Citation Nr: 20006471 Decision Date: 01/28/20 Archive Date: 01/27/20 DOCKET NO. 14-36 981 DATE: January 28, 2020 ORDER Entitlement to service connection for left knee osteoarthritis is denied. Entitlement to service connection for right knee osteoarthritis is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for lumbar spine disability is denied. Entitlement to service connection for bronchitis is denied. Entitlement to service connection for heart disability is denied. Entitlement to service connection for stomach condition, to include ulcers, is denied. Entitlement to service connection for epidermal inclusion cyst is granted. FINDINGS OF FACT 1. The Veteran’s bilateral knee osteoarthritis was not shown or incurred in service and manifested many years after separation. 2. The Veteran’s hypertension was not shown or incurred in service and manifested many years after separation. 3. The Veteran’s lumbar strain was not shown or incurred in service and manifested many years after separation. 4. The Veteran’s chronic bronchitis was not shown or incurred in service and manifested many years after separation. 5. The Veteran’s heart disability was not shown or incurred in service and manifested many years after separation. 6. The Veteran does not have a current stomach or gastrointestinal condition, to include ulcers. 7. The Veteran’s epidermal inclusion cyst was shown to exist in service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for left knee osteoarthritis have not been met. 38 U.S.C. § 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for right knee osteoarthritis have not been met. 38 U.S.C. § 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. § 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for entitlement to service connection for a lumbar spine disability have not been met.38 U.S.C. § 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for entitlement to service connection for bronchitis have not been met. 38 U.S.C. § 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307. 6. The criteria for entitlement to service connection for a heart disability have not been met. 38 U.S.C. § 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for entitlement to service connection for stomach condition, to include ulcers have not been met. 38 U.S.C. § 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 8. The criteria for entitlement to service connection for an epidermal inclusion cyst have been met. 38 U.S.C. § 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Air Force from December 1966 to December 1970. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established with certain chronic diseases based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). The disease need not be diagnosed within the presumption period, but it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. The law also provides a disability may be service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim must be denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Bilateral Knee Osteoarthritis The Veteran asserts that during his time in service he had to crawl under an engine quite often and over a period of time both his knees become painful and began to ache. The Veteran also alleges his bilateral knee arthritis is caused by his service-connected depression. A most recent April 2019 VA examination shows the Veteran has a current diagnosis of bilateral knee joint osteoarthritis. The Veteran’s DD214 shows he was a jet engine mechanic and it is quite conceivable he would be required to regularly crawl under an engine for repair and maintenance. Although the Veteran maintains he was seen in service for his knees, his service treatment records (STRs) are silent for any complaints, treatment, or diagnosis for any left or right knee disabilities. His entrance and separation examinations are also silent for any lower extremity disabilities. His medical treatment records first note chronic right knee and multiple joint pain in 2001. The Veteran’s knees were examined by VA in March 2013 and the examiner noted a 2003 diagnosis of osteoarthritis of the bilateral knees. The VA examiner opined the Veteran’s bilateral knee arthritis is not proximately due to his depression reasoning that there is no literature found that lists depression as a cause of arthritis. The Veteran knees were examined again by VA in April 2019 and that examiner opined the Veteran’s left and right knee osteoarthritis is less likely than not related to active service. The examiner reasoned that the Veteran’s STRs show no knee complaints in service and no post-service complaints until approximately 2001. The examiner also noted that it is unlikely that without significant trauma, such as a direct injury to the joints, that four years in service would cause the “wear and tear” leading to bilateral osteoarthritis. The examiner pointed out that the Veteran worked in a mechanics shop, in construction, and as a cashier post-service. The examiner found it is far more likely the 30 to 40 years of these physically demanding job responsibilities led to osteoarthritis in the knees. Additionally, the examiner opined the Veteran’s bilateral knee arthritis is less likely than not caused by the Veteran’s service-connected depression. The examiner stated that a review of the medical and scientific literature fails to provide a causal link between depression and the bilateral knee arthritis. “Arthritis is due to direct trauma to a joint, cumulative trauma due to activities, body mass index or an inflammatory condition. Depression is not known to be capable of inducing arthritis.” After weighing all the evidence, the Board finds great probative value in the March 2013 and April 2019 VA examiner opinions. The negative opinions are sufficient to satisfy the statutory requirements of producing an adequate statement of reasons and bases where the expert has fairly considered material evidence which appears to support the Veteran’s position. Wray v. Brown, 7 Vet. App. 488, at 492-93 (1995). Further, the evidence of record fails to show the Veteran’s arthritis of the bilateral knees manifested within one year of his separation from service or that his service-connected depression caused his bilateral knee disability. Although not dispositive, a lengthy period without complaint or treatment is considered evidence that there has not been a continuity of symptomatology and weighs heavily against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Consideration has been given to the Veteran’s personal assertion that his bilateral knee arthritis was due to his active service and/or his service-connected depression. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, the etiology of arthritis, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Osteoarthritis is not the type of condition that is readily amenable to mere lay diagnosis or probative comment regarding its etiology, as the evidence shows that physical examinations that include x-rays are needed to properly assess and diagnose the disorder. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Accordingly, the Veteran’s assertions do not constitute competent medical evidence. The Veteran has not offered any medical opinion of record that refutes the conclusion of the 2013 and 2019 VA examiners. As such, that opinions are given great weight. Accordingly, as the criteria for service connection for hypertension have not been met, the Veteran’s claims for bilateral knee arthritis are denied. 2. Hypertension The Veteran asserts his hypertension had its onset in service, is related to service or is aggravated by service-connected depression. The Veteran’s hypertension diagnosis was most recently confirmed in an April 2019 VA examination. For VA compensation purposes, the term “hypertension” means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. Multiple blood pressure readings are required to confirm the diagnosis of hypertension with two or more readings on at least three different days. 38 C.F.R. § 4.104, DC 7101, Note 1. The Veteran’s STRs show a blood pressure (BP) of 132/72 at entrance and a BP of 130/62 at separation. Additionally, the Veteran’s remaining STRs do not show elevated blood pressure readings during his time in service. The Veteran’s medical records first note his hypertension in 2001 however in a March 2013 VA examination the Veteran asserts he has had hypertension since 1972. The March 2013 VA examination confirmed the Veteran’s diagnosis of hypertension but opined that it was less likely than not incurred in or caused by the chest pain he experienced in service. The rationale provided by the examiner was that the Veteran had no elevated BP readings during active service. The Veteran was most recently examined by VA in April 2019 and the examiner noted his diagnosis of hypertension, which is well controlled with medication. The examiner concluded that the Veteran’s hypertension is less likely than not incurred in or caused by active service to include his in-service complaints of chest pain. The examiner reasoned that the Veteran did not have elevated BP during service and that even though the Veteran had episodes of diastolic BP over 100 noted in his record, “these are always in the context of co-existing significant elevations in the systolic BP so the diastolic hypertension is not an isolated event which allows it to be its own diagnosis.” The Veteran has a diagnosis of essential hypertension based on the examiner’s review of the BP readings in the record. The examiner also reasoned that although the Veteran claims his hypertension is related to his chest pain episode in service “[BP] measurements taken during that event did not meet [the] criteria for hypertension.” Additionally, the examiner opined the Veteran’s hypertension was not due to his service-connected depression. The examiner noted there is no indication that a causal relationship exists between depression and the development of essential hypertension. The examiner went on to note that essential hypertension indicates a definite etiology is not noted and the examiner stated the Veteran has several risk factors for developing hypertension such as smoking, alcohol use, and obesity. After weighing all the evidence, the Board finds great probative value in the March 2013 and April 2019 VA examiners’ opinions. The negative opinions are sufficient to satisfy the statutory requirements of producing an adequate statement of reasons and bases where the expert has fairly considered material evidence, which appears to support the Veteran’s position. The examiner did not give a specific opinion regarding the Veteran’s hypertension being aggravated by his now service-connected depression. Nevertheless, the record shows that the Veteran’s essential hypertension has been well-controlled, and there is no competent indication of aggravation during the appeal period. Further, the evidence of record fails to show the Veteran’s hypertension manifested within one year of his separation from service, even given the Veteran’s assertion that his hypertension was diagnosed in 1972. However, the medical treatment evidence of record does not mention treatment for hypertension until 2001. Although not dispositive, a lengthy period without complaint or treatment is considered evidence that there has not been a continuity of symptomatology and weighs heavily against the claim. Consideration has been given to the Veteran’s personal assertion that his hypertension was due to his active service or secondary to his service-connected depression. Lay persons are competent to provide opinions on some medical issues, but as to the specific issues in this case, the etiology of hypertension, falls outside the realm of common knowledge of a lay person. Hypertension is not the type of condition that is readily amenable to mere lay diagnosis or probative comment regarding its etiology, as the evidence shows that physical examinations that include multiple blood pressure readings and kidney function studies are needed to properly assess and diagnose the disorder. Accordingly, the Veteran’s assertions do not constitute competent medical evidence. The Veteran has not offered any medical opinion of record that refutes the conclusion of the 2013 and 2019 VA examiners. As such, that opinions are given great probative weight. Accordingly, as the criteria for service connection for hypertension have not been met, and the Veteran’s claim is denied. 3. Lumbar Spine The Veteran asserts that during active service he injured his back when he dove in a lake and struck his head on the bottom. He rested after the injury, but it bothered him for a few days before resolving. About six to seven months later, he awoke to find his back hurting so bad he could not get up to walk. The Veteran also reports that in 1978 he experienced an accident at the machine shop where he was employed, which resulted in a crushed vertebra in his lower back. He also alleges his service-connected depression caused him to develop lumbar pain. The Veteran’s most recent VA examination confirms a diagnosis of lumbar strain. The Veteran’s STRs, to include his entrance and separation examinations, are silent for any complaints, treatment, or diagnosis of a lumbar spine disability. The Veteran does not argue he received treatment for his low back in service. The first indication of low back pain appears in his medical treatment records in 2001. The Veteran’s lumbar spine was examined in March 2013 and the examiner noted he had an injury to his low back in 1978 while working at a machine shop in which he crushed a vertebra in his lower back. He reported having had surgery on his low back in 1978 in which he states a disc was removed from his back. He also reported not having had any other problems with his back. Upon physical examination the VA examiner determined the Veteran did not have a diagnosed disability of the lumbar spine. The Veteran’s lumbar spine was most recently examined in April 2019 and the examiner diagnosed the Veteran with lumbar strain. The Veteran reported to the examiner that during active service he dove into a lake and hit his head at the bottom injuring his back. He reported the injury resolved after a few days but returned six to seven months later. The Veteran further reported that in 1978 he injured his back on the job, had a discectomy to treat the injury and his back pain improved for many years. The pain gradually worsened over the last five years. The VA examiner opined that it is unlikely that without significant trauma, such as direct injury to the back or spine, that four years in service would cause the “wear and tear” leading to chronic back strain. The examiner reasoned that it is more likely the Veteran’s work at a machine shop, working construction, and working as a cashier led to his lumbosacral strain. The examiner also opined the Veteran’s lumbar strain is not causally related to his service-connected depression. The examiner noted there is no indication that a causal relationship exists between depression and the Veteran’s lumbosacral strain. “The lumbar spine condition is due to injury, surgery and the aging process. There is no way for depression to influence the spine in any way.” After weighing all the evidence, the Board finds great probative value in the March 2013 and April 2019 VA examiner opinions. The negative opinions are sufficient to satisfy the statutory requirements of producing an adequate statement of reasons and bases where the expert has fairly considered material evidence which appears to support the Veteran’s position. The Veteran admits to an intervening injury to his lumbar spine in 1978, while on the job, requiring surgery to remove a disc from his lower back. His medical treatment records show a complaint of low back pain in 2001. Further, the evidence of record fails to show the Veteran’s lumbar strain manifested within one year of his separation from service or is otherwise related to service. The Board acknowledges the Veteran’s contention that active service and/or his service-connected depression caused his lumbar strain and 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 such as the etiology of his lumbar strain. Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. There is no competent opinion linking the Veteran’s current low back complaints to service or as secondary to his service-connected depression. Although there is no opinion as to whether the Veteran’s depression aggravated his low back disability, an opinion is not required. There is no competent evidence of record to show the possibility that depression could cause or aggravate a low back strain. Moreover, the 2019 examiner found that there is no way depression would influence the spine in any way. The Veteran’s assertions do not constitute competent medical evidence as to the etiology of his low back disability. The Veteran has not offered any medical opinion of record that refutes the conclusion of the 2013 and 2019 VA examiners. As such, that opinions are given great probative weight. Accordingly, as the criteria for service connection for lumbar strain have not been met, the Veteran’s claim is denied. 4. Bronchitis The Veteran asserts his chronic bronchitis is related to active service. The Veteran’s diagnosis was most recently confirmed in an April 2019 VA respiratory examination. The Veteran’s STRs are silent for any respiratory complaints, treatment or diagnosis in service. The Veteran asserts his coughing and wheezing did not begin for many years after service. In March 2013, the Veteran was examined by VA and diagnosed with chronic bronchitis, however the examiner opined the Veteran’s trouble breathing was secondary to his cigarette use. The Veteran was examined again by VA in April 2019 and the examiner opined his chronic bronchitis is less likely than not related to or caused by active service. The examiner reasoned the Veteran’s symptoms did not begin for many years after separation from service. The Veteran reported that around fifteen years ago he began having issues with feeling short of breath and with wheezing and coughing. The Veteran also reported he was told he had chronic bronchitis in 1993 and prescribed inhalers. Additionally, the examiner reasoned the Veteran’s STRs were silent for any respiratory symptoms. The Veteran reports his respiratory systems began well after separation from service, to include more than one year. Further, there is no event in service for which a nexus can be attached or linked. As stated above, although not dispositive, a lengthy period without complaint or treatment is considered evidence that there has not been a continuity of symptomatology and weighs heavily against the claim. The Board acknowledges the Veteran’s contention that his bronchitis is related to active service, however there is no indication the Veteran possesses the skills, expertise and/or training to make such a medical determination. As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt doctrine does not apply and the claim for service connection for bronchitis must be denied. 5. Heart Disease The Veteran contends the chest pain episode he experienced in service is a manifestation of his current heart disease and post myocardial infarction suffered in 1996. In April 2019, the Veteran’s heart disease was confirmed and diagnosed by examination. The Veteran complained of chest pain in service in June 1970. The Veteran states, but STRs do not reflect, he was told he had an enlarged heart and told to rest and take it easy. He says some tests were performed and he returned to regular duty. The Veteran also asserts he had a heart attack in 1996 and was diagnosed with myocardial infarction and CAD. He had a stent placed in his heart at the time. He maintains he suffered another heart attack in 1998, receiving another stent. He was also hospitalized for chest pain in 2000, again receiving a stent. His medical records show he had coronary bypass surgery in January 2011. In March 2013, the Veteran’s heart was examined by VA and at that time the examiner noted diagnoses of myocardial infarction and coronary artery disease. The March 2013 examiner opined the Veteran’s heart disease is less likely than not related to the chest pain he had in service because an EKG taken in service was negative for myocardial infarction. During an April 2019 VA examination, the VA examiner opined the Veteran’s heart disabilities were not incurred in service, to include the June 1970 complaint of chest pain. The Veteran’s military EKG changes indicated low potassium levels and not the onset of coronary artery disease. The examiner stated that excessive alcohol intake is a common reason for young people to present with low potassium levels and the Veteran has confirmed a past history of alcohol dependence. The examiner noted the Veteran’s first heart attack was in 2005-2006 when the Veteran was 57-58 years of age and this is when coronary artery disease tends to reveal itself in those predisposed or with significant risk factors. The examiner opined the Veteran’s chest pain during service was “certainly not” arteriosclerotic in origin based upon review of the record and the Veteran’s age at the time. The Board finds that after weighing all the evidence, the 2013 and 2019 VA opinions are quite probative. The evidence of record fails to establish the Veteran’s heart disease manifested within one year of separation or that his heart disability is otherwise related to active service, to include his June 1970 complaint of chest pain. The Board acknowledges the Veteran’s contention that his heart conditions are related to active service, however there is no indication the Veteran possesses the skills, expertise and/or training to make such a medical determination. As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt doctrine does not apply and the claim for service connection for a heart disability (formerly chest pain) must be denied. 6. Stomach Condition to Include Ulcers The Veteran alleges he has a stomach condition, to include ulcers, which is related to active service. However, the is no competent evidence of record that the Veteran has a current diagnosis of a stomach condition or ulcers. In a March 2013 VA examination, the examiner concluded the Veteran did not have symptoms or a diagnosis of stomach disability. The examiner noted the Veteran had not had endoscopy for conditions of the stomach or colon. The examiner also noted the Veteran’s report that he had a previous bleeding ulcer, but that he is not currently experiencing any abdominal pain, nausea, melena, or other gastrointestinal symptoms. In an April 2019 VA examination, the examiner noted the Veteran denies ever having a stomach ulcer. The Veteran reported experiencing very chronic, recurrent episodes of bright red blood in stools when toileting with onset shortly after his appendectomy performed in service. The Veteran also reported that he assumed the blood in his stool meant he had an ulcer, but he never underwent endoscopy or other diagnostic procedures. The examiner noted a colonoscopy was scheduled to investigate the blood in stool, but the Veteran canceled the procedure. The examiner reported the Veteran was diagnosed with hemorrhoids in 2012 and was never noted to be anemic, as from excessive blood loss. The examiner concluded no diagnosis of a stomach disability or ulcers was warranted. None of the objective medical evidence of record shows a current diagnosis of a stomach condition, to include ulcers, at any time during the appeal period. The Veteran’s STRs and medical treatment records are silent for a diagnosis of a gastrointestinal condition, to include ulcers. Additionally, the Veteran’s lay statements indicate he does not suffer symptoms of a stomach, colon, or other gastrointestinal condition. As there is no competent evidence that would establish the current disability element, entitlement to service connection for sleep apnea cannot be granted on any basis. Brammer v Derwinski, 3 Vet. App. 223, 225 (1992) (holding that there can be no valid claim for service connection “[i]n the absence of proof of a present disability”). Moreover, even if there were a current diagnosis of a gastrointestinal condition, there is no objective medical evidence of record suggesting that any such gastrointestinal condition had its onset in or is otherwise related to his military service. The nexus element of direct service connection has also not been demonstrated, and entitlement to service connection for a stomach condition, to include ulcers is denied. In reaching all the conclusions stated above, the Board has considered the applicability of the benefit-of-the-doubt doctrine, however, that doctrine is not applicable in the instant appeal as the preponderance of the evidence is against the claim. 7. Skin Condition The Veteran contends the cyst in his neck manifested during service or is otherwise related to active service. The Veteran is currently diagnosed with an epidermal inclusion cyst in his neck. Although the Veteran’s STRs are silent for complaints, treatment or diagnosis for a skin condition, his report of medical history at separation indicates a “tumor” was removed from his neck in 1969. This note is in addition to his reports of boils which “resolved with heat and medication” in 1968. In March 2013, the Veteran had a VA skin examination and that examiner diagnosed him with an epidermal inclusion cyst of the neck. The examiner noted the Veteran’s report that he had a cyst in his neck lanced while serving on active duty. The examiner opined that the neck cyst is less likely than not related to active service. The examiner reasoned that although the Veteran’s separation examination notes a tumor removal, there is no evidence in his STRs which documents tumor removal. The examiner noted the Veteran was not currently being treated for the cyst. The Veteran had a VA skin examination in April 2019. At that time, the examiner noted the Veteran experienced boils in the perianal area while in service which were treated with incision, drainage, hot compresses, and antibiotics. According to the Veteran and his STRs, the boils resolved without recurrence. The Veteran also reported that his first epidermal cyst of the neck occurred in service and it was removed in service. The Veteran further reported he has been treated for cysts to the back of the neck and upper back several times throughout the years since separating from service. The examiner documented a recurrent epidermal inclusion cyst to the posterior of the neck. The examiner noted the “current cyst is a recurrence of one surgically removed some years ago.” The Veteran stated that although he has had the cyst treated multiple times “it always comes back” and he just “plans to live with” it. The examiner opined the Veteran’s neck cyst was less likely than not incurred in or caused by active service, to include as the result of hot oil being poured onto the skin or the having boils lanced in service, as the Veteran claims. The examiner reasoned that boils are quite different from inclusion cysts, and the boils resolved according to the Veteran. The Veteran’s separation examination notes the removal of a tumor from the neck in 1969. Although none of the STRs of record document the tumor removal procedure, the note was included in the physician summary. This corroborates the Veteran’s assertion that the he had a cyst or tumor removed from his neck during active service. The March 2013 VA opinion is based solely on the fact that the Veteran’s STRs do not document evidence of the procedure or treatment for the tumor removal. The opinion is deemed less probative as it based solely on the absence of medical information and disregards that the fact that the notation was made almost decades in advance of the Veteran’s request for service connection and is too specific to be a mere coincidence. Although the April 2019 VA examiner notes the Veteran’s report that he had a neck cyst removed in service, the examiner fails to consider this assertion in the opinion. Specifically, the examiner fails to address the documentation of a tumor removal from the neck upon separation and instead addresses the Veteran’s reports of having perianal boils in service. The April 2019 VA opinion is not probative in that in fails to address the documented neck tumor removal upon separation. However, the April 2019 is probative in that it identifies the Veteran’s epidermal inclusion cyst as recurrent and chronic. To establish service connection based on a continuity of symptoms, there must be evidence demonstrating (1) that a condition was “noted” during service; (2) post-service continuity of the same symptoms; and (3) a causal link between the present disability and the continuous symptoms. Fountain v. McDonald, 27 Vet. App. 258, 272 (2015). The Veteran is competent to note a growth in his neck, that the growth was removed, and that the growth has returned. Here, the Veteran has been diagnosed with a recurrent chronic epidermal neck cyst. The April 2019 examiner noted the Veteran’s currently diagnosed epidermal inclusion cyst is a recurrence of one removed “some years ago.” The Veteran asserts he has had the cyst removed from his neck, but the cyst always returns. The April 2019 concurs that the cyst is recurrent. The Veteran contends he had a cyst in his neck removed in service. Although his STRs do not document treatment for a tumor removal his report of medical history physician’s summary notes he had a tumor removed from his neck in 1969. The Board finds the Veteran has established a continuity of symptoms as he has shown his chronic epidermal neck cyst existed in service and has continued to present day. After weighing the two negative VA medical opinions against the Veteran’s consistent lay statements, the April 2019 VA examiners findings and the record as a whole, the Board finds the evidence is at least in relative equipoise in showing the Veteran’s chronic epidermal neck cyst manifested in active service. After applying the benefit of the doubt doctrine, the claim for service connection for chronic epidermal neck cyst must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REMANDED Entitlement to total disability based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Board granted service-connection for a recurrent neck cyst. The issue of entitlement to a TDIU must be deferred pending the RO assigning a rating for the now service-connected neck cyst. In other words, entitlement to TDIU is dependent upon the processing of the Veteran’s granted service-connection claim. The matters are REMANDED for the following action: 1. Provide the Veteran with appropriate notice regarding how to substantiate his claim for entitlement to a TDIU and request that he submit a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. 2. After issuance of a rating for the neck cyst, readjudicate the TDIU issue. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T.N. Shannon The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.