C.F.R. § 3.317, a presumption of service connection is warranted for qualifying chronic disabilities, to include a medically unexplained chronic multi- symptom illness. The United States Court of Appeals for Veterans Claims has found that under 38 C.F.R. § 3.317 (a)(2)(i)(B), if a veteran has a chronic multi symptom illness other than chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome, it is solely a medical determination as to whether that illness qualifies under this section as a “medically unexplained chronic multisystem illness.” See 75 Fed. Reg. 61,995, 61, 996 (Oct. 7, 2010) (final rule). Here, in a January 2017 VA examination report, the VA examiner expressly stated that the Veteran’s chronic diarrhea is a medically unexplained chronic multisystem illness of unknown etiology, thereby, triggering the presumption of service connection. Indeed, the examiner is competent to render an opinion to this effect. Additionally, the examiner’s opinion that the Veteran’s diarrhea could be related to exposure to environmental hazards in Southwest Asia, albeit speculative, weights in favor of presumptive service connection. Absent evidence against the presumption of service connection, service connection for chronic diarrhea is warranted. As the reasonable doubt created by this approximate balance in the evidence must be resolved in favor of the Veteran, entitlement to service connection for chronic diarrhea is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. As to diverticulitis, the Veteran’s STRs do not show a diagnosis of diverticulitis or complaints of symptoms thereof. In June 2010, the Veteran was afforded a VA examination. The examiner the diagnosed diverticulosis. In February 2011, the VA examiner, who examined the Veteran in June 2010, opined that the Veteran’s diverticulitis was not related to service. The examiner reasoned that diverticulitis is a structural abnormality in the large intestine with no known nexus to service in the Gulf War. The February 2011 VA examiner’s opinion is entitled to significant probative weight. As the VA examiner explained the reasons for his conclusions based on an accurate characterization of the evidence of record, his opinion is entitled to significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). To any extent that the Veteran asserts that his diverticulitis is due to his military service is afforded no probative value, as the etiology of diverticulitis, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The etiology of the diverticulitis would require medical expertise to opine as to the causes of it and its relationship to the Veteran’s military service. Thus, the Veteran’s statements as to etiology of the diverticulitis are afforded no probative value. As the probative evidence of record does not indicate that the Veteran’s diverticulitis is related to service or that it had its onset in service, service connection for diverticulitis is not warranted. For the foregoing reasons, entitlement to service connection for diverticulitis is not warranted. The preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for diverticulitis and benefit of the doubt doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to service connection for fibromyalgia. In March 2010, the Veteran submitted a service connection claim for fibromyalgia. In June 2010, the Veteran was afforded a VA examination. The Veteran reported that he has never been diagnosed with fibromyalgia, but he “hurts everywhere.” The examiner concluded that there was no diagnosis of fibromyalgia. The examiner indicated that a muscle examination was normal. In January 2017 the Veteran was afforded fibromyalgia examination. The examiner indicated that he explained fibromyalgia symptoms with the Veteran and that the Veteran denied symptoms of fibromyalgia. The examiner indicated that a muscle examination was normal. The examiner indicated that the Veteran has never been diagnosed with fibromyalgia. For the following reasons, entitlement to service connection for fibromyalgia is not warranted. The Veteran’s claim must be denied because there is no diagnosis of fibromyalgia during the pendency of the claim. In fact, during the January 2017 VA examination, the Veteran denied any symptoms of fibromyalgia. To this extent 38 U.S.C. § 1117 is not applicable as the Veteran has denied experiencing any symptoms. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Thus, a necessary element for establishing any claim for entitlement to service connection is the existence of a current disability. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that section 1110 of the statute requires the existence of a present disability for VA compensation purposes); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board’s adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As noted, the Veteran filed his claim in this case in July 2008. However, there is no bright line rule prohibiting consideration of evidence dated prior to the claim, and the Board has considered such evidence in the decision below. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013) (Board erred in failing to address pre-claim evidence in assessing whether a current disability existed, for purposes of service connection, at the time the claim was filed or during its pendency). To any extent that the Veteran asserts that he has a current fibromyalgia disability that is related to his military service, his statements are not probative, as the Veteran lacks the medical expertise to diagnose a complex condition such as a fibromyalgia or to render a nexus opinion relating such condition to a service-connected disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Given the lack of competent evidence that the Veteran has or has had fibromyalgia during the appeal period, the claim must be denied. In the absence of proof of a present disability there can be no valid claim. Brammer, 3 Vet. App. at 225; see also Rabideau, 2 Vet. App. at 143-44. 6. Entitlement to service connection for symptoms involving the respiratory system, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. The Veteran seeks service connection for symptoms involving the respiratory system, such as shortness of breath, dyspnea, and wheezing, attributes to his military service. The Veteran’s STRs show no complaints of symptoms involving the respiratory system. His March 1991 separation report from his second period of active duty reveals normal clinical evaluation of the nose, sinuses, mouth, throat, and ears. In June 2010, the Veteran was afforded a VA examination. He reported shortness of breath with exertion. The examiner noted that an April 2010 CT of the chest showed no abnormalities of the chest. The examiner concluded that there was no current diagnosis as the respiratory examination showed a normal examination. In January 2017, he was afforded a VA examination. During the examination, the Veteran reported that he experiences exertional dyspnea without wheezing when walking short distances. The examiner indicated that the Veteran has never been diagnosed with a respiratory condition. The Veteran denied the use of any medication to treat his reported his respiratory symptoms. The VA examiner opined that the Veteran’s reported respiratory symptoms are not due to undiagnosed illness or his military service. The examiner reasoned that the Veteran’s exertional dyspnea is due obesity and not conditioned. Based on the foregoing, service connection for symptoms involving the respiratory system is not warranted. First, the Veteran does not have a current respiratory disorder. In fact, VA examiners made affirmative findings to this effect in June 2010 and January 2017. These opinions and findings carry significant probative weight as they were rendered by medical professionals who considered the Veteran’s prior medical history and in-person examination of the Veteran. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Additionally, the Veteran does not contend that he has a specific respiratory diagnosis. Absent evidence of a current disability, service connection on a direct basis is not warranted. Second, the Veteran’s reported shortness of breath, dyspnea, and wheezing, are symptoms of his nonservice-connected obesity. For the reasons detailed above, the January 2017 VA examiner’s opinion that the Veteran’s reported symptoms are related to his nonservice-connected obesity carries significant probative value. See Stefl v, 21 Vet. App. at 123. While the Veteran is competent and credible to report such symptoms, his opinion that the symptoms are related to his service in the Southwest Asia theater of operations during the Persian Gulf War carries no probative value as he lacks the requisite medical expertise to render an opinion regarding the complex etiology of a symptoms such as shortness of breath, dyspnea, and wheezing. Based on the foregoing, the preponderance of evidence, namely the uncontroverted January 2017 VA examiner’s opinion, shows that the Veteran’s reported shortness of breath, dyspnea, and wheezing are symptoms of his nonservice-connected obesity. Third, the preponderance of the evidence reflects that the Veteran does not meet the criteria for a qualifying chronic disability under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. As discussed above, the January 2017 VA examiner persuasively explained that the symptoms for which the Veteran seeks service connection—shortness of breath, dyspnea, and wheezing—are attributable to nonservice-connected obesity. Additionally, the Veteran’s medical records show that he has not been diagnosed with a current respiratory disorder and the June 2010 and January 2017 VA examiners affirmatively determined that the Veteran does not have a current respiratory disorder. As there are no other symptoms that could not be attributed to a known clinical diagnosis, entitlement to service connection is therefore not warranted on a direct basis or under the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for symptoms involving the respiratory system. The benefit-of- the-doubt doctrine is therefore not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea is remanded. Further development is needed to ascertain the etiology of the Veteran’s current obstructive sleep apnea, which was initially diagnosed via polysomnogram in October 2016. See VA examination (February 2011) (noting that the Veteran did not have a current diagnosis of sleep apnea at that time). While several VA treatment providers, to include the provider that referred the Veteran for sleep study, note that the Veteran’s now service-connected psychiatric disorder causes sleep disturbance, the record is absent competent medical evidence directly addressing whether the Veteran’s current sleep apnea is related to service or a service-connected disability, to include chronic fatigue syndrome or PTSD. Absent competent medical evidence to this effect, the Board lacks the requisite medical expertise to render a decision on the Veteran’s claim. 2. Entitlement to service connection for thyroid and skin disabilities are remanded. The Veteran claims that his thyroid and skin disabilities are due to his military service. In November 2016, the Board remanded the Veteran’s claims to obtain VA examination to determine the nature and etiology of the Veteran’s thyroid and skin disabilities. In January 2017, the Veteran was afforded a VA examination. The VA examiner diagnosed hypothyroidism and malignant neoplasm and actinic keratosis and opined that they are less likely than not related to his military service. As to the thyroid disability, the examiner reasoned that the etiology is “partially explained” as the Veteran in 2005 underwent a right hemithyroidectomy and thereafter he developed hypothyroidism. With respect to the skin disability, no rationale was provided. The January 2017 opinion as to the thyroid and skin disabilities are flawed. As to the negative nexus opinion with respect to the thyroid disability, the examiner opinion was unclear and contradictory as the examiner stated that his disability was “partially explained” and suggested that his disability was the result of his right hemithyroidectomy procedure. As to the skin disability, the examiner did not provide a rationale for the negative nexus opinion rendered. Therefore, a remand is necessary to obtain an obtain that addressed the etiology of the Veteran’s thyroid and skin disabilities and to ensure compliance with the November 2016 Board remand. The matters are REMANDED for the following action: 1. The claims folder should be referred to an appropriate physician for an opinion as to the etiology of the Veteran’s obstructive sleep apnea. The physician should provide an opinion whether it is as least as likely as not (50 percent probability or more) that the Veteran’s diagnosed obstructive sleep apnea had its onset in service or is otherwise related to service. In addressing the above, the physician is to specifically address whether the Veteran’s sleep apnea is related to exposure to environmental hazards while serving in Southwest Asia. The physician should also provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the service-connected PTSD and/or chronic fatigue syndrome caused or aggravated his obstructive sleep apnea. If aggravated, specify the baseline of disability prior to aggravation, and the permanent, measurable increase in disability resulting from the aggravation. In addressing the above, the physician should address the Veteran’s private treatment provider’s statements that the Veteran’s sleep apnea is related to sleep disturbance, which has been attributable to his service-connected psychiatric disorder. 2. The claims folder should be referred to an appropriate physician for an opinion as to the etiology of the Veteran’s thyroid disability. The physician should provide an opinion whether it is as least as likely as not (50 percent probability or more) that the Veteran’s thyroid disability, diagnosed as hypothyroidism and malignant neoplasm, had its onset in service or is otherwise related to service. A complete rationale should accompany any opinion provided. The physician is advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account in formulating the requested opinion. 3. The claims folder should be referred to an appropriate physician for an opinion as to the etiology of any skin disability. The physician should provide an opinion whether it is as least as likely as not (50 percent probability or more) that the Veteran’s skin disability, diagnosed as actinic keratosis, had its onset in service or is otherwise related to service. A complete rationale should accompany any opinion provided. The physician is advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account in formulating the requested opinion. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Castillo, Associate Counsel