Citation Nr: 1808501 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 08-18 732 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to service connection for tinea versicolor. 2. Entitlement to service connection for cold injury residuals of the hands is dismissed. 3. Entitlement to service connection for allergic rhinitis, to include as secondary to asthma.. 4. Entitlement to service connection for sinusitis, to include as secondary to asthma. 5. Entitlement to service connection for anosmia. 6. Entitlement to service connection for a back disability. 7. Entitlement to service connection for a liver disability. 8. Entitlement to service connection for chronic fatigue, to include as a manifestation of undiagnosed illness or other qualifying, chronic disability pursuant to 38 U.S.C. § 1117. 9. Entitlement to service connection for diabetes mellitus, Type II. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. D. Simpson, Counsel INTRODUCTION The Veteran served on active duty from July 1977 to July 1986, and from February 1987 to December 1999. This appeal before the Board of Veterans' Appeals (Board) arose from a February 2006 rating decision in which the RO, inter alia, denied the Veteran's claim for a rating in excess of 10 percent for chondromalacia of the left knee and proposed to reduce the rating for discoid lupus erythematosus from 30 to 10 percent. A notice of disagreement (NOD) with respect to the denial of the claim for an increased rating for chondromalacia of the left knee and the proposed reduction in the rating for discoid lupus erythematosus was filed in April 2006. The reduction of the rating for discoid lupus erythematosus to 10 percent, effective September 1, 2006, was implemented by a June 2006 rating decision. Thereafter, a January 2007 rating decision denied a rating in excess of 10 percent for discoid lupus erythematosus and a claim for service connection for a liver disability. An NOD with respect to this decision was filed in March 2007. The RO issued a statement of the case (SOC) in May 2008 with respect to the ratings assigned for chondromalacia and discoid lupus erythematosus of the left knee and a denial of the claim for service connection for a liver disability and the Veteran submitted a substantive appeal with respect to all three of these issues (via a VA Form 9, Appeal to Board of Veterans' Appeals) in June 2008. After further development, an April 2009 supplemental SOC (SSOC) was completed that reflects the continuing denial of these three claims. This appeal to the Board also arose from a July 2009 rating decision in which the RO, inter alia, denied claims for service connection for a disability manifested by low temperature fevers, chronic fatigue syndrome, tinea versicolor, hyperlipidemia, diabetes, cold injury residuals of the hands, allergic rhinitis, sinusitis, anosmia, and a back disability. The Veteran submitted an NOD with respect to the denial of the claim for service connection for tinea versicolor in September 2009 and an SOC with respect to this matter was completed in December 2009. The Veteran submitted a substantive appeal with respect to the denial of the claim for service connection for tinea versicolor (via a VA Form 9) later in December 2009. The Veteran also filed an NOD with respect to remaining claims, as listed herein above, denied by the July 2009 rating decision in December 2009, and an SOC with respect to these issues was completed in June 2010. A substantive appeal with respect to the denial of these claims (via a VA Form 9) was filed in July 2010. Following additional development, an October 2014 SSOC was completed that reflects the continued denial of the claims addressed in the May 2008, December 2009, and June 2010 SOCs. In April 2015, Veteran was afforded a Board videoconference hearing pursuant to the provisions of 38 U.S.C. § 7107(e). During this hearing, the undersigned Veterans Law Judge was located in Washington, D.C., and the Veteran was located at the RO. A transcript of this hearing is of record. In September 2015, the Board dismissed the issues of service connection for a disability manifested by low temperature fevers and hyperlipidemia. The Board granted a restoration of a 30 percent rating for service-connected discoid lupus erythematosus from September 1, 2006. In a November 2016 rating decision, the agency of original jurisdiction (AOJ), inter alia, granted service connection for intervertebral disc syndrome with lumbosacral strain and degenerative disc disease and pityriasis versicolor (claimed as tinea versicolor). In a February 2017 rating decision, the AOJ granted service connection for cold injury residuals, bilateral hands, allergic rhinitis, anosmia, and sinusitis. While the Veteran previously had a paper claims file, this appeal is now being processed utilizing the paperless, electronic Veterans Benefits Management System (VBMS) and Legacy Content Manager (Virtual VA) claims processing systems. All records have been reviewed. The Board's disposition of the granted service connection claims, as well as its decisions on the remaining service connection claims are set forth below. The claim for an increased rating for left knee chondromalacia is addressed in the remand following the order; this matter is, again, being remanded to the AOJ. VA will notify the Veteran when further action, on his part, is required. FINDINGS OF FACT 1. In a November 2016 rating decision, the AOJ granted the Veteran's claims for service connection for intervertebral disc syndrome with lumbosacral strain and degenerative disc disease and pityriasis versicolor (claimed as tinea versicolor). 2. In a February 2017 rating decision, the AOJ granted the Veteran's claims for service connection for cold injury residual of the bilateral hands, allergic rhinitis, anosmia and sinusitis. 3. All notification and development actions needed to fairly adjudicate the claims herein decided have been accomplished. 4. The weight of the competent, probative evidence is against a finding of any active liver disease at any point pertinent to the current claim on appeal. 5. The weight of the competent, probative evidence is against a finding of chronic fatigue syndrome at any point pertinent to the current claim on appeal. 6. Type II diabetes mellitus was not manifest during active service or for many years thereafter, and the only competent, probative medical etiology opinions weigh against a nexus between the diagnosed disability and service. CONCLUSIONS OF LAW 1. As the November 2016 awards of service connection for intervertebral disc syndrome with lumbosacral strain and degenerative disc disease and pityriasis versicolor (claimed as tinea versicolor) fully resolved these claims, there remains no case or controversy with respect to these claims affecting the provision of benefits by VA over which the Board may exercise jurisdiction. 38 U.S.C. §§ 511, 5107, 7104 (2012); 38 C.F.R. §§ 19.4, 19.5, 20.101 (2017). 2. As the February 2017 awards of service connection for cold injury residual of the bilateral hands, allergic rhinitis, anosmia and sinusitis fully resolved these claims, there remains no case or controversy with respect to these claims affecting the provision of benefits by VA over which the Board may exercise jurisdiction. 38 U.S.C. §§ 511, 5107, 7104 (2012); 38 C.F.R. §§ 19.4, 19.5, 20.101 (2017). 3. The criteria for service connection for a liver disability are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 4. The criteria for service connection for chronic fatigue syndrome to include as due to undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C. § 1117, are not met. 38 U.S.C. §§ 1101, 1110, 1117, 1131, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2017). 5. The criteria for service connection for diabetes mellitus, Type II are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Dismissals The Secretary shall decide all questions of law and fact necessary to a decision by the Secretary under a law that affects the provision of benefits by the Secretary to veterans or the dependents or survivors of veterans. 38 U.S.C. § 511(a); 38 C.F.R. § 20.101(a). One of the principal functions of the Board is to make determinations of appellate jurisdiction. 38 C.F.R. § 19.4. The Board may address questions pertaining to its jurisdictional authority to review a particular case or issue. 38 C.F.R. § 20.101(d). Although the Veteran perfected an appeal to the Board with respect to the July 2009 denials of service connection for: intervertebral disc syndrome with lumbosacral strain and degenerative disc disease and pityriasis versicolor (claimed as tinea versicolor), cold injury residual of the bilateral hands, allergic rhinitis, anosmia and sinusitis, in subsequent rating decisions issued in November 2016 and February 2017, the RO granted service connection for these claims. Under these circumstances, the Board finds that these claims, which were formerly in appellate status prior to the above referenced RO rating decisions, have been granted by the decision of the lower adjudicative body, fully resolving the Veteran's appeal as to these matters. Hence, there is no longer any case or controversy pending before the Board as contemplated by 38 U.S.C. §§ 7104, 7105 and 38 C.F.R. §19.4 with respect to these claims. In the absence of any justiciable question, the appeal as to these claims for service connection must be dismissed. II. Due Process Considerations for Claims Decided The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (2012) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2017). Here, in a September 2008 letter issued prior to the rating decision on appeal, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate a service connection claim, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice letter also provided general information pertaining to VA's assignment of disability ratings and effective dates (in the event service connection is granted), as well as the type of evidence that impacts those determinations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006): Hence, the September 2008 letter met the VCAA's content and timing of notice requirements. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b). The Veteran does not assert any prejudicial error from any notification deficiency and none is found by the Board. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). The record also reflects that, consistent with applicable duty-to-assist provisions, VA has made reasonable efforts to develop the claims herein decided, to include obtaining or assisting in obtaining all relevant records and other evidence pertinent to the claims. Available service treatment records (STRs) and post service VA treatment records have been obtained. The Veteran was afforded appropriate VA examinations in September 2016 with December 2016 addendum medical opinions for the claims decided herein. The Board finds that no further action on any of these claims, prior to appellate consideration, is required. As for the April 2015 Board hearing, the transcript reflects that, during the hearing, the undersigned identified the issues then on appeal, to include the issues herein decided. Pertinent testimony was elicited regarding the nature and etiology of, and treatment for liver disease, chronic fatigue syndrome and diabetes. Although the undersigned did not explicitly suggest the submission of any specific, additional evidence, the Board subsequently sought further development of these claims based, in part, upon the Veteran's hearing testimony, and additional evidence was received. The hearing was legally sufficient. See 38 C.F.R. 3.103(c)(2) (2017); Bryant v Shinseki, 23 Vet. App. 488 (2010). In the September 2015 remand, the AOJ was directed to request updated VA treatment records, provide the Veteran an opportunity to submit additional medical records, obtain appropriate VA examinations and then readjudicate the claims. The AOJ obtained updated VA treatment records. In an April 2016 letter, the AOJ requested that the Veteran identify any additional evidence for consideration, but did not receive a response to warrant additional development for private medical records. The AOJ obtained appropriate VA examinations and then readjudicated the claims in an April 2017 SSOC. As the requested development has been accomplished, to the extent possible, no further action to ensure compliance with the prior remand directives is required. See Stegall v. West, 11 Vet. App. 268 (1998). See also Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In sum, there is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required in connection with these claims. Notably, neither the Veteran, nor his representative, has raised any specific issue regarding any notice or assistance provided (or not provided) with respect to these claims. See Scott, 789 F.3d at 1381 (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Accordingly, the Veteran is not prejudiced by the Board proceeding to a decision for these service connection claims on appeal, at this juncture. III. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). In addition, 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). Generally, to establish service connection, there must be competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). See also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The determination as to whether elements are met is based on an analysis of all the evidence of record, and evaluation of its competency, credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Evidence generated prior to the claim must also be considered in determining a current disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013) (Board erred in failing to address pre-claim evidence in assessing whether a current disability existed, for purposes of service connection, at the time the claim was filed or during its pendency). Service connection may be presumed, for certain chronic diseases, such as diabetes, which develop to a compensable degree within one year of separation, although there is no evidence of such disease during the period of service. This presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. While the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree. 38 C.F.R. § 3.307(c). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is questioned. When the fact of chronicity in service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit has clarified that the law providing for awards of service connection on the basis of continuity of symptomatology (in lieu of medical opinion) is limited to "chronic" diseases listed under 38 C.F.R. § 3.309(a) (such as diabetes). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran had service in the Southwest Asia theater of operations during the Persian Gulf War and asserts that he has a qualifying chronic disability manifesting as chronic fatigue syndrome. 38 U.S.C. § 1117. Under 38 U.S.C. § 1117(a)(1) compensation is warranted for a Persian Gulf veteran who exhibits objective indications of a "qualifying chronic disability" that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the Secretary. The period within which such disabilities must become manifest to a compensable degree in order for entitlement to compensation to be established is currently December 31, 2021. 81 Fed. Reg. 71,382 (October 17, 2016); see also 38 C.F.R. § 3.317(a)(1)(i). In order to qualify, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a), (b). The term "objective indications of a qualifying chronic disability" include both "signs," in a medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or a chronic multi-symptom illness include the following: fatigue, unexplained rashes or other dermatological signs or symptoms, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 U.S.C. § 1117(g). The term "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). The Board must weigh any competent lay evidence and make a credibility determination as to whether it supports a finding of service incurrence; or, if applicable, continuity of symptomatology; or both, sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Layno, supra. The credibility of lay evidence may not be refuted solely by the absence of corroborating contemporaneous medical evidence, but it is a factor. Davidson v. Shinseki, 581 F.3d at 1313, 1316 (Fed. Cir. 2009). Other credibility factors are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence thereof, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). See Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53-57 (1990). A. Liver disability Service treatment records (STRs) include the report of a February 1982 malaria evaluation. The clinician noted that the Veteran had possible malaria exposure, but did not find any obvious disease process. November 1993 and March 1995 STRs showed that the Veteran was treated for acute viral illnesses. In the June 1999 Report of Medical History the Veteran denied having or ever having liver trouble. He underwent a contemporaneous physical examination for retirement. His abdomen was clinically evaluated as deemed to be normal. Urinalysis was negative. The report of a December 2000 VA Gulf War clinic consultation reflects that the Veteran had a normal liver function test (LFT). October 2001 VA primary care (PC) records show that the Veteran described himself as well. Physical examination was grossly normal. November 2002 VA PC records show that clinical evaluation of the abdomen was negative for tenderness and guarding. Laboratory testing was performed. Hepatitis findings were negative. However, the clinician assessed mild abnormal LFT. An ultrasound was recommended. It confirmed a normal liver. January 2003 VA PC records again list mild abnormal LFT. However, in May 2003 VA PC records the condition was described as inactive. November 2005 VA PC records reflect that the Veteran was advised to discontinue Ibuprofen and alcohol use due to abnormal LFTs. A liver ultrasound was scheduled. The December 2005 liver ultrasound listed an impression of negative right upper quadrant sonogram. The clinician included abnormal LFT in the assessment. July 2006 VA PC records reflect that the abnormal LFT was inactive. In December 2006, the Veteran stated that his PC provider informed him that he had a swollen liver and it dated back to 1998. He was advised to have a liver biopsy. In his June 2008 substantive appeal, the Veteran reported having liver damage from in-service Motrin use and current Hydroxychloroquine Sulfate use over the past two years. In August 2011, the Veteran had a VA Gulf War examination. As relevant, the physical examination listed normal liver and spleen. During the April 2015 Board hearing, the Veteran reported being diagnosed with a swollen liver in 2003 or 2004. Currently, he had tenderness over his stomach area. He reported that he had not been medically evaluated for his liver since 2004. He acknowledged that he did not receive any additional diagnosis for his liver. During service, he recalled that he had stomach problems and at one time was diagnosed with hepatitis B. He also noted that he had low white and red blood cell counts. In September 2016, the Veteran was afforded a VA liver examination. The examiner declined to list a diagnosis. He cited several pertinent clinical studies from 2002 and 2005 that were negative for liver disease, in addition to the current liver enzyme blood test that returned negative. He listed the current laboratory liver studies. He provided a negative medical opinion. He stated that all indicated tests suggested a normal liver and that there was no evidence of any type of hepatitis. In a December 2016 addendum, the VA examiner confirmed that there was no evidence of chronic liver disease from his review of the record. The Board has considered the medical and lay evidence of record and finds that the preponderance of the evidence weighs against an award of service connection for the claimed liver disability. The Veteran asserts that he has a current liver disability from active service, specifically stomach pain and Motrin use. He is competent to report the circumstances of his service and his reports concerning stomach pain, illness, hepatitis and Motrin use have been considered. However, in this particular case, establishing a current liver disability from reports of stomach pain, acute illness, recollection of a hepatitis diagnosis or medication side effects raises questions concerning internal medical processes that extend beyond an immediately observable cause-and-effect relationship. It is the type of etiology or nexus that the courts have found to be complex medical matters beyond the competence of lay witnesses. Jandreau, 492 F.3d at 1377, n.4; Woehlaert, 21 Vet. App. 456; Waters, 601 F. 3d at 1278. The Veteran is not shown to possess the medical training or expertise to competently opine as to the presence and nature of liver disease and an etiology to in-service illness. Consequently, the Veteran's assertions as to a current liver disease and nexus to military service have no probative value. See id.; 38 C.F.R. § 3.159(a)(1). The September 2016 VA medical opinion with December 2016 addendum weighs against the claim. The VA examiner is qualified a physician. He expressed a negative medical opinion as to the presence of liver disease with citations to relevant laboratory studies from the past and present. His determination is plausible and consistent with the additional evidence. It is not countered by any other medical opinion suggesting the presence of liver disease during the claims period. McClain, supra.; Romanowsky, supra. Accordingly, the Board finds the September 2016 VA medical opinion to be highly probative and weigh against the claim. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (setting forth factors to be considered in assigning probative weight to an opinion); King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2013) (Board may properly prefer medical opinion over lay reports of etiology). For all the forgoing reasons, the Board concludes that the preponderance of the evidence is against the Veteran's claim for a liver disability. The benefit-of-the-doubt doctrine is therefore not applicable, and service connection for the claimed liver disability must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. at 55-57. B. Chronic Fatigue Syndrome (CFS) STRs reflect that the Veteran had viral illnesses in February 1981, November 1993 and March 1995 and associated malaise. In his June 1999 Report of Medical History, the Veteran stated that he had difficulty sleeping. Physical examination did not include any relevant findings. In June 2008, the Veteran reported that for several months he had migratory joint pains, headaches, sleep disturbances, muscle aches, low temperature fevers and complete exhaustion lasting sometimes for three days. A June 2009 VA psychiatric examination report documents the Veteran reported fatigue due to poor sleep. January 2011 VA mental health records document complaints about sleep disruption and daytime fatigue. In March 2011, the Veteran underwent a VA Gulf War examination. He reported being diagnosed with sleep apnea in 2006. He used a continuous positive airway pressure (CPAP) machine. However, he continued to feel tired and have daytime somnolence. The examiner assessed sleep apnea with associated symptoms of snoring, sleep disturbance and daytime somnolence. During the April 2015 Board hearing, the Veteran reported that he always felt tired without explanation during service. He did not seek medical attention. He reported that his fatigue had its onset during his Gulf War deployment. He recalled that prior to his Gulf War deployment he was a top runner, but after his deployment he had great difficulty completing physical training runs due to fatigue. He reported being in an area subjected to a chemical alarm during the Gulf War. In September 2016, the Veteran was afforded a VA fatigue examination with review of the claims folder. The examiner declined to provide a diagnosis. He noted that the reports of summer fatigue were attributed to Lupus. He expressed a negative medical opinion. He stated that the Veteran's tiredness/ fatigue symptoms did not fit into the classic criteria to justify a Chronic Fatigue Syndrome (CFS) diagnosis. The Veteran also had lupus, which caused fatigue. In a December 2016 VA addendum, the VA examiner reiterated his negative medical opinion. He explained that a requirement of CFS was that it could not be explained by any underlying clinical disorder and did not improve with rest. In this case, the Veteran had lupus and sleep apnea that could cause fatigue. The examiner also noted a medication that had muscle pain as a side effect. He listed a published medical article explaining the CFS diagnostic requirements. The Board has considered the medical and lay evidence of record and finds that the preponderance of the evidence weighs against an award of service connection for the claimed CFS disability. The Veteran asserts that he has a current CFS from active service. He is competent to report the circumstances of his service, including hazardous chemical exposure in Southwest Asia, and his symptoms concerning fatigue and tiredness. These lay reports have been considered. However, in this particular case, establishing a current CFS disability raises questions concerning internal medical processes and concurrent lupus and sleep apnea disabilities also productive of fatigue, that extend beyond an immediately observable cause-and-effect relationship. It is the type of etiology or nexus that the courts have found to be complex medical matters beyond the competence of lay witnesses. Jandreau, 492 F.3d at 1377, n.4; Woehlaert, 21 Vet. App. 456; Waters, 601 F. 3d at 1278. The Veteran is not shown to possess the medical training or expertise to competently opine as to the presence and nature of CFS and an etiology to in-service illness or exposures. Id. Consequently, the Veteran's assertions as to a current CFS diagnosis and nexus to military service have no probative value. Id. The September 2016 and December 2016 VA medical opinions weigh against the claim. The VA examiner is qualified a physician. He expressed a negative medical opinion as to the presence of CFS. His determination is plausible and consistent with the additional evidence indicating that the Veteran has an active lupus condition and sleep apnea as known medical conditions responsible for fatigue symptoms. It is not countered by any other medical opinion suggesting the presence of CFS independent of the other known medical conditions during the claims period. McClain, supra.; Romanowsky, supra. Accordingly, the Board finds the September 2016 and December 2016 VA medical opinions to be highly probative and weigh against the claim. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (setting forth factors to be considered in assigning probative weight to an opinion); King, 700 F.3d at 1345. For all the forgoing reasons, the Board concludes that the preponderance of the evidence is against the Veteran's claim for CFS. The benefit-of-the-doubt doctrine is therefore not applicable, and service connection for claimed CFS disability must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. at 55-57. C. Diabetes Mellitus, Type II STRs reflect that the Veteran had viral illnesses in February 1981, November 1993 and March 1995 and associated malaise. In his June 1999 Report of Medical History, the Veteran denied frequent urination. June 1999 urine sugar testing was negative. No pertinent metabolic findings were made on the contemporaneous physical examination. October 2001 and April 2002 VA PC records indicated that the Veteran was clinically evaluated. He was not suspected, nor assessed to have diabetes. May 2003 VA PC records reflected that the Veteran had hemoglobin A1c (HBA1C) of 6.4 percent. A diabetic clinic referral was placed. In June 2003, the Veteran attended a diabetic management class. A June 2003 VA dermatology clinic record noted that the Veteran had upper limit blood sugar and had been working with a dietitian. April 2004 VA PC records showed that the Veteran had a HBA1C of 6.1 percent and it was assessed as normal limit (nl). The clinician assessed hyperglucemia, glucose impairment. October 2004 VA PC records did not include any findings concerning diabetes or blood sugar impairment. September 2005 VA PC records included an assessment of hyperglycemia. January 2006 VA PC records show that the Veteran had HBA1C of 6.5 percent that was listed as high. The clinician assessed hyperglycemia. A similar HBA1C reading and assessment was given in July 2006. July 2006 VA PC records include a HBA1C reading of 6.8 percent, which was assessed as high. The clinician listed an assessment of hyperglycemia suggestive of diabetes. June 2008 VA PC records show that the Veteran had elevated blood sugar. He was referred to a diabetes class. The diabetes consultation confirmed that the Veteran received blood glucose monitoring instructions. August 2008 VA PC records reflect that the Veteran had diabetes for the past one to two months. It was under control with oral medication. VA treatment records through 2016 reflect that the Veteran continued to be monitored for diabetes. During the April 2015 hearing, the Veteran reported that he was informed about abnormal blood sugar in late 1992 or so. He recalled having medication and attending diabetes classes for diet instructions. He was again diagnosed with diabetes in 2002 at the VA Medical Center (VAMC) in El Paso and he received Metformin. To the best of his recollection, he believed that he was initially assessed with pre-diabetes when he enrolled in VA care and received a formal diabetes diagnosis in 2002. In September 2016, the Veteran was afforded a VA diabetes examination. The examiner diagnosed diabetes mellitus, Type II, with a 2008 onset. Pertinent blood sugar testing was performed. The examiner commented that the Veteran began having elevated blood sugar in 2001, assessed as hyperglycemia and treated with oral medication. The examiner expressed a negative medical opinion. He cited the initial instance of elevated blood sugar occurring in October 2001 after military service. In a December 2016 addendum, the examiner further indicated that the Veteran had no sign of diabetes at the 1999 retirement evaluation with a negative urine test and he denied having sugar or albumin in urine as part of his medical history. He reported that it was only the second elevated blood sugar reading that allowed a diagnosis of diabetes mellitus, Type II. He confirmed review of the entire record and reiterated his negative medical opinion. The Board has considered the medical and lay evidence of record and finds that the preponderance of the evidence weighs against an award of service connection for diabetes mellitus, Type II. The Veteran asserts that his current diabetes mellitus, Type II, is related to active service. He is competent to report the circumstances of his service, including recollections of medical diagnoses and his symptoms. These lay reports have been considered. In this case, the Board does not find the Veteran's reports of diabetes diagnosis or assessment in service to be probative due to the absence of such an assessment within the voluminous STRs and negative urine findings in June 1999. Caluza, 7 Vet. App. at 510-511; AZ v. Shinseki, 731 F.3d 1303, 1315-16 (Fed. Cir. 2013) (silence within records is pertinent evidence when records would typically document event in dispute). A diabetes diagnosis is not shown in service. In this particular case, establishing a nexus for post service diabetes raises questions concerning internal medical processes that extend beyond an immediately observable cause-and-effect relationship. It is the type of etiology or nexus that the courts have found to be complex medical matters beyond the competence of lay witnesses. Jandreau, 492 F.3d at 1377, n.4; Woehlaert, 21 Vet. App. 456; Waters, 601 F. 3d at 1278. The Veteran is not shown to possess the medical training or expertise to competently opine as to the etiology for post service diabetes. Consequently, the Veteran's assertions as to a nexus to military service for current diabetes have no probative value. Id. The September 2016 VA medical opinion and December 2016 addendum weigh against the claim. The VA examiner is qualified a physician. He expressed negative medical opinions. His determination is plausible and consistent with the additional evidence indicating that the Veteran did not have elevated blood sugar until October 2001. It is not countered by any other medical opinion suggesting an earlier presence for elevated blood sugar. Accordingly, the Board finds the September 2016 VA medical opinion and December 2016 addendum to be highly probative and weigh against the claim. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (setting forth factors to be considered in assigning probative weight to an opinion). The Board has also considered the chronic disease and continuity of symptomatology provisions for this claim. Here, diabetes was not noted in service or within the first post-service year. 38 C.F.R. §§ 3.307, 3.309. Due to inconsistency with the additional evidence, the Board does not find the Veteran's recollections of an in-service diabetes or similar diagnosis probative. Caluza, 7 Vet. App. at 506; AZ, 731 F.3d at 1315-16. To the extent the Veteran has asserted a continuity of symptomatology, the Board finds the specific, reasoned medical opinion above regarding disease onset and STRs indicating absence an of a blood sugar abnormality to be of greater probative weight than the Veteran's more general lay assertions. Id. The Veteran's statements regarding disease onset were considered in the above noted VA medical opinion. Overall, the evidence reflects that it is more likely that the Veteran did not have symptoms of diabetes during service or within the one year presumptive period that were early manifestations of the subsequently diagnosed diabetes. Id. For all the forgoing reasons, the Board concludes that the preponderance of the evidence is against the Veteran's claim for diabetes. The benefit-of-the-doubt doctrine is therefore not applicable, and service connection for claimed diabetes mellitus, Type II, must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. at 55-57. ORDER The appeal as to the claim for service connection for tinea versicolor is dismissed. Service connection for cold injury residuals of the hands is dismissed. The appeal as to the claim for service connection for allergic rhinitis, to include as secondary to asthma, is dismissed. The appeal as to the claim for service connection for sinusitis, to include as secondary to asthma, is dismissed. The appeal as to the claim for service connection for anosmia is dismissed. The appeal as to the claim for service connection for a back disability is dismissed. Service connection for a liver disability is denied. Service connection for chronic fatigue, to include as a manifestation of undiagnosed illness or other qualifying, chronic disability pursuant to 38 U.S.C. § 1117, is denied. Service connection for diabetes mellitus, Type II, is denied. REMAND Unfortunately, the Board finds that further AOJ action on the remaining claim on appeal is warranted, even though such will, regrettably, further delay an appellate decision on this matter. There are outstanding private medical records pertinent to the increased rating claim for a left knee disability. VA has adopted a regulation requiring that when it becomes aware of private treatment records it will specifically notify the Veteran of the records and provide a release to obtain the records. If the Veteran does not provide the release, VA will request that the claimant obtain the records and provide them to VA. 38 C.F.R. § 3.159(e)(2) (2017). In this case, May 2016 VA treatment records reflect that the Veteran was approved through the VA Choice program for left knee surgery and associated physical therapy. The September 2016 VA knee examination report confirmed that the Veteran had private arthroscopic surgery for left knee in June 2016. The private medical records for the surgery and post-operative treatment are not available. The Veteran must be afforded an opportunity to submit these private medical records. Id. While this matter is on remand, to ensure that all due process requirements are met, and the record is complete, the AOJ should undertake appropriate action to obtain and associate with the claims file all outstanding, pertinent records. As for VA records, the claims file reflects that the most recent VA treatment records associated with the Veteran's claims file are from the VA Medical Center (VAMC) in El Paso, Texas from February 16, 2017. On remand, the AOJ should obtain updated records of any relevant VA treatment of the Veteran. See 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (c) (2017); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (holding that VA is charged with constructive notice of medical evidence in its possession). The actions identified herein are consistent with the duties imposed by the VCAA. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the remaining claim on appeal. Accordingly, this matter is hereby REMANDED for the following action: 1. Obtain from the El Paso VAMC all outstanding, pertinent records of VA evaluation and/or treatment of the Veteran, dated since February 16, 2017. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with regards to requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Send to the Veteran a letter requesting that he Veteran provide sufficient information and, if necessary, authorization, to obtain any additional evidence pertinent to the remaining claim on appeal that is not currently of record. Specifically request that the Veteran identify the medical provider, and either furnish, or furnish appropriate authorization to obtain, medical records for left knee arthroscopy and associated physical therapy through the May 2016 authorization through the VA Veteran's Choice program and any other outstanding, pertinent private (non-VA) records. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 3. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. If and only if newly received evidence indicates a material increase in the service-connected left knee disability since September 2016, schedule the Veteran for another VA examination to evaluate the severity of his service-connected left knee disability. 5. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268 (1998). 6. After completing the requested actions, and any additional notification and/or development deemed warranted, adjudicate the remaining claim on appeal in light of all pertinent evidence (to include all that added to the VBMS and/or Virtual VA (Legacy Content Manger) file(s) since the last adjudication) and legal authority. 7. If the benefit sought on appeal remains denied, furnish to the Veteran and his representative an SSOC that includes clear reasons and bases for all determinations, and afford them an appropriate time period for response. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefit requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs