Citation Nr: 1807921 Decision Date: 02/07/18 Archive Date: 02/20/18 DOCKET NO. 11-09 796 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a thyroid disability, including hypothyroidism with fatigue, to include as due to exposure to chemical and anti-viral agents, to also include as due to an undiagnosed illness. 2. Entitlement to service connection for a throat disability, to include as due to exposure to chemicals, to also include as due to an undiagnosed illness. 3. Entitlement to service connection for hair loss, including male pattern baldness, to include as due to exposure to chemical and anti-viral agents. 4. Entitlement to service connection for muscle weakness, to include as due to exposure to chemical and anti-viral agents, to also include as due to an undiagnosed illness. 5. Entitlement to service connection for defective vision, to include as a residual of a traumatic brain injury. 6. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as due to exposure to chemical and anti-viral agents, to also include as secondary to service-connected disability. 7. Entitlement to service connection for Bell's palsy, to include as due to exposure to chemical and anti-viral agents. 8. Entitlement to service connection for gall bladder dysfunction, to include as due to exposure to chemical and anti-viral agents, to also include as secondary to service-connected disability. 9. Entitlement to service connection for recurrent allergies, to include as due to exposure to chemicals. 10. Entitlement to service connection for a sleep disability, including sleep apnea, to include as exposure to chemical and anti-viral agents, to also include as secondary to service-connected disability. 11. Entitlement to service connection for hypertension. 12. Entitlement to a compensable rating for a traumatic brain injury, previously captioned as a head injury. REPRESENTATION The Veteran is represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Sean G. Pflugner, Counsel INTRODUCTION The Veteran served on active duty from November 1982 to September 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. In May 2016, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of this hearing has been associated with the claims file. In August 2016, the Board remanded the above-captioned claims for additional development. After this development, the Agency of Original Jurisdiction re-adjudicated the Veteran's claim and issued a July 2017 supplemental statement of the case. The appeal was remitted to the Board for further appellate review. The issues of entitlement to service connection for a thyroid disability, a throat disability, muscle weakness, and GERD will be addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ) for additional development. FINDINGS OF FACT 1. Male pattern baldness is not a "disability" for VA compensation purposes, and there was no superimposed injury or disease in service that caused additional disability. 2. Bell's palsy was not incurred in or due to the Veteran's active service, did not manifest to a compensable level within one year of his service separation, and there has not been a continuity of Bell's palsy symptoms since his service separation. 3. Gall bladder dysfunction was not incurred in or due to the Veteran's active service and was not caused or aggravated by a service-connected disability. 4. Allergies were not incurred in or due to the Veteran's active service. 5. Sleep apnea was not incurred in or due to the Veteran's active service and was not caused or aggravated by a service-connected disability. 6. Hypertension was not incurred in or due to the Veteran's active service, did not manifest to a compensable level within one year of his service separation, and there has not been a continuity of hypertension symptoms since his service separation. 7. Defective vision is not associated with the Veteran's TBI. 8. The only diagnoses pertaining to the Veteran's defective vision are a refractive error and presbyopia. 9. Service connection has been granted for post-traumatic headaches and tinnitus as residuals of TBI, and separate disability ratings have been assigned to each. 10. The Veteran's residuals of TBI have been assigned facet scores of "0" throughout the pendency of this appeal. CONCLUSIONS OF LAW 1. The criteria for service connection for hair loss have not been met. 38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2017). 2. The criteria for service connection for Bell's palsy have not been met. 38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017). 3. The criteria for service connection for gall bladder dysfunction have not been met. 38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2017). 4. The criteria for service connection for allergies have not been met. 38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2017). 5. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2017). 6. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 7. The criteria for service connection for defective vision have not been met. 38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 4.9 (2017). 8. The criteria for a compensable rating for residuals of TBI have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 8045 (2016). REASONS AND BASES FOR FINDINGS ANF CONCLUSIONS Preliminarily, the National Personnel Records Center determined that the Veteran's service records were partially unavailable for reasons unknown to the Board. When records in the possession of the government are unavailable through no fault of the Veteran, VA has a heightened obligation to assist the Veteran in the development of his case, and to explain findings and conclusions, as well as carefully consider the benefit of the doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). In August 2016, the Board remanded the Veteran's above-captioned claims for additional development, specifically requesting the he be afforded VA examinations wherein the salient diagnostic and etiological issues were addressed. After a series of VA examinations in February 2017, the AOJ re-adjudicated the Veteran's claims and then issued a July 2017 supplemental statement case. Based on a review of the record, the Board finds that the AOJ substantially complied with the August 2016 remand and, thus, a remand for corrective actions is not required. Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 U.S.C. § 1113(b) (West 2014); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). In order to establish direct service connection for a disorder, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); see Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v. West, 12 Vet App. 341, 346 (1999). Service connection may be established on a secondary basis for a disability, which is proximately due to, the result of, or chronically aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection may also be awarded where the evidence shows that a Veteran had a chronic condition in service or during an applicable presumptive period and still has the condition. 38 C.F.R. §§ 3.303 (b), 3.307, 3.309. Certain disabilities are presumed to have been incurred in service if manifested to a compensable degree within one year after service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. If there is no evidence of a chronic condition during service or during an applicable presumptive period, then a showing of continuity of symptomatology after service is required to support the claim. The continuity of symptomatology language in § 3.303(b) is limited to the chronic diseases listed under 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Hair Loss Male pattern balding is not, by itself, considered a disability for which service connection may be granted. See generally 38 C.F.R. Part 4 (VA Schedule for Rating Disabilities) (does not contemplate a separate disability rating for male pattern baldness). Rather, applicable VA regulations use the term "disability" to refer to the average impairment in earning capacity resulting from diseases or injuries encountered as a result of or incident to military service. Allen v. Brown, 7 Vet. App. 439, 448 (1995); Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); 38 C.F.R. § 4.1 (2017). There must be competent evidence of a current disability to support service connection, and male pattern balding does not itself constitute disease or disability. Further, the evidence of record does not establish that the Veteran has a disability manifested by hair loss. Photographs of the Veteran during his active duty appear to show that he began balding during his military service. The Veteran asserts that his hair loss was due to exposure to chemical and/or anti-viral agents during his active duty. The Veteran's service treatment records do not demonstrate that he complained of or was treated for a disability manifested by hair loss. In February 2017, the Veteran underwent a VA examination. The examiner reviewed the evidence of record, the Veteran's assertions, and examined the Veteran. The examiner acknowledged that the Veteran's hair loss began during his active duty and that the Veteran asserts that his loss was/is due to exposure to sand, heat, and stress, as well as chemical and anti-viral agents. Ultimately, the examiner diagnosed the Veteran's hair loss as male pattern baldness or androgenetic alopecia. The examiner then opined as follows: The [V]eteran is diagnosed with androgenetic alopecia, or male pattern balding. This is highly prevalent in the normal male population and can have onset as early as adolescence (hyperlink omitted). Although there is photographic evidence of related hair loss during service, this condition does not represent a chronic disability. Because the examiner is trained as a doctor and provided sound rationale based on accurate facts and data, the February 2017 opinion is of significant probative value. The examiner found no underlying disability to which the Veteran's hair loss is attributable. The evidence of record did not include other competent evidence demonstrating that the Veteran's hair loss is a manifestation of a disability for which service connection is available or that the Veteran's hair loss is not androgenetic alopecia (male pattern baldness). Although the Veteran's assertions throughout this appeal and the testimony at the May 2016 Board hearing as to the onset of hair loss are considered competent evidence, as hair loss is lay observable, he does not have the requisite expertise to render a competent opinion as to whether his hair loss is a disability itself (as defined by the regulations), is a manifestation of disability for which service-connected is available, or that his hair loss is a diagnosable as something other than androgenetic alopecia/male pattern baldness. Layno v. Brown, 6 Vet. App. 465, 469 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Congress has specifically limited entitlement to service connection to instances where disease or injury has resulted in a disability. See 38 U.S.C. § 1110. The evidence does not reflect that the Veteran has a chronic disability manifested by hair loss and androgenetic alopecia/male pattern baldness is not a disability in and of itself. In the absence of proof of current disability, the claim of service connection for hair loss may not be granted. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). In addition to the laws and regulations outlined above, service connection may also be granted on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). Because the hair loss is attributed to a known clinical diagnosis (i.e., androgenetic alopecia/male pattern baldness), the law and regulations pertaining to qualifying chronic disabilities for Persian Gulf veterans are not applicable in this case. For the foregoing reasons, the Board finds that the claim of service connection for hair loss, on any basis of entitlement, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of service connection, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-6 (1990). Bell's Palsy, Gall Bladder, Allergies, Sleep, and Hypertension The Veteran asserts that his Bell's Palsy (or residuals thereof), gall bladder dysfunction, allergies, sleep disability, and hypertension were incurred in or due to his active duty, to include as due to exposure to chemical and/or anti-viral agents and/or secondary to a service-connected disability. The evidence of record includes a current diagnosis of each of these disabilities. In making this determination, the Board observes that service-connected has been granted for the Veteran's posttraumatic stress disorder (PTSD), and a 50 percent rating has been assigned thereto. The rating assigned to the Veteran's PTSD contemplates associated sleep disturbances. However, the evidence of record also establishes the presence of a separately diagnosable sleep disability, namely sleep apnea. As such, the Board will consider the merits of this claim herein. Similarly, service connection has already been granted for the Veteran sinusitis. The Board is considering the Veteran's claim regarding allergies to the extent that is a separate and distinct from his sinusitis. The Veteran's available service treatment records do not demonstrate that he complained of or received treatment for Bell's palsy, gall bladder dysfunction, allergies, sleep apnea, or hypertension. With respect to hypertension, the Veteran underwent a "five-day blood pressure check" during his active duty, occurring between March 30 and April 3, 1987. The resulting report did not indicate why the Veteran was undergoing this check, but no diagnosis of hypertension appears to have been rendered. According to a May 1992 report of medical history created consequent to his separation from active duty, the Veteran denied then or ever experiencing high or low blood pressure and frequent trouble sleeping. Further, the Veteran did not complain of Bell's palsy, gall bladder dysfunction, or allergies. The examiner determined that the Veteran's blood pressure at that time was 130/60. Additionally, the examiner indicated each of the aspects of the Veteran's PUHLES profile was scored a "1." The "PULHES" profile reflects the overall physical and psychiatric condition of an individual on a scale of 1 (high level of fitness) to a 4 (medical condition or physical defect that is below the level of medical fitness required for retention in the military service). The "P" stands for "physical capacity or stamina," the "U" indicates "upper extremities," the "L" is indicative of "lower extremities," the "H" reflects the condition of the "hearing and ears," the "E" is indicative of the "eyes," and the "S" stands for "psychiatric condition." Odiorne v. Principi, 3 Vet. App. 456, 457 (1992). Thus, in every tested aspect, the Veteran demonstrated a high level of fitness upon separation from active duty. No relevant diagnosis was listed by the examiner in the designated section of the report (it appears the examiner thought that the Veteran was borderline diabetic, as indicated by the abbreviated note "Borderline diab," but the writing is not entirely legible). In August 2009, the Veteran underwent a VA examination. With respect to hypertension, he reported experiencing high blood pressure beginning in approximately 1987, but that he did not start taking medication until 2008. This examination also references the Veteran's "allergies/sinusitis," but focuses on the specific diagnoses of sinusitis and rhinitis, without distinguishes a separate allergy disability. Regarding Bell's palsy, the Veteran stated that it onset in 2006. Ultimately, the examiner rendered diagnoses of hypertension with borderline control; atopic rhinitis; and Bell's palsy, resolved, without residuals. In September 2012, the Veteran underwent a series of VA examination with respect to his esophagus and gastrointestinal tract, during which his gall bladder was assessed. After reviewing the evidence of record, the Veteran's assertions, and the findings from clinical testing, the examiner rendered a diagnosis of delayed gall bladder emptying. With respect to whether this dysfunction (claimed a biliary tract condition) was etiologically related to the Veteran's service-connected irritable bowel syndrome (IBS), the examiner opined that it was "less likely than not (less than a 50 percent probability) proximately due to or the result [there]of." In support of this opinion, the examiner reasoned that delayed gallbladder emptying is not "medically considered to be due to [IBS]." The examiner did not address whether the Veteran's gall bladder dysfunction incurred in or due to his active duty or whether service-connected IBS aggravated his gall bladder dysfunction. In February 2017, the Veteran underwent a series of VA examinations to ascertain the presence of these disabilities and, if present, whether each was etiologically related his active service and/or a service-connected disability. After the examiners reviewed the relevant evidence of record, including the Veteran's available service treatment records, the Veteran's assertions, and the post-service evidence, clinical evaluations were administered. Ultimately, the examiners opined that it was "less likely than not" that the Veteran's Bell's palsy, gall bladder dysfunction, allergies, sleep disability, and hypertension had their clinical onset during his active duty service or are otherwise etiologically related to this active service, to include as due to exposure to chemicals of anti-viral agents. In support of this opinion, an examiner provided the following rationale with respect to Bell's palsy: This condition is a...diagnosable chronic multi-symptom illness with a partially explained etiology. It is less likely than not that this disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia. Per Veteran's report and documentation, this condition started in 2006, well after Veteran's reported discharge from service in 1992, and thus did not have its onset during service. This did not occur while in the presence of the chemicals or anti-viral agents in service, and did not occur afterwards for more than a decade. If toxic exposures were to cause a Bell's Palsy, it would commence at the time of the exposure and that is an unrecognized etiology of Bell's Palsy regardless. While the ultimate etiology of Bell's palsy is not certain, the weight of the current medical science describes Bell's palsy as due to a viral etiology, and is common in the general population. With respect to the Veteran's gall bladder dysfunction, an examiner provided this rationale: The [service treatment records] is [sic] silent for any symptoms consistent with biliary colic. Further, the [V]eteran does not report to this examiner onset of symptoms during service, and he was only diagnosed with gall bladder dysfunction years after separation in 2005. Therefore, the condition and service are not temporally related. Further, although the mechanism of gallbladder dysfunction is incompletely understood, it is believed to result from structural narrowing of the ducts and abnormal smooth muscle function but is not thought to result from environmental exposure [cite omitted]. This examiner was also asked to provide an opinion as to the relationship, if any, between the Veteran's gall bladder dysfunction and his service-connected IBS. The examiner opined that it is "less likely than not" that the Veteran's gall bladder dysfunction was caused or aggravated by his IBS, with the following rationale: IBS and gallbladder dysfunction are mechanistically distinct. Please see above discussion for contributory mechanisms to each. Therefore, they are unlikely to be causally related. ... IBS and gallbladder dysfunction are mechanistically distinct. Please see above discussion for contributory mechanisms to each. Therefore, they are unlikely to aggravate one another. Concerning the Veteran's allergies, the examiner provided the following rationale to support the negative etiological opinion: The [service treatment records] is [sic] silent for allergy symptoms. The only similar reported symptoms were diagnosed as upper respiratory tract infections at the time. Further, in 1988 an [Ear, Nose, and Throat] specialist documents in an admission note that the [V]eteran has no history of allergies. The [V]eteran was first diagnosed with and treated for allergies in 1998, 6 years after separation. Even if the [V]eteran had an initial respiratory allergenic exposure during service, allergy only develops after a period of sensitization with repeated exposure. This makes it mechanistically more likely that the ultimate sensitizing event occurred after service. Further, the only consistent exposure from service the [V]eteran reports is fuel as he worked in petroleum refueling. Chemical related allergies (such as with petroleum products) generally manifest as a skin contact dermatitis, and the [V]eteran does not report any contact allergy symptoms. Regarding sleep apnea, an examiner explained the negative etiological opinion as follows: The [service treatment records] is [sic] silent for sleep related complaints. Further, the [V]eteran reports to this examiner that his wife noticed apneic events on a time-frame that would place the observed events years post-separation. Additionally, the diagnosis of mild obstructive sleep apnea was only made in 2015, and the [V]eteran was noted to be obese at the time. The [V]eteran reported to this examiner that he has gained significant weight over the years, and obesity is the single greatest risk factor for the development of obstructive sleep apnea. Finally, obstructive sleep apnea is caused by mechanical obstruction of the upper airways and is not known to be caused by environmental exposure. The examiner was also asked to provide an opinion as to whether there was an etiological relationship between the Veteran sleep apnea and his service-connected PTSD. The examiner responded in the negative, opining that it was "less likely than not" that his sleep apnea was caused or aggravated by this PTSD. For both causation and aggravation, the examiner explained the opinion as follows: As explained above, obstructive sleep apnea is caused by mechanical blockage of the upper airways. How this relates to PTSD, if at all, is unknown. While there are a few medical reports in the literature suggesting an association between PTSD and sleep apnea, an association does not equate to causality. There is as of this time, no data to support a causal relationship. The negative etiological opinion rendered with respect to hypertension was supported by the following rationale: While a few elevated blood pressure readings are noted during service, this is expected normal physiologic variability and they are not persistent. This examiner reviewed every available documented blood pressure reading during service and the majority are in the normotensive range. The evidence of record did not include other competent evidence demonstrating that the Veteran's Bell's palsy, gall bladder dysfunction, allergies, sleep apnea, or hypertension were incurred in or due to his active duty. Further, the evidence did not otherwise include competent evidence showing that the Veteran's gall bladder dysfunction or sleep apnea was caused or aggravated by a service-connected disability. In this, and in other cases, the Board may not base a decision on its own unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The only competent and probative opinions of record are those of the VA examiners, which are negative to the Veteran's claims. Although the Veteran's assertions as to lay observable symptoms are considered competent, he does not have the requisite expertise to render a competent opinion as to etiology or aggravation, especially in the presence of other etiological possibilities. Layno, 6 Vet. App. at 469; Jandreau, 492 F.3d at 1377. Because the Bell's palsy, gall bladder dysfunction (delayed gall bladder emptying), allergies, and sleep apnea are known clinical diagnosis, the law and regulations pertaining to qualifying chronic disabilities for Persian Gulf veterans are not applicable. For the foregoing reasons, the Board finds that the claims of service connection for Bell's palsy (or residuals thereof), gall bladder dysfunction, allergies, sleep apnea, and hypertension on any basis of entitlement, must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims of service connection, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-6. In making this determination, the Board considered service connection on the basis of a continuity of symptomatology. 38 C.F.R. § 3.303(d); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, gall bladder dysfunction/delayed emptying (which are not gall bladder calculi), allergies, and sleep apnea are not disabilities for which service connection can be granted in this manner. With respect to Bell's palsy and hypertension, the Veteran's service treatment records are negative for complaints of or treatment for these disabilities. Further, during the February 2017 VA examination, the Veteran reported, and the evidence of record is otherwise supportive of finding, that his Bell's palsy had its onset in 2006, approximately 14 years after his separation from service. With respect to hypertension, the Veteran stated that he did not start taking medication until 2008. As such, the Board finds that the preponderance of evidence is against finding that (1) the Veteran's Bell's palsy and hypertension manifested to a compensable degree within one year from the date of his separation; and (2) and that there has been a continuity of Bell's palsy symptoms and hypertension since his separation from service. As such, service connection for Bell's palsy and hypertension is denied on a presumptive basis and on the basis of continuity. 38 C.F.R. §§ 3.303, 3.307, 3.309. The Board acknowledges that the May 2017 letter from Andrew Ellias, D.O., wherein he asserts that the Veteran had already been prescribed hypertension medication in 1995. As discussed above, the Veteran reported during the August 2009 VA examination that he did not start taking hypertension medication until 2008. Given this contradiction, to the extent that it concerns hypertension, the Board finds that Dr. Ellias' May 2017 letter is not probative. In the May 2017 letter, Dr. Ellias also explains that medical articles and studies show a "correlation" between sleep apnea and PTSD, but that an "exact relationship and cause could not be elicited." The doctor goes on to opine that he feels that there is "a greater than 50 percent chance" that this correlation is "definitely a factor in his diagnosis." (emphasis added) Neither the diagnosis of sleep apnea nor PTSD is in question in this case. Thus, the doctor's opinion as to a diagnosis is confusing, as it does not pertain to etiology. Further, the February 2017 VA examiner acknowledges that there exists some evidence of a correlation between sleep apnea and PTSD, but that correlation does not equal causation. Based on the above, the Board assigns greater probative weight to the VA examiner's opinion than to Dr. Ellias' letter insofar as sleep apnea is concerned. Residuals of Traumatic Brain Injury and Vision Initially, the Board observes that a "head injury," is not a disability for which service connection is available. A head injury is the underlying incident that results in residual disability; it is these residuals that are assigned disability ratings. As such, the Board has re-captioned the Veteran's service-connected "head injury" as residuals of a traumatic brain injury (TBI). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2017). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2017). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Veteran's residuals of TBI have been assigned a noncompensable rating under Diagnostic Code 8045. Under Diagnostic Code 8045, there are three main areas of dysfunction listed that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Adjudicators are to evaluate cognitive impairment under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." 38 C.F.R. § 4.124a. Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Adjudicators are to evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." However, they are to separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. Id. Adjudicators are to evaluate emotional/behavioral dysfunction under 38 C.F.R. § 4.130 (Schedule of ratings--mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, they are to evaluate emotional/behavioral symptoms under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Id. Adjudicators are to evaluate physical (including neurological) dysfunction based on the following list, under an appropriate Diagnostic Code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. Id. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, adjudicators are to evaluate under the most appropriate diagnostic code. Adjudicators are to evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under 38 C.F.R. § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. Id. The table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled "total." However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than total, since any level of impaired consciousness would be totally disabling. Adjudicators are to assign a 100-percent evaluation if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," adjudicators are to assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. Id. The evaluation assigned is based upon the highest level of severity for any facet of cognitive impairment and other residuals of TBI not otherwise classified as determined on examination. Only one evaluation is assigned for all the applicable facets. A higher evaluation is not warranted unless a higher level of severity for a facet is established on examination. Physical and/or emotional/behavioral disabilities found on examination that are determined to be residuals of traumatic brain injury are evaluated separately. The Veteran's post-traumatic headaches and tinnitus have both been determined to be residuals of his TBI, and have already been granted service-connection. A 30 percent rating has been assigned to his post-traumatic headaches, and a 10 percent rating has been assigned to his tinnitus. Service connection has also been granted for the Veteran's PTSD, and a 50 percent rating has been assigned thereto. As the Veteran is already being compensated for disability associated these TBI residuals and PTSD, the manifestations thereof will not be contemplated here. 38 C.F.R. § 4.14 (2017). Although the Board will discuss symptoms associated with these already service-connected disabilities below, their inclusion does not necessitate consideration thereof in determining the appropriate disability rating. In October 2009, the Veteran underwent a VA examination to assess the residuals of his TBI. The examiner reviewed the evidence of record and detailed the Veteran's relevant histories prior to administering clinical testing. During the examination, the Veteran endorsed insomnia, irritability, and low energy. Further, he reported cognitive symptoms of memory deficits, attention problems, concentration problems, distractibility, and problems with speed of processing information. Moreover, the Veteran stated that he has problems with judgment, decision making, and prioritizing. The Veteran stated that all of these claimed deficits affect his employment and his activities of daily living (i.e., misplacing items, remembering conversations and people's names, and forgetting where he is going). Ultimately, the examiner provided the following assessment: The [V]eteran does not have a diagnosis of a cognitive disorder as a result of the normal performance he demonstrated on [clinical testing]. The [V]eteran's symptoms of insomnia have persisted since 1994, and are unrelated to his military experiences. He stated his problems with insomnia have progress over the years. His depressive symptoms are not consistent enough to warrant Axis I diagnosis, and are also unrelated to his military experiences. The examiner then assign level of impairment scores of "0" for each of the following categories: memory, attention, concentration, executive functioning; judgment; social interaction; orientation; visual spatial orientation; and neurobehavioral effects. The examiner concluded by reiterating that cognitive testing did not indicate impairment in the Veteran's cognitive functioning. The Veteran underwent a separate VA examination in October 2009, focused more so in the neurologic residuals of his TBI. The examiner reviewed the evidence of record, the Veteran's assertions, and administered clinical testing. The Veteran denied vertigo, anosmia, photosensitivity, visual blurring, tinnitus, fatigue, paresthesia, orthostasis, erectile dysfunction, dysphagia, paralysis, loss of bowel or bladder control, and seizures. The examiner determined that the Veteran ambulation was not impaired, and neither his employment activities nor his activities of daily living were affected. After a physical examination, the diagnosis was "head injury in 1991 with no residuals." The examiner then assigned a level of impairment score of "0" for subjective symptoms; motor activity with intact motor sensory systems; communication; and consciousness. With respect to vertigo, the examiner opined that it was most likely benign positional vertigo or labyrinthitis and, moreover, was "less likely as not (less than 50/50 probability)" caused by or a result of the Veteran's TBI. The examiner reiterated that the Veteran experienced no residuals of his TBI, and that vertigo occurred in 2000 and 2004, which resolved after treatment. In May 2010, the Veteran asserted in a supplemental claim that residuals of his TBI include defective vision. In May 2011, the Veteran underwent a VA eye examination. The examiner reported that the Veteran had "no complains of visual symptoms." After administering testing, the examiner rendered diagnoses of refractive error and age-related presbyopia, bilaterally, "no related to head injury." The Veteran underwent a separate May 2011 VA examination to assess the severity of the residuals of TBI. After reviewing the evidence of record, including a lengthy narrative regarding the Veteran's post-service treatment and complaints, the examiner administered neurologic testing. Ultimately, the diagnosis was "mild" TBI, with residuals feature of post-traumatic chronic migraine headaches. With respect to facet scores, the examiner assigned a "1" to subjective symptoms and a "0" for each of the following facets: motor activity, communications, and consciousness. The examiner continued as follows: These headache complaints vary in their intensity/severity. Early treatment helps. When severe, they can cause dysfunctional problems and affect his work performance. They interfere at this point his quality of life but are only 1 component of his complex medical picture, all of which unfortunately, seem to be interrelated and interdependent with 1 medical problem having affect upon the other. ... The [October 2009 VA examination] describes a traumatic brain injury event without residual deficits and a facet score of zero. Of note is the fact that this [Veteran]'s psychiatric [VA examination in October 2009] described no residual cognitive impairment post traumatic brain injury which is consistent with his ongoing ability to work effectively at his current job as a postal driver for the last 17 years. The examiner then rendered a positive opinion regarding the Veteran's post-traumatic headaches as a TBI residual. The examiner predicated this opinion on the current understanding of post-traumatic headaches and "their evolution with time along with the comorbid features that are associated with anxiety, depression, sleep disorders, and other ongoing medical problems including that of IBS, etc." In February 2017, the Veteran underwent a VA eye examination. The Veteran stated that, even with his current bifocal glasses, he experiences "blurred vision" and needs to rub his eyes briefly about three times each day to regain clear vision. After testing, echoing the May 2011 findings, the examiner rendered diagnoses of minimal congenital refractive error with age-related presbyopia. The examiner then opined that these diagnoses were not as likely as not incurred in, caused by, aggravated by or had its onset during the Veteran's active duty and was not as likely as not caused by, incurred by, or aggravated beyond its normal progression by the Veteran's TBI. The Veteran underwent another February 2017 VA examination focusing on possible neurological residuals of the Veteran's TBI. After reviewing the relevant evidence, the examiner recorded the Veteran's assertions regarding his symptoms. The Veteran denied seizures. He endorsed problems with his sense of taste or smell, vertigo, tinnitus, and numbness/tingling in his fingers and toes. However, based on the Veteran's reported onset of these alleged symptoms, the examiner concluded that were not associated with or a residuals of his TBI. The examiner determined that the Veteran's motor activity with intact motor and sensory system was normal; that the Veteran was able to communicate by spoken and written language and to comprehend the same; and that his consciousness was normal. With respect to subjective symptoms, the only such symptom was headaches. The examiner indicated that he was a board-certified neurologist and addressed only the facets that pertained to neurology. He deferred assigning scores to other facets, which concerning the Veteran's psychiatric status. However, as discussed above, service-connection for PTSD has already been granted and, thus, any psychiatric deficits are already being compensated under the 50 percent rating. After additional testing, including imaging that revealed brain white matter, the examiner opined as follows: [Magnetic resonance imagining] brain white matter findings are small and nonspecific. Clinically these were felt to be due to microvascular disease, however they can also be caused by migraines. These are not in a location and appearance that would be consistent with a mild remote TBI history and thus are less likely than not due to TBI. Given the Veteran's strong history of migraines, these are at least as likely as not due to migraines. Throughout the pendency of this appeal, only one examiner has provide a facet score of "1," which was assigned in May 2011 for the Veteran's subjective symptoms. While a facet score of "1" generally results in a 10 percent rating, the nature of the Veteran's subjective symptoms underlying that score must been addressed. The May 2011 VA examiner that assigned the subject symptoms facet score of "1," found no other residuals of the Veteran's TBI beyond his already service-connected post-traumatic headaches. This finding is bolstered by the February 2017 VA examiner, who also determined that the Veteran's only subjective symptoms were headaches. Thus, the Board finds that the score assigned by May 2011 VA examiner is attributable to the deficits associated with a disability for which the Veteran is already receiving disability benefits (i.e., post-traumatic headaches). Consequently, the Board finds that a compensable rating for residuals of TBI is not warranted based on the May 2011 VA examiner's subjective symptoms facet score of "1." 38 C.F.R. § 4.14. The VA examiners are the only medical professionals that have assigned facet scores to the Veteran's residuals of TBI. Beyond the exception discussed immediately above, the Veteran has been assigned scores of "0" for every facet throughout the pendency of this appeal. Colvin, 1 Vet. App. at 175. While the Veteran asserts that a variety of symptoms should be considered as residuals of his TBI, the preponderance of the evidence is against findings these alleged residuals are actually associated with his TBI (such as vertigo, vision impairment, taste and smell impairment, and numbness/tingling in his fingers). In this case, the Veteran's assertions are competent evidence insofar they attest to experiencing lay observable symptoms. See Layno, 6 Vet. App. at 470. However, he does not have the requisite expertise to render competent opinions as to whether his observed symptoms are associated with or are residuals of his TBI, especially in the presence of other diagnostic or etiological possibilities. Jandreau, 492 F.3d at 1377. Indeed, the February 2017 VA examiner specifically determined that the Veteran alleged residuals were not associated with his TBI given the reported timing of their onset. Consequently, the Board finds that the preponderance of evidence is against finding that a compensable rating for the Veteran's residuals of TBI is warranted for any distinct period throughout the entirety of this appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-6. In making this determination, the Board acknowledges March 2017 letter from Judith Kirwan, MA, LMFT. Therein she stated that the Veteran's residuals of TBI included post-traumatic headaches, migraine headaches, and periods of vertigo. She also provided examples of TBI-related cognitive impairment and symptoms (memory, attention, concentration, and executive functions). However, Mrs. Kirwan did not attribute these cognitive deficits to the Veteran, provided not clinical data that attributes these deficits to the Veteran, and stand in contradiction the clinical results elicited by the VA examiners. Without clinical evidence and a rationale as to how Mrs. Kirwan arrived at the conclusion that the Veteran's residuals of TBI include vertigo, the Board finds that the March 2017 letter is of not probative value. Finally, while the Veteran has diagnoses of a refractive error and presbyopia, VA law provides these conditions do not constitute a disease or injury. 38 C.F.R. §§ 3.303(c), 4.9. In the absence of superimposed disease or injury, service connection may not be allowed for refractive error of the eyes, including myopia, and presbyopia, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. 38 C.F.R. §§ 3.303(c), 4.9. Accordingly, VA regulations specifically prohibit service connection for refractive error and presbyopia, unless such defect was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90, 55 Fed. Reg. 45711 (1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). There is no competent evidence of record demonstrating that the Veteran experiences defective vision associated with his TBI. Indeed, the May 2011 VA examiner specifically determined that the Veteran's refractive error and presbyopia were not associated with his TBI. The only diagnoses pertaining to the Veteran's vision are a refractive error and age-related presbyopia; these are diagnoses for which service connection is prohibited. As such, there is no evidence that the Veteran experienced a superimposed disease or injury that resulted in additional disability. Consequently, the Board finds that the preponderance of the evidence is against the Veteran's claim and, thus, defective vision is not a residual of the Veteran's TBI and service connection for defective vision is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-6. ORDER Service connection for hair loss, including male pattern baldness, to include as due to exposure to chemical and anti-viral agents, is denied. Service connection for Bell's palsy, to include as due to exposure to chemical and anti-viral agents, is denied. Service connection for gall bladder dysfunction, to include as due to as secondary to service-connected disability, is denied. Service connection for allergies, to include as due to exposure to chemicals and anti-viral agents, is denied. Service connection for sleep apnea, to include as secondary to service-connected disability, is denied. Service connection for hypertension is denied. Service connection for defective vision is denied. A compensable rating for residuals of TBI is denied. REMAND Thyroid Pursuant to the August 2016 Board remand, the Veteran underwent a VA examination in February 2017. Ultimately, the examiner rendered a negative etiological opinion, finding, in part, that the first post-service evidence of record demonstrating the presence of a thyroid disability was dated in 1998. Subsequently, the Veteran submitted a May 2017 letter from Andrew Ellias, D.O., wherein he states that the Veteran first received treatment from him in 1995. According to Dr. Ellias, on that occasion, the Veteran had already been prescribed medication to treat his thyroid disability. The doctor went on to state that "some adjustments" needed to be made to the Veteran's prescribed thyroid medication. Neither the Veteran nor Dr. Ellias submitted treatment records showing that the Veteran had already been prescribed medication in 1995. Further, neither the Veteran nor Dr. Ellias submitted documentation demonstrating that adjustments were made to this already-prescribed medication. As such, the Board finds that remand is warranted in order to attempt to obtain treatment records from Dr. Ellias. See O'Hare, 1 Vet. App. at 367. Muscle Weakness In an August 2016 decision, the Board granted entitlement to service connection for fibromyalgia. That same month, the AOJ issued a rating decision effectuating the Board's decision and assigned an initial rating of 10 percent thereto, effective April 24, 2014. The Veteran submitted a notice of disagreement with this rating decision, both as to the initial rating and effective date assigned. Documentation associated with the claims file indicates that the AOJ is responding to the Veteran's disagreements and, thus, the Board will not exercise limited jurisdiction over the increased initial rating and earlier effective date claims for purposes of a remand. See Manlicon v. West, 12 Vet. App. 238 (1999). Additionally, in November 2015, the RO denied the Veteran's claim of entitlement to service connection for lupus (claimed as an autoimmune disorder). In October 2016, the Veteran submitted a submitted a notice of disagreement with this decision. Again, documentation associated with the claims file indicates the AOJ is addressing the Veteran's contentions and, thus, the Board will not exercise limited jurisdiction over this claim for remand purposes. Id. Based on the Veteran assertions and the other evidence of record, the Board finds that his claim of entitlement to service connection for muscle weakness is inextricably intertwined with his claim of entitlement to service connection for lupus and his claim of entitlement to an increased initial rating for fibromyalgia, both of which are pending before the AOJ. Consequently, the Board finds that this claim should be remanded for contemporaneous consideration. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Throat and GERD Pursuant to the Board's August 2016 remand, the Veteran underwent a February 2017 VA examination to ascertain the presence of throat disability. Ultimately, the examiner determined that the Veteran experienced GERD, of which dysphagia was an aspect. The examiner did not find a separate and distinct throat disability or residuals thereof. Service-connected has been granted for several of the Veteran's disabilities. The Board observes that the Veteran is prescribed medication to treat these disabilities. The February 2017 VA examiner did not discuss whether the Veteran's GERD, with dysphagia, was caused for aggravated by his prescribed medications. Consequently, the Board finds that a remand is warranted in order to obtain a supplemental opinion. The Board has kept separate the Veteran's claims of entitlement to service connection for a throat disability and GERD in case new evidence demonstrates a separately diagnosable throat disability. The claims are remanded together for contemporaneous consideration. Id. Accordingly, the case is REMANDED for the following action: 1. The AOJ should undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claim of entitlement to service connection for a thyroid disability from Andrew Ellias, D.O., specifically, but not limited to, evidence demonstrating that the Veteran had already been prescribed medication to treat his thyroid in 1995. If possible, the Veteran himself should submit this evidence. 2. The AOJ should obtain a supplemental opinion from the February 2017 VA examiner, or an appropriate substitute, regarding the Veteran's GERD, with dysphagia/throat disability. Based on a review of the relevant evidence of record, the examiner is asked to opine as to whether it is as least as likely as not (a 50 percent probability or greater) that the Veteran's GERD, with dysphagia/throat disability, is aggravated by medications prescribed to treat the Veteran's service-connected disabilities. Any opinion(s) offered should be accompanied by a thorough rationale. 3. The AOJ should consider the Veteran's claim of entitlement to service connection for muscle weakness, to include as due to exposure to chemical and anti-viral agents, to include as due to an undiagnosed illness, contemporaneous to the adjudication of the Veteran's claim of entitlement to service connection for lupus, as well as the claim of entitlement to an initial rating in excess of 10 percent for fibromyalgia. 4. This is a highly complex case. The AOJ is asked to review the case in detail. 5. After completing the above action, and any other indicated development, the AOJ must re-adjudicate the Veteran's claims. If any benefit sought on appeal remains denied, the AOJ must issue a supplemental statement of the case to the Veteran and his representative. After they have had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the U.S. Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2014). JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs Department of Veterans Affairs