Citation Nr: 21001514 Decision Date: 01/08/21 Archive Date: 01/08/21 DOCKET NO. 14-29 141A DATE: January 8, 2021 ORDER New and material evidence sufficient to reopen the claim for entitlement to service connection for hypertension (HTN) has been received, and the application to reopen is granted. New and material evidence sufficient to reopen the claim for entitlement to service connection for DDD of the cervical spine has been received, and the application to reopen is granted. Service connection for HTN is denied. Service connection for erectile dysfunction (ED), secondary to HTN, is denied. Service connection for DDD of the cervical spine is denied. Service connection for a lumbar spine disability is denied. REMANDED Entitlement to an initial compensable rating for gastroesophageal reflux disease (GERD), prior to September 11, 2020, and in excess of 10 percent thereafter, to include on an extraschedular basis, is remanded. Entitlement to a rating in excess of 10 percent for left (minor) wrist injury residuals with degenerative changes, (left wrist disability), to include on an extraschedular basis, is remanded. Entitlement to a rating in excess of 30 percent for residuals of right foot frostbite with degenerative changes, to include on an extraschedular basis, is remanded. Entitlement to a rating in excess of 30 percent for residuals of left foot frostbite with degenerative changes, to include on an extraschedular basis, is remanded. FINDINGS OF FACT 1. In an unappealed July 2011 decision, the Board denied entitlement to service connection for HTN. 2. The evidence associated with the claims file subsequent to the July 2011 decision includes evidence that relates to an unestablished fact necessary to substantiate the claim for service connection, is not cumulative or redundant of the evidence previously of record and raises a reasonable possibility of substantiating the claim for service connection for HTN. 3. In an unappealed September 2015 rating decision, the RO denied entitlement to service connection for DDD of the cervical spine. 4. The evidence associated with the claims file subsequent to the September 2015 denial includes evidence that relates to an unestablished fact necessary to substantiate the claim for service connection, is not cumulative or redundant of the evidence previously of record and raises a reasonable possibility of substantiating the claim for service connection for DDD of the cervical spine. 5. HTN was not present in service was not present in service or for years thereafter, and is not etiologically related to service. 6. ED was not present in service or for years thereafter, and is not etiologically related to service or a service-connected disability. 7. DDD of the cervical spine was not present in service or for years thereafter, and is not etiologically related to service. 8. A lumbar spine disability was not present in service or for years thereafter, and is not etiologically related to service. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen a claim for service connection for HTN. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (a) (2019). 2. New and material evidence has been received to reopen a claim for service connection for DDD of the cervical spine. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (a) (2019). 3. The criteria for service connection for hypertension have not been met. 38 U.S.C. § 1101, 1131, 5107 (2012); 38 C.F.R. § 3.102, 3.303, 3.307, 3.309(a) (2019). 4. The criteria for service connection for ED have not been met. 38 U.S.C. §§ 1101, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). 5. The criteria for service connection for DDD of the cervical spine have not been met. 38 U.S.C. §§ 1101, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 6. The criteria for service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 1101, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1981 to August 1984 and from November 1990 to August 1991. He had additional service with the Georgia Army National Guard from 1984 to 2004. In May 2019, the Board remanded the case for further development by the originating agency. While the case was in remand status, the RO granted a temporary 100 percent total disability rating for the service-connected left knee disability, effective December 29, 2010 to April 1, 2011. See August 2019 rating decision. This was a full grant of the benefit sought with regard to that issue. Grantham v. Brown, 114 F .3d 1156 (Fed. Cir. 1997). The case has been returned to the Board for further appellate action. New and Material Evidence As a general rule, a previously denied claim shall be reopened and reviewed if new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. When a claimant seeks to reopen a final decision, the first inquiry is whether the evidence obtained after the last disallowance is "new and material." Under 38 C.F.R. § 3.156 (a), new evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing 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 of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The submission of "new and material" evidence is a jurisdictional prerequisite to the Board's review of such an attempt to reopen a claim. Absent the submission of evidence that is sufficient to reopen the claim, the Board's analysis must cease. See Barnett v. Brown, 83 F.3d 1380, 1384 (Fed. Cir. 1996); Butler v. Brown, 9 Vet. App. 167, 171 (1996); McGinnis v. Brown, 4 Vet. App. 239, 244 (1993). The United States Court of Appeals for Veterans Claims has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim, in the final sentence of 38 C.F.R. § 3.156 (a), does not create a third element in the reopening process, but is a component of the question of what is new and material evidence, rather than a separate determination to be made if evidence is new and material. See Shade v. Shinseki, 24 Vet. App.110, 117 (2010) (noting that 38 U.S.C. § 5108 requires only new and material evidence to reopen). Shade further holds that 38 C.F.R. § 3.156 "suggests a standard that would require reopening if newly submitted evidence, combined with VA assistance and considering the other evidence of record, raises a reasonable possibility of substantiating the claim[.]" Id. Further, the Board should not focus solely on whether the evidence remedies the principal reason for denial in the last prior decision, and regulations do not require new and material evidence as to each previously unproven element of a claim. Id. Rather, the Board should focus on whether the evidence, taken together, could at least trigger the duty to assist by providing a medical opinion. Id. See also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Simply stated, the standard is low, but it is a standard that needs to be met. When determining whether a claim should be reopened, the credibility of the newly submitted evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510 (1992). If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. Smith v. West, 12 Vet. App. 312 (1999). Once evidence is deemed new and material, the Board can proceed to review the claim based on the merits and the entire evidence of record. 1. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for HTN, and if so, whether the reopened claim should be granted In a July 2011 decision, the Board denied service connection for HTN. The Veteran did not file an appeal and the decision became final. In October 2013 the Veteran filed a new claim for service connection for HTN, indicating that he believed his HTN was related to exposure to toxic chemicals at Fort McClellan in 1981. In an August 2014 rating decision, the RO denied service connection for HTN based on a finding that no new and material evidence had been submitted to reopen the claim. In August 2014, the Veteran filed a notice of disagreement (NOD) with the August 2014 denial. He then filed additional claims for service connection for HTN in May and November 2015. In March 2016, the RO again denied the Veteran’s claim for service connection for HTN, again based simply on a finding that no new and material evidence had been submitted to reopen the claim. The Veteran was then issued a statement of the case (SOC) in April 2017. The Board finds that, as the Veteran was never given an SOC in response to his August 2014 NOD until April 2017, the October 2013 petition to reopen was never finally adjudicated, and the last final denial was the Board’s July 2011 decision. Pertinent evidence added to the record since the July 2011 Board denial includes the Veteran’s statements that his currently diagnosed HTN is related to exposure to Agent Orange and other toxic chemicals while stationed at Fort McClellan in 1981. This new evidence is not cumulative or redundant of the evidence previously of record. Furthermore, the Board can find no statements in the record at the time of or prior to the July 2011 decision, in which the Veteran asserted that his HTN was related to exposure to Agent Orange and other toxic chemicals during service. Accordingly, given the low threshold applicable to the evidence needed to reopen claims under Shade v. Shinseki, 24 Vet. App. 110 (2010), the Board finds that this newly expressed theory is new and material since it could be substantiated through further development, and that the reopening of the claim for service connection for HTN is therefore, warranted. 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for degenerative disc disease (DDD) of the cervical spine, and if so, whether the reopened claim should be granted In a June 2013 decision, the Board denied service connection for DDD of the cervical spine. The Veteran did not file an appeal and the decision became final. In August 2014, the Veteran filed a petition to reopen his claim for service connection for DDD of the cervical spine. In December 2014, the RO denied the claim, based on a finding that there was no evidence of a disease or injury in service, and no evidence that his disability developed to a compensable degree within one year of his discharge. In January 2015, the Veteran filed statements, requesting reconsideration of the December 2014 decision. In April and May 2015, the Veteran filed claims for service connection for a “back condition.” He never indicated an intent to file a claim for a cervical spine disability. Nevertheless, in a September 2015 rating decision, the RO reopened and denied the Veteran’s claim for service connection for DDD of the cervical spine based on a finding that there was no evidence that the condition was incurred in or aggravated by military service, that the disability did not develop to a compensable degree within a year of discharge, and that there was no evidence showing that the disability was related to hazardous material exposure at Fort McClellan. In October 2015, the Veteran filed a NOD with the September 2015 denial. He was issued a SOC in April 2017. As the Veteran filed statements that can reasonably be construed as a NOD following the December 2014 rating decision, but was never issued an SOC until April 2017, the Board finds that the last final decision was the June 2013 Board decision. Pertinent evidence added to the record since the June 2013 Board denial includes the Veteran’s statements that his currently diagnosed DDD of the cervical spine is related to exposure to Agent Orange and other toxic chemicals during active duty at Fort McClellan. This new evidence is not cumulative or redundant of the evidence previously of record. Furthermore, the Board can find no statements in the record at the time of or prior to the June 2013 decision, in which the Veteran asserted that his DDD of the cervical spine was related to exposure to Agent Orange and other toxic chemicals during active duty at Fort McClellan. Accordingly, given the low threshold applicable to the evidence needed to reopen claims under Shade v. Shinseki, 24 Vet. App. 110 (2010), the Board finds that this newly expressed theory is new and material since it could be substantiated through further development, and that the reopening of the claim for service connection for DDD of the cervical spine is therefore, warranted.   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 (a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. 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). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic disabilities, including arthritis and HTN, to a degree of at least 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. A disability which is proximately due to or the result of a service-connected disease or injury shall be service-connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (2019); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). For service connection purposes, "active military, naval, or air service" means (1) active duty; (2) any period of active duty for training (ACDUTRA) during which the Veteran was disabled or died from a disease or injury incurred or aggravated in line of duty; and (3) any period of inactive duty for training (INACDUTRA) during which the Veteran was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C. § 101(24); 38 C.F.R. § 3.6(a). ACDUTRA includes full time duty in the Armed Forces performed by members of the Reserves for training purposes. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c). INACDUTRA is generally duty (other than full-time duty) prescribed for Reserves or duty performed by a member of the National Guard (other than full-time duty). 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d). Annual training is an example of ACDUTRA, while weekend drills are INACDUTRA. For periods of ACDUTRA, service connection may be granted for disability resulting from injuries or diseases incurred or aggravated during such periods. For periods of INACDUTRA, service connection may be granted for disability resulting only from injuries incurred or aggravated during such periods, not disability resulting from diseases. 38 U.S.C. § 101(22), (24); 38 C.F.R. § 3.6; see McManaway v. West, 13 Vet. App. 60, 67 (1999). For service connection claims based on a period of ACDUTRA or INACDUTRA, certain evidentiary presumptions, including sound condition upon entry into service, aggravation of preservice disability, and service connection for chronic diseases, are not applicable. Smith v. Shinseki, 24 Vet. App. 40, 47 (2010). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2018); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), (citing Gilbert, 1 Vet. App. at 54). Initially, the Board notes that the Veteran contends that his claimed HTN, cervical spine disability and lumbar spine disability all developed as a result of exposure to Agent Orange and other toxic chemicals during active duty at Fort McClellan. A VA internet-source report noted that some members of the U.S. Army Chemical Corp School, Army Combat Development Command Chemical/Biological/Radiological Agency, Army Military Police School, and Women's Army Corps, among others, may have been exposed to one or more of several hazardous materials, likely at low levels, during their service at Fort McClellan. Potential exposures could have included but are not limited to: radioactive compounds (cesium-137 and cobalt-60) used in decontamination training activities in isolated locations on base, chemical warfare agents (mustard gas and nerve agents) used in decontamination testing activities in isolated locations on base, and airborne polychlorinated biphenyls (PCBs) from the Monsanto plant in the neighboring town. Although exposures to high levels of these compounds, it was noted, had been shown to cause a variety of adverse health effects in humans and laboratory animals, there was no evidence of exposures of this magnitude having occurred at Fort McClellan. It was specifically noted that there were currently no adverse health conditions associated with service at Fort McClellan. Specifically, the report stated: From 1929 to 1971, an off-post Monsanto chemical plant operated south of Fort McClellan in Anniston. PCBs from the plant entered into the environment, and the surrounding community was exposed. Since the 1990s, several investigations have been conducted to characterize the exposure of Anniston residents to PCBs from the Monsanto plant. In 2015, the Agency for Toxic Substances and Disease Registry (ATSDR) published an assessment of the potential health risks caused by airborne PCBs in Anniston and concluded that the concentrations found were "not expected to result in an increased cancer risk or other harmful health effects in people living in the neighborhoods outside of the perimeter of the former PCT manufacturing facility." Accordingly, exposure to toxic chemicals at Fort McClellan is not presumed by VA. Furthermore, the Board notes that the Veteran was not present at Fort McClellan until 1981, approximately ten years after the plant ceased operation. See https://www.publichealth.va.gov/exposures/fort-mcclellan/index.asp (last accessed January 7, 2021). In addition, in an October 2017 memorandum, the Director of the Department of Defense, Armed Forces Pest Management Board, noted that Agent Orange was never used on, tested on, transported through, or stored on Fort McClellan, and all tactical herbicide use under US control was terminated in 1971, 10 years prior to the Veteran’s duty at Fort McClellan and Redstone Arsenal. Based on this evidence, the Board finds that the Veteran was not exposed to Agent Orange or other toxic chemicals during active duty at Fort McClellan. 2. Service connection for HTN The Veteran contends that his currently diagnosed HTN related to his active military service, including exposure to Agent Orange and other toxic chemicals at Fort McClellan, or that it was caused by heat injuries sustained during active duty for training (ACDUTRA) in the National Guard from 1984 to 2004. In a November 2004 statement, the Veteran reported that he began treatment for HTN in 1996. He asserted that his HTN was a direct result of his military service, including National Guard service from 1984 to 2004. He contended that recurrent heat injury that he had in 2003 was directly associated with his high blood pressure. In December 2004 statements, the Veteran reported that he was seen for high blood pressure at a private facility in 1987 or 1988, during a National Guard summer ACDUTRA period in 1995, and at a VA clinic after 1999. During a February 2005 VA examination, the Veteran reported a history of HTN since 1988. In a May 2007 statement, the Veteran reported that he was diagnosed with HTN during his National Guard service from 1984 to 2004. During a December 2009 Travel Board hearing, he testified that he was diagnosed with HTN in the early 1990s. He reported that his HTN was related to heat injuries that he sustained on two occasions during National Guard ACDUTRA periods. During a VA general medical examination in December 1991, following his second period of active duty, the Veteran had blood pressure readings of 158/94 sitting, 140/80 recumbent, and 152/90 standing. He was diagnosed with probable untreated essential hypertension. During ACDUTRA in the National Guard in June 1996, the Veteran was treated for a heat injury. His blood pressure on admission was 154/105. In February 2003, he was placed on a no running profile due to recurrent heat injury on two occasions. Treatment records from 1999 through 2006, while the Veteran was serving in the National Guard, show a diagnosis and treatment for hypertension. VA treatment records dated from 1999 to 2010, during the Veteran’s National Guard service, show the Veteran was followed for HTN. During VA examination in February 2005, the Veteran was diagnosed with hypertension that was not well-controlled. During VA examination in July 2010, the Veteran had blood pressure readings that showed ongoing HTN and the examiner noted that his HTN required medication for control. The medical evidence shows a probable diagnosis for HTN as early as 1991, but HTN to a compensable degree was not shown at that time. In this regard, diastolic pressure of 100 or more was not noted and the Veteran was not taking continuous medication to control HTN. Furthermore, medical records four and five years later, from 1994 and 1995, did not show continuous HTN. The evidence does not show compensable HTN earlier than 1999, several years after the Veteran’s second period of active duty service. These records do not indicate that the Veteran's HTN is related to either period of active duty. There is no evidence of earlier treatment for or an earlier diagnosis of HTN to a compensable degree of record. There is no evidence otherwise linking the current disability to active duty. In this regard, the July 2010 examiner opined that the Veteran’s HTN was less likely than not related to active service. His rationale was that service treatment records showed blood pressure readings well within normal limits on multiple occasions, with no readings that were even borderline. The examiner also concluded that the Veteran did not have residuals of his past heat injuries during his service in the National Guard. There is no contradictory medical opinion of record. The presumption of service connection for chronic diseases diagnosed within one year following discharge from active duty is also not applicable to this case because as noted above, the evidence demonstrates that HTN manifested to a compensable degree was initially shown more than one year after the Veteran's discharge from active service. In addition, while the Veteran was diagnosed with HTN during the time period when he was a member of the reserves, there is no competent evidence linking HTN to the Veteran’s military service. There is no medical evidence suggesting any such link, and the Veteran and his representative have not identified any outstanding medical evidence that would provide this link. While the Veteran contends that he developed HTN as a result of exposure to heat during reserve service, he is not competent to make such an assertion and, in any event, only active service periods are relevant here. See Jandreau, 492 F.3d at 1377. Competent lay evidence is any evidence not requiring that the proponent have specialized education, training or experience, but is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Determining the etiology of hypertension is not a matter that can be observed, and requires specialized education, training or experience. See Jandreau, supra. Service connection for HTN is also not warranted based on a theory of aggravation. A claimant seeking benefits based on aggravation of an injury or disease during ACDUTRA has the burden of showing that he experienced a permanent increase in disability beyond the natural progress of that disease or injury during his period of ACDUTRA. See Donnellan v. Shinseki, 24 Vet. App. 167, 174 (2010). In this case, the Veteran has offered no evidence indicating that his hypertension increased beyond the natural progress of that disease during a period of ACDUTRA. The Board notes that a mere showing of an increase in disability during the time the Veteran was a member of the reserves would not be enough; rather, there must be a worsening during a period of ACDUTRA. There is no evidence of worsening or aggravation beyond the natural progress of the disease during a period of ACDUTRA in this case. The Veteran also contends that his currently diagnosed HTN developed as a result of exposure to Agent Orange and other toxic chemicals during active duty at Fort McClellan. As noted above, the Board finds that the Veteran was not exposed to Agent Orange and other toxic chemicals during active duty at Fort McClellan, and therefore, service connection based on this theory is not warranted. For the reasons above, the Board finds that the preponderance of the evidence is against a finding that the Veteran's HTN was caused or aggravated by his active or reserve military service. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 3. Service connection for ED, claimed as secondary to HTN The Veteran does not contend and the evidence does not show that his ED is directly related to his active military service. Rather, he has stated that he believes his currently diagnosed ED is directly related to his currently diagnosed HTN, which he believes is related to his active military service. See September 2015 notice of disagreement. However, the Board notes that, as discussed above, service connection is denied herein for HTN. As such, secondary service connection for ED is not warranted. See 38 C.F.R. § 3.310 (2019).   4. Service connection for DDD of the cervical spine 5. Service connection for a lumbar spine disability The Veteran contends that his currently diagnosed DDD of the cervical spine and lumbar spine disability developed as a result of physical activity, including lifting of heavy objects, during active duty and during service in the Army National Guard service. He also contends that his currently diagnosed cervical spine and lumbar spine disabilities are related to exposure to Agent Orange and other toxic chemicals during active duty at Fort McClellan. A current cervical spine or lumbar spine disability was not diagnosed until many years after service, and there is no competent evidence to establish that any current cervical spine or lumbar spine disability is due to any event or incident of the Veteran's period of active duty. Service treatment records show the Veteran had a back injury in June 1986. They do not show a diagnosis of a cervical spine or lumbar spine disability during active duty or at discharge. Post-service treatment records, dated many years after discharge, show the Veteran has current diagnoses of a current cervical spine disability (DDD of the cervical spine) and a current lumbar spine disability (degenerative changes and retrolisthesis of L3-L4). See VA treatment records from the Dublin VA Medical Center. However, the evidence does not indicate that the diagnosed cervical spine or lumbar spine disabilities are due to any event or incident of the Veteran’s period of active duty. Post-service records also show that the Veteran was involved in a motor vehicle accident (MVA) in 2006, and the he complained of neck and back pain afterwards. There is no other medical evidence of record, VA or private showing that the Veteran's current cervical spine or lumbar spine disabilities are related to his active military service, including his reserve service in the National Guard. In this regard, in support of his claim for service connection for a cervical spine disability, the Veteran submitted medical statements from his private treating chiropractor. In December 2009, the private doctor noted that he first treated the Veteran following the noted 2006 MVA. He indicated that the 2006 diagnosis was neck and back sprains associated with and complicated by extreme pre-existing spinal arthritic spurring and joint degeneration. The doctor stated that the type and severity of the Veteran’s spondylosis takes many years to develop, and he opined that the Veteran’s spinal condition was not caused by the 2006 MVA, but by extreme wear and tear over a long period of time, such as the Veteran experienced in his armed services career. In his August 2010 statement, the private doctor reiterated that the Veteran’s cervical spine spurring developed over a long period of time, through continuous micro-traumas, such as the Veteran reported experiencing over a long military career, and opined that there was a 90 percent probability that the Veteran’s cervical spine disorder was a result of his military service. July 2010, March 2012 and May 2012 VA examiners, as well as a VHA medical expert who submitted an opinion in September 2012, all opined that the Veteran’s current cervical spine disability was less likely than not due to service. The July 2010 examiner explained that the Veteran did not report neck pain during service, and the chiropractic records were consistent with a finding of onset of neck pain after the 2006 MVA. The examiner opined that the Veteran’s neck pain was caused more by muscle strain that was sustained in the 2006 MVA than by spine degeneration. The March 2012 VA examiner noted that there were no entries to indicate any significant cervical spine condition during either period of active duty service. The May 2012 VA examiner noted that the record showed the 2006 MVA and the Veteran’s report of being told at the time that he had arthritis and calcification in the neck and back, as well as the Veteran’s recollection of prior neck stiffness related to strenuous activities while on active duty. The examiner stated that the only potentially pertinent injuries noted while on active duty were acute self-limited minor injuries to the low back. In the September 2012 opinion, following a review of the Veteran's claims file, the reviewing VHA orthopedic surgeon noted that the evidence showed that the Veteran's cervical spine became symptomatic after the March 2006 MVA, at which time spondylosis and osteophytes interiorly from C4-C7 were noted on x-ray. The specialist stated he could not find any reference in the claims file to a neck condition prior to that time. The specialist reviewed the opinion reports submitted by the Veteran’s treating chiropractor, and opined that his opinions were highly speculative and not supported by the evidence of record. The specialist agreed with the private doctor’s findings that osteophyte formation was a slow process that took a long time to develop. He also agreed that the condition could be aggravated by strenuous activity. However, he stated that how the private doctor arrived at the conclusion that the Veteran's current cervical spine disability was caused by undocumented and unreported injuries allegedly incurred in service, as opposed to the many years the Veteran was employed in jobs that required heavy lifting and straining, was beyond comprehension. Moreover, the private doctor’s exclusion of a violent MVA as the cause of the Veteran's current cervical spine complaints, and to which the Veteran has attributed onset of his neck problems, was also beyond reasonable evaluation. The Board assigns greater weight to the opinion of the orthopedic surgeon because he has greater specialized expertise in the area of diagnosing and determining the etiology of orthopedic disorders. Also, the VHA specialist's opinion is based on review of the claims folder, to include the Veteran's service treatment records, post-service treatment records, and VA examination reports, and refers to relevant documentation in the claims file, to include the medical opinions rendered by the private treating chiropractor. The orthopedic surgeon explained, based on sound medical principles, why the Veteran's cervical spine disability was not caused or aggravated by service and why the private doctor’s opinions were inadequate and inconsistent with the evidence of record. The VHA physician's conclusion is fully explained and is consistent with the competent and credible evidence of record. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In this regard, the Board observes that the VHA physician and VA examiners in July 2010, March 2012, and May 2012, reached the same conclusions. Indeed, following a review of the Veteran's claims file and an examination of the Veteran, the VA examiners concurred as to the lack of any nexus between the Veteran's active service and his current cervical spine problems and instead attributed the neck problems to occupational heavy lifting and straining, as well as the March 2006 MVA. Conversely, the private chiropractor appears to have considered the Veteran's entire reserve service as being equivalent to full time active duty service, and does not make a distinction between the length of time the Veteran spent on active duty and the two to three weeks of ACDUTRA per year with the National Guard, versus the years spent in non-training status as a member of the National Guard. Furthermore, the private doctor did not take into account the Veteran's civilian work history during his 20 years of reserve service. As noted above, only diseases or injuries incurred or aggravated during periods of ACDUTRA (or injuries sustained during INACDUTRA) can be considered for establishing service connection. A disability arising during non-training periods with the National Guard is not subject to service connection. As his opinion does not differentiate between the Veteran's periods of active duty and ACDUTRA, versus the non-training periods during his "Armed Services career" and civilian employment, the opinion is afforded significantly less probative weight. Additionally, the Board finds the opinion of an orthopedic surgeon to be more probative than an opinion from a chiropractor, as the orthopedic surgeon has significantly more extensive education and training than a chiropractor. Thus, although the opinions from the chiropractor are competent medical evidence, they are significantly less probative than the opinion from the VA orthopedic surgeon. With regard to the lumbar spine disability, a February 2017 VA examiner opined that the Veteran’s diagnosed degenerative arthritis of the lumbar spine was less likely than not incurred in or caused by active military service and found instead that the Veteran’s symptoms were related to aging. There is no contrary medical opinion of record. With regard to the years-long evidentiary gap in this case between active service and the earliest manifestations of cervical spine or lumbar spine problems, the Board notes that this passage of time weighs significantly against a finding of direct service connection for a cervical spine disability or a lumbar spine disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The presumption of service connection for chronic diseases diagnosed within one year following discharge from active duty is also not applicable to this case because the evidence demonstrates that arthritis of the cervical and lumbar spines was initially shown more than one year after the Veteran's discharge from service. The Board acknowledges the Veteran's assertion that his cervical spine and lumbar spine disabilities are due to active military service. However, while the Veteran is competent to report the observable symptoms of a disability, and in certain situations a lay person may be competent to establish the etiology of a disability; in the present case, the Veteran is not competent to provide a nexus between his currently diagnosed cervical spine or lumbar spine disability and his active service. Such an opinion would require medical expertise as it would require clinical testing and interpretation of clinical findings as well as assessing the relevance of any noted symptomatology. Thus, the Board finds that the Veteran, as a layperson, is not qualified to render an opinion concerning the cause of his cervical spine or lumbar spine disability. 38 C.F.R. § 3.159 (a)(1), (2) (2019). The Veteran also contends that his current cervical spine and lumbar spine disabilities are related to exposure to Agent Orange and other toxic chemicals during active duty at Fort McClellan. As noted above, the Board finds that the Veteran was not exposed to Agent Orange and other toxic chemicals during active duty at Fort McClellan, and therefore, service connection based on this theory is not warranted. For the reasons and basis stated above, the Board finds that service connection for a cervical spine disability or a lumbar spine disability not warranted. In reaching this decision, the Board has considered benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. REASONS FOR REMAND Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2019). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). 1. Entitlement to an initial compensable rating for GERD, prior to September 11, 2020, and in excess of 10 percent thereafter, to include on an extraschedular basis is remanded. The Veteran asserts that increased ratings for the service-connected GERD are warranted, as it is productive of significant vocational impairment. An August 2018 private evaluation from Dr. H. S. indicates that the Veteran’s service-connected conditions, including GERD, prevent him being able to maintain substantial gainful employment. During the September 2020 VA examination, the Veteran reported that he does not get enough rest at night due to the symptoms of his GERD and is therefore, unable to concentrate or stay awake during the day. The effects of the Veteran's GERD, and significant occupational effects, are not contemplated in the schedular 0 percent and 10 percent evaluations and suggest that there may be frequent periods of hospitalization and/or marked interference with employment. Hence, the criteria have been met for referral for consideration of an extraschedular rating for the GERD. 2. Entitlement to a rating in excess of 10 percent for left (minor) wrist injury residuals w/ degenerative changes, (left wrist disability), to include on an extraschedular basis is remanded. The report of a February 2017 VA wrist examination states that the service-connected left wrist disability affected the Veteran’s ability to work with “mild impact with repetitive lifting and writing.” The August 2018 private evaluation from Dr. H. S. conveys that the Veteran is unable to lift or carry more than 10 pounds due to his left wrist and foot pain; that because of his left wrist, which is his dominant hand, he stated that he is not able to use a computer keyboard to type for long before he struggles with the pain and stiffness in his left wrist; and that he struggles using his left hand to brush his teeth and hair and will have to try to rely in using his right hand. The doctor concluded that the Veteran’s service-connected left wrist disability significantly affected his ability to maintain substantially gainful employment. During the September 2020 VA examination, it was noted that functional loss from pain and weakness reduce range of motion in the left wrist to 0 degrees palmar flexion, dorsiflexion, ulnar deviation and radial deviation. It was also noted that the Veteran is unable to use the left hand to perform daily activities, and he has to rely on his right hand for all strength to do things such as bathing, eating and using the restroom. In addition, when pain increases in his left hand, he is unable to use the left wrist at all, and the left hand becomes weaker than normal. The effects of the Veteran's left wrist disability, and significant occupational effects, are not contemplated in the schedular 10 percent evaluation and suggest that there may be frequent periods of hospitalization and/or marked interference with employment. Hence, the criteria have been met for referral for consideration of an extraschedular rating for the left wrist disability. 3. Entitlement to a rating in excess of 30 percent for residuals of right foot frostbite with degenerative changes, to include on an extraschedular basis is remanded. 4. Entitlement to a rating in excess of 30 percent for residuals of left foot frostbite with degenerative changes is remanded. The Veteran asserts that ratings in excess of 30 percent for the service-connected right foot and left foot frostbite residuals are warranted because they are productive of significant vocational impairment. The report of a February 2017 VA cold injury residuals examination states that the service-connected right foot and left foot frostbite residuals affected the Veteran’s ability to work with “mild impact with walking due to altered sensation and pain.” In his August 2018 private evaluation, Dr. H. S. concluded that the Veteran would be unable to stand for 60 minutes without needing to lean on something because his feet hurt too much and swell; that the Veteran is only able to walk for 45 minutes, slowly and assisted occasionally with a cane, due to his foot and left knee pain; and that he can sit for a total of 60 minutes at a time before his feet begin to swell and he must elevate them. The doctor concluded that the Veteran’s service-connected right foot and left foot disabilities rendered him unable to maintain substantially gainful employment. During the September 2020 VA examination, it was noted that due to the residuals of frostbite of the left and right foot, he is unable to stand or sit for an extended period of time due to pain and numbness in his feet. In addition, he has little sensation in the feet, which makes walking difficulty, and he reported that he will stumble and fall at times due to the inability to feel his feet. The effects of the Veteran's residuals of right foot frostbite with degenerative changes, and residuals of left foot frostbite with degenerative changes, and significant occupational effects, are not contemplated in the schedular 30 percent evaluations and suggest that there may be frequent periods of hospitalization and/or marked interference with employment. Hence, the criteria have been met for referral for consideration of an extraschedular rating for left and right foot disabilities. The matters are REMANDED for the following action: 1. Updated treatment records should be obtained and added to the claims folder/efolder. 2. Following completion of the above, the issues of an increased rating for GERD, a left wrist disability, and right and left foot frostbite residuals must be submitted to the Director, Compensation Service, or the Under Secretary for Benefits for extraschedular consideration under 38 C.F.R. § 3.321(b)(1). (Continued on the next page)   3. Readjudicate the Veteran's remaining claims. If any benefit sought on appeal is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board F. Yankey, Counsel 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.