Citation Nr: 18151822 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 17-07 969 DATE: November 20, 2018 ORDER New and material evidence having been received, the previously denied claim of service connection for a seizure disorder, now claimed as a disability characterized by blackouts and seizures, is reopened. New and material evidence having been received, the previously denied claim of service connection for a disability manifested by decreased energy level, to include as due to an undiagnosed illness, now claimed as chronic fatigue syndrome, is reopened. Entitlement to service connection for a cervical spine disability is granted. Entitlement to service connection for a lumbar spine disability is granted. Entitlement to service connection for a left foot disability, claimed as plantar fasciitis, is granted. Entitlement to service connection for chronic fatigue syndrome is granted. Entitlement to service connection for chronic sinusitis is granted. Entitlement to service connection for lung cancer, claimed as a respiratory disability, is granted. Entitlement to service connection for obstructive sleep apnea is granted. Entitlement to service connection for irritable bowel syndrome is granted. Entitlement to service connection for a disability characterized by blackouts and seizures is granted. FINDINGS OF FACT 1. An August 2000 rating decision denied service connection for seizure disorder. The appellant was duly notified of the RO’s determination and his appellate rights but he did not appeal within the applicable time period, nor was new and material evidence received in the year following notification of the decision. 2. Evidence received since the final August 2000 rating decision denying service connection for seizure disorder relates to an unestablished fact necessary to substantiate the claim and, presuming its credibility, raises a reasonable possibility of substantiating the claim of service connection for a disability characterized by blackouts and seizures. 3. A January 2002 rating decision denied service connection for a disability manifested by decreased energy level. The appellant was duly notified of the RO’s determination and his appellate rights but he did not appeal within the applicable time period, nor was new and material evidence received in the year following notification of the decision. 4. Evidence received since the final January 2002 rating decision denying service connection for a disability manifested by decreased energy level relates to an unestablished fact necessary to substantiate the claim and, presuming its credibility, raises a reasonable possibility of substantiating the claim of service connection for chronic fatigue syndrome. 5. The evidence is in relative equipoise as to whether the appellant’s current cervical spine disability is causally related to his active service. 6. The evidence is in relative equipoise as to whether the appellant’s current lumbar spine disability is causally related to his active service. 7. The evidence is in relative equipoise as to whether the appellant’s current left foot disability is causally related to his active service. 8. The evidence is in relative equipoise as to whether the appellant’s chronic fatigue syndrome is causally related to his active service. 9. The evidence is in relative equipoise as to whether the appellant’s chronic sinusitis is causally related to his active service. 10. The evidence is in relative equipoise as to whether the appellant’s lung cancer is causally related to his active service. 11. The evidence is in relative equipoise as to whether the appellant’s obstructive sleep apnea is causally related to his active service. 12. The evidence is in relative equipoise as to whether the appellant’s irritable bowel syndrome is causally related to his active service. 13. The evidence is in relative equipoise as to whether the appellant’s disability characterized by blackouts and seizures is causally related to his active service. CONCLUSIONS OF LAW 1. The August 2000 rating decision denying service connection for seizure disorder is final. 38 U.S.C. § 7105(c) (1994); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2000). 2. New and material evidence has been received to warrant reopening of the previously denied claim of service connection for seizure disorder, now claimed as a disability characterized by blackouts and seizures. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The January 2002 rating decision denying service connection for a disability manifested by decreased energy level is final. 38 U.S.C. § 7105(c) (2000); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2001). 4. New and material evidence has been received to warrant reopening of the previously denied claim of service connection for a disability manifested by decreased energy level, to include as due to an undiagnosed illness, now claimed as chronic fatigue syndrome. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156 (2017). 5. The criteria for entitlement to service connection for a cervical spine disability have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 6. The criteria for entitlement to service connection for a lumbar spine disability have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 7. The criteria for entitlement to service connection for a left foot disability have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 8. The criteria for entitlement to service connection for chronic fatigue syndrome have been met. 38 U.S.C. §§ 1110, 1117, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2017). 9. The criteria for entitlement to service connection for chronic sinusitis have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 10. The criteria for entitlement to service connection for lung cancer have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 11. The criteria for entitlement to service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 12. The criteria for entitlement to service connection for irritable bowel syndrome have been met. 38 U.S.C. §§ 1110, 1117, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2017). 13. The criteria for entitlement to service connection for a disability characterized by blackouts and seizures have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant had a period of active duty for training (ACDUTRA) from September 27, 1983, to June 19, 1985. He also served on active duty in the Army from January 22, 1991, to May 10, 1991, from February 10, 1995, to August 7, 1995, from August 5, 2002, to July 30, 2003, from August 2007 to August 2008, from December 1, 2009, to December 27, 2010, and from July 1, 2011, to December 26, 2011. Such active service included service in the Southwest Asia theater of operations. He is the recipient of the Combat Medical Badge, the Parachutist Badge, and the Bronze Star Medal. He has additional service in the Army Reserves and Army National Guard. This matter comes before the Board of Veterans’ Appeals (Board) from a July 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The appellant filed a timely Notice of Disagreement (NOD), received in August 2012. A Statement of the Case (SOC) was issued in December 2016. A timely substantive appeal was received in February 2017. The appellant was afforded a hearing before the undersigned via videoconference in August 2018. A transcript is of record. A December 2016 rating decision granted service connection for residuals of status post derangement left medial meniscus. Such constitutes a full award of the benefit sought on appeal with respect to that claim. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of “downstream” elements such as the disability rating or effective date assigned). An August 2018 rating decision, inter alia, denied service connection for lung adenocarcinoma. A timely NOD was received in October 2018. Generally, the filing of a NOD confers jurisdiction on the Board and the next step is for the Agency of Original Jurisdiction (AOJ) to issue an SOC. See Manlincon v. West, 12 Vet. App. 238 (1999). However, for the reasons explained infra, lung adenocarcinoma is encompassed by the claim of entitlement to service connection for a respiratory disability, currently before the Board. As the Board is granting service connection for lung cancer, there is no prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The issues of entitlement to service connection for bilateral hearing loss, tinnitus, traumatic brain injury (TBI) to include short-term memory loss, headaches, bilateral shoulder disability, bilateral hip disability, bilateral knee disability, right foot disability, bilateral ankle disability, a disability manifested by chest pain, a bilateral hand disability, and skin cancer have been raised by the record, to include a Statement in Support of Claim received in August 2014, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2017). New and Material Evidence In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. See 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.1100, 20.1103. Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. For claims such as this one, filed on or after August 29, 2001, new evidence means existing evidence not previously submitted to agency decision makers. 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. To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the credibility of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary’s duty to assist. Id. at 118; but see Villalobos v. Principi, 3 Vet. App. 450 (1992) (evidence that is unfavorable to a claimant is not new and material). An August 2000 rating decision denied service connection for seizure disorder and a disability manifested by decreased energy level, to include as due to an undiagnosed illness. The appellant was duly notified of this decision and his appellate rights in September 2000, but did not appeal. Because the latter issue was denied as being not well grounded, a January 2002 rating decision was issued, which denied service connection for a disability manifested by decreased energy level, to include as due to an undiagnosed illness. See Veterans Claims Assistance Act of 2000. The appellant was duly notified of this decision and his appellate rights in February 2002. Because the appellant did not appeal either rating decision within the applicable time period, nor was new and material evidence received in the year following notification of the decisions, the September 2000 rating decision is final with regard to the seizure claim; and the February 2002 rating decision is final with respect to the decreased energy level claim. Despite the finality of a prior adverse decision, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. The Board has therefore reviewed the entire record, with particular attention to the additional evidence received since these last final rating decisions. The additional evidence includes a July 2018 medical opinion by V.E., a Physician’s Assistant, to the effect that the appellant’s chronic fatigue syndrome and seizure disorder had their inception during active service. This evidence is new, as it was not before the RO at the time of its February 1997 rating decision. Further, presuming its credibility, it is material, as it relates to unestablished facts necessary to substantiate the claims. Service connection was denied, in part, because there was no positive nexus opinion linking the appellant’s active service to current seizure and fatigue disabilities. Under these circumstances, the Board finds that new and material evidence has been presented. Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). Accordingly, the Board finds that the appellant’s previously denied claims of service connection for seizure disorder and chronic fatigue syndrome are reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. “To establish a right to compensation for a present disability, a Veteran must show: ‘(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service’—the so-called ‘nexus’ requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis and other organic diseases of the nervous system, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Additionally, VA will pay compensation to a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that 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 or more before December 31, 2021. 38 U.S.C. § 1117; see 38 C.F.R. § 3.317(a); 81 Fed. Reg. 71,382-84 (Oct. 17, 2016) (extending the presumptive period for compensation for Gulf War veterans from December 31, 2016 to December 31, 2021). A qualifying chronic disability is as a chronic disability that results from an undiagnosed illness or a medically unexplained chronic multisymptom illness such as chronic fatigue syndrome, fibromyalgia, or a functional gastrointestinal disorder (excluding structural gastrointestinal diseases). 38 C.F.R. § 3.317(a)(2)(i). A “medically unexplained chronic multisymptom illness” has been defined as 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.” 38 C.F.R. § 3.317(a)(2)(ii). “Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained.” Id. Along with the three examples of a medically unexplained chronic multisymptom illness provided by section 1117(a)(2)(B), Congress has provided a list of signs or symptoms that may be a manifestation of a medically unexplained chronic multisymptom illness that includes: skin symptoms, headaches, muscle pain, joint pain, neurologic symptoms, neuropsychological symptoms, respiratory system symptoms, sleep disturbances, gastrointestinal symptoms, cardiovascular symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C. § 1117(g); 38 C.F.R. § 3.317(b). Cervical spine disability Upon weighing the evidence, the Board finds that service connection for a cervical spine disability is warranted. A December 2010 Statement of Medical Examination and Duty Status states that the appellant’s cervical spondylosis was incurred in the line of duty in July 2010, while he was serving on active duty. The appellant has a current disability of cervical spine degenerative disc disease. See July 2016 VA examination report. V.E., a physician’s assistant, stated that she treated the appellant for cervical and lumbar pain following a hard parachute landing fall in July 2010. She opined in July 2018 that the appellant’s cervical disc bulges were more likely than not the result of the hard parachute landing fall, and that his degenerative arthritis was more likely than not the result of his active airborne service, which included numerous parachute landing falls. Similarly, Dr. D.G., who served with the appellant, opined in April 2018 that it was more likely than not that the appellant’s degenerative arthritis of the cervical spine was caused by numerous parachute jumps and high-impact training events throughout his many periods of active service. Dr. D.G. explained that an individual microtrauma from each event was not the concern, but repeated microtraumas and microinjuries from numerous parachute jumps and other duties of an airborne soldier would result in arthritis. It was noted that it was very reasonable that there would be no records of any single microtrauma, as one might not even be aware of its incurrence. While the July 2016 VA examiner offered a negative etiological opinion, attributing the appellant’s current disability to obesity and his civilian occupation of police officer, the examiner stated that the appellant had neck pain in December 2010. The July 2010 incident was not discussed. Thus, such is based on an inaccurate factual premise and is entitled to minimal probative weight. While the RO indicated that the July 2010 cervical spine injury did not occur during a period of active service, and there is no DD Form 214 indicating active service in July 2010, the record includes orders which indicate that the appellant was ordered to active duty from December 1, 2009, to November 30, 2010. Even if the appellant was not on active duty in July 2010, service connection would still be warranted because the July 2018 opinion from V.E. attributes the appellant’s current cervical spine disability to the numerous parachute jumps the appellant, as an airborne soldier, performed during his numerous periods of active duty. As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award service connection for a cervical spine disability. Lumbar spine disability The Board finds that service connection for a lumbar spine disability is warranted. V.E.’s July 2018 medical opinion, discussed supra, also states that the appellant complained of lumbar pain following the July 2010 hard parachute landing fall. As with the appellant’s cervical spine disability, the numerous parachute landing falls performed by the appellant during his multiple periods of active service as an airborne soldier caused his current lumbar spine disability. Likewise, Dr. D.G. opined in April 2018 that it was more likely than not that the appellant’s degenerative arthritis of the lumbar spine was caused by numerous parachute jumps and high-impact training events throughout his many periods of active service. Dr. D.G. explained that an individual microtrauma from each event was not the concern, but repeated microtraumas and microinjuries from numerous parachute jumps and other duties of an airborne soldier would result in arthritis. It was noted that it was very reasonable that there would be no records of any single microtrauma, as one might not even be aware of its incurrence. While the July 2016 VA examiner diagnosed degenerative disc disease of the lumbar spine, the negative etiological opinion is entitled to minimal probative weight because such states that the appellant only complained of back pain in November 1983 during a period of inactive service. First, the record indicates that the appellant was on ACDUTRA at that time. Second, the effects of numerous parachute landing falls during multiple periods of active service, discussed by V.E. and Dr. D.G. in their opinions, do not appear to have been considered. As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award service connection for a lumbar spine disability. Left foot disability, claimed as plantar fasciitis The evidence is in relative equipoise as to whether the appellant has a left foot disability which is causally related to his active service. The appellant was diagnosed with flat feet in July 2010, while on active duty. He was issued arch supports. Records from Humana Military indicate that the appellant was provided orthotics for left plantar fasciitis in November 2008. Service treatment records also indicate a diagnosis of left plantar fasciitis in January 2009. While the July 2016 examiner diagnosed left plantar fasciitis, it was noted that the appellant reported that his left plantar fasciitis resolved following treatment. Current residuals were denied. During his August 2018 hearing, the appellant did not indicate that his symptoms had resolved. Likewise, the remaining evidence of record does not indicate that the appellant no longer experienced left foot symptomatology. Indeed, the evidence of record establishes that the appellant continues to use left foot orthotics. In August 2018, V.E., the physician’s assistant, opined that the appellant’s left flat foot/plantar fasciitis was the result of his airborne military duties over many years, including marching with a 100-pound rucksack. In any event, the appellant has experienced functional impairment from his left foot pain during the period on appeal. The Board notes that “disability” as defined in 38 U.S.C. §§ 1110 and 1131 refers to the functional impairment of earning capacity, not the underlying cause of said disability, and that pain alone can reach the level of a functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award service connection for a left foot disability. Chronic fatigue syndrome Upon weighing the evidence, the Board finds that a grant of service connection is warranted for chronic fatigue syndrome. As noted supra, the appellant served on active duty in Southwest Asia. Following his service in Operation Desert Storm, the appellant was observed by W.P., who has served with the appellant since 1983, to have less energy, less pep, and difficulty breathing. The appellant also appeared unfocused at times. V.E., a physician’s assistant, treated the appellant for symptoms of fatigue at Fox Army Medical Center in August 2009 and diagnosed chronic fatigue syndrome. V.E. again diagnosed the appellant with chronic fatigue syndrome and opined in August 2018 that such was the result of his service in Southwest Asia. C.P., a nurse practitioner, also noted the appellant’s diagnosed chronic fatigue syndrome in August 2018. The Board affords greater probative weight to V.E. and C.P.’s diagnoses of chronic fatigue syndrome than to the July 2016 VA examiner’s statement that the appellant did not have chronic fatigue syndrome because the VA examiner did not explain why the appellant had been diagnosed with such in August 2009 and either no longer suffered from chronic fatigue syndrome or that the prior diagnosis had been made in error. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The appellant has competently and credibly reported continuity of symptomatology; and the evidence of record establishes that he has had symptoms of fatigue since his active service during Operation Desert Storm and that he has a current diagnosis of chronic fatigue syndrome. As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award service connection for chronic fatigue syndrome. Chronic sinusitis Upon weighing the evidence, the Board finds that service connection is warranted for chronic sinusitis. Service treatment records indicate that the appellant was diagnosed with and treated for allergic rhinitis and sinusitis. The appellant testified that he received treatment for sinus problems at Fox Army Medical Center. He reported exposure to environmental hazards while deployed on active duty. A December 2002 memorandum for the record states that the appellant was exposed to intense dust storms and airborne particulate matter while serving in Afghanistan. There was also exposure to a documented fume source in a former Soviet compound. In an August 2018 opinion, V.E., a physician’s assistant, opined that it was more likely than not that the appellant’s chronic sinusitis was due to his active service. V.E. had treated the appellant at Fox Army Medical Center. As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award service connection for chronic sinusitis. Respiratory disability As an initial matter, the Board observes that the RO has treated entitlement to service connection for lung adenocarcinoma as a separate issue. See e.g. August 2018 rating decision. As noted in the INTRODUCTION, however, the claim of service connection for a respiratory disability encompasses lung adenocarcinoma. The grant of service connection is thus not prejudicial. See Bernard, supra. Dr. R.K. opined in April 2018 that the appellant’s current stage-three lung adenocarcinoma was more likely than not that the result of the appellant’s active service, to include multiple environmental exposures. It was noted that the appellant had never smoked and was surrounded by non-smokers. Smoking was noted to be the cause of 90 percent of lung cancer cases. The Board affords greater probative weight to this opinion than to the negative July 2018 VA medical opinion because the latter does not address the fact that medical records establish that the appellant was never a smoker. Most of the probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award service connection for lung cancer. Obstructive sleep apnea The Board finds that service connection is warranted for obstructive sleep apnea. The appellant reported in August 2009 that he snored and would wake up choking and gasping. In September 2009, the diagnosis was rule out sleep apnea. He was diagnosed with obstructive sleep apnea by sleep study in November 2010, during a period of active service. The July 2016 VA examiner stated that he appellant was diagnosed with sleep apnea in November 2009 and opined that such was less likely than not due to environmental exposures in Southwest Asia. Rather, the examiner attributed the appellant’s sleep apnea to his BMI of greater than 30. However, the Board finds that this opinion is inadequate as it does not consider that the appellant was diagnosed by sleep study while on active duty, nor does it discuss when the appellant’s symptoms actually began. Further, V.E. opined in August 2018 that it was more likely than not that the appellant’s obstructive sleep apnea was the result of his active service. The record indicates that the appellant was on active duty in November 2010, when he was diagnosed with obstructive sleep apnea. The July 2016 VA medical opinion reports an incorrect date of diagnosis. Even though the appellant had symptoms possibly indicative of sleep apnea prior to November 2010, including during periods when he was not on active duty or during a period of ACDUTRA, he is entitled to the presumption of soundness for his period of active duty from December 1, 2009, to December 27, 2010, as sleep apnea was not noted at the beginning of such period. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award service connection for obstructive sleep apnea. Irritable bowel syndrome Service connection is warranted for irritable bowel syndrome. The appellant served on active duty in the Southwest Asia theater of operations. While the July 2016 VA examiner stated that the appellant had never been treated for or diagnosed with irritable bowel syndrome, this is incorrect. Thus, the negative opinion is entitled to minimal probative weight. Service treatment records indicate that the appellant was diagnosed with irritable bowel syndrome in 2009. In addition, in August 2018, C.P., a nurse practitioner, noted that the appellant currently had irritable bowel syndrome. In August 2018, V.E., a physician’s assistant, explained that the signs and symptoms the appellant presented with at Fox Army Medical Center were consistent with irritable bowel syndrome. She opined that such was more likely than not that such was the result of his active service in the Southwest Asia theater of operations. As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award service connection for irritable bowel syndrome. A disability characterized by blackouts and seizures Service connection is warranted for the appellant’s disability characterized by blackouts and seizures. The appellant first experienced a seizure in 1991. While the evidence indicates that some clinicians did not consider the episode in 1991 to be a seizure, the Board affords great probative weight to the August 2018 statement by L.B., a licensed practical nurse. She stated that she personally observed the appellant’s July 1991 seizure while she was visiting him. At that time, she had more than a decade of medical experience. The appellant was diagnosed in October 1996 with partial complex seizure disorder by Atlanta Neurology. Service treatment records indicate a 2011 diagnosis of seizure disorder. The appellant also experienced a seizure in April 2016, during the period on appeal. In August 2018, V.E. observed that the appellant’s 1991 seizure occurred within 60 days of service in the Persian Gulf. She opined that it was more likely than not that the appellant’s epilepsy/seizure disability was the result of his 1991 deployment.   As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award service connection for a disability characterized by blackouts and seizures. K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Behlen, Associate Counsel