Citation Nr: 18153313 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 14-23 147 DATE: November 27, 2018 ORDER Service connection for hypertension, to include as secondary to the service-connected posttraumatic stress disorder (PTSD) and/or diabetes mellitus type II, is denied. Service connection for gastroesophageal reflux disease (GERD), including as secondary to the service-connected PTSD, is denied. Service connection for obstructive sleep apnea, including as secondary to the service-connected PTSD, is denied. Service connection for a cervical spine disability is denied. Service connection for thyroid cancer, including as due to herbicide exposure, is denied. The reduction of the 50 percent disability rating to 30 percent for posttraumatic stress disorder (PTSD) effective from February 1, 2016 was not proper; restoration of the 50 percent rating for PTSD is granted. An initial disability rating higher than 30 percent for service-connected basal cell carcinoma of the right ear, squamous cell carcinoma of the left ear, and actinic keratosis (skin cancer residuals) is denied. FINDINGS OF FACT 1. There was no vascular injury or disease during service, and chronic symptoms of hypertension were not manifested during service; symptoms of hypertension have not been continuous since service separation, and hypertension did not manifest to a compensable degree in the year following separation from service; hypertension was manifested many years after service and is not causally or etiologically related to service; and hypertension was neither caused nor worsened beyond the natural progression by service-connected diabetes mellitus or service-connected PTSD. 2. There was no gastrointestinal injury or disease during service; GERD was manifested many years after service separation and is not causally or etiologically related to service; and GERD was neither caused nor worsened beyond the natural progression by the service-connected PTSD. 3. There was no respiratory injury or disease or sleep apnea symptoms during service; sleep apnea was manifested many years after service and is not causally or etiologically related to service; and sleep apnea was neither caused nor worsened beyond the natural progression by service-connected PTSD. 4. There was no cervical spine injury or disease during active service and chronic symptoms of cervical spine arthritis were not manifested during active service; symptoms of cervical spine arthritis have not been continuous since service separation, and cervical spine arthritis did not manifest to a compensable degree in the year following separation from service; and the current cervical spine disability was manifested many years after service and is not causally or etiologically related to service. 5. There was no endocrine system injury or disease and no chronic symptoms of thyroid cancer were manifested during service; thyroid cancer was not manifested to a compensable degree within one year of service, and continuous symptoms of thyroid cancer were not manifested since service; the currently diagnosed thyroid cancer is not causally or etiologically related to service. 6. A November 2015 rating decision reduced the rating for the service-connected PTSD from 50 percent to 30 percent, effective from February 1, 2016, and met all due process requirements; as of February 1, 2016, the 50 percent rating for the PTSD had been in effect for less than five years; and a preponderance of the evidence does not show that the PTSD demonstrated material improvement under the ordinary conditions of life and work. 7. For the entire initial rating period from January 1, 2013, skin cancer residuals are manifested by a mid-helix scar of the right ear measuring 1 centimeter in length by 1 centimeter in width and was depressed on palpation, and a mid-antihelix left ear painful scar measuring 1 centimeter in length by 0.5 centimeter in width; no other disfiguring characteristics or symptoms and no functional impairment were shown. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension, to include as secondary to service-connected diabetes mellitus type II and/or service-connected PTSD, are not met. 38 U.S.C. §§ 1110, 1112, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for GERD, to include as secondary to the service-connected PTSD, are not met or approximated. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 3. The criteria for service connection for obstructive sleep apnea, to include as secondary to PTSD, are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 4. The criteria for service connection for a cervical spine disability are not met. 38 U.S.C. §§ 1110, 1112, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 5. The criteria for service connection for thyroid cancer, including as due to herbicide exposure, are not met. 38 U.S.C. §§ 1110, 1112, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 6. The reduction of the 50 percent rating for PTSD to 30 percent was not proper, and the 50 percent disability rating is restored effective from February 1, 2016. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.105, 3.344, 4.130, Diagnostic Code (DC) 9411. 7. The criteria for an initial rating higher than 30 percent rating for skin cancer residuals are not met or approximated for the entire rating period. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.21, 4.118, DC 7818-7800. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, had active service in the U.S. Navy from November 1968 to December 1971, and subsequent unverified inactive duty training (INACDUTRA) and active duty for training (ACDUTRA) periods in the Reserves. These matters are on appeal from August 2013, October 2014, November 2015, and December 2017 rating decisions. In January 2017, the Board remanded the issues on appeal for verification of INACDUTRA and ACDUTRA service periods, VA examinations with medical opinions addressing the likelihood of a nexus relationship between hypertension, sleep apnea, and GERD to service or as secondary to service-connected PTSD, and the likelihood of a nexus relationship between hypertension and service-connected diabetes mellitus. Because VA examinations with medical opinions were obtained in February 2018 and March 2018, and adequate attempts to verify the Veteran’s INACDUTRA and ACDUTRA service periods were made but were ultimately unsuccessful, the Board finds that there was substantial compliance with the prior remand directives for the appeals adjudicated herein. The Board finds that the duties to notify and assist the Veteran in this case have been fulfilled. Neither the Veteran nor the evidence has raised any specific contentions regarding the duties to notify or assist. Service Connection Legal Authority 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. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a direct basis when there is competent, credible evidence of: (1) a current disability; (2) a disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. 38 C.F.R. § 3.303(a), (d). Service connection may be established on a presumptive basis for chronic diseases listed under 38 C.F.R. § 3.309(a) if chronic symptoms of the disease were shown in service; the disease was manifested to a compensable degree with a presumptive period, usually one year after service separation; or continuous symptoms of the disease were manifested since service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.33(b), 3.307, 3.309(a); see also Walker v. Shinseki, 708 F. 3d 1131 (Fed. Cir. 2013). Because the current diagnoses of GERD and sleep apnea are not listed as a chronic disease(s) under 38 C.F.R. § 3.303(b), the presumptive service connection provisions are not applicable to those diagnoses; however, hypertension, cervical spondylosis (i.e., arthritis), and thyroid cancer (as a malignant tumor) are chronic diseases under 38 C.F.R. § 3.303(b), so the presumptive service connection provisions are applicable to those diagnoses. See Dorland's Illustrated Medical Dictionary 1743 (30th ed. 2003) (defining spondylosis as ankylosis of a vertebral joint or degenerative spinal changes due to osteoarthritis). In order to establish presumptive service connection for a disease associated with exposure to certain herbicide agents, the evidence must show the following: (1) that the veteran served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 (or was otherwise exposed to an herbicide agent during active service); (2) that he currently suffers from a disease associated with exposure to certain herbicide agents listed under 38 C.F.R. § 3.309(e); and (3) that the current disease process manifested to a degree of 10 percent or more within the specified time period prescribed in section 3.307(a)(6)(ii). 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). If a veteran was exposed to an herbicide agent during active military, naval, or air service, the certain diseases shall be service-connected, if the requirements of 38 C.F.R. § 3.307 (a) are met, even if there is no record of such disease during service. The list of diseases associated with exposure to certain herbicide agents does not include thyroid cancer. See 38 C.F.R. § 3.309 (e). Service connection may be established on a secondary basis for a disability which was either: (1) caused by, or (2) aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Compensation based on secondary aggravation will be awarded only for the degree of disability over and above the degree of disability prior to aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). 1. Service Connection Analysis for Hypertension The Veteran contends that the current hypertension was either caused or worsened beyond its normal progression (i.e., aggravated) by the service-connected diabetes mellitus type II or the service-connected PTSD. In the alternative, he asserts that hypertension had its onset during service or was otherwise causally or etiologically related to service. "Hypertension" refers to persistently high arterial blood pressure. Medical authorities have suggested various thresholds ranging from 140 mm Hg systolic and from 90 mm Hg diastolic to as high as 200 mm Hg systolic and 110 mm Hg diastolic as reflective of hypertension. See Dorland's Illustrated Medical Dictionary 909 (31st ed. 2007). Similarly, for VA rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mm or greater. The term "isolated systolic hypertension" means that the systolic blood pressure is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. The Board finds that the weight of the evidence is against a finding that current hypertension was either caused or aggravated by the service-connected diabetes mellitus type II or the service-connected PTSD. After interview and examination of the Veteran and review of the record, the March 2018 VA examiner opined that hypertension was less likely than not caused by, or the result of, service-connected diabetes mellitus or the service-connected PTSD. When providing rationale for the medical opinion, the March 2018 VA examiner noted that the Veteran was not a former prisoner of war so no presumption of service connection for hypertension was warranted and explained that the present medical literature did not definitely show essential hypertension as being caused and/or aggravated by PTSD. The March 2018 VA examiner further explained that recent laboratory test results showed that the estimated glomerular filtration rate (EGFR) and creatine for the Veteran appeared to be within normal limits. The March 2018 VA examiner wrote that diabetes mellitus could adversely affect kidney function resulting in renal hypertension in some cases but no causal association between the Veteran’s hypertension and diabetes mellitus could be made because the Veteran’s kidney function was within normal limits. The Board notes that the March 2018 VA examiner did not explicitly address the theory of secondary aggravation; however, it is reasonable to infer that there was no aggravation of hypertension by the service-connected diabetes mellitus on the basis that the evidence does not show adversely affected kidney function, which would be present if diabetes mellitus had aggravated hypertension. The March 2018 VA examiner has medical training and expertise, had adequate information on which to base the medical opinions, and provided adequate rationale based on an accurate medical history and medical principles. For these reasons, the collective VA medical opinions are of significant probative value and weigh against a finding of service connection for hypertension on a secondary basis. There is no competent medical opinion to the contrary of record. The Board notes that treating medical providers have diagnosed essential hypertension, which is defined as hypertension occurring without a discoverable organic cause. Such evidence shows no link between the current hypertension and service-connected disability. See e.g., December 2010 Lackland Air Force Base family health clinic outpatient treatment record (noting a diagnosis of essential hypertension); Dorland's Illustrated Medical Dictionary 909 (31st ed. 2007) (defining essential hypertension). The Veteran has repeatedly asserted his belief that service-connected diabetes mellitus or PTSD caused or worsened beyond the normal progression the claimed hypertension; however, as a lay person, he does not have the requisite medical expertise to render a competent medical opinion either on the relationship between the complex interaction between the cardiovascular and endocrine systems or the complex interaction between the cardiovascular and neuropsychiatric systems, on either a causal or aggravation basis. Such diagnoses and opinions as to relationship involve an understanding of complex interactions between body systems (cardiovascular and endocrine and cardiovascular and neuropsychiatric), involve making findings based on medical knowledge and clinical testing results, and involve unseen systems processes and disease processes that are not observable by the five senses of a lay person. In addition, while a medical opinion considers symptoms to help determine the dates of onset of disabilities of hypertension and diabetes or PTSD, the opinion is not based primarily on the reported symptoms that are capable of lay observation. It is also based on medical knowledge and an understanding of the various potential causes or etiologies of hypertension and any factors or conditions that may contribute to the worsening of hypertension. Consequently, the Veteran's purported opinion relating hypertension to his service-connected diabetes mellitus or service-connected PTSD is of no probative value and is outweighed by the March 2018 VA medical opinion discussed above. The Board further finds that the lay and medical evidence demonstrates that no vascular injury, disease, or chronic symptoms of hypertension occurred during service or were manifested during service. Review of the service treatment records, which are complete, shows that the blood pressure readings were consistently within normal limits during service, to include at the December 1971 service separation examination (i.e., 120/80). Because the service treatment records are complete, and blood pressure readings were recorded during service and were consistently within normal limits, including at service separation, the Board finds that hypertension is a condition that would have ordinarily been recorded during service, including at the service separation examination, had it been present during service; therefore, the lay and medical evidence generated contemporaneous to service, which showed no in-service vascular injury or disease and no chronic symptoms of hypertension, is likely to reflect accurately the Veteran's physical condition, so is of significant probative value and provides evidence against a finding of hypertension or "chronic" symptoms of hypertension during service. See Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (citing Fed. R. Evid. 803(7) for the proposition that the absence of an entry in a record may be evidence against the existence of a fact if it would ordinarily be recorded). As the weight of the evidence demonstrates no vascular injury or disease or "chronic" symptoms of hypertension during service, the criteria for presumptive service connection under 38 C.F.R. § 3.303(b) based on "chronic" symptoms in service are not met. The Board next finds that the evidence shows that symptoms of hypertension were not continuous since service, including not to a degree of ten percent within one year of service separation. See 38 C.F.R. § 4.104, Diagnostic Code 7101. The earliest evidence suggesting the onset of hypertension is shown in 1998, approximately 27 years after service separation. See November 1998 service consultation note (noting high blood pressure and a provisional diagnosis of hypertension); see also March 2018 VA examination report (noting the Veteran’s report that hypertension was diagnosed approximately 10 years earlier). Considered together with the absence of in-service vascular injury or disease or symptoms of hypertension during service, and the vascular system clinically evaluated as normal with blood pressure readings within normal limits at the August 1984, July 1988, and June 1993 periodic Reserve service examinations, the 27-year gap between service and the onset of hypertension is one factor that tends to weigh against a finding of continuous symptoms of hypertension after service separation. See Buchanan v. Nicholson, 451 F.3d 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor to consider as evidence against a claim of service connection). As the weight of the evidence demonstrates no "continuous" symptoms of hypertension since service, including to a compensable degree within the first post-service year, the criteria under 38 C.F.R. § 3.303 (b) for presumptive service connection based on "continuous" hypertension symptoms or hypertension manifested to a degree of ten percent within one year of service separation are not met. 38 C.F.R. §§ 3.307, 3.309. The Board further finds that the weight of the evidence demonstrates that hypertension, which was first manifested many years after service, was not caused by or otherwise related to service. After review of the record and examination and interview of the Veteran, the March 2018 VA examiner provided a negative medical opinion on the question of whether hypertension was causally or etiologically related to service. In support of the medical opinion, the March 2018 VA examiner reasoned that there appeared to be no medical documentation of chronic or persistently elevated blood pressures during service. The March 2018 VA examiner also wrote that the December 1971 service examination report showed a blood pressure reading of 120/80, which was within normal blood pressure limits. Because the March 2018 VA examiner based the medical opinion on an accurate and sufficient history, had medical expertise and training, and provided a sound rationale for the medical opinion, the March 2018 VA medical opinion is of significant probative value. There is no medical opinion to the contrary of record. As such, direct and presumptive service connection for hypertension may not be established. 38 C.F.R. §§ 3.303, 3.307, 3.309. Although the Veteran has asserted his belief that hypertension was caused by service, he is a lay person and does not have the requisite medical expertise to render a competent medical opinion in this case regarding the etiology of hypertension, which was manifested many years after service. Such diagnoses and opinions as to relationship involve unseen systems processes and disease processes that are largely unobservable by the five senses of a lay person, involve an understanding of the cardiovascular system and the possible causes or etiologies of hypertension, and involve making findings based on medical knowledge and clinical testing results. Consequently, the Veteran's purported opinion relating hypertension to service is of no probative value. Thus, the weight of the evidence is against a finding that hypertension was incurred in or was otherwise caused by active service, or was caused or aggravated by service-connected diabetes mellitus type II or the service-connected PTSD. In consideration of the foregoing, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against service connection for hypertension, including as secondary to the service-connected diabetes mellitus type II or service-connected PTSD, so the appeal must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Service Connection Analysis for GERD The Veteran contends that symptoms of the current GERD were manifested during service and continued thereafter. In the alternative, he asserts that GERD was either caused or aggravated by the service-connected PTSD. After review of all the lay and medical evidence of record, the Board finds that gastrointestinal symptoms were manifested during active service. In February 1970, the Veteran received treatment for gastrointestinal symptoms of nausea, abdominal pain, and vomiting, and the service medical provider attributed the symptoms to an upper respiratory infection. There was no diagnosis of a chronic gastrointestinal disability during service, including GERD. The weight of the evidence is against finding that GERD is causally or etiologically related to service. The evidence shows that GERD was first manifested approximately in 2011, 40 years after service. Considered together with the absence of report, diagnosis, or treatment for a chronic gastrointestinal disability, including GERD, during service, and the post-service evidence showing a normal abdomen and viscera at the August 1984, July 1988, June 1993, and November 1998 Reserve service examinations, the gap of approximately 40 years between service and diagnosis of GERD is one factor that tends to weigh against a finding of service incurrence. Although the Veteran told the March 2018 VA examiner that he had a 20-year history of reflux disease, the account is inconsistent with other, more credible lay and medical evidence showing no chronic gastrointestinal disability until 2011, so the account is not credible and is of no probative value. See, e.g., September 2014 VA examination report (noting a GERD diagnosis for three years duration). Moreover, by the Veteran’s own report, GERD has its onset many years after service separation. After review of the record and interview and examination of the Veteran, the September 2014 VA examiner opined that the current GERD was less likely than not caused or worsened beyond the natural progression by the service-connected PTSD. In support of the medical opinion, the September 2014 VA examiner explained that it was unlikely that GERD was caused by PTSD because there was no pathophysiological relationship between the two conditions. Also, after reviewing the record and examining the Veteran, the March 2018 VA examiner similarly opined that it was less likely than not that GERD was either caused or aggravated by the service-connected PTSD. The March 2018 VA examiner reasoned that there were a number of medical studies that showed that GERD and psychological conditions such as PTSD coexist with many co-morbidities but that did not mean that PTSD caused or aggravated GERD. The March 2018 VA examiner noted that, in order to definitely make this type of cause and effect association, prospective studies were required to show a cause and effect relationship or risk for GERD; however, to date, no such prospective studies had been published showing PTSD caused or increased the risk for GERD. The March 2018 VA examiner added that, in the absence of prospective studies, other associations might be examined. The March 2018 VA examiner further wrote that the medical literature showed that psychological stress clinically insignificantly decreased esophageal sphincter tone, but did not decrease phases or activity of the esophageal junction pressure. The September 2014 and March 2018 VA examiners had accurate facts and data on which to base the medical opinion, and provided sound rationale for the medical opinion; therefore, the Board finds the collective September 2014 and March 2018 VA medical opinions to be of significant probative value. There is no competent medical opinion to the contrary of record. The Veteran is competent to report any gastrointestinal symptoms that come to him through the senses; however, as a lay person, he lacks the requisite medical expertise and medical training to attribute any symptoms he experiences to a diagnosed disability other than a simple medical condition capable of lay diagnosis. GERD is not a condition for which lay evidence is sufficient to establish a diagnosis. A competent medical diagnosis of GERD involves making findings based on history, complaints and symptoms, signs, medical knowledge, and, in some cases, clinical testing results. The Veteran is not competent to diagnose GERD or provide a medical opinion regarding its likely etiology when the facts show that GERD was manifested many years after service; therefore, the Veteran's purported lay opinion that GERD is related to service or to service-connected PTSD on either a causation or aggravation basis is of no probative value. The unsupported lay opinion is outweighed by the lay and medical evidence showing that GERD was manifested many years after service separation and is otherwise unrelated to service or the service-connected PTSD on either a causation or aggravation basis. Thus, the weight of the evidence is against a finding that GERD was incurred in or were otherwise caused by active service. In consideration of the foregoing, the Board finds that a preponderance of the lay and medical evidence weighs against the appeal of service connection for GERD; consequently, the appeal must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Service Connection Analysis for Sleep Apnea The Veteran contends that symptoms of obstructive sleep apnea were manifested during service and continued after service. In the alternative, he contends that sleep apnea was either caused or worsened beyond the natural progression by the service-connected PTSD. After review of all the lay and medical evidence of record, the Board finds that the weight of the lay and medical evidence is against finding that a respiratory injury or disease or sleep apnea symptoms were manifested during service. The service treatment records, which are complete, are absent of complaints of, diagnoses of, or treatment for sleep apnea or sleep apnea symptoms or for respiratory problems other than acute upper respiratory illnesses, which all resolved during service. Because the service treatment records are complete, the Veteran received in-service treatment for upper respiratory illnesses during service with no report or complaint of sleep apnea symptoms, the Board finds that sleep apnea is a condition that would have ordinarily been recorded during service, if it had been present; therefore, the lay and medical evidence contemporaneous to service is of significant probative value and weighs against a finding of respiratory injury or disease or sleep apnea symptoms during service. The weight of the evidence is against finding that sleep apnea was otherwise causally or etiologically related to service. The evidence shows no sleep apnea symptoms until approximately 2010 (i.e., 39 years after service separation). See, e.g., April 2012 VA Form 21-526 (reporting that sleep apnea began in June 2010). The earliest evidence of a sleep apnea diagnosis confirmed by a sleep study was shown in 2011, approximately 40 years after service separation. Considered together with the lay and medical evidence contemporaneous to service showing no sleep apnea symptoms, the approximate 39-year period between service separation in 1971 and the onset of sleep apnea symptoms approximately in 2010 is an additional factor that weighs against service incurrence. The Board has considered whether sleep apnea symptoms began during service and continued thereafter; however, because the account is inconsistent with, and outweighed by, the lay and medical evidence contemporaneous to service showing no respiratory injury, disease, or symptoms other than for acute upper respiratory illnesses that resolved during service, no sleep apnea symptoms, diagnosis, or treatment during service, and the post-service lay and medical evidence showing an onset of sleep apnea approximately 39 years after service with the earliest diagnosis of sleep apnea made 40 years after service separation, it is not deemed credible, so is of no probative value. After review of the record and examination and interview of the Veteran, the March 2018 VA examiner opined that it was less likely than not that sleep apnea was incurred in or caused by service. In support of the medical opinion, the March 2018 VA examiner noted that there was no clinical documentation regarding a suspected diagnosis or medical evaluation for the work-up of obstructive sleep apnea. The weight of the evidence is against a finding that the sleep apnea was either caused or worsened beyond the natural progression by service-connected PTSD. After reviewing the record and considering the relevant medical literature, the March 2018 VA examiner provided a negative medical opinion on the question of whether sleep apnea was either caused or aggravated by the service-connected PTSD. In support of the medical opinion, the March 2018 VA examiner explained that obstructive sleep apnea was an anatomical disturbance in which the upper airway narrowing occurs from the soft tissues to include the soft palate and the tongue resulting in an insufficient supply of air to the pulmonary system, and deprivation of oxygen to arterial blood flow. The March 2018 VA examiner wrote that symptoms include daytime fatigue and sleepiness, arousals and disturbance during sleep, and noted that the diagnosis of PTSD – a mental health condition –can indeed overlap the symptoms of obstructive sleep apnea. The March 2018 VA examiner wrote that there were several medical reports stating that many Veterans have the co-morbidities of obstructive sleep apnea and PTSD and raised further questions as to a possible cause and effect relationship. The March 2018 VA examiner noted that there were no definitive medical studies stating that PTSD caused and/or aggravated obstructive sleep apnea. The March 2018 VA examiner has medical expertise, had adequate information on which to base the medical opinion, and provided adequate rationale based on an accurate medical history and known medical principles. For these reasons, the March 2018 VA medical opinion is of significant probative value. Although the Veteran has asserted that sleep apnea is causally related to service or was caused or aggravated by service-connected PTSD, he is a lay person and, under the specific facts of this case that include no in-service symptoms and negative findings upon examination, and documented post-service onset of symptoms and diagnosis of sleep apnea years after service, does not have the requisite medical training or credentials to be able to render an opinion regarding the cause of his sleep apnea. The etiology of the Veteran's sleep apnea is a complex medical etiological question dealing with the origin and progression of the respiratory system; sleep apnea is a disorder diagnosed primarily on symptoms, clinical findings and physiological testing; and would require knowledge of a complex interaction or relationship between the different body systems – physical (respiratory) disorder of sleep apnea with the psychological impairments of PTSD. See Waters v. Shinseki, 601 F.3d 1274, 1277-1278 (Fed. Cir. 2010) (recognizing similarly the complexity of a nexus between a psychiatric disorder physical disorder). While the Veteran is competent to report respiratory symptoms that he experiences at any time, he is not competent to opine on whether there is a link between sleep apnea, symptoms of which were manifested several years after service, and active service or the service-connected PTSD (causation or aggravation) because such opinions require specific medical knowledge and training. For these reasons, the Veteran's unsupported lay opinion is of no probative value. The only competent medical opinion evidence of record shows no causal relationship between service or service-connected PTSD and sleep apnea, and no aggravation relationship between service-connected PTSD and sleep apnea. Thus, the weight of the evidence is against a finding that sleep apnea was caused by active service, or was otherwise caused or worsened beyond the normal progression by the service-connected PTSD. In consideration of the foregoing, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the appeal of service connection for sleep apnea, including as secondary to PTSD; consequently, the appeal must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Service Connection Analysis for a Cervical Spine Disability The Veteran contends that the current cervical spine disability is due to frequent heavy lifting during active service. He seeks service connection on this basis. After review of the lay and medical evidence of record, the Board finds that the weight of the evidence is against a finding of neck injury or disease during service or chronic symptoms of cervical spine arthritis were manifested during service. Service treatment records, which are complete, are absent of any report of, complaint of, diagnosis of, or treatment for a neck injury or disease or cervical spine problems other than neck pain associated with migraine headaches during service. Because the service treatment records are complete, and show treatment for other orthopedic problems such as a nose injury in September 1969 and a right finger injury in October 1971, the spine and musculoskeletal system were clinically evaluated and determined to be normal at the August 1984, July 1988, June 1993, and November 1998 Air Force Reserve service examinations, and the Veteran was provided the opportunity to report any ongoing neck problems on the November 1998 Reserve service report of medical history and specifically answered "No" when asked if he then had or had ever had bone, joint or other deformity and arthritis, rheumatism, or bursitis, the Board finds that a neck injury or disease and cervical spine arthritis, to include chronic symptoms related thereto, are conditions that would have ordinarily been recorded during active service had they been present or occurred; therefore, the lay and medical evidence generated contemporaneous to service, which shows no neck injury or disease and no chronic symptoms of cervical spine arthritis during service, is likely to reflect accurately the Veteran's physical condition, so is of significant probative value and provides evidence against a finding of cervical spine injury or disease or chronic symptoms of cervical arthritis during service. As the weight of the evidence demonstrates no neck injury or disease or "chronic" symptoms of cervical spine arthritis during service, the criteria for presumptive service connection under 38 C.F.R. § 3.303(b) based on "chronic" symptoms in service are not met. The weight of the evidence is against a finding of continuous symptoms of cervical spine arthritis since service, including to a compensable degree within one year of service separation. The earliest evidence of cervical spine disability included in the record is in 2011, approximately 40 years after active service. See, e.g., April 2012 VA Form 21-526. Considered together with the absence of any neck injury or disease or neck symptoms other than pain related to migraine during active service, the gap of approximately 40 years between active service and the onset of cervical spine symptoms is another factor that tends to weigh against a finding of continuous symptoms of cervical spine arthritis after service separation. As the weight of the evidence demonstrates no "continuous" symptoms of cervical spine arthritis since service, including to a compensable degree within the first post-service year, the criteria under 38 C.F.R. § 3.303(b) for presumptive service connection based on "continuous" symptoms of cervical spine arthritis manifested to a degree of ten percent within one year of service separation are not met. 38 C.F.R. §§ 3.307, 3.309. The weight of the evidence is against a finding that the cervical spine disability, which was manifested many years after service, is otherwise related to service. There is no competent evidence linking the current cervical spine disability to service. Although the Veteran has asserted that the current cervical spine disability is causally related to service, he is a lay person and, under the specific facts of this case, does not have the requisite medical expertise to be able to diagnose the cervical spine disability or render a competent medical opinion regarding its cause where the facts show an in-service cervical spine injury, no in-service cervical spine disease, and no cervical spine arthritis symptoms manifested until many years after service. Arthritis is complex and involves unseen systems processes and disease processes, only some of which are observable by the five senses of a lay person, and includes various possible etiologies, only one of which involves trauma to a joint and/or vertebra, and is diagnosable only by X-ray or similar specific specialized clinical testing; therefore, under the facts presented in this case, the Veteran is not competent to diagnose cervical spine arthritis or to opine as to its etiology, where in this case there is an absence of in-service cervical spine disease or symptoms, and the cervical spine arthritis symptoms began many years after service. Thus, while the Veteran is competent to relate symptoms of neck pain that he experienced at any time, in the absence of in-service neck injury or disease or chronic cervical arthritis symptoms as in this case, he is not competent to opine on whether there is a link between the cervical spine arthritis, which was manifested many years after service separation, and active service because such diagnosis and nexus require specific medical knowledge and training regarding the disease process involving the musculoskeletal system. For these reasons, the Veteran's purported opinion that the current cervical spine disability is related to service is of no probative value. Thus, in consideration of the foregoing, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against service connection for a cervical spine disability; therefore, the appeal must be denied. 5. Service Connection Analysis for Thyroid Cancer The Veteran contends that thyroid cancer is related to presumed herbicide exposure during service. Because the Veteran visited the Republic of Vietnam in November 1971, herbicide (i.e., Agent Orange) exposure during service is presumed; however, thyroid cancer is not a disease presumed to be associated with herbicide exposure so the Board will consider whether service connection for thyroid cancer otherwise may be established on a direct basis or a presumptive basis as a chronic disease. After review of all the lay and medical evidence of record, the Board finds that the weight of the evidence is against finding that an injury or disease of the endocrine system or prostate was manifested during service or that chronic symptoms of thyroid cancer were manifested during service. The service treatment records, which are complete, show no complaints, diagnoses, or treatment related to thyroid cancer. Because the service treatment records are complete, and serology testing was performed at service separation and shown to be negative, the Board finds that thyroid cancer is a condition that would have ordinarily been recorded during service, including at the service separation examination, had it been present during service; therefore, the lay and medical evidence generated contemporaneous to service, which showed no in-service endocrine system injury or disease and no chronic symptoms of thyroid cancer, is likely to reflect accurately the Veteran's physical condition, so is of significant probative value and provides evidence against a finding of thyroid cancer or "chronic" symptoms of thyroid cancer during service. As the weight of the evidence demonstrates no endocrine injury or disease or "chronic" symptoms of thyroid cancer during service, the criteria for presumptive service connection under 38 C.F.R. § 3.303(b) based on "chronic" symptoms in service are not met. The Board next finds that the evidence shows that symptoms of thyroid cancer were not continuous since service, including not to a degree of ten percent within one year of service separation. Periodic Reserve service examinations performed after service in August 1984, July 1988, June 1993, and November 1998 showed that the endocrine system was clinically evaluated as normal. Thyroid cancer was not manifested until approximately 2017, approximately 46 years after service separation. Considered together with the absence of in-service endocrine system injury or disease or symptoms of thyroid cancer during service, the 46-year gap between service and the onset and diagnosis of thyroid cancer, is one factor that tends to weigh against a finding of continuous symptoms of thyroid cancer after service separation. See Buchanan, 451 F.3d at 1336; see also Maxson, 230 F.3d at 1333. As the weight of the evidence demonstrates no "continuous" thyroid cancer symptoms since service, including to a compensable degree within the first post-service year, the criteria under 38 C.F.R. § 3.303 (b) for presumptive service connection based on "continuous" thyroid cancer symptoms or thyroid cancer symptoms manifested to a degree of ten percent within one year of service separation are not met. 38 C.F.R. §§ 3.307, 3.309. The Board further finds that the weight of the evidence demonstrates that thyroid cancer, which was first manifested many years after service, was not caused by or otherwise related to service. After review of the record and interview and examination of the Veteran, the February 2018 VA reviewer opined that it was less likely than not that the thyroid cancer was incurred in or caused by service, including Agent Orange and/or herbicide exposure. In support of the medical opinion, the February 2018 VA reviewer explained that the Mayo clinic, American thyroid organization, cancer organization, and Harrison's Principles of Internal Medicine all cited other risk factors for thyroid cancer. The February 2018 VA reviewer noted that herbicides and/or chemicals were not noted or found to be a cause for thyroid cancer. The February 2018 VA examiner also noted that the February 2018 Federal Register cited an extensive and in-depth biologic, medical, toxicological, and chemical review by the National Academy of Sciences, and the conclusion that there was insufficient evidence regarding endocrine cancers (including thyroid and thymus) remained unchanged. The February 2018 VA reviewer further noted that the 2014 Veterans and Agent Orange Update reviewed additional studies which could not provide statistical significance between thyroid cancer and Agent Orange in human and/or animal studies so the conclusion that there was insufficient evidence regarding endocrine and/or thyroid cancer remained unchanged. The February 2018 VA reviewer noted that authors of the December 2017 article did not conclusively associate and/or link thyroid cancer to Agent Orange, and based the conclusion only on self-reported exposure. The February 2018 VA reviewer noted that the Vietnam-era veteran population referenced in the article did not amount to actual service in Southeast Asia and/or Vietnam. The February 2018 VA reviewer then concluded that thyroid cancer was not caused by or associated with Agent Orange and/or herbicide exposure based on the medical literature reviewed. The February 2018 VA examiner has medical expertise, had adequate information on which to base the medical opinion, and provided adequate rationale based on an accurate medical history and known medical principles. For these reasons, the February 2018 VA medical opinion is of significant probative value. There is no competent medical opinion to the contrary of record. As such, direct and presumptive service connection for thyroid cancer may not be established. 38 C.F.R. §§ 3.303, 3.307, 3.309. Although the Veteran has asserted his belief that thyroid cancer was caused by herbicide exposure during service, he is a lay person and does not have the requisite medical expertise to render a competent medical opinion in this case regarding the etiology of thyroid cancer, which was not manifested until many years after service. Such a diagnosis and an opinion as to its relationship to service involve unseen systems processes and disease processes that are largely unobservable by the five senses of a lay person, involve an understanding of the endocrine system and the possible causes or etiologies of thyroid cancer, and involve making findings based on medical knowledge and clinical testing results. Consequently, the Veteran's purported opinion relating thyroid cancer to service is of no probative value. Thus, the weight of the evidence shows that thyroid cancer had its onset many years after service and is unrelated to service, including presumed herbicide exposure; therefore, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against service connection for thyroid cancer, so the appeal must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 6. Rating Reduction Criteria and Restoration Analysis for PTSD In August 2015, the RO proposed to reduce the 50 percent rating for the service-connected PTSD to 30 percent. This reduction was accomplished in a November 2015 rating decision, effective February 1, 2016. Initially, the Board observes the RO procedurally complied with the procedural safeguards regarding notice of the proposed rating reduction and the implementation of that reduction. See 38 C.F.R. § 3.105. The Board will now consider the propriety of the rating reduction. At the time the reduction became effective, February 1, 2016, the 50 percent rating for PTSD had been continuously in effect for less than five years. A rating reduction is not proper unless the Veteran’s disability shows actual improvement in his or her ability to function under the ordinary conditions of life and work. See Faust v. West, 13 Vet. App. 342, 349 (2000). In considering the propriety of a reduction, the Board must focus on the evidence available to the RO at the time the reduction was effectuated (although post-reduction medical evidence may be considered in the context of considering whether actual improvement was demonstrated). Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-82 (1992). The Veteran need not demonstrate that retention of the higher evaluation is warranted; rather, it must be shown by a preponderance of the evidence that the reduction was warranted. See Brown v. Brown, 5 Vet. App. 413, 418 (1993). The question of whether a disability has improved involves consideration of the applicable rating criteria. For the rating period at issue, PTSD was rated under the criteria found at 38 C.F.R. § 4.130, DC 9411. PTSD is rated under the General Rating Formula for Mental Disorders. Under the Mental Disorders rating formula, a 30 percent rating is prescribed when there is evidence of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is prescribed when there is evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. After review of the lay and medical evidence of record, a material improvement of PTSD has not been demonstrated, including under the ordinary conditions of life and work; therefore, the rating reduction was not proper so the criteria for restoration of a 50 percent rating for PTSD, effective February 1, 2016, have been met. In October 2014, the RO granted service connection for PTSD with a 50 percent rating effective from January 13, 2014. The 50 percent rating for PTSD was based on the September 2014 VA examination results showing PTSD symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work-like setting. The evidence further showed a 44-year marriage, few friends, good relationships with adult children, with a 36-year history of working for a public transit company before retiring in 2010. In consideration of the foregoing, the RO found that the PTSD disability picture was consistent with the 50 percent rating criteria under DC 9411. At the time of the rating reduction, the September 2014 VA examiner wrote, in a June 2015 supplemental VA medical opinion, that the service-connected PTSD impaired the Veteran’s current interpersonal relationships minimally in a work environment. The September 2014 VA examiner opined that PTSD caused minimal impairment regarding the ability to function in a work environment. In support of the medical opinion, the September 2014 VA examiner wrote that there were only occasional verbal problems with peers during the 35 years that the Veteran worked at the transit company and he was never disciplined for problematic behavior or missed excessive time from work due to mental health issues. The RO reduced the rating based on the June 2015 supplemental VA medical opinion. However, the June 2015 supplemental VA medical opinion from the September 2014 VA examiner that PTSD caused minimal occupational and social impairment contradicts the earlier findings by the same VA examiner that PTSD was manifested by difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work-like setting. The September 2014 VA examiner based the supplemental VA medical opinion on review of the record, including the September 2014 VA examination findings, and does not explain the contradiction. The Board also notes that the symptoms of flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships identified in the September 2014 VA examination report as manifestations of the Veteran’s PTSD are specifically contemplated by the 50 percent schedular rating criteria under DC 9411. When compared to the evidence of record when the 50 percent rating was initially awarded for the PTSD in October 2014, the evidence at the time of the rating reduction showed no improvement of PTSD. Rather, it contained contradictory findings from the September 2014 VA examiner regarding the severity of occupational and social impairment caused by PTSD and showed no change in PTSD symptoms from the time of the September 2014 VA examinations. In consideration thereof, the Board finds that it has not been established by a preponderance of the evidence that PTSD had undergone material improvement under the ordinary conditions of life and work at the time of the rating reduction decision. Because the burden of proof is on VA to establish that a reduction is warranted by the weight of the evidence, and the weight of the evidence of record in this case shows no material improvement in the service-connected PTSD at the time of the November 2015 rating reduction decision, the Board finds that the reduction of the 50 percent rating to 30 percent rating effective from February 1, 2016, was not proper; therefore, restoration of the 50 percent disability rating is warranted. Disability Rating Legal Authority Disability ratings are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. 7. Initial Rating Analysis for Skin Cancer Residuals For the entire initial rating period from January 13, 2014, basal cell carcinoma of the right ear, squamous cell carcinoma of the left ear, and actinic keratoses have been jointly rated at 30 percent under the criteria at 38 C.F.R. § 4.118, DC 7818-7800 (i.e., malignant skin neoplasms other than malignant melanoma with residual disfigurement of the head, face, or neck). DC 7818 for malignant skin neoplasms provides that the disability should be rated as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801, 7802, 7803, 7803, 7804, or 7805), or impairment of function when there has been no local recurrence or metastasis, which are the circumstances in this case. Under Diagnostic Code 7800, a 10 percent rating is provided for scars that are located on the head, face, or neck when there is one characteristic of disfigurement. 38 C.F.R. § 4.118. A 30 percent rating is provided when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, or lips), or; with two or three characteristics of disfigurement. Id. A 50 percent rating is provided when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement. Id. An 80 percent rating is provided when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or; with six or more characteristics of disfigurement. Id. For purposes of evaluation of under 38 C.F.R. § 4.118, the eight characteristics of disfigurement are: a scar that is five or more inches, or thirteen centimeters, in length; a scar that is at least one-quarter of an inch, or 0.6 centimeters, wide at the widest part; surface contour of the scar that is elevated or depressed on palpation; a scar that is adherent to underlying tissue; skin that is hypo- or hyper-pigmented in an area exceeding six square inches, or 39 square centimeters; skin texture that is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches, or 39 square centimeters; underlying soft tissue that is missing in an area exceeding six square inches, or 39 square centimeters; and skin that is indurated and inflexible in an area exceeding six square inches, or 39 square centimeters. 38 C.F.R. § 4.118, Diagnostic Code 7800, Note 1. VA is to consider unretouched color photographs when evaluating under these criteria. Id. at Note 3. Additionally, VA is to separately evaluate disabling effects other than disfigurement that are associated with individual scars of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code(s) and apply 38 C.F.R. § 4.25 to combine the evaluation(s) with the evaluation assigned under Diagnostic Code 7800. Id. at Note 4. Finally, the characteristics of disfigurement may be caused by one scar or by multiple scars; the characteristics that are required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. Id. at Note 5. After review of all the lay and medical evidence of record, the Board finds that the weight of the evidence is against finding that the criteria for an initial rating higher than 30 percent under DC 7800 for skin cancer residuals are met or approximated for any period. The June 2015 VA examination report notes a mid-helix scar of the right ear measuring 1 centimeter in length by 1 centimeter in width. The right ear scar was not hyperpigmented or hypopigmented, was depressed on palpation, demonstrated normal texture, had underlying soft tissue is intact, was not adherent to underlying tissue, and was not painful or unstable. There was also a mid-antihelix left ear painful scar measuring 1 centimeter in length by 0.5 centimeter in width. The left ear scar was not hyperpigmented or hypopigmented, demonstrated a normal texture and intact underlying soft tissue, was smooth on palpation, was not adherent to underlying tissue, and was not unstable. The evidence demonstrated a right ear scar measuring 1 centimeter in width and a left ear scar measuring 0.5 centimeters in width, and a scar measuring at least 0.6 centimeters in width is considered a disfiguring characteristic under the rating criteria. Also, the left ear scar was manifested by depressed on palpation, and surface contour of a scar elevated or depressed on palpation is a disfiguring characteristic under the rating criteria; therefore, the Board finds that two characteristics of disfigurement are shown in this case, which is consistent with the 30 percent rating criteria under DC 7800. Because there was no evidence of visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, and no evidence of four or five characteristics of disfigurement, the criteria for a disability rating higher than 30 percent under DC 7800 for skin cancer residuals are not met or approximated for any period. The Board has considered whether the Veteran or the record has raised the question of referral for an extraschedular rating adjudication under 38 C.F.R. § 3.321 (b) for any period for the initial rating issue on appeal. See Thun v. Peake, 22 Vet. App. 111 (2008). After review of the lay and medical evidence of record, the Board finds that the question of an extraschedular rating has not been raised in this case. 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). REMANDED An increased disability rating higher than 50 percent for service-connected PTSD is remanded. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND 8. Increased Rating for PTSD The current severity of occupational and social impairment caused by PTSD is unclear from the record due to conflicting evidence provided by the September 2014 VA examiner; therefore, another VA examination is needed. 9. TDIU The outcome of the increased rating appeal for PTSD potentially impacts the TDIU appeal; therefore, final adjudication of the TDIU appeal will be deferred until completion of the ordered development. The matters are REMANDED for the following action: (Continued on the next page)   Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of PTSD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria – i.e., describe any occupational and social impairment and symptoms caused by PTSD. J. PARKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Ferguson, Counsel