Citation Nr: 18143934 Decision Date: 10/22/18 Archive Date: 10/22/18 DOCKET NO. 13-32 751 DATE: October 22, 2018 ORDER New and material evidence not having been received, the application to reopen a claim of entitlement to service connection for otitis media is denied. New and material evidence having been received, the claim of entitlement to service connection for a right shoulder disorder is reopened; the appeal is granted to this extent only. Service connection for a right shoulder disorder is denied. Service connection for a left knee disorder is denied. Service connection for a right knee disorder is denied. Service connection for obstructive sleep apnea is denied. An initial compensable rating for latent tuberculosis (TB) is denied. REMANDED Entitlement to a rating in excess of 10 percent for skin tags is remanded. FINDINGS OF FACT 1. In a final rating decision issued in July 2000, the Agency of Original Jurisdiction (AOJ) determined that new and material evidence had not been received in order to reopen a claim of entitlement to service connection for otitis media. 2. Evidence added to the record since the final July 2000 denial is cumulative or redundant of the evidence of record at the time of the decision and does not raise a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for otitis media. 3. In a final rating decision issued in March 2009, the AOJ denied service connection for a right shoulder disorder. 4. Evidence associated with the record since the final March 2009 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a right shoulder disorder. 5. A right shoulder disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, arthritis did not manifest within one year of service discharge, and such is not caused or aggravated by service-connected latent TB. 6. A left knee disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, arthritis did not manifest within one year of service discharge, and such is not caused or aggravated by service-connected latent TB. 7. A right knee disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, arthritis did not manifest within one year of service discharge, and such is not caused or aggravated by service-connected latent TB. 8. Obstructive sleep apnea is not shown to be causally or etiologically related to any disease, injury, or incident during service, and is not caused or aggravated by service-connected latent TB. 9. For the entire appeal period, the Veteran’s latent TB is inactive, asymptomatic, and does not result in residual disability. CONCLUSIONS OF LAW 1. The July 2000 rating decision that determined that new and material evidence had not been received in order to reopen a claim of entitlement to service connection for otitis media is final. 38 U.S.C. § 7105(c) (West 1991) [(2012)]; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2000) [(2017)]. 2. New and material evidence has not been received to reopen a claim of entitlement to service connection for otitis media. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The March 2009 rating decision that denied service connection for a right shoulder disorder on is final. 38 U.S.C. § 7105(c) (2002) [(2012)]; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2008) [(2017)]. 4. New and material evidence has been received to reopen a claim of entitlement to service connection for a right shoulder disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. The criteria for service connection for a right shoulder disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 6. The criteria for service connection for a left knee disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 7. The criteria for service connection for a right knee disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 8. The criteria for service connection for obstructive sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 9. The criteria for an initial compensable rating for latent TB have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.88b, Diagnostic Code 6311, 4.88c. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1976 to November 1981 and from January 1985 to December 1990. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in April 2012, February 2016, April 2016 and August 2016 by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2015, the Veteran testified at a Board hearing before a Veterans Law Judge regarding the issue of entitlement to an increased rating for skin tags. A transcript of the hearing is of record. However, since such time, the Veterans Law Judge who conducted the hearing retired. Furthermore, the Veteran subsequently requested a Board hearing in connection with the other issues before the Board. As such, in October 2017, the Board requested clarification as to whether the Veteran desired a Board hearing on all issues. Later that month, he indicated that he did not wish to testify at another Board hearing in regard to his increased rating claim, and, in February 2018, he withdrew his request for a Board hearing as to the remaining issues on appeal. The Board observes that, subsequent to the AOJ’s most recent adjudication of the Veteran’s claims, additional evidence, to include updated VA treatment records and an August 2018 VA examination pertinent to his skin tags, was associated with the record. While the Veteran has not waived AOJ consideration of such evidence, the Board finds no prejudice to him in proceeding with an adjudication of his claims at this time. Specifically, as such evidence is duplicative of the evidence previously considered by the AOJ in regard to the claims denied herein, it is irrelevant to such matters. Furthermore, while it is relevant to the Veteran’s claim for an increased rating for skin tags, the Board is remanding such matter. Therefore, the AOJ will have an opportunity to review the newly received evidence in connection with such claim. Thus, there is no prejudice results to the Veteran in the Board considering such evidence for the limited purpose of issuing a comprehensive and thorough remand in regard to such matter. New and Material Evidence Claims Generally, a claim which has been denied in an unappealed Board decision or an unappealed AOJ decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). New evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary’s duty to assist by providing a medical opinion. See Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). 1. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for otitis media. By way of background, the AOJ originally denied service connection for otitis media in a March 1991 rating decision. At such time, the AOJ considered the Veteran’s service treatment records and noted that such showed a diagnosis of left ear otitis externa in September 1985, which was treated. Service connection for otitis was denied as such disorder was considered acute and transitory, and resolved without residual disability. In April 1991, the Veteran was the Veteran was advised of the decision and his appellate rights; however, he did not enter a notice of disagreement. Additionally, no new and material evidence was physically or constructively received within one year of the issuance of such decision, and no relevant service department records have since been received. In this regard, while the Veteran’s service personnel records were received in March 2010, such are irrelevant to his claim for service connection for otitis media. Therefore, the April 1991 decision is final. 38 U.S.C. § 4005(c) (1988) [38 U.S.C. § 7105(c) (2012)]; 38 C.F.R. §§ 3.104, 19.129, 19.192 (1990) [38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2017)]. Thereafter, the Veteran attempted to reopen his previously denied claim; however, in a June 2000 rating decision, the AOJ determined that new and material evidence had not been received in order to reopen a claim of entitlement to service connection for otitis media. In this regard, the AOJ again considered the Veteran’s service treatment records as well as the subsequently received medical and lay evidence; however, as none pertained to the instant matter, the Board found that it was not new and material. In July 2000, the Veteran was the Veteran was advised of the decision and his appellate rights; however, he did not enter a notice of disagreement. Additionally, no new and material evidence was physically or constructively received within one year of the issuance of such decision, and no relevant service department records have since been received. Again, while the Veteran’s service personnel records were received in March 2010, such are irrelevant to his claim for service connection for otitis media. Therefore, the July 2000 decision is final. 38 U.S.C. § 7105(c) (West 1991) [(2012)]; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2000) [(2017)]. The Veteran most recently filed an application to reopen his previously denied claim for service connection for otitis media in May 2016. The evidence received since the July 2000 rating decision includes additional post-service treatment records and lay statements. In this regard, he claims that he has otitis media manifested by dizziness and vertigo. An August 2016 private treatment record shows the Veteran’s complaint of dizziness with change of head position, with onset 4 months previously. He described sense of dysequilibrium with walking or when watching objects move past him. A June 2016 VA audiology diagnostic note reveals that the Veteran recently completed vestibular rehabilitation therapy for positional vertigo, but his history was negative for ear infections, ear surgery, otalgia, drainage, and known ototoxic medication. However, a May 2017 VA examiner evaluated the Veteran and determined that, while he had an episode of acute otitis media in 1985, the condition resolved with no sequela as there was no middle ear pathology noted on his separation examination in 1990. During the VA examination, the Veteran also reported that the last known ear infection he remembered was this episode in service. The examiner further opined that the Veteran’s current complaints were related to eustachian dysfunction, which was not caused by the otitis media episode during service). Consequently, the newly received evidence is duplicative of the evidence previously of record at the time of the July 2000 rating decision as such continues to reflect the Veteran’s belief that he has an ear disorder related to service while the objective evidence of record fails to show any residuals. Therefore, the Board finds that the evidence added to the record since the final July 2000 denial is cumulative or redundant of the evidence of record at the time of the decision and does not raise a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for otitis media. As such, new and material evidence has not been received to reopen his previously denied claim and the appeal must be denied. 2. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a right shoulder disorder. By way of background, the AOJ originally denied service connection for a right shoulder disorder in a March 2009 rating decision. At such time, the AOJ considered the Veteran’s service treatment records and noted that such were negative for treatment or a diagnosis referable to a right shoulder disorder. The AOJ further noted that no post-service treatment records showing a diagnosis of a right shoulder disorder had been received, and there was no evidence showing that a currently diagnosed disability was related to a chronic in-service disability. Consequently, the AOJ denied service connection for a right shoulder disorder as there was no evidence that such existed or had been clinically diagnosed. In March 2009, the Veteran was the Veteran was advised of the decision and his appellate rights; however, he did not enter a notice of disagreement. Additionally, no new and material evidence was physically or constructively received within one year of the issuance of such decision, and no relevant service department records have since been received. In this regard, while the Veteran’s service personnel records were received in March 2010, such are irrelevant to his claim for service connection for a right shoulder disorder. Therefore, the March 2009 decision is final. 38 U.S.C. § 7105(c) (2002) [(2012)]; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2008) [(2017)]. The Veteran filed a claim to reopen his claim for service connection for a right shoulder disorder in January 2016. Evidence received since the March 2009 rating decision includes VA and private treatment records and an October 2016 VA examination. In particular, such reflect a diagnosis of osteoarthritis and degenerative joint disease of the right shoulder. Thus, the Board finds the evidence associated with the record is not cumulative or redundant of the evidence of record at the time of the prior decision and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a right shoulder disorder. Consequently, new and material evidence has been received to reopen the claim. Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as arthritis, to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 3. Entitlement to service connection for a right shoulder disorder, to include as secondary to service-connected latent TB. The Veteran is seeking service connection for a right shoulder disorder as directly related to service, or as caused or aggravated by his service-connected latent TB. Service treatment records are silent for any right shoulder symptoms or diagnoses. On his December 1990 separation examination report, the Veteran reported pain in multiple joints and a consult to rheumatology in September 1990 resulted in a diagnosis of non-specific polyarthralgias and myalgias not associated with any identifiable inflammatory disease or systemic rheumatic disease. After service, the first evidence of record noting a right shoulder disorder is a September 2008 VA treatment record. At such time, the Veteran complained of right shoulder pain that started in approximately June 2008. It was reported that there was no history of trauma and no previous history of shoulder pain. The Veteran was diagnosed with bilateral shoulder osteoarthritis in December 2015. In October 2016, a VA examiner opined that it is less likely than not that the Veteran’s current acromioclavicular joint degenerative joint disease was incurred during military service, secondary to latent TB, or aggravated by latent TB. After reviewing the Veteran’s service and post-service treatment records, the examiner reasoned that there was no evidence that the Veteran developed a right shoulder condition during his military service that became an ongoing concern requiring ongoing evaluation and treatment by medical providers. Specifically, he noted that the Veteran’s medical records are silent for a right shoulder condition from 1990 to 2008. The October 2016 VA examiner further opined that there is no evidence to support a determination that the Veteran’s right shoulder condition was due to, secondary to, or aggravated by latent TB because the evidence does not show that the Veteran had or has active TB. The VA examiner based his opinions on a review of the complete record and examination. Factors for assessing the probative value of a medical opinion include the physician’s access to the claims folder and the thoroughness and detail of the opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). As the VA examiner’s opinion is well-rationalized and included a thorough analysis of the record and examination of the Veteran with consideration of his allegations, it is considered highly probative, competent medical evidence weighing heavily against the Veteran’s claim. There is no medical opinion to the contrary. The Veteran maintains that his right shoulder disorder is related to service or secondary to his service-connected latent TB. While he is competent to report his symptoms, the Board finds he is not competent to offer an opinion as to whether arthritis of the right shoulder is related to any instance of his service, or his service-connected latent TB, since he does not possess the requisite medical knowledge to offer such an opinion. Specifically, the etiology of such disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, as such is a complex medical question, the Veteran is not competent to offer an opinion as to the etiology his right shoulder disorder, and, consequently, his opinion on such matter is afforded no probative weight. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Furthermore, as discussed previously, the first report of right shoulder symptoms after service occurred in approximately 2008, and there is no evidence that arthritis manifested within a year after the Veteran’s separation from service. Therefore, presumptive service connection is likewise not warranted. In conclusion, a right shoulder disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, arthritis did not manifest within one year of service discharge, and such is not caused or aggravated by service-connected latent TB. Therefore, service connection for such disorder is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for entitlement to service connection for a right shoulder disorder. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 8 U.S.C. 5107; 38 C.F.R. 3.102; Gilbert, supra. 4. Entitlement to service connection for a left knee disorder, to include as secondary to latent TB. 5. Entitlement to service connection for a right knee disorder, to include as secondary to latent TB. The Veteran is seeking service connection for a bilateral knee disorder as directly related to service, or as caused or aggravated by his service-connected latent TB. Service treatment records show that the Veteran had a right knee strain in July 1985, for which he was followed up in August 1985. After separation from service, a June 2005 VA treatment record shows that the Veteran sustained a left knee contusion when he fell off a bicycle and skinned his knee. Thereafter, he complained of bilateral knee pain in December 2015, at which time he reported that he had constant bilateral knee pain for a year and a half. X-ray of the knees revealed mild bilateral medial femorotibial compartment degenerative joint disease. In October 2016, a VA examiner opined that it is less likely than not that the Veteran’s current mild bilateral medial compartment degenerative joint disease was incurred during military service, secondary to latent TB, or aggravated by latent TB. In reaching this conclusion, the examiner reviewed the Veteran’s claims file, to include service treatment records and post-service VA medical records, and indicated that there was no evidence that the Veteran developed a bilateral knee condition during his military service that became an ongoing concern requiring ongoing evaluation and treatment by medical providers. Specifically, the examiner noted that the Veteran’s medical records are silent for a bilateral knee condition from 1990 to 2005, at which time he was involved in a bicycle accident that could explained his current left knee symptoms. Further, there was no evidence to support that the Veteran’s bilateral knee condition was due to, secondary to, or aggravated by latent TB because there is no evidence he had or has active TB. The VA examiner based his assessment on a review of the complete record and examination. Factors for assessing the probative value of a medical opinion include the physician’s access to the claims folder and the thoroughness and detail of the opinion. See Nieves-Rodriguez, 22 Vet. App. 295; Prejean, 13 Vet. App. at 448-9. As the VA examiner’s opinion is well-rationalized and included a thorough analysis of the record and examination of the Veteran with consideration of his allegations, it is considered highly probative, competent medical evidence weighing heavily against the Veteran’s claims. There is no medical opinion to the contrary. The Veteran maintains that his bilateral knee disorder is related to service or secondary to his service-connected latent TB. While he is competent to report his symptoms, the Board finds he is not competent to offer an opinion as to whether arthritis of the bilateral knees is related to any instance of his service, or his service-connected latent TB, since he does not possess the requisite medical knowledge to offer such an opinion. Specifically, the etiology of such disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, as such is a complex medical question, the Veteran is not competent to offer an opinion as to the etiology his bilateral knee disorder, and, consequently, his opinion on such matter is afforded no probative weight. Kahana, supra; Jandreau, supra; Woehlaert, supra. Furthermore, as discussed previously, the first report of left knee symptoms after service occurred in approximately 2005, with right knee symptoms first reported in 2015, and there is no evidence that arthritis manifested within a year after the Veteran’s separation from service. Therefore, presumptive service connection is likewise not warranted. In conclusion, a bilateral knee disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, arthritis did not manifest within one year of service discharge, and such is not caused or aggravated by service-connected latent TB. Therefore, service connection for such disorder is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for entitlement to service connection for a bilateral knee disorder. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 8 U.S.C. 5107; 38 C.F.R. 3.102; Gilbert, supra. 6. Entitlement to service connection for obstructive sleep apnea, to include as secondary to latent TB. The Veteran is seeking service connection for obstructive sleep apnea as directly related to service, or as caused or aggravated by his service-connected latent TB. In May 2016, the Veteran’s wife submitted a written statement to the effect that the Veteran has suffered sleep apnea for over 20 years although he was first diagnosed in January 2016. Service treatment records are silent for sleep apnea. On his December 1990 separation examination report, the Veteran reported history of frequent trouble sleeping. After separation from service, the Veteran underwent a VA sleep study in January 2016, at which time moderate obstructive sleep apnea syndrome with mild oxygen desaturation during sleep was diagnosed. In October 2016, a VA examiner opined that the Veteran’s obstructive sleep apnea was less likely than not (less than 50 percent probability) incurred in or caused by service. In support of this opinion, the examiner provided the following rationale: Obstructive sleep apnea is a common sleep disorder characterized by intermittent complete and partial upper airway collapse during sleep, resulting in frequent episodes of apnea and hyponea. … The important risk factors for obstructive sleep apnea are advancing age, male gender, obesity, craniofacial and upper airway soft tissue abnormalities, with obesity being the most important. As noted in his separation medical examination “frequent trouble sleeping” remark occurred during an upper respiratory tract infection which had resolved at the time of his separation physical examination. The Veteran’s obstructive sleep apnea, diagnosed more than 15 years after post service, is not a result of or related to his remote history of trouble sleeping during an upper respiratory tract infection. The Veteran’s obstructive sleep apnea is more likely than not the results of his over 80 pound weight gain since his separation from the service. The Board notes that the Veteran and his wife have submitted arguments to the effect that his sleep apnea was caused by the service-connected latent TB, which caused fluid buildup every morning and overgrowth of throat tissue, which caused the snoring and stopping of breathing. However, a February 2016 VA examiner indicated that the Veteran’s latent TB caused no signs, symptoms or condition and any signs or symptoms would require active TB and, as noted by the October 2016 examiner, there is no evidence he had or has active TB. Furthermore, the October 2016 VA examiner found that the Veteran’s obstructive sleep apnea was not aggravated by his latent TB as such is caused by certain characteristics of the anatomy of the upper airway. Obesity and aging can facilitate these anatomical changes, resulting in sleep apnea. She further stated that there was no evidence in the medical literature that latent TB causes anatomical changes in the upper airway so as to cause sleep apnea. The VA examiners based their assessment on a review of the complete record and examination. Factors for assessing the probative value of a medical opinion include the physician’s access to the claims folder and the thoroughness and detail of the opinion. See Nieves-Rodriguez, 22 Vet. App. 295; Prejean, 13 Vet. App. at 448-9. As the VA examiners’ opinions are well-rationalized and included a thorough analysis of the record and examination of the Veteran with consideration of his allegations, they are considered highly probative, competent medical evidence weighing heavily against the Veteran’s claim. There is no medical opinion to the contrary. The Veteran and his wife maintain that his obstructive sleep apnea is related to service or secondary to his service-connected latent TB. While they are competent to report his symptoms, the Board finds they are not competent to offer an opinion as to whether obstructive sleep apnea is related to any instance of his service, or his service-connected latent TB, since they do not possess the requisite medical knowledge to offer such an opinion. Specifically, the etiology of such disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, as such is a complex medical question, the Veteran and his wife are not competent to offer an opinion as to the etiology his obstructive sleep apnea, and, consequently, his opinion on such matter is afforded no probative weight. Kahana, supra; Jandreau, supra; Woehlaert, supra. In conclusion, obstructive sleep apnea is not shown to be causally or etiologically related to any disease, injury, or incident during service, and is not caused or aggravated by service-connected latent TB. Therefore, service connection for such disorder is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for entitlement to service connection for obstructive sleep apnea. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 8 U.S.C. 5107; 38 C.F.R. 3.102; Gilbert, supra. Increased Rating Claim Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. 7. Entitlement to an initial compensable rating for latent TB. The Veteran’s service-connected latent TB is evaluated under 38 C.F.R. § 4.88b, Diagnostic Code 6311, provides for a 100 percent rating for miliary TB, as active disease. This diagnostic code provides that inactive tuberculosis should be rated under 38 C.F.R. §§ 4.88c or 4.89, whichever is appropriate. 38 C.F.R. § 4.88c provides ratings for inactive nonpulmonary tuberculosis initially entitled after August 19, 1968, and 38 C.F.R. § 4.89 provides ratings for inactive nonpulmonary tuberculosis in effect on August 19, 1968. Here, the Veteran was not service-connected for tuberculosis on August 19, 1968. Thus, 38 C.F.R. § 4.88c would be for application. That section provides that, for one year after date of inactivity, following active tuberculosis, a 100 percent rating is warranted, following which residuals are to be rated under the specific body system or systems affected. The Board finds that the preponderance of the evidence is against the Veteran’s claim for an initial compensable rating for his service-connected latent TB. The Veteran asserts that this disability is more disabling than currently evaluated because it has caused various symptoms, to include shortness of breath, constriction of veins, upset stomach, joint pain, and sleep apnea. However, the medical evidence of record does not support his assertions. Rather, such shows that, while the Veteran has complained of, and been treated for, a variety of symptoms, his service-connected latent TB has been inactive and asymptomatic, and does not result in residuals. In this regard, a February 2016 VA examiner noted a diagnosis of latent TB and explained that, at some time before a positive skin test in 1986, the Veteran was exposed to tuberculin bacteria. The examiner further stated that, in most people, the bacteria is contained by host defenses and causes no signs of symptoms of illness and it detectable only by skin test (PPD) or blood test (Quantiferon), which is called latent TB or skin test positive. The examiner indicated that, while in service, the Veteran had a positive PPD test in December 1986, but subsequent PPDs were negative in 1987 and 1988. After separation from service, he was seen by a TB nurse at VA in January 1998, June 1998, June 2005, and November 2007, and took Isoniazid (INH) for 1 month in 1987 and in 1997. The examiner noted that persons with latent TB have a 0.1 percent (1:1000) annual risk of developing active TB disease and the risk is higher after a recent exposure and skin test conversion to positive, which is why it was recommended to the Veteran that he be treated with INH to prevent future active TB infection. The examiner added that the Veteran did not complete the 9 month course of medication and therefore was still at risk for reactivation and development of active disease. However, there was no evidence of active TB disease diagnosed at present, nor has there ever been evidence of active disease—the most recent test being the chest X-ray in February 2016 showing no evidence of active disease. As the Veteran’s latent TB currently is inactive, asymptomatic, and does not result in any residual disability, a compensable rating for such disability is not warranted under any potentially applicable diagnostic code. In reaching such determination, the Board notes that, while the Veteran has alleged that he has various residuals of his latent TB, the Board finds that he is not competent to attribute any of his claimed symptoms to his service-connected latent TB since he does not possess the requisite medical knowledge to offer such an opinion. Specifically, the etiology of such symptoms involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, as such is a complex medical question, the Veteran is not competent to offer an opinion as to whether his symptoms are related to his latent TB, and, consequently, his opinion on such matter is afforded no probative weight. Kahana, supra; Jandreau, supra; Woehlaert, supra. Neither the Veteran nor his representatives have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to such claim. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for an initial compensable rating for latent TB. As such, that doctrine is not applicable in the instant appeal, and his initial rating claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 8. Entitlement to a rating in excess of 10 percent for skin tags. Most recently, the Veteran underwent a VA skin examination in August 2018. However, the findings noted on this examination are inconsistent with the previous VA examinations conducted in April 2012 and February 2016. This examination report itself also contains some conflicting information. For instance, the August 2018 VA examiner noted that the Veteran has been treated with systemic corticosteroids or other immunosuppressive medications, but listed “none” when asked to specify the medication used. Additionally, the examiner indicated that the Veteran had 4 or more debilitating episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic necrolysis but also stated the debilitating episodes are caused by skin tags. The examiner also noted that the Veteran described the episodes as “I have seen same vasculitis on my legs, hand, and back.” The examiner further indicated that the Veteran had 4 or more nondebilitating episodes caused by urticaria, primary cutaneous vasculitis, erythema multiforme, and toxic epidermal necrolysis. Given the conflicting information provided in the VA examination, the Board must remand this case for a supplemental medical opinion. The matter is REMANDED for the following action: 1. Forward the record to the VA examiner who conducted the August 2018 VA skin examination, if available, to obtain a supplemental medical opinion regarding the current nature and severity of the Veteran’s service-connected skin tags. If the August 2018 VA examiner is not available, schedule the Veteran for an appropriate VA examination to assess his service-connected skin tags. The record must be reviewed in conjunction with the examination and any indicated testing should be completed. Please identify all medications used by the Veteran for treatment of his service-connected skin tags (versus any nonservice-connected skin disorder(s)) and indicate whether each is a systemic therapy, i.e., affecting the body as a whole, or is like or similar to corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs. In offering such opinion, please be advised that systemic therapy is defined as treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin The examiner should also clarify whether the Veteran’s service-connected skin tags (versus any nonservice-connected skin disorder(s)) cause any debilitating or non debilitating episodes, and indicate the frequency of such episodes. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. J. In, Counsel