Citation Nr: 19132425 Decision Date: 04/25/19 Archive Date: 04/25/19 DOCKET NO. 16-62 808 DATE: April 25, 2019 ORDER The application to reopen the previously denied service connection claim for a skin condition is granted. Entitlement to service connection for Ichthyosis vulgaris, claimed as a skin condition, is granted. The application to reopen the previously denied service connection claim for hypertension is denied. The application to reopen the previously denied service connection claim for bilateral hearing loss is denied. Entitlement to service connection for posttraumatic stress disorder (PTSD), also claimed as a depressive disorder and anxiety disorder, is granted. Entitlement to service connection for sleep apnea is granted. FINDINGS OF FACT 1. In a January 1998 rating decision, the RO denied the Veteran’s claim of entitlement to service connection for a skin condition. The Veteran did not appeal and new and material evidence was not received within the one-year appeal period. 2. Evidence received concerning a skin condition since the January 1998 rating decision is related to the basis for the prior denial and raises a reasonable possibility of substantiating the service connection claim for this disability. 3. The Veteran is presumed sound with respect to his skin when he entered active duty service in December 1990, and the presumption of soundness has not been rebutted. 4. The evidence is at least evenly balanced as to whether the Veteran's current Ichthyosis vulgaris, claimed as a skin condition, is etiologically related to his December 1990 to September 1991 active duty service. 5. In a July 2011 rating decision, the RO denied the Veteran's petition to reopen a previously denied service connection claim for hypertension; the Veteran submitted a timely notice of disagreement August 2011 and a statement of the case was issued in December 2012, but the Veteran did not file a substantive appeal with respect to the issue denied in the July 2011 decision and new and material evidence was not received within the remainder of the appeals period. 6. Evidence received concerning hypertension since the July 2011 rating decision is cumulative and does not raise a reasonable possibility of substantiating the service connection claim for hypertension. 7. In a July 2015 rating decision, the RO denied service connection for bilateral hearing loss; the Veteran submitted a timely notice of disagreement September 2015 and a statement of the case was issued in June 2016, but the Veteran did not file a substantive appeal with respect to the issue denied in the July 2015 decision and new and material evidence was not received within the remainder of the appeals period. 8. Evidence received concerning hearing loss since the July 2015 rating decision is cumulative and does not raise a reasonable possibility of substantiating the service connection claim for hearing loss. 9. The evidence is at least evenly balanced as to whether the Veteran has a current PTSD diagnosis due to Gulf War stressors relating to fear of hostile military or terrorist activity. 10. The evidence is at least evenly balanced as to whether the Veteran’s sleep apnea had its onset during the Veteran’s period of active duty service. CONCLUSIONS OF LAW 1. The January 1998 rating decision that denied the claim of service connection for a skin condition is final. 38 U.S.C. § 7105(d); 38 C.F.R. §§ 3.104, 3.156(a)-(c), 20.200, 20.302. 2. Evidence received concerning a skin condition since the January 1998 rating decision is related to the basis for the prior denial and raises a reasonable possibility of substantiating the service connection claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for service connection for Ichthyosis vulgaris, claimed as a skin condition, are met. 38 U.S.C. §§ 1101, 1110, 1111, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 4. The RO's July 2011 rating decision that denied the claim of service connection for hypertension is final. 38 U.S.C. § 7105(d); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 19.32, 20.200, 20.302, 20.1103. 5. The additional evidence received since the July 2011 RO decision is not new and material with respect to hypertension, and the claim of service connection for hypertension is not reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 6. The RO's July 2015 rating decision that denied the claim of service connection for bilateral hearing loss is final. 38 U.S.C. § 7105(d); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 19.32, 20.200, 20.302, 20.1103. 7. The additional evidence received since the July 2015 RO decision is not new and material with respect to bilateral hearing loss, and the claim of service connection for bilateral hearing loss is not reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 8. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for PTSD, claimed a depressive disorder and anxiety disorder, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 9. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for sleep apnea have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1990 to September 1991. He had subsequent service in the Army National Guard, including periods of active duty for training (ACDUTRA) from March 1987 to July 1987, August 2011 to September 2011, and June 4, 2016 to June 18, 2016. These matters come before the Board of Veterans' Appeals (Board) from February 2016 and March 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Board has characterized the hypertension, bilateral hearing loss, and skin disorder claims as petitions to reopen previously denied claims since each claim, as explained in detail below, is subject to a final prior adjudication. For the psychiatric disability, the Board has recharacterized the disability to reflect the favorable evidence. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (the scope of a mental health disability claim includes any mental disorder that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and other information of record). The depressive disorder and anxiety disorder symptoms substantially overlap with PTSD and are encompassed by the service connection grant in the instant decision. The Board notes that the Veteran requested a RO hearing in the June 2017 substantive appeal. In January 2018, an informal Decision Review Officer (DRO) conference took place, and the Veteran withdrew his request for a formal RO hearing. Additional VA treatment records from January 2018 to August 2018 have been received since the most recent adjudication by the RO. However, these newly received VA treatment records are cumulative and redundant of previously available evidence. Thus, the Veteran is not prejudiced by the Board’s consideration of these records in the first instance. 38 C.F.R. § 20.1304(c). I. Duty to notify and assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. The instant decision results in complete grants for the skin disability and psychiatric claims. For the remaining hearing loss and hypertension claims, the Veteran’s representative requested an additional VA examination in the event these claims could not be granted. See April 2019 Informal Hearing Presentation. However, neither the Veteran, nor his representative, identify any specific deficiency with VA’s duty to notify or assist for the hearing loss or hypertension claims and none is found by the Board. With respect to the bilateral hearing loss and hypertension claims, the duty to obtain an examination or medical opinion under 38 U.S.C. § 5103A and 38 C.F.R. § 3.159(c)(4) applies to a claim to reopen only if new and material evidence is presented or secured. Paralyzed Veterans of America v. Secretary of Veterans Affairs, 345 F.3d 1334 (Fed. Cir. 2003) (holding that VA need not provide a medical examination or medical opinion until a claim is reopened); see also Woehlaert v. Nicholson, 21 Vet. App. 456, 463-64 (2007) (holding that adequacy of VA medical examination mooted upon Board's determination that claimant not entitled to reopening of claim). As explained below, the Board finds that no new and material evidence has been received with respect to these claims. Any issue as to the adequacy of the VA examination reports or absence of examination is moot. II. Petition to reopen previously denied claims Generally, a claim that has been denied in an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim that has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). There is a low threshold for determining whether evidence raises a reasonable possibility of substantiating a claim. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). For the purposes of establishing whether new and material evidence has been submitted, the credibility of the evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). (a) Skin condition In this case, the RO initially denied service connection for a skin condition in a January 1998 rating decision. The Veteran did not appeal this decision and new and material evidence was not received within the remaining appeals period. The January 1998 rating decision considered service treatment records (STRs), VA examination and June 1996 private medical records. The VA examiner found that Ichthyosis, X linked was the only diagnosis of record and noted on the entrance examination. He assessed it as a preexisting disability. Then, since it was a known disability, it could not be considered as an undiagnosed illness associated with active service in Southwest Asia. The additionally received evidence includes updated VA treatment records, December 2016 VA skin examination report, and additional statements from the Veteran. The December 2016 VA examination report confirmed a current disability, but the examiner found that the disability preexisted service and an aggravation did not occur. In April 2017, the Veteran reported that he entered active duty with Ichthyosis vulgaris and it worsened while he was in Southwest Asia. He cited environmental exposures as the cause. The Veteran is competent to report about his readily observable dermatological symptoms and history. Jandreau v. Nicholson, 492 F.3d 1372, 1377, n. 4 (Fed. Cir. 2007). For reopening purposes, his reports are presumed credible. Justus, 3 Vet. App. at 513. His April 2017 report is thus competent and presumably credible evidence of a military nexus. It relates to the service connection nexus element found missing in the January 1998 rating decision. It is presumably probative evidence to counter the negative December 2016 VA examination report and raises a reasonable possibility of substantiating the claim. The Board thus considers the additionally received evidence to include new and material evidence. Reopening of the service connection claim for a skin condition is therefore warranted. (b) Hypertension In this case, the RO denied service connection for hypertension in a July 2011 rating decision. The Veteran submitted a timely notice of disagreement in August 2011 and a statement of the case was issued in December 2012. Appellate review is initiated by a notice of disagreement and completed by a substantive appeal filed after a statement of the case has been furnished to an appellant. 38 U.S.C. § 7105(a); 38 C.F.R. § 20.200. A substantive appeal must be filed within 60 days from the date of mailing of a statement of the case, or within the remainder of the one year period from the date of mailing of the notification of the determination being appealed, whichever period ends later. 38 U.S.C. § 7105 (b)(2); 38 C.F.R. § 20.302(b). In the absence of a properly perfected appeal, the RO may close the appeal and the decision becomes final. 38 U.S.C. § 7105(d)(3); Roy v. Brown, 5 Vet. App. 554, 556 (1993); 38 C.F.R. § 19.32. In this case, the Veteran had 60 days from the December 6, 2012 notification of the statement of the case to perfect the appeal or submit new and material evidence. See Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). In February 22, 2013, more than 60 days following the December 6, 2012 statement of the case, the Veteran filed a substantive appeal. The RO informed the Veteran in a March 2013 letter that the substantive appeal was untimely and an appeal was not perfected. The RO did not certify this issue to the Board following the December 2012 statement of the case or otherwise took any action to indicate this issue remained on appeal. C.f. Percy v. Shinseki, 23 Vet. App. 37, 45 (2009). Thus, the July 2011 rating decision became final. See 38 U.S.C. § 7105(d)(3); Fenderson v. West, 12 Vet. App. 119, 128-31 (1999) (discussing the necessity of filing a substantive appeal which comports with governing regulations); 38 C.F.R. §§ 3.104, 20.302, 20.1103. The previously considered evidence includes STRs and VA treatment records from January 2010 to June 2011. Notably, February 2010 VA treatment records confirmed that the Veteran was recently diagnosed with hypertension. It reviewed multiple blood pressure readings from service. The RO found that while the Veteran currently had hypertension, the evidence did not show it was incurred during service or within the first post-service year. The newly received evidence includes a February 2013 statement from the Veteran where he acknowledged not having any hypertension treatment during service. However, he explained that during service he was discouraged from seeking medical attention. In this case, the Board finds that hypertension is most accurately characterized as a complex disease. This is because it typically does not produce readily observable symptoms and requires clinical confirmation for diagnosis. Thus, the Veteran is not competent to report a continuity of symptomatology or a nexus from any elevated blood pressure reading in service. Jandreau, 492 F.3d at 1377, n. 4; Justus, 3 Vet. App. at 513. However, he is competent to report limited medical treatment in service and such a report is presumed credible. Id. The February 2013 report about limited medical treatment in service, standing alone, is generalized and unclear as to a military nexus for hypertension. When considered in conjunction with the additional evidence of record, it does not suggest a disease onset prior to January 2010. The additional statements from the Veteran do not include any additional information about regarding the missing nexus element, such as a clinician relating his post-service hypertension to military service or a hypertension diagnosis prior to January 2010. Accordingly, the Board finds that the additionally received evidence does not satisfy the low standard of new and material evidence. In conclusion, the evidence received since the most recent prior denial is essentially cumulative and redundant and could not reasonably substantiate the claim were the claim to be reopened, either by triggering VA’s duty to assist or through consideration of an alternative theory of entitlement. Shade, 24 Vet. App. at 118. As new and material has not been received, reopening of the claim for service connection for hypertension is not warranted. The benefit of the doubt doctrine is not applicable to applications to reopen a claim unless the threshold burden of submitting new and material evidence has been met. Annoni v. Brown, 5 Vet. App. 463, 467 (1993). (c) Hearing Loss In this case, the RO denied a petition to reopen a service connection claim for hearing loss in a July 2015 rating decision. The Veteran submitted a timely September 2015 notice of disagreement and a statement of the case was issued in June 2016. Appellate review is initiated by a notice of disagreement and completed by a substantive appeal filed after a statement of the case has been furnished to an appellant. 38 U.S.C. § 7105(a); 38 C.F.R. § 20.200. A substantive appeal must be filed within 60 days from the date of mailing of a statement of the case, or within the remainder of the one year period from the date of mailing of the notification of the determination being appealed, whichever period ends later. 38 U.S.C. § 7105 (b)(2); 38 C.F.R. § 20.302(b). In the absence of a properly perfected appeal, the RO may close the appeal and the decision becomes final. 38 U.S.C. § 7105(d)(3); Roy v. Brown, 5 Vet. App. 554, 556 (1993); 38 C.F.R. § 19.32. In this case, the Veteran had 60 days from the June 2016 SOC to perfect the appeal or submit new and material evidence. See Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). Neither the Veteran, nor his representative submitted any document that could be construed as a timely substantive appeal following the June 2016 statement of the case. The RO did not certify these issues to the Board following the June 2016 statement of the case or otherwise took any action to indicate this issue was on appeal. Cf. Percy, 23 Vet. App. at 45. Thus, the July 2015 rating decision became final. See 38 U.S.C. § 7105(d)(3); Fenderson v. West, 12 Vet. App. 119, 128-31 (1999) (discussing the necessity of filing a substantive appeal which comports with governing regulations); 38 C.F.R. §§ 3.104, 20.302, 20.1103. The previously considered evidence includes STRs, VA treatment records from January 2010 to June 2016, July 2015 VA audiology examination and reports from the Veteran. STRs did not show any complaints or treatment for hearing loss. In September 1991, the Veteran had an audiogram as part of his separation evaluation. It showed normal hearing in both ears. A February 1994 audiogram taken for National Guard service showed that the Veteran had normal hearing. In March 1996, the Veteran had a VA audiology examination. The Veteran reported that he might have hearing loss. He cited his history for seven months of noise exposure in Southwest Asia. He denied any occupational noise exposure. The audiogram showed normal hearing acuity and speech discrimination for both ears. May 2014 VA audiology clinic records noted complaints about decreased speech recognition ability and occasional right ear tinnitus over the past eight months. The Veteran reported vertigo and imbalance from rapid head movements over the past month. He also reported 13 years history for military noise exposure. Audiogram showed hearing loss in each ear. The audiologist assessed bilateral mild to moderate sensorineural hearing loss with excellent speech recognition ability. In March 2015, the Veteran had a VA audiology examination. The audiogram did not show VA defined hearing loss in either ear. 38 C.F.R. § 3.385. Speech discrimination was perfect in each ear. The examiner diagnosed sensorineural hearing loss in frequency of 6000 hertz or above. In July 2015, the Veteran had another VA audiology examination. Audiogram confirmed bilateral hearing loss. However, the examiner reported the audiogram was invalid. She cited the Veteran’s inconsistent responses and overall behavior suggesting an exaggerated response. Speech discrimination scores were perfect in each ear. The audiologist expressed a negative medical opinion. She cited normal bilateral hearing shown on audiograms spanning from March 1986 to February 1996 and inconsistent current results. She found that hearing loss could not be estimated with any certainty. In July 2015, the RO denied the claim due to absence of a nexus to service. It cited STRs and the negative medical opinion from the July 2015 VA audiology examination. The newly received evidence includes additional statements from the Veteran and an updated VA audiology examination and addendum medical opinion. In September 2015, the Veteran reported that he had military noise exposure from serving in an artillery unit. February 2016 STRs included an audiogram confirming bilateral hearing loss. In November 2016, the Veteran asserted that he had bilateral hearing loss secondary to tinnitus. In December 2016, the Veteran underwent another VA audiology examination. Audiogram revealed bilateral hearing loss. However, the examiner reported that the audiogram was invalid. She cited inconsistent responses from the Veteran and clinical observation of the Veteran’s inconsistent responses. She listed 0 percent for speech discrimination scores in each ear. She diagnosed sensorineural hearing loss and expressed a negative medical opinion. She stated that the current examination indicated an unresolved non-organic component to the Veteran’s hearing loss. She noted that noise exposure is a well-known cause of hearing loss. However, any hearing deficit would appear coincident to the acoustic injury. A retroactive effect is not expected many years later. In December 2016 addendum, the VA audiologist addressed the Veteran’s assertion that service-connected tinnitus caused bilateral hearing loss. She expressed a negative medical opinion. She explained that tinnitus was a symptom, not a disease. Thus, it cannot cause hearing loss. In April 2017, the Veteran reported that he had military noise exposure as a heavy equipment operator. The noise exposure sources included bombs, heavy vehicles, and helicopters, as well as artillery fire. In January 2018, an addendum medical opinion was obtained. The audiologist explained that the December 2016 audiogram was invalid. The presence of acoustic reflex thresholds within normal limits indicated pure tone thresholds were much better than the Veteran’s responses. The presence of normal acoustic reflex was consistent with pure tone threshold responses below 50 decibels. Moreover, clinical observations confirmed that the Veteran could hear and respond to complex speech way below the levels of his pure tone voluntary responses without the use of amplification. The test inconsistencies suggested an unresolved non-organic component. In sum, the newly received evidence reflects that the Veteran continues to assert that his bilateral hearing loss is associated with military noise exposures. He does not provide new reports about continuous symptoms from service, but introduces an alternative theory of entitlement that hearing loss is related to service-connected tinnitus. The issue of whether post service hearing loss is related to military noise exposure or secondary to service-connected tinnitus are complex medical questions for which he is not competent report. Jandreau, 492 F.3d at 1377, n. 4; Justus, 3 Vet. App. at 513. There is no new competent evidence that the claimed hearing loss disability had its onset in service, was manifest to a compensable degree within one year of the Veteran's separation from service, is otherwise the result of a disease or injury in service, or is related to service-connected tinnitus. The Board notes that the Veteran elaborated on the sources of military noise exposure in an April 2017 report. However, the Board considers this report to be cumulative and redundant of previously available reports of noise exposure in May 2014 VA treatment records and in March 1996. Based on the above, the Board finds that the above-cited evidence is either duplicative or cumulative of the evidence previously of record, or, if new, is either not relevant to the claim of service connection for hearing loss, or does not provide a reasonable possibility of substantiating the claim. Under these circumstances, the Board concludes that, even when considering the "low threshold" for determining whether evidence is new and material pursuant to Shade, 24 Vet. App. at 118, the criteria for reopening the claim of service connection for bilateral hearing loss is not met. As new and material has not been received, reopening of the claim for service connection for hearing loss is not warranted. The benefit of the doubt doctrine is not applicable to applications to reopen a claim unless the threshold burden of submitting new and material evidence has been met. Annoni, 5 Vet. App. at 467. III. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The term "active military, naval, or air service" includes active duty, and any period of ACDUTRA during which the individual concerned was disabled from a disease or injury incurred or aggravated in line of duty, and any period of INACDUTRA during which the individual concerned was disabled from an injury incurred or aggravated in line of duty. 38 U.S.C. § 101(24); 38 C.F.R. § 3.6(a). ACDUTRA is, among other things, full-time duty in the Armed Forces performed by Reserves for training purposes or by members of the National Guard of any state. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c)(1). INACDUTRA is part-time duty in the Armed Forces performed by Reserves for training purposes or by members of the National Guard of any state. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6 (c)(1). The presumptions of soundness and in-service incurrence for certain chronic disabilities do not generally apply to ACDUTRA. See Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). Therefore, consideration of 38 C.F.R. 3.304(b), 3.307 and 3.309 (presumption of service incurrence for certain diseases first manifested after separation) for any ACDUTRA period is not appropriate in this case. (a) Ichthyosis vulgaris, claimed as dry skin As an initial matter, the issue of a preexisting skin condition is raised by the evidence below. The supplementary regulations concerning the presumption of soundness must be considered. In this regard, every veteran is presumed to have been in sound condition when examined, accepted, and enrolled into service except as to defects, infirmities, or disorders noted at the time of such entry, or where clear and unmistakable evidence demonstrates that the injury or disease existed before entry and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). The term “noted” refers to “[o]nly such conditions as are recorded in examination reports.” 38 C.F.R. § 3.304(b). When a condition is not noted on entry into service, the burden falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran’s disability was both preexisting and not aggravated by service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). In a March 1986 Army National Guard enlistment examination, the examiner noted Xcthyosis (Ichthyosis), mild to moderate. A contemporaneous dermatology consultation recommended topical treatment for dry skin and listed an impression of Ichthyosis vulgaris, mild to moderate in nature. September 1990 physical examination showed that the Veteran’s skin was clinically evaluated and deemed normal. September 1991 separation examination again reflected that the Veteran’s skin was clinically evaluated and deemed normal. In an accompanying Report of Medical History, the Veteran denied having or ever having any skin disease. February 1994 Army National Guard periodic physical examination reflected that the Veteran’s skin was clinically evaluated and deemed normal. In an accompanying Report of Medical History, the Veteran denied having or ever having any skin disease. February 1995 VA Gulf War Registry consultation showed that the Veteran complained about a history of pruritic rash. It responded to Benadryl. Physical evaluation showed that the skin had good tissue turgor. The clinician assessed rash and placed a dermatology clinic referral. In January 1996, the Veteran had a VA skin examination. He reported a history of skin dryness and left arm warts. The dryness followed Southwest Asia service. The wart occurred one year ago. He had some itching and denied any treatment. Clinical evaluation revealed marked skin dryness with formation of the fish-like scales on the forearms, arms and legs. The VA examiner diagnosed Ichthyosis (X-linked) and Verruca vulgaris. January 2004 Report of Medical History, the Veteran denied having or ever having any skin disease. February 2010 VA primary care records showed that the Veteran reported recently being diagnosed with hypertension and requested medical treatment. Clinical evaluation of the skin revealed that there was no lesion or dryness. In February 2013, the Veteran requested that unrelated claims be considered even though they were not noted in service. He reported that he was discouraged from visiting sick call during active service. In December 2016, the Veteran had a VA skin disease examination. The examiner diagnosed Ichthyosis vulgaris with an unknown onset. The Veteran reported that when he entered the National Guard he had a skin condition. He asserted that during active service his skin condition worsened, but he did not seek medical attention. Currently, he used body lotion for treatment. Clinical evaluation revealed dry, scaly skin of the legs, thighs, buttocks, abdomen, forearms, arms and posterior aspect of hands. It covered more than 40 percent of the total body area and less than 5 percent of the exposed body area. The examiner expressed a negative medical opinion. He noted that the Veteran was initially evaluated for Ichthyosis vulgaris in 1986 prior to active military service. He indicated the condition clearly and unmistakably preexisted service and was not aggravated beyond its natural progression by an in-service event, injury or illness. He cited absence of aggravation or complications, such as secondary infections during active service. In April 2017, the Veteran reported that he had Ichthyosis vulgaris when he entered active duty. However, it worsened during Desert Storm. He believed the worsening was related to environmental type exposures in Southwest Asia. The Veteran contends that service connection for a skin condition is warranted. For the following reasons, the Board finds that the presumption of soundness applied when the Veteran entered active duty in December 1990 and it is not rebutted. The evidence is at least evenly balanced as to whether his current Ichthyosis vulgaris is causally related to Southwest Asia environmental exposures and service connection for Ichthyosis vulgaris, claimed as a skin condition, is granted. The issue of preexisting Ichthyosis vulgaris is raised by the record. For VA compensation purposes, there are specific considerations in determining whether there is a preexisting disability as noted above. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). The Veteran is entitled to the presumption of soundness when an entrance evaluation fails to note a disorder. Id. The term “noted” refers to “[o]nly such conditions as are recorded in examination reports.” 38 C.F.R. § 3.304(b). However, it is presumed that prior to any period of active duty service that an entrance examination was furnished and the presumption of soundness applies even in cases where the entrance examination report was lost or missing in VA custody. Quirin v. Shinseki, 22 Vet. App. 390, 396, n.5 (2009). The Board finds that the presumption of soundness applies to the Veteran’s skin when he entered active service in December 1990. Although a March 1986 physical evaluation noted Ichthyosis vulgaris, a physical evaluation is not of record when the Veteran entered active service in December 1990. The Court has clarified that an entrance examination is presumed to have been furnished prior to entrance into active duty service and that presumption of soundness applies in cases where the entrance examination report is lost or missing. Quirin, 22 Vet. App. at 396, n.5. Thus, the Veteran is entitled to the presumption of soundness for his December 1990 entrance into active service. The next issue is whether the presumption of soundness is rebutted. The Board finds that it is not since there is evidence of aggravation, as opposed to the clear and unmistakable evidence of lack of aggravation that is required to satisfy the second prong of the test for rebutting the presumption of soundness. Wagner, 370 F.3d at 1096. At the December 2016 VA examination and in April 2017, the Veteran reported that his skin condition worsened during active service in Southwest Asia. He also previously reported that he was discouraged from visiting sick call during active service. See February 2013 Veteran statement. He is competent to report about his skin condition and history since it is readily observable. Jandreau, 492 F.3d at 1377, n. 4. The Board considers his reports of a military increase generally plausible and persuasive to indicate an aggravation. Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (Board has authority to weigh evidence on factors such as basic plausibility and consistency with additional evidence). The evidence weighing against an aggravation is the September 1991 physical evaluation and medical history and December 2016 VA medical opinion. As noted, the Veteran reported that he was discouraged from seeking medical treatment during service. It is reasonable to note that he may not have disclosed his skin symptoms or given the variable nature of rash type symptoms, he may have been in a quiescent state at the time of evaluation. As to the December 2016 VA medical opinion, the VA examiner did not consider the higher, clear and unmistakable, evidentiary standard imposed by the applicable law and regulation. Overall, the Board finds that there is not clear and unmistakable evidence of lack of aggravation. For these reasons, the presumption of soundness is not rebutted. Since the presumption of soundness is not rebutted, the issue becomes whether there is a nexus between the current Ichthyosis vulgaris and active military service. Wagner, supra. In this case, the Veteran reports an aggravation occurred during active service from Southwest Asia exposures. He is competent to make this report due to the readily observable nature of skin symptoms. Jandreau, 492 F.3d at 1377, n. 4. The Board finds this report generally plausible, and it is competent and credible evidence of aggravation. Caluza, 7 Vet. App. at 510-511. The evidence weighing against the Veteran’s assertions includes the September 1991 physical evaluation and medical history and December 2016 VA medical opinion. Again, due to the intermittent nature of rashes and consideration to the Veteran’s report about being discouraged from seeking medical attention during active service, it is plausible that a current skin disorder was overlooked in September 1991. Id. As to the December 2016 VA medical opinion, the Board considers it to be flawed since it does not consider the competent and credible reports about an aggravation and heavily relies on an absence of a contemporaneous treatment. The evidence is, thus, at least evenly balanced as to whether the Veteran's current Ichthyosis vulgaris, claimed as a skin condition, is related to December 1990 to September 1991 active duty service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for Ichthyosis vulgaris, claimed as a skin condition, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. (b) PTSD, claimed as a depressive disorder and anxiety disorder This claim raises specific PTSD regulations, in addition to the above general service connection regulations. Under 38 C.F.R. § 3.304(f), there are particular requirements for establishing service connection for PTSD. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD generally requires: (1) medical evidence diagnosing the condition in accordance with applicable criteria; (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). If a stressor claimed by a veteran is related to the veteran's fear of hostile military activity, and a VA psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD, a veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor, as long as the claimed stressor is consistent with the places, types, and circumstances of the veteran's service and there is no clear and convincing evidence to the contrary. 38 C.F.R. § 3.304(f)(3). "Fear of hostile military activity" is defined to mean that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. An example of such an event or circumstance is incoming mortar fire. Service department records confirm that the Veteran’s active service included February 1991 to August 1991 duty in Southwest Asia as part of Operation Desert Shield/ Desert Storm. STRs do not show any reports or treatment for a psychiatric disorder coincident with his deployment to Southwest Asia. In May 2016, the Veteran had an initial VA mental health (MH) consultation. He was prompted to seek treatment by complaints from his wife about irritability and poor sleep. He reported having nightmares about Desert Storm. He witnessed another solider undergoing treatment for blast injuries during an infirmary visit. He reported having longstanding irritability, insomnia and nightmares. Mental status examination (MSE) was notable for a dysphoric mood, restricted affect, and nighttime auditory hallucinations. The clinician diagnosed unspecified depressive disorder and anxiety disorder. In July 2016, the Veteran had an initial VA MH evaluation to determine the impact of any traumatic event and benefit from specialized trauma treatment. The Veteran complained about continued nightmares regarding an injured soldier and general military experience of being on guard for chemical attacks. He also had episodes of irritability and anhedonia. For social history, he reported a divorce from his first wife and currently marriage to a second wife. He described good family relationships with some emotional distance. For employment history, he stated that he retired from work as an educator. He had worked for 25 years and denied any work problems. He reported his psychiatric symptoms started immediately after his deployment. He began noticing irritability, anger management difficulties, and frequent nightmares. It was a precipitant to his divorce. His current wife encouraged him to seek help. MSE was notable for a moderately anxious mood, but otherwise normal. The clinician recounted the traumatic event as witnessing another solider being treated for blast injuries at a hospital. Quantitative testing was performed. The clinician assessed an unspecified trauma disorder from review of the entire record. She reported that the Veteran did not meet the full PTSD criteria or other trauma related disorder. She recommended no changes to the care plan. She listed a diagnostic impression of major depressive disorder, single and moderate and unspecific trauma related disorder. September 2016 VA MH records showed that the Veteran was seen for an initial psychotherapy evaluation. He reported experiencing isolation, numbness, crowd avoidance, among other symptoms. These symptoms had been present since his Gulf War deployment. He cited witnessing a wounded soldier as a traumatic stressor, as well as seeing other wounded soldiers. He avoided talking about his experiences as it caused anxiety and depression. MSE was notable for a moderately depressed and anxious mood. The VA psychologist diagnosed PTSD. She related the moderate anxiety and depression symptoms to his military service. In December 2016, the Veteran had a VA psychiatric examination. The examiner listed an unspecified anxiety disorder diagnosis. She did not find another disorder present. She noted the pertinent medical history. The Veteran was currently married to his second wife and retired from his longstanding job as a physical education teacher in 2013. Current symptoms were noted as depressed mood, anxiety, chronic sleep impairment and disturbance of motivation and mood. Behavioral observations showed the Veteran to exhibit an appropriate appearance and cooperative attitude. He had a relaxed mood and broad affect. The examiner furnished a negative medical opinion for the unspecified anxiety disorder. She cited the absence of treatment until 2016. For the following reasons, the Board finds that the evidence is at least evenly balanced as to whether a grant of service connection for PTSD under 38 C.F.R. § 3.304(f)(3) is warranted. Briefly, the Veteran is competent to report psychiatric symptoms. He is not competent to provide any self-diagnosis of his symptoms due to the medical complexity of psychiatric disorders. Jandreau, 492 F.3d at 1377, n. 4. He generally asserts longstanding psychiatric symptoms coincident to his Southwest Asia/ Gulf War deployment. Although STRs do not include any psychiatric complaints, his reports about longstanding psychiatric type symptoms are plausible and entitled to probative weight. Caluza, 7 Vet. App. at 510-511. The September 2016 VA MH records appear to meet the basic PTSD service connection criteria for a stressor based on fear of hostile military activity. Id.; 3.304(f)(3). The VA clinician is qualified as a psychologist and makes a PTSD diagnosis based on a Gulf War stressor. The Gulf War stressor described by the Veteran in September 2016 VA MH records is indirectly related to fear of hostile military activity. The September 2016 VA psychologist’s report shows that she believed it was sufficient for a PTSD diagnosis. Cf. Cohen v. Brown, 10 Vet. App. 128, 139, 140 (1997) (mental health professionals “are presumed to know the DSM requirements applicable to their practice and to have taken them into account in providing a PTSD diagnosis”). In this regard, the Board applies the reasonable doubt doctrine to find that the stressor of witnessing a soldier’s treatment for a blast injury is encompassed by fear of hostile military activity. 38 C.F.R. § 3.102. The Veteran’s claimed stressor is otherwise consistent with places, types and circumstances of his Southwest Asia/ Gulf War deployment. 38 U.S.C. § 1154(a). The evidence weighing against the claim is the May 2016 and July 2016 VA treatment records and December 2016 VA examination report. Although the May 2016 and July 2016 VA clinician did not issue a PTSD diagnosis, they affirmed a seemingly closely related anxiety disorder. They generally affirm that the Veteran had some psychiatric symptoms since service. It is reasonable to characterize the varying conclusions as a difference of medical opinion. Caluza, 7 Vet. App. at 510-511. The December 2016 VA examiner does not address the September 2016 VA MH records and relies primarily on an absence of medical treatment for a negative opinion. The Board does not find this medical opinion persuasive since it does not consider the competent and credible reports of longstanding psychiatric symptoms. The Board notes this claim was initially developed as an anxiety disorder and depressive disorder claim. In this case, the PTSD symptoms substantially overlap with the anxiety and depression symptoms and separate adjudication of an anxiety claim would not result in additional benefit to the Veteran. Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009) (considering the possibility that bipolar disorder and PTSD did not constitute the same disability, but rejecting this argument based on the facts of that case); Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing 61 Fed. Reg. 52698 (Oct. 8, 1996)) (when it is not possible to separate the effects of the service-connected and non-service-connected disabilities, the benefit of the doubt doctrine described in 38 C.F.R. § 3.102 dictates that such signs and symptoms be attributed to the service-connected disability or disabilities); see also Scott, 789 F.3d at 1381 (noting that "[a] veteran's interest may be better served by prompt resolution of his claims rather than by further remands to cure procedural errors that, at the end of the day, may be irrelevant to final resolution and may indeed merely delay resolution"). Hence, further consideration of a separate anxiety or depression claim is not required in this particular case. See id. For the foregoing reasons, the evidence for this claim is at least in a state of relative equipoise for each service connection element and service connection for PTSD, claimed as an anxiety disorder and depressive disorder, is therefore warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. (c) Entitlement to service connection for sleep apnea As noted, the Veteran is presumed sound when he entered his period of regular active duty service. 38 U.S.C. § 1111. The December 2016 VA examiner in a May 2017 addendum indicated that the Veteran’s April 1987 diagnosis of acute respiratory disease was indicative of a disorder that was acute and transitory and resolved without residual disability. Complaints of trouble sleeping were noted in September 1991. This evidence tends to show that the sleep apnea had its onset in service, as those same symptoms formed the basis of the July 2015 diagnosis of sleep apnea. Although the May 2016 VA examiner indicated that trouble sleeping and snoring are non-specific symptoms that are not diagnostic of obstructive sleep apnea, the evidence as a whole, including the lay statements, show that the symptoms of sleep apnea first manifested during service and continued until diagnosis. Maples v. Wilkie, No. 18-2016 (Vet. App. Feb. 11, 2019) (lay evidence can be sufficient to support a claim for service connection for sleep apnea); Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain). For the foregoing reasons, the evidence is at least evenly balanced as to whether the Veteran’s sleep apnea had its onset during his period of active duty service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for sleep apnea is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. See also 38 C.F.R. § 3.303(a) (“service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces”); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006) (“[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself”). Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. D. Simpson, Counsel