Citation Nr: 18144366 Decision Date: 10/24/18 Archive Date: 10/24/18 DOCKET NO. 15-19 229 DATE: October 24, 2018 ORDER Entitlement to service connection for a coronary artery disability, to include as due to an undiagnosed illness, is denied. Entitlement to service connection for a migraine headache disability, to include as due to an undiagnosed illness, is denied. REMANDED Entitlement to an initial compensable rating for eczematous-type lesions is remanded for additional development. FINDINGS OF FACT 1. The preponderance of the evidence reflects that the Veteran’s coronary artery disease was neither incurred in nor caused by his active military service. 2. The preponderance of the evidence reflects that the Veteran’s migraine headaches were neither incurred in nor caused by his active military service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for coronary artery disease have not been satisfied. 38 U.S.C. §§ 501, 1101, 1112, 1113, 1116, 1117, 1131, 1137, 1154, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.317 (2016). 2. The criteria for entitlement to service connection for migraine headaches have not been satisfied. 38 U.S.C. §§ 501, 1101, 1112, 1113, 1116, 1117, 1131, 1137, 1154, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.317 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service with the U.S. Navy from August 1989 to July 1993, to include service in the Southwest Asia theatre of operations during the Persian Gulf War. During this time, he was awarded the Southwest Asia Service Medal, the Kuwait Liberation Medal, the Combat Action Ribbon, and the National Defense Service Medal, among other medals. These matters come to the Board of Veteran’s Appeals (Board) on appeal from June 2014 and January 2017 rating decisions from the Department of Veterans Affairs (VA) regional office (RO) in Lincoln, Nebraska. In June 2018, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the claims file. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §1131; 38 C.F.R. § 3.303(a). In addition, disorders diagnosed after discharge may also still be service-connected if all the evidence, including pertinent service records, establishes the disorder was incurred in service. 38 C.F.R. § 3.303(d). Generally, service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the “nexus” requirement. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). There is no categorical rule that medical evidence is required when the determinative issue is either medical etiology or a medical nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Therefore, the Board will assess the competence and credibility of lay statements as well. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In adjudicating claims for VA benefits, the burden of proof only requires an approximate balance of the evidence for and against a claim. 38 U.S.C. 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1991). This low standard of proof is unique to the VA adjudicatory process, and the nation, in recognition of our debt to our veterans, has taken upon itself the risk of error in awarding such benefits. Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) (citing Gilbert, 1 Vet. App. at 54). Additionally, for the chronic diseases listed in 38 C.F.R. § 3.309(a), if the chronic disease manifested in service, then service connection will be established for subsequent manifestations of the same chronic disease at any date after service, no matter how remote, without having to show a causal relationship or medical nexus, unless the later manifestations are clearly due to causes unrelated to service (“intercurrent causes”). 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012) (holding that § 3.303(b) only applies to the chronic diseases listed in 38 U.S.C. § 1101 § 3.309(a)). When the condition noted during service is not shown to be chronic, or its chronicity may be legitimately questioned, then a continuity of symptoms after service must be shown to establish service connection under this provision. Id.; Walker, 708 F.3d at 1338-39 (observing that a continuity of symptoms after service is a relaxed evidentiary showing that itself “establishes the link, or nexus” to service and also “confirm[s] the existence of the chronic disease while in service or [during a] presumptive period”). To establish service connection based on a continuity of symptoms under § 3.303(b), the evidence must show: (1) a condition “noted” during service; (2) post-service continuity of the same symptoms; and (3) a nexus between the present disability and the post-service symptoms. Fountain v. McDonald, 27 Vet. App. 258, 263-64 (2015). In addition, where a Veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, there is a presumption of service connection for VA-defined chronic diseases if the disease manifested to a degree of 10 percent or more within one year from the date of separation from service, even if there is no evidence of the disease during the service period itself. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). This presumption may be rebutted by affirmative evidence to the contrary. 38 C.F.R. § 3.307(d). The Veteran served in the Southwest Asia Theater of Operations after August 2, 1990, so during the Persian Gulf War. See 38 C.F.R. § 3.2 (i) (2016). Therefore, he is a Persian Gulf veteran. Service connection may be established for a Persian Gulf veteran who has a qualifying chronic disability that became manifest during service or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317; 81 Fed. Reg. 71382 (Oct. 7, 2016). A “qualifying chronic disability” includes: (A) an undiagnosed illness, or (B) a medically unexplained chronic multisymptom illness, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal disease). 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i). The term “medically unexplained chronic multisymptom 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, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Disabilities that have existed for six months or more, and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period, will be considered chronic. 38 C.F.R. § 3.317 (a)(4). A qualifying chronic disability shall be considered service connected. 38 C.F.R. § 3.317 (a)(6). Compensation shall not be paid for a qualifying chronic disability if there is affirmative evidence that the disability was caused by a supervening condition or event that occurred between the Veteran’s most recent Southwest Asia duty and the onset of the disability. 38 C.F.R. § 3.317 (a)(7)(ii). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) fatigue, (2) signs or symptoms involving skin, (3) headache, (4) muscle pain, (5) joint pain, (6) neurological signs or symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the upper or lower respiratory system, (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, or (13) menstrual disorders. 38 C.F.R. § 3.317 (b). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In this vein, the Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of evidence contained in a record; every item does not have the same probative value. The Board must account for the evidence which it finds to be persuasive or unpersuasive, analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, and provide the reasons for its rejection of any such evidence. See, e.g., Struck v. Brown, 9 Vet. App. 145, 152 (1996); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). 1. Entitlement to service connection for a coronary artery disability The Veteran asserts that he has coronary artery disease (CAD) that is related to his active service. In particular, he maintains that this disability had its onset during his active duty service, including his service in the Persian Gulf. A review of the case file reveals that the Veteran was first diagnosed with CAD in July 2013. See July 2013 Bergan Mercy Medical Center Discharge Summary (diagnosing the Veteran with CAD, hypertension, dyslipidemia, and obstructive sleep apnea after the placing of a drug-eluting stent to his proximal left anterior descending artery). Thus, the first required element of service connection, a current disability, is fulfilled. Regarding direct service connection, as to in-service evidence, as noted above, a review of the Veteran’s STRs, including his separation examination, are negative for any notations of CAD, and reflect notations of sinus brachycardia on a May 1993 EKG, and the presence of crystals on a 1993 urinalysis. See, e.g., May 1993 EKG Report; May 1993 Urinalysis Report. As previously noted, the Veteran was first diagnosed with CAD in July 2013 after waking up with chest pain. With respect to nexus, the probative medical evidence of record does not establish a direct relationship between the Veteran’s CAD and his period of active service. 38 C.F.R. § 3.303(a), (d); Holton, 557 F.3d at 1366. In April 2014, the Veteran underwent a VA heart examination. See April 2014 Heart Conditions DBQ. In June 2014, a VA examiner opined that the Veteran’s CAD was less likely than not related to his active duty service. See June 2014 Medical Opinion DBQ. In arriving at this conclusion, the VA examiner cited to: the Veteran’s other diagnoses of hypertension, obstructive sleep apnea, and hyperlipidemia as risk factors for CAD; the Veteran’s 16 years of smoking a pack of cigarettes a day; citing the Framingham study in support of the conclusion that these risk factors were likely more contributory to the Veteran’s CAD; and addressing the 1993 findings of the Veteran’s sinus brachycardia and crystals in urine as more likely non-specific findings unrelated to his 2013 diagnosis of CAD. Id. With respect to presumptive service connection for chronic diseases, while cardiovascular disease is enumerated as a qualifying chronic disease in the relevant statues, the disease must have manifested to a degree of 10 percent or more within 1 year of separation from service to be presumed as service-connected. 38 C.F.R. § 3.307(a)(3), § 3.309(a). As noted earlier, a review of the Veteran’s service treatment records (STRs) indicate that his separation examination is negative for any notations of CAD. His post-service treatment records indicated that the Veteran was first diagnosed with CAD in July 2013 after waking up in the middle of the night with chest pain. See July 2013 Alegent Creighton Clinic Office Visit Record (reflecting that the Veteran’s chest pain kept him awake all night, and that he had elevated blood pressure). Prior to this diagnosis, the Veteran’s heart sounds were listed as normal in August 2003. See August 2003 San Diego VA Medical Center (VAMC) Addendum (noting that the Veteran was initially seen by neurology for headaches and recording during the examination that the Veteran’s “[c]hest is clear and heart sounds n[orma]l”). Because the Veteran’s CAD manifested over a year after his separation from active service, he is not entitled to presumptive service connection for CAD as a VA-defined chronic disease. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Regarding presumptive service connection as related to Gulf War service, as previously noted above, the evidence of record reflects that the Veteran served in the Southwest Asia Theater of Operations after August 2, 1990, is therefore a Persian Gulf veteran, and thus is eligible for establishment of service connection for those qualifying chronic disabilities that became manifest during service or to a degree of 10 percent or more not later than December 31, 2021. A “qualifying chronic disability” for VA purposes is a chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). In April 2014, a VA examiner reviewed the Veteran’s claims file, and concluded that his coronary artery disease was a “diagnosable illness with a specific etiolog[y]” and that it was “unlikely that [the Veteran’s] heart disease is due to service in Southwest Asia” and further noted that the Veteran possessed a number of risk factors associated with the development of coronary artery disease. See April 2014 Medical Opinion DBQ. In July 2018, the Veteran submitted an opinion from his private doctor that his CAD was in fact related to his service in the Persian Gulf. See July 2018 Alegent Creighton Clinic Correspondence. His private doctor stated that the Veteran had “spent time in the Gulf during Desert Storm and was exposed to hazardous chemicals by his report.” Id. He further elaborated that because the Veteran required a cardiac procedure despite the absence of any significant factors, he felt that the Veteran’s CAD was “just as likely as not to have been caused exposure to hazardous air and chemicals during Desert Storm as any other cause.” Id. Concerning lay evidence of a nexus between the Veteran’s CAD and his military service, while lay persons are not unconditionally incompetent to speak about medical diagnosis or etiology issues, see Davidson, 581 F.3d at 1316, the Board again must consider the type of condition specifically claimed and whether it is readily amenable to lay diagnosis or probative comment on etiology. Woehlaert, 21 Vet. App. at 462. The Veteran has made multiple statements asserting that his CAD first manifested during active duty service. See, e.g., May 2015 Appeal to Board of Veterans’ Appeals (VA Form 9) (reflecting that the Veteran stated that he was exposed to toxic smoke while in Desert Storm, and asserted that both crystals in urine and sinus brachycardia “can be indicative of heart related problems” according to the American Heart Association and Mayo Clinic); July 2018 Correspondence (reiterating the Veteran’s assertion that his CAD was the result of his inhaling smoke during Desert Storm; that his abnormal EKG and crystals in urine noted in service were linked to his CAD; and further arguing he had had high cholesterol and blood pressure noted in service as well). At his Board hearing, the Veteran presented testimony regarding the initial manifestations of his CAD. See June 2018 Board Hearing Transcript. He again asserted that he was treated for brachycardia and crystals in his urine, and that these conditions were manifestations of CAD. Id. He indicated that he was currently on multiple medications for his CAD. Id. He also indicated that while in-service, on one occasion his blood pressure was taken and “it was abnormally high, but not like off the charts high.” Id. While lay persons are competent to report symptoms that are observable, of which they have personal knowledge, and may provide opinions on some medical issues, 38 C.F.R. § 3.159(a)(2); Layno, 6 Vet. App. at 470; Kahana, 24 Vet. App. at 435, the particular issue of whether the Veteran’s CAD is etiologically related to service falls outside the realm of common knowledge of a lay person. Jandreau, 492 F.3d at 1377 n.4. Further, while the Veteran is competent to report that he suffered physical symptoms associated with CAD, the Board assigns more probative value to the medical evidence of record with respect to nexus. Buchanan, 451 F.3d at 1336. Nor has the Veteran identified any symptoms which have not been associated with one or more diagnoses, nor does the relevant medical evidence of record reflect any clusters of illness or complaints, such as those described in 38 C.F.R. § 3.317(a)(2)(i)(B). Further, the Board finds the opinions of the VA examiners in April 2014 and June 2014 to be more persuasive and probative than the July 2018 private opinion in finding that the evidence does not support a conclusion that the Veteran’s CAD is due to service on either a direct or presumptive basis. The findings of the VA examiners were based on a thorough review of the evidence, and cited to the medical evidence. The examiners considered the complete record, including the Veteran’s contentions regarding the possible connection between his CAD and his Southwest Asia service as well as specific treatment records that he cited in his STRs, and provided an explanation as to why the evidence does not support a finding that the Veteran’s CAD was incurred in or caused by service, and further noted that the Veteran possessed multiple risk factors for CAD. The opinions contain an internal logic consistent with the known facts, as well as with other evidence of record. See, e.g., July 2013 Alegent Creighton Clinic Office Visit Record (reporting that the Veteran was seen for chest pain and that he smoked a pack of cigarettes a day for 16 years before quitting 10 years prior); July 2013 Bergan Mercy Medical Center Discharge Summary (diagnosing the Veteran with CAD, hypertension, and dyslipidemia); June 2014 Medical Opinion DBQ (indicating that risk factors for CAD include age, gender, prior tobacco use, hypertension, and hyperlipidemia). The Board finds the VA opinions to be significantly more probative than the private opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Notably, the private opinion while noting that the absence of any significant risk factors, he failed to address the Veteran’s prior history of smoking and other potential risk factors discussed by the VA examiners. As a result, the Board places more probative value on the opinions reached by the VA examiners as they consider a thorough review of the claims folder and account for the Veteran’s prior history of smoking and other risk factors that were not discussed by the private physician. Accordingly, the Board finds that for the Veteran’s CAD, the preponderance of the evidence is against a finding of direct service connection; against a finding of presumptive service connection for a qualifying chronic disability based on VA-defined chronic diseases; as well as against a finding of presumptive service connection based on Persian Gulf War service, and the benefit-of-the-doubt doctrine is inapplicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for a migraine headache disability The Veteran also maintains that he has current migraine headaches that are related to his active service. He further specifies that these disabilities had their onset during his active duty service in the Persian Gulf. A review of the case file reveals that as of April 2014, the Veteran has a current diagnosis of migraine headaches. See April 2014 Headaches Disability Benefits Questionnaire (DBQ) (noting that the Veteran had been diagnosed with migraine and migraine variant headaches “for some years”). Accordingly, the first required element of service connection, a current disability, is fulfilled. As previously noted, the evidence of record reflects that the Veteran served in the Southwest Asia Theater of Operations after August 2, 1990, is therefore a Persian Gulf veteran, and thus is eligible for establishment of service connection for those qualifying chronic disabilities that became manifest during service or to a degree of 10 percent or more not later than December 31, 2021. Again, as earlier stated above, a “qualifying chronic disability” for VA purposes is a chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). In April 2014, a VA examiner reviewed the Veteran’s claims file, and concluded that his migraine headaches were a “diagnosable illness with a specific etiolog[y]” and that it was “unlikely that [the Veteran’s] migraine headaches are due to service in Southwest Asia.” See April 2014 Medical Opinion DBQ. While the examiner’s opinion was rendered on a medical basis, the Board reaches the same conclusion, but on a legal basis. Specifically, the Veteran has not identified any symptoms which have not been associated with one or more diagnoses, nor does the relevant medical evidence of record reflect any clusters of illness or complaints, such as those described in 38 C.F.R. § 3.317(a)(2)(i)(B). Accordingly, service connection for a qualifying chronic disability based on Persian Gulf War service cannot be granted at this time. With respect to presumptive service connection for chronic diseases, headaches are not enumerated as a chronic disease in the relevant statues, and therefore the Veteran is not entitled to presumptive service connection for headaches as a VA-defined chronic disease. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Regarding direct service connection, as to in-service evidence, the Veteran’s STRs reflect that the Veteran had reported headaches associated with either respiratory or throat-related issues. See, e.g., November 1989 USS Horne Chronological Record of Medical Care (noting that the Veteran had a sinus congestion headache and diagnosing the Veteran with upper respiratory infection (URI) congestion); April 1992 USS Horne Chronological Record of Medical Care (recording that the Veteran had headache, swollen tonsils, an enlarged uvula, and diagnosing strep throat). A review of the Veteran’s post-service treatment records indicates that the Veteran received medical treatment dating back to 1997, but manifestations of headaches were first recorded in 2003, after a motor vehicle accident. See August 2003 San Diego VA Medical Center (VAMC) Neurology Resident Inpatient Note (reflecting the Veteran had a motor vehicle accident in August 2002, after which he began experiencing throbbing headaches approximately once a month that were “associated with nausea, ‘dark sparkles’, and photophobia with throbbing, band-like pain in the frontal area”). With respect to nexus, the probative medical evidence of record does not reflect a relationship between the Veteran’s current headaches and his period of active service. 38 C.F.R. § 3.303(a), (d); Holton, 557 F.3d at 1366. In April 2014, the Veteran underwent a VA headaches examination. See April 2014 Headaches DBQ. In June 2014, a VA examiner opined that the Veteran’s headaches were less likely than not related to his active duty service. See June 2014 Medical Opinion DBQ. In arriving at this conclusion, the VA examiner cited to: STRs only reflecting manifestations of headaches in conjunction with respiratory or throat issues; no indications that headaches were manifesting at the time of his separation from the military in 1993, as well as a lack of medical records showing chronicity or continuity of headaches over the past 20 years after separation from active service. Id. Concerning lay evidence of a nexus between the Veteran’s headaches and his military service, while lay persons are not unconditionally incompetent to speak about medical diagnosis or etiology issues, see Davidson, 581 F.3d at 1316, the Board again must consider the type of condition specifically claimed and whether it is readily amenable to lay diagnosis or probative comment on etiology. Woehlaert, 21 Vet. App. at 462. The Veteran has made statements asserting that his headaches first manifested during his active duty service. See, e.g., May 2015 Appeal to Board of Veterans’ Appeals (VA Form 9) (reflecting that the Veteran stated that he started having migraines while in service during Desert Storm, and that have not gone away since); July 2018 Correspondence (reiterating the Veteran’s assertion that his migraine headaches began during his Desert Storm combat and further noting that his migraines have become more frequent over time and have resulted in his having to miss work). At his Board hearing, the Veteran presented testimony regarding the initial manifestations of his headaches. See Board Hearing Transcript. He stated that he had both sinus and migraine headaches during service, and that the medical treatment he received for both was the same, specifically, that he was given ibuprofen. Id. He asserted that the headaches had been going on since service and had worsened to the point that he had to miss “a considerable amount of work.” Id. He indicated that the headaches were initially mild but then worsened. Id. He indicated that he had ongoing migraines as well as sinus headaches. Id. While lay persons are competent to report symptoms that are observable, of which they have personal knowledge, and may provide opinions on some medical issues, 38 C.F.R. § 3.159(a)(2); Layno, 6 Vet. App. at 470; Kahana, 24 Vet. App. at 435, the particular issue of whether the Veteran’s headaches are etiologically related to service falls outside the realm of common knowledge of a lay person. Jandreau, 492 F.3d at 1377 n.4. Further, while the Veteran is competent to report that he suffered headaches, the Board assigns more probative value to medical evidence of record with respect to nexus. Buchanan, 451 F.3d at 1336. Specifically, the Board finds the opinions of the VA examiners in April 2014 and June 2014 to be highly persuasive and probative in finding that the evidence does not support a conclusion that the Veteran’s migraine headache condition is due to service. The findings of the VA examiner were based on a thorough review of the evidence, and cited to the medical evidence. The examiners considered the complete record, including the Veteran’s contention regarding the possible connection between his headaches and his Southwest Asia service, and provided an explanation as to why the evidence does not support a finding that the Veteran’s current headache condition diagnosed as migraines was incurred in or caused by service. The opinions contain an internal logic consistent with the known facts, as well as with other evidence of record. The Board finds these opinions to be highly probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). The most probative and persuasive evidence is against finding that the Veteran’s current headache condition is related to service. Accordingly, service connection for headaches is denied. As the preponderance of the evidence is against the Veteran’s headaches claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Entitlement to an initial compensable rating for eczematous-type lesions is remanded. The Board sincerely regrets the delay that inevitably will result from the remand of this portion of the claim, but it is necessary to ensure there is a complete record and so the Veteran is afforded every possible consideration. The Veteran has asserted that an initial rating higher than the noncompensable rating currently assigned is warranted for his service-connected eczematous-type lesions. Specifically, he asserts that his skin condition affects 40 percent of his body, causes some facial disfigurement, and is characterized by flare-ups resulting in scarring that last for approximately 6 months to 1 year. See June 2018 Board Hearing Transcript. The Veteran previously underwent a VA skin examination in January 2017. See January 2017 VA Skin Diseases DBQ. However, at the time of the examination, the Veteran was not in the midst of a skin flare-up; he described the lesions to the examiner and showed photographs of previous lesions that had been taken on his cell phone, but the examiner was not able to make any determinations regarding the nature of the lesions based on those photographs. Id. The Veteran indicated to the examiner that the flare-ups of his skin condition lasted approximately 1 to 2 months in length, with a 1 to 2 month period between flare-ups. Id. The Veteran also reported that he suffered similar lesions on his scalp, and the examiner noted that the Veteran had 2 healing lesions on his scalp that were consistent with his descriptions. Id. In light of the Veteran’s assertions that his unidentified skin condition undergoes periods of remission and recurrence lasting between 1 and 2 months, VA must attempt to provide the Veteran with a VA skin examination during a period of recurrence, and the Board has determined that the new examination is warranted to accurately determine the current severity of the Veteran’s service-connected skin disability. See Ardison v. Brown, 6 Vet. App. 405, 407 (1994) (concluding that an examination during a remission phase was inadequate because it did not “accurately reflect the elements of the present disability”); see also Bowers v. Derwinski, 2 Vet. App. 675, 676 (1992) (holding that ‘it is the frequency and duration of the outbreaks and the appearance and virulence of them during the outbreaks that must be addressed’).   The matter is REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the claims file. 2. After completion of the above development, schedule the Veteran for appropriate VA examination(s) to assist in determining the current severity of his service-connected skin condition. The skin examination should be conducted during an exacerbation or active phase of the Veteran’s skin condition, if possible, in coordination with the Veteran, in order to accurately determine the nature and current severity of his skin condition. If the Veteran has a period of exacerbation of the disability before the VA examination can be scheduled, or if the examination cannot be scheduled in conjunction with an exacerbation, he should be advised of alternative ways to present evidence of the nature and severity of his service-connected skin condition, such as hard copy photographs. Efforts to schedule the Veteran for an examination during an active period of his recurrent skin condition must be documented, and such documentation associated with the claims file. The electronic claims file, including a copy of this remand, must be made available for the examiner to review. The examination report must include a notation that this record review took place. The Veteran must be interviewed. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. The examiner must comment on any credibility issues raised by the record from a medical perspective. The examination should include any diagnostic testing or evaluation deemed necessary for the specific disability. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Raj, Associate Counsel