Citation Nr: 21004147 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 17-28 517A DATE: January 26, 2021 ORDER Entitlement to service connection for high blood pressure, to include as due to an undiagnosed illness, is denied. Entitlement to service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness, is denied. Entitlement to service connection for frequent nose bleeds, to include as due to an undiagnosed illness, is denied. FINDINGS OF FACT 1. The Veteran's hypertension did not manifest during service or within one year of separation from service, is a diagnosed and medically explained condition, and is not related to any disease, injury or exposure during service. 2. The preponderance of the evidence indicates is against finding that the Veteran has chronic fatigue syndrome, and his fatigue symptoms are not due to an undiagnosed illness or medically unexplained chronic multisymptom illness. 3. The Veteran does not have an undiagnosed illness, characterized by nosebleeds; and does not have a disability manifested by nosebleeds that either had its onset in active service, or is otherwise related to a disease or injury during active service-to include service in Southwest Asia. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for high blood pressure have not been met. 38 U.S.C. §§ 1101, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.317. 2. The criteria for entitlement to service connection for chronic fatigue syndrome have not been met. 38 U.S.C. §§ 1101, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.317. 3. The criteria for entitlement to service connection for nose bleeds have not been met. 38 U.S.C. §§ 1101, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1983 to July 1991. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In January 2020, the Veteran provided sworn testimony before the undersigned Veterans Law Judge (VLJ) at a Board hearing. A copy of the hearing transcript has been associated with the electronic claims file. In May 2020, this appeal was before the Board, at which time it was remanded for further evidentiary development. Specifically, the Board instructed the RO to obtain the Veteran’s VA medical records; any private records from his time in service; and to request from the Veteran the necessary authorization to request his private medical records since 1992 to present. Then, the RO was to schedule the Veteran for a VA examination if it was determined another one was needed per any updated records. The RO sent the post-remand development requests to the Veteran, and the private sleep study records were submitted, and records from Dr. Murthy were requested and provided, but only between 2011 through 2020 (plus the 1995 to 2014 records previously submitted in 2014). The Board notes that despite the Veteran’s testimony that he first started going to Dr. Murthy in 1992, the first record in February 1995 clearly states “initial” visit, indicating that he was a first-time patient and there is no indication earlier records potentially exist. As such, the RO complied with the remand directives to the extent possible. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board also notes that the record contains additional pertinent evidence submitted by the Veteran directly to the Board following the supplemental statement of the case, including private medical records and statements from the Veteran’s family members. Although the evidence has not yet been considered by the Agency of Original Jurisdiction (AOJ), as this evidence was submitted directly by the Veteran, the Board may proceed with appellate adjudication. The Veteran has not raised any issues with the duty to notify or duty to assist in obtaining documentary evidence. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Thus, the Board need not discuss any potential issues in this regard. Further, neither the Veteran nor his representative has alleged any deficiency with the conduct of his Board hearing as to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). In this regard, the Federal Circuit ruled in Dickens, 814 F.3d at 1361, that a Bryant hearing deficiency was subject to the doctrine of issue exhaustion as laid out in Scott, 789 F.3d at 1381. Thus, the Board need not discuss any potential Bryant problem because the Veteran has not raised that issue before the Board. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). With regard to the element of a current disability, current means near the time a claim is filed or at any time during its pendency. McClain v. Nicholson, 21 Vet. App. 319 (2007). Disability refers to the functional impairment of earning capacity. Saunders v. Wilkie, No. 886 F.3d. 1356 (Fed. Cir. 2018) (holding that pain can constitute a current disability, even without an underlying diagnosis, if it causes sufficient functional impairment). For veterans who served in the Southwest Asia theater of operations during the Persian Gulf War, service connection may also be established for chronic disability that cannot be attributed to a known clinical diagnosis (undiagnosed illness) or for a medically unexplained multisymptom illness (e.g., chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome). See 38 C.F.R. § 3.317. A claimant’s signs or symptoms need not be shown by medical evidence; however, some objective indications of disability are required. 38 C.F.R. § 3.317(a). Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. See 38 C.F.R. § 3.317(b). The Veteran’s personnel records indicate that he had active service in the Southwest Asia Theater of Operations during the Persian Gulf War. See 38 C.F.R. § 3.317. As a result, the law and regulations pertaining to undiagnosed illness incurred due to Persian Gulf service are applicable in this case. 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. See 38 U.S.C. § § 5107; 38 C.F.R. § 3.102; 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. Id. 1. High blood pressure The Veteran contends that service connection is warranted for his current diagnosis of hypertension, to include as due to his service in Southwest Asia. The Veteran was diagnosed with hypertension by his private doctor, Dr. Murthy, in June 2001, with additional VA and private medical records showing ongoing additional treatment for hypertension. As such, as an initial matter, the Veteran is not entitled to presumptive service connection under 38 C.F.R. § 3.317. Although it is conceded that the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, the medical evidence of record shows that it is a known, diagnosed disability and does not meet the criteria for consideration under 38 C.F.R. § 3.317. The Veteran’s hypertension has been clinically diagnosed, which firmly rules out the possibility of it being a symptom of an undiagnosed illness. Further, the Board also finds that the Veteran’s hypertension is not warranted on a direct basis as the competent opinion evidence weighs against such a connection. Also, as discussed more below, he is not entitled to presumptive service connection based on a showing of a chronic disease within one year of service. First, service treatment records (STRs) are silent for complaints, treatment or diagnosis of hypertension. There was an isolated elevated reading in April 1990 of 136/100 but, as specifically addressed by the 2015 examiner (see below), this is not indicative of hypertension as isolated high blood pressure readings can have multiple factors causing elevation, such as pain. Further, at an August 1984 in-service examination, the Veteran specifically denied having high blood pressure in a report medical history. The Veteran similarly denied any high blood pressure at a January 1991 report of medical history and his clinical evaluation at both examinations was normal. A review of the record does not indicate that the Veteran experienced high blood pressure while in active service, but only the aforementioned 1990 isolated elevated reading, and STRs document the Veteran specifically denying the presence of high blood pressure and specifically showing no relevant symptoms in his 1991 separation examination. Further, in a VA examination a year and a half following service in November 1992, the Veteran’s blood pressure reading was 122/80 – a normal reading. Next, in a February 2015 VA examination, the Veteran reported that he was diagnosed with hypertension within one year of separation from service and that it is high when he goes to the doctors but is good when he takes it at home. Following an examination and interview, the examiner opined that the Veteran's hypertension was not related to service. Specifically, the examiner stated that there was no clinical evidence to suggest any link between hypertension and Gulf War environmental factors and that the Veteran’s hypertension “is not due to, proximately caused by or aggravated to any degree by his environmental exposures during deployment in Southwest Asia.” The rationale included citing to medical literature that there is no support “of a cause and effect relationship between environmental exposures in Southwest Asia and the subsequent development of hypertension, years following the cessation of the exposure.” Further, the examiner opined that the hypertension was less likely than not incurred in or caused by service, as “there is no objective evidence of chronic hypertension during [active duty] or within close proximity to separation from service” as the Veteran was not diagnosed with hypertension for 10 years following separation from service. The examiner considered the Veteran’s STRs and noted all readings were normal except for the April 1990 elevated blood pressure reading but opined that “a diagnosis of hypertension is not based on a single BP reading because blood pressure varies throughout the day. In addition, other factors such as pain or anxiety can affect blood pressure and be associated with a transient or temporary increase in blood pressure.” As such, the examiner determined it was less likely than not that the current hypertension is related to the Veteran service in any way. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In this case, the examiner was aware of the Veteran’s medical history, provided a fully articulated opinion, discussed specific medical records, considered the Veteran’s lay statements, and furnished a reasoned analysis for the conclusions. The Board therefore attaches significant probative value to this opinion. The only medical opinion of record, as noted above, found against a relationship between the Veteran’s current hypertension and his military service. There is no other competent medical opinion to the contrary. The Veteran has offered his own opinion on diagnosis and etiology, stating that his hypertension was caused by service. The Board acknowledges that the Veteran is competent to describe his symptoms without any specialized knowledge or training. Layno v. Brown, 6 Vet. App. 465, 469-470 (1994). However, as a layperson, the Veteran is not competent to diagnose his symptoms as a specific disease, nor is he competent to render a nexus opinion regarding the etiology of any current disorder as both of these determinations require medical expertise as hypertension is a complex medical issue that goes beyond a simple and immediately observable cause-and-effect relationship. Jandreau, 492 F.3d at 1372. Further, to the extent the Veteran has argued he has had high blood pressure since service, and that he was diagnosed with hypertension within one year after service, the medical records do not support such arguments. Presumptive service connection is not warranted as there was no continuity after service. For example, as noted above, his November 1992 VA examination blood pressure reading was within normal limits. His April 1995 private record showed his blood pressure within normal limits. The December 1997 private record showed that any elevated blood pressure had resolved. In 1998, he had elevated blood pressure after suffering dog bites. Thereafter, in June 2001, he was first diagnosed with hypertension after reporting having high blood pressure at work. The doctor marked this was “new onset” indicating this was the first diagnosis for hypertension. He was thereafter consistently treated and prescribed medication for his hypertension – but no indication that it is due to or caused by service. Therefore, the Veteran was not diagnosed with hypertension until June 2001, one decade after his separation from service, with several normal blood pressure readings in the 1990s. As such, the Board has considered the benefit of the doubt doctrine, but as the preponderance of the evidence is against the claim for service connection, there is no doubt to be resolved. Gilbert, 1 Vet. App. at 54-56. Therefore, service connection for hypertension, on a direct/presumptive basis or as due to undiagnosed illness or other chronic qualifying disability pursuant to 38 U.S.C. § 1117, is not warranted and the claim is denied. 2. Chronic Fatigue Syndrome The Veteran asserts he has chronic fatigue syndrome (CFS) due to service, to include as due to his service in Southwest Asia. A review of his STRs do not document any relevant complaints, treatment, diagnosis, or other notations. At an August 1984 in-service examination, the Veteran specifically denied any sleep trouble in a report of medical history. The Veteran similarly denied any sleep trouble at the January 1991 separation examination in the report of medical history and the clinical evaluation also revealed no relevant abnormalities. Further, in a VA examination a year and a half following service in November 1992, the Veteran did not assert or report any fatigue or symptoms of CFS, fatigue or sleep difficulties. To warrant entitlement to service connection for chronic fatigue syndrome under 38 C.F.R. § 3.317, the evidence must show a condition characterized by chronic or recurrent symptoms. In this case, the most probative medical evidence of record, specifically a February 2015 VA examination, indicates that there have been no objective findings of chronic or recurrent symptoms suggestive of chronic fatigue syndrome. Further, there is no evidence at this time that chronic fatigue syndrome has manifested to a compensable degree. Finally, the Veteran’s private medical records show he was diagnosed with sleep apnea in 2016, which caused his sleep disorders. This is a separate diagnosis than chronic fatigue syndrome. Specifically, the 2015 VA examiner noted that the Veteran reported that since separation in 1991, he has since felt tired with no explanation for it. He stated his private doctor told him to just “get some rest” but he never had any testing done. He states he still feels tired on and off, and that his wife will sleep in the other room because she states he kicks and snores. However, following this interview and an examination, the examiner noted that there was no objective evidence of a chronic fatigue condition, no undiagnosed illnesses, and no conditions presumptive of Gulf War environmental hazards. The examiner determined that the Veteran had no objective findings, signs, or symptoms attributable to chronic fatigue syndrome. The examiner stated there was only subjective reports of intermittent fatigue and, citing to medical literature, that “to meet the diagnostic criteria of chronic fatigue syndrome, you must have unexplained, persistent fatigue for six months or more, along with at least four of the following signs and symptoms: loss of memory or concentration; sore throat; enlarged lymph nodes in your neck or armpits; unexplained muscle pain; pain that moves from one joint to another without swelling or redness; headache of a new type, pattern or severity; unrefreshing sleep; extreme exhaustion lasting more than 24 hours after physical or mental exercise.” For this particular Veteran, the examiner noted that “he does not have symptoms that would suggest a diagnosis for CFS but rather only a subjective complaint of fatigue, which is a nonspecific symptom “which may have many potential causes.” The examiner elaborated that “a complaint of the symptom of fatigue is common. According to NIH approximately one in every five Americans claims to have fatigue that interferes with daily life. More cases of fatigue have a mental than physical cause according to the collected data.” As such, it is less than likely that the Veteran’s subjectively reported fatigue is related to or incurred in service or related to any exposure event during SW Asia service. The Board finds that the 2015 VA examination and determination that the Veteran does not have a diagnosis of chronic fatigue syndrome to be probative. The 2015 VA examiner reviewed the Veteran’s entire claims file, noted specific medical records, and cited to medical literature to support the conclusions. Nieves-Rodriguez, 22 Vet. App. 295. The examiner also found there was no relationship between his subjective complaints of fatigue and his service. There are no other opinions to the contrary. Further, none of the Veteran’s private or VA medical records indicate he has a diagnosis for or symptoms of chronic fatigue syndrome. For example, the private records with Dr. Murthy from 1995 to present show he had complaints of occasional tiredness – first reported in March 2002 – and that he reported some joint pain occasionally but most of these reports concerned other illnesses such as respiratory infections. For example, in February 2006 when he complained of tiredness and headaches, he was diagnosed with acute pharyngitis and bronchitis. Additionally, although medical records since then all indicated reports of some tiredness, there was no indication of CFS. In essence, the Veteran does not exhibit chronic fatigue syndrome that had its clinical onset in service or that is otherwise related to active service. Without diagnosis of CFS, the provisions allowing service connection based on a medically unexplained multisymptom illness is not warranted, and there is no persuasive evidence he has symptoms of fatigue related to an undiagnosed illness. He himself stated in the 2020 Board hearing that none of his doctors have diagnosed him with CFS, and that his doctors have told him that there is no evidence that he has CFS. Further, the Veteran himself reported the fatigue is only intermittent/off and on, which is contrary to the required “persistent fatigue for six months or more” for a diagnosis for CFS. For example, in the January 2020 Board hearing, the Veteran testified that although his doctors have said there is no evidence of CFS, that he still has it every now and then but not every day. Further, in the July 2016 sleep study, the Board notes he has a diagnosis for sleep apnea, which is not service connected, and the results of his sleep study indicated that he has “significantly reduced sleep efficiency…reduced duration of sleep… reduced REM state of sleep…and severe obstructive sleep apnea.” The April 2017 VA medical records also indicated that the Veteran’s sleep disorder is his obstructive sleep apnea which causes his significantly reduced sleep efficiency with a long sleep latency suggestive of insomnia. Finally, the October 2017 VA medical record noted that he was now sleeping good and doing well with the CPAP. There is no suggestion in the medical evidence the sleep apnea is related in any way to his service, nor has he stated doctors have told him such. The Board acknowledges the Veteran’s assertions that he currently suffers from chronic fatigue that is related to his active duty service, to include as due to an undiagnosed illness. The Board recognizes that lay persons are competent to provide medical opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, although the Veteran is competent to report his symptoms, any opinion regarding whether any chronic fatigue syndrome is present, and/or is related to his military service, to include as an undiagnosed illness, requires medical expertise that the Veteran has not demonstrated since disabilities can have many causes. Jandreau, 492 F.3d 1372, 1376. The Board acknowledges the multiple 2020 statements submitted by the Veteran and his wife, daughter, sons, and stepdaughter, indicating that since 1991, they witnessed the Veteran having sleep trouble and fatigue. However, the Board also notes that they reported he has insomnia, difficulty sleeping, sleep apnea, and nightmares due to possible PTSD, which correlates with the VA examiner who cited to medical literature that fatigue has more mental causes than physical. If he wishes to file a claim for service connection for a mental health disability, he should do so. In the absence of any competent evidence of chronic fatigue syndrome or documentation of complaints of chronic or recurrent symptoms of fatigue related to service, the Board concludes that the preponderance of evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim is denied. Gilbert, 1 Vet. App. 49. 3. Nose bleeds The Veteran contends that he has experienced frequent nose bleeds in the aftermath of service that are due to his service in Southwest Asia, and he has reported nosebleeds during the period on appeal, and is competent to report nosebleeds. However, the Board finds that the medical evidence of record does not reflect the Veteran has a current chronic nosebleed condition and has not had one at any time during the pendency of the claim or recent to the filing of the claim. See 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303 (a), (d). Therefore, direct service connection is not warranted. Further, a review of his STRs does not document any relevant complaints, treatment, diagnosis, or other notation. At an August 1984 in-service examination, the Veteran specifically denied any nose trouble in a report of medical history. The Veteran similarly denied any nose trouble at a January 1991 report of medical history and his clinical examination in 1991 was normal. A review of the record does not indicate that the Veteran experienced nosebleeds while in active service, as STRs document the Veteran specifically denying the presence of nose trouble and specifically showing no relevant symptoms at separation. Further, in a VA examination a year and a half following service in November 1992, the Veteran’s HEENT testing was marked as unremarkable. As such, there is no evidence suggesting that service connection is warranted for nose bleeds on a direct basis. See 38 U.S.C. § 1110, 1131. In addition, as to the alleged nosebleeds being due to his service in Southwest Asia, although the Veteran claims to have intermittent nosebleeds, there is no medical documentation in his records substantiating this claim. As such, they cannot be considered undiagnosed illnesses or a qualifying chronic disability for entitlement to service connection based on the Veteran’s service in the Persian Gulf. In addition, there is no indication that the Veteran’s reported intermittent nosebleeds would amount to a sign or symptoms of undiagnosed illness or medically unexplained chronic multisymptom illnesses, and there is no indication that the Veteran’s intermittent nosebleeds amount to signs or symptoms involving the respiratory system consistent with manifestations of undiagnosed illness consistent with 38 C.F.R. § 3.317. Specifically, in the 2015 Persian Gulf examination, the Veteran reported that he had experienced intermittent nosebleeds since 1991 (following his deployment to Southwest Asia), approximately twice per year. To warrant entitlement to service connection for nosebleeds under 38 C.F.R. § 3.317, the evidence must show a condition characterized by chronic or recurrent symptoms; evidence of an undiagnosed illness which cannot be attributed to any known clinical diagnosis. In this case, the most probative medical evidence of record, specifically the 2015 VA examination, indicates that there are no objective findings of chronic or recurrent symptoms suggestive of chronic nosebleeds; therefore, there is no evidence that chronic nosebleeds have manifested to a compensable degree. In the February 2015 VA examination, the examiner noted that the Veteran had a self-reported history of nosebleeds, but that they were not noted in service treatment records or in the VA medical records. The examiner further noted that the Veteran reported he had never been evaluated by an Ear Nose and Throat (ENT) doctor. As such, the examiner stated that there is no objective evidence of a chronic nosebleed condition and opined that there are no undiagnosed illnesses and there are no conditions presumptive of Gulf War environmental hazards. Additional VA and private treatment records do not contradict this finding. In fact, the Veteran’s medical evidence shows that he consistently denied having any nose trouble or complaints of nosebleeds. These medical records are far more reliable and credible than the Veteran’s lay statements. For example, as noted, the Veteran consistently denied having any nose conditions in his private and VA medical records. In fact, he specifically denied having nosebleeds (see November 2004, January 2006, August 2008, July 2009, August 2010, and November 2011 private examinations) and his ENT/HEENT testing was all marked unremarkable and his nose was clear outside of any nasal congestion due to intermittent respiratory infections, sinusitis, or his allergic rhinitis. These more contemporaneous medical records are far more credible than the statements he and his family make now, since it is reasonable to expect one would report chronic or even intermittent nosebleeds to their medical providers. Although he states he has had nosebleeds ever since service, the fact is the Veteran himself consistently reported not having nose trouble for several decades after service. In addition, in the 2020 Board hearing, the Veteran testified that the nosebleeds are not every day and only happen randomly, mostly at night and that he was unsure if he had any sinus issues. The Veteran and his wife both testified that Dr. Murthy had diagnosed him with chronic nosebleeds, but the records from Dr. Murthy do not indicate any such diagnosis, but rather, as noted above, the medical records actually indicate negative findings following ENT/HEENT testing, and the only indication of a nose condition was due to nasal congestion as part of intermittent illnesses, but there is no diagnosis or any reports of nosebleeds. Further, the Board considered the multiple 2020 statements submitted by the Veteran and his wife, daughter, sons, and stepdaughter, indicating that since 1991 he has had nosebleeds. However, as noted above, a layperson is not competent to diagnose a condition or to provide an etiology. Therefore, although these statements were considered as part of the Veteran’s claim that he has had chronic nosebleeds, they are not sufficient to establish service connection for his nosebleed condition, as they do not establish that he has a qualifying chronic disability that cannot be attributed to a known clinical diagnosis nor do they establish the nosebleeds are a medically unexplained chronic multisymptom illness. Although the Board acknowledges that the Veteran has also contended that his chronic nosebleed is due to an undiagnosed illness as a result of his service in Southwest Asia, the Veteran has not provided any medical records documenting a nosebleed condition and the February 2015 VA examiner found that the Veteran does not suffer from a chronic nosebleed condition. Therefore, the condition does not meet the requirements of presumptive service connection under 38 U.S.C. § 1117, 38 C.F.R. § 3.317. The Board further acknowledges the Veteran’s assertions that he currently suffers from nosebleeds that are related to his active duty service and recognizes that lay persons are competent to provide medical opinions on some medical issues. Kahana, 24 Vet. App. 428, 435. However, although the Veteran is competent to report his symptoms, any opinion regarding whether a nose bleed condition is present, and/or is related to his military service, to include as an undiagnosed illness, requires medical expertise that the Veteran has not demonstrated since disabilities can have many causes. Jandreau, 492 F.3d 1372, 1376. As such, the Board finds the February 2015 VA examination and opinion to be of significant probative value in determining that the Veteran does not currently suffer from a chronic nosebleed condition that is related to his active duty service. Here, the reviewing examiner’s opinion was based on review of the Veteran’s lay contentions, his reported medical history, medical literature, and review of the medical evidence of record. Further, it is consistent with the contemporaneous medical records showing the Veteran consistently reported no nose conditions and specifically stated “no” to having nosebleeds. The presumptive provisions of 38 C.F.R. § 3.317 require, at a minimum, some objective indications of a disability, and there is no such objective evidence here. Therefore, there is no indication that the Veteran’s reported intermittent nosebleeds amount to a chronic disability that cannot be attributed to a known clinical diagnosis (undiagnosed illness) or for a medically unexplained multisymptom illness. See 38 C.F.R. § 3.317. As a result, service connection under the provisions of section 3.317 is not warranted. In light of the foregoing, the Board concludes that as the preponderance of the evidence is against the claim on either a direct or presumptive basis, the benefit of the doubt doctrine is not for application, and the claim for service connection for the claimed nosebleeds is denied. Gilbert, 1 Vet. App. 49. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G.Hoy, Associate 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.