Citation Nr: 21005030 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 12-19 148 DATE: January 28, 2021 ORDER Entitlement to service connection for chloracne is denied. Entitlement to service connection for chronic fatigue syndrome (CFS) is denied. Entitlement to service connection for left hand arthritis is denied. Entitlement to service connection for left knee degenerative joint disease (DJD) is denied. Entitlement to service connection for an enlarged prostate is denied. Entitlement to service connection for headaches is denied. Entitlement to service connection for neuropathy of the upper extremities is denied. Entitlement to service connection for neuropathy of the lower extremities is denied. Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder with anxiety and depression, is denied. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had chloracne or CFS at any time during or approximate to the pendency of these claims. 2. The preponderance of the evidence is against finding that the Veteran’s enlarged prostate began during his active military service or is otherwise related to an in-service injury or disease. 3. The Veteran’s headaches, left hand arthritis, left knee arthritis, and acquired psychiatric disorder were not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period following his discharge; moreover, continuity of symptomatology since service is not established and these disabilities are not shown to otherwise be etiologically related to an injury or disease or event during his service. 4. The Veteran’s bilateral upper and lower extremity neuropathy was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period following his discharge; moreover, continuity of symptomatology since his service is not established and these disabilities are not otherwise shown to be etiologically related to an in-service injury, disease, or event, including presumed exposure to herbicide agents such as Agent Orange. CONCLUSION OF LAW The criteria are not met for entitlement to service connection for chloracne, CFS, left hand arthritis, left knee DJD, an enlarged prostate, headaches, neuropathy of the upper extremities, neuropathy of the lower extremities, or an acquired psychiatric disorder of any sort. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.   REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from May 1965 to August 1969 and had additional service in the reserves, so presumably also on active duty for training and inactive duty training. This appeal to the Board of Veterans’ Appeals (Board) is from April 2011, September 2011, and February 2012 decisions of a Department of Veterans Affairs (VA) Regional Office (RO). Pertinently to this appeal, the February 2011 rating decision denied service connection for an enlarged prostate; the September 2011 rating decision denied service connection for CFS, neuropathy of the lower extremities, and chloracne; and the February 2012 rating decision denied service connection for numbness of the upper extremities, headaches, an acquired psychiatric disability, left hand arthritis, and left knee DJD. This case was previously before the Board in April 2015, June 2017, September 2018, and August 2020, and each time the claims were remanded for further development. The specified remand instructions since have been completed as directed. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions); but see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only “substantial” rather than strict or exact compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Most recently, in August 2020, the Board remanded this appeal to request that the Veteran complete a VA Form 21-4142, Authorization and Consent to Release Information to VA, for each of his private healthcare providers, including specifically records from practitioner K.B. To this end, VA sent this form to him in September 2020, thus, there has been compliance with that August 2020 remand directive. Despite provision of this form, however, the Veteran did not respond to this request for authorization and, resultantly, his confidential private treatment records cannot be obtained by VA and will not be considered in adjudicating this appeal. The duty to assist is not a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190 (1991). Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Certain diseases, including arthritis, psychoses, and other organic disease of the nervous system such as neuropathy and potentially headaches, may be presumed to have been incurred in service if they manifested to a compensable degree (generally meaning to at least 10-percent disabling) within a year after the Veteran’s separation from service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, a veteran who had active service in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975 (Vietnam era) will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. See 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). "Service in the Republic of Vietnam" includes service in the waters offshore (now, as far away as 12-nautical miles) and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). A review of the Veteran’s records shows that he had qualifying service in Vietnam and is presumed to have been exposed to an herbicide agent, to include Agent Orange. 1. Entitlement to service connection for chloracne and CFS The Veteran contends that he is entitled to service connection for both chloracne and CFS. The Board concludes that the Veteran does not have a current diagnosis of either chloracne or CFS and has not had one at any time during the pendency of these claims or recent to the filing of them. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Concerning chloracne, a September 2006 private treatment letter from a dermatologist states that after examination, the Veteran’s skin condition consisted of seborrheic keratoses and sebaceous hyperplasia. The August 2015 VA examiner evaluated the Veteran and determined that, while he experienced subjective symptoms of acne, he did not have a diagnosis of chloracne. The examiner explained that while the Veteran had some “suspicious areas about the forearms that looked unusual, the remainder of his skin issues/findings were NOT typical of chloracne cases we normally see.” The examiner noted that the Veteran’s “lumps and cysts,” noted as being lipomas by the Veteran, are common to the general public, and further, chloracne is not characterized by lumps and cysts. Additionally, there is no relationship between chloracne and lumps or cysts. There were also no skin malignancies. Similarly, a June 2012 VA examiner found that the Veteran had not diagnosis of chloracne. Concerning CFS, the August 2015 VA examiner found that while the Veteran had intermittent complaints of fatigue, there was no evidence of CFS with shortness of breath. The examiner noted that the Veteran’s VA treatment records do reflect complaints of fatigue, sometimes even characterized as CFS based on the Veteran’s reports to medical practitioners, however the examiner noted the Veteran’s fatigue was multifactorial and not CFS. Ultimately, the examiner found the objective medical evidence of record did not support a diagnosis of CFS. While the Veteran believes he has a current diagnosis of both chloracne and CFS, he is not competent to provide diagnoses in this case. The issues are medically complex and require specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. As the evidence does not show that the Veteran has a current diagnosis of either chloracne or CFS, entitlement to service connection for chloracne or CFS is not warranted. 2. Entitlement to service connection for an enlarged prostate The Veteran contends that his enlarged prostate is due to his military service, including exposure to an herbicide agent, inclusive of Agent Orange. The Board finds that the Veteran has a current diagnosis of an enlarged prostate but concludes that it is not related to his service, including exposure to Agent Orange, and did not onset during his service. The Veteran is presumed to have been exposed to Agent Orange during his service in the Republic of Vietnam. The Veteran’s enlarged prostate does not fall under the presumption of service connection due to herbicide agent exposure. 38 C.F.R. § 3.309(e). Because of this, the Veteran’s theory of entitlement is a direct service connection rather than a presumptive service connection. In a January 2011 written statement to the Board, the Veteran stated that his enlarged prostate onset five years earlier, so in 2006. This represents an onset 37 years after his separation from service. An August 2015 VA examiner opined that the Veteran’s enlarged prostate is not a result of herbicide exposure, it is due to the natural progression of disease with age. The examiner further explained that an enlarged prostate is common in men of the Veteran’s age. Further, the examiner stated that because it is due to age, it is not due to any other disease or injury during any period of active service. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran believes his enlarged prostate is related to an in-service injury, event, or disease, including presumed exposure to Agent Orange. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex as it requires knowledge of pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the August 2015 VA examiner’s opinion. As such, the Board finds that entitlement to service connection for an enlarged prostate is not warranted. 3. Entitlement to service connection for headaches, left hand arthritis, left knee arthritis, and an acquired psychiatric disorder The Veteran contends that his headaches, left hand arthritis, left knee arthritis and acquired psychiatric disorder are either the direct result of his service or warrant service connection under the chronic disability presumption. Concerning the Veteran’s headaches, the Veteran believes that they are related to his military service. However, the Board finds that the preponderance of the evidence weighs against finding that the Veteran’s headaches began during service or are otherwise related to an in-service injury, event, or disease, and did not onset within one year of his separation from service. A January 2008 private treatment record shows that the Veteran denied having chronic headaches. However, in a November 2011 statement, the Veteran stated that he has had headaches his “whole adult life.” Though, the Veteran also denied frequent or severe headaches in available service treatment records (STRs). The Veteran has claimed multiple theories of entitlement concerning his headaches. As noted by the August 2015 VA examiner, headaches generally can be considered an organic disease of the nervous system, which means they can be presumed to be service connected as a chronic disease if specific criteria are met. However, the examiner noted that there is no “valid evidence that [the Veteran’s] headaches became manifest to a compensable degree within one year after discharge from service, despite his comments or recollections.” Again, the Board notes that the Veteran separated from active service in 1969, and then later denied having chronic headaches in 2008, 38 years after the applicable presumptive period. Further, the examiner stated that there is no valid, reproducible evidence to support the Veteran’s headaches are due to herbicide exposure. The examiner explained that the Veteran has multiple other comorbidities, citing the Veteran’s own statements – sinus, neck, and shoulder problems – that cause the Veteran’s headaches. Further, the examiner found no evidence that the Veteran’s headaches are due to or related to a disease or injury during a period of active service. The evidence of record does not support that the Veteran’s headaches are related to his military service or onset within a year of his separation from service. Concerning the Veteran’s left-hand arthritis, the Board notes that the Veteran had a left hand scar from an accident prior to service and he contends it was aggravated by his typing duties during service. Alternatively, he asserts that his arthritis is a chronic disability that warrants presumptive service connection. A Veteran will be considered to have been in sound condition when examined and accepted for service, except as to disorders noted on entrance into service, or when clear and unmistakable evidence demonstrates that the disability existed prior to service and was not aggravated by service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). When a defect, infirmity, or disorder is noted on the enlistment examination, the presumption of soundness never attaches, and the only benefits that can be awarded are for aggravation pursuant to 38 U.S.C. § 1153 and 38 C.F.R. § 3.306. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). In such claims, a veteran must simply show that there was an increase in disability during service to trigger the presumption of aggravation. See Wagner, 370 F.3d at 1096; Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). "If the presumption of aggravation under section 1153 arises, the burden then shifts to the government to show a lack of aggravation by establishing 'that the increase in disability is due to the natural progress of the disease.'" Wagner, 370 F.3d at 1096 (citing 38 U.S.C. § 1153). This requires the government to show by clear and unmistakable evidence that any increase in disability was due to the natural progress of the condition. See Cotant v. Principi, 17 Vet. App. 116, 130-32 (2003); see also 38 C.F.R. § 3.306(b). Temporary or intermittent flare-ups during service of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Crowe v. Brown, 7 Vet. App. 238, 247-48 (1994); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). A pre-existing disease or injury will be found to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a). Evidence of the Veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). If the disorder becomes worse during service and then improves due to in-service treatment to the point that it was no more disabling than it was at entrance into service, the disorder has not been aggravated by service. Verdon v. Brown, 8 Vet. App. 529 (1996). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all of the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). The Board concludes that, while the Veteran has a diagnosis of let hand arthritis, the preponderance of the evidence is against finding that it began during active service or was otherwise aggravated by the Veteran’s service, including by his typing duties. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Further, evidence does not show the arthritis onset within a year of his separation from service in 1969. The August 2015 VA examiner confirmed that the Veteran now has a diagnosis of arthritis in his left hand via x-rays taken that same day. After reviewing the x-rays, the August 2015 examiner stated that the Veteran’s left-hand arthritis is polyarticular and because of this, opined that it is more likely due to natural progression of the disease with age rather than due to the isolated injury prior to the Veteran’s service. Even further, the examiner stated that he “could find no objective evidence of the hand issue being truly aggravated beyond natural progression during service. The Veteran even mentions the hand not bothering him or worsening during service.” Concerning the Veteran’s chronic disability claim, arthritis is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. The August 2015 VA examiner stated that the Veteran’s left-hand arthritis was “highly unlikely” to have onset within a year of his 1969 separation from service as no testing during that period showed a diagnosis of arthritis. Further, the Veteran was not diagnosed with arthritis during active service. The examiner’s opinions are probative, because they are based on an accurate medical history and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 304. Finally, the August 2015 examiner also stated that the Veteran’s left hand arthritis is not due to Agent Orange exposure as his arthritis is a mechanical disability and there is no factual basis for a relationship between Agent Orange exposure and a mechanical disability such as arthritis. The Veteran believes preexisting left-hand laceration was aggravated by service, or that his arthritis was caused by his service, but he is not competent to provide an opinion regarding this issue. The issue is medically complex, as it requires knowledge of anatomical relationships. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, 492 F.3d at 1377 n.4; see also Kahana, 24. Vet. App.at 428. Consequently, the Board gives more probative weight to the August 2015 VA examiner’s opinions. As such, the Board finds that service connection for the Veteran’s left-hand arthritis is not warranted on any theory of entitlement. Concerning the Veteran’s left knee arthritis, he contends that it is caused by multiple motor vehicle accidents (MVAs) during service, specifically two motorcycle accidents and one automobile accident. As confirmed by the August 2015 VA examiner, the Veteran has a current diagnosis of left knee arthritis. However, this disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. A private treatment record from February 2009 shows that the Veteran suffered a fall and sought treatment for left leg pain and swelling. A MRI from February 2009 showed a bruise from the Veteran’s fall, but was otherwise unremarkable. The doctor did not observe any arthritis on this MRI. The August 2015 VA examiner opined that the Veteran’s left knee arthritis could not have onset within one year of his separation from service as his arthritis is currently mild, and if it onset within a year of his 1969 separation, current findings would show a much worse case of arthritis “after so many years.” To comply with previous remand directives, the examiner also stated that the Veteran’s left knee arthritis is not due to Agent Orange exposure as again, arthritis is a mechanical disability and medical literature does not support a relationship between Agent Orange exposure and mechanical disabilities such as arthritis. While the Veteran is competent to report having experienced symptoms of left leg pain and swelling, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of arthritis prior to x-ray diagnosis as the Veteran has not demonstrated the necessary medical expertise. The issue is medically complex, as it requires knowledge of interpretation of complicated diagnostic medical testing. Jandreau, 492 F.3d at 1377 n.4.   Service connection for left knee arthritis may still be granted on a direct basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s left knee arthritis and an in-service injury, event or disease, including his multiple MVAs. 38 U.S.C. § 1110; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. The August 2015 VA examiner opined that it is less likely than not that the Veteran’s left knee arthritis was caused by injury or disease during service. The rationale was that the Veteran’s left knee arthritis is mild, and if it was caused by the accidents during service, it would be expected to be “MUCH worse than they present themselves today.” The examiner also explained that the Veteran has the same range of motion in both knees, so it is not only his left knee that is impaired. In other words, the Veteran’s left knee arthritis is not attributable to his left knee injuries resulting from multiple MVAs during service, as testing at the 2015 examination showed the same limited range of motion in both knees, it was not specific to the Veteran’s left knee. As such, the Board finds that entitlement to service connection for left knee arthritis is not warranted on any basis of entitlement. Concerning the Veteran’s claim for a psychiatric disorder, the Board notes that as a function of the Board's de novo review authority, after considering the medical evidence of record, the Board has recharacterized the Veteran’s claim for a general mood disorder as a claim for an acquired psychiatric disorder, inclusive of adjustment disorder with anxiety and depression. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009). A psychosis, as defined by 38 C.F.R. § 3.384, may be presumed to have been incurred in service if it manifested to a compensable degree (meaning to at least 10-percent disabling) within the initial year after service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). The July 2015 VA examiner however, diagnosed the Veteran with adjustment disorder with anxiety and depression, and attributed it to “situational stressors at present, and frustration he feels related to thoughts and feeling about the Vietnam engagement and the effects that it had on people, including himself.” Thus, the Veteran’s acquired psychiatric disorder, adjustment disorder with anxiety and depression, does not fit the definition of psychosis and is therefore not subject to presumptive service connection for a chronic disability under 38 C.F.R. § 3.309(a). The Board notes that depression (as opposed to major depressive disorder) is a neurosis, not a psychosis. The Veteran has also contended that his acquired psychiatric disability is caused by CFS. Service connection may be granted on a secondary basis for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. As discussed above, the medical evidence of record does not show that the Veteran has diagnosed CFS, rather he has general fatigue. Resultantly, he is not service connected for CFS. As such, there is no basis for secondary service connection for an acquired psychiatric disorder due to a service-connected disability, as the underlying disability, CFS, is not service-connected or even diagnosed. The Veteran has further contended that his acquired psychiatric disability is the direct result of his active service, including his time in Vietnam. Concerning this claim, the July 2015 VA examiner opined that it was less likely than not that the Veteran’s acquired psychiatric disorder was caused or aggravated by any disease or injury during a period of active duty (inclusive of ACDUTRA and INACDUTRA), less likely than not that it is the result of presumed exposure to Agent Orange, and is not due to any service-connected disability. The rationale was that the Veteran’s adjustment disorder with anxiety and depression does not appear to be caused by a specific event that occurred during the Veteran’s active service. The examiner noted that the Veteran’s adjustment disorder with anxiety and depression was more likely due to his present situational stressors and general frustration he feels towards the Vietnam War and the effects it had on people generally, himself included.   Ultimately, the July 2015 VA examiner found that the Veteran’s acquired psychiatric disorder was due to his general situational stressors including his general feelings on Vietnam, rather than due to a specific incident or event during his service, including his time in Vietnam. During the July 2015 examination, the Veteran stated that he did not experience any marked psychological distress during his time in Vietnam. For the reasons stated above, the Board finds that service connection is not warranted, on either a direct, chronic, or other basis for headaches, left hand arthritis, left knee arthritis, or an acquired psychiatric disorder. 4. Entitlement to service connection for bilateral upper extremity neuropathy and bilateral lower extremity neuropathy The Veteran contends that his neuropathy of the bilateral upper extremities (claimed as numbness) and bilateral lower extremities is due to his military service, including as a chronic disease or due ot his presumed Agent Orange exposure. Because the Veteran has been diagnosed with peripheral neuropathy of the bilateral upper extremities, the Board is recharacterizing his claim for “numbness” as a claim for peripheral neuropathy. The Veteran has a current diagnosis of neuropathy in the bilateral upper extremities and bilateral lower extremities as confirmed by August 2015 VA examination. “Other organic disease of the nervous system” is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. This enumerated condition is inclusive of neuropathy. However, the disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. In a June 2011 written statement to VA, the Veteran stated that his neuropathy onset six years prior, so in 2005. This is 35 years outside of the applicable presumptive period for chronic disabilities. The Board gives more probative weight to competent medical evidence, which establishes that his numbness, and later peripheral neuropathy is instead attributable to non-service-connected neck, back, and shoulder problems. Concerning the Veteran’s claim that his neuropathy is due to his presumed Agent Orange exposure, the Board notes that under 38 C.F.R. § 3.309(e), only early onset peripheral neuropathy is an enumerated condition. The August 2015 VA examiner noted explicitly that the Veteran’s diagnosis is peripheral neuropathy, not instead early onset peripheral neuropathy. The August 2015 VA examiner stated that the medical evidence of record does not support an onset of peripheral neuropathy within one year of the Veteran’s 1969 separation from active service, including because the Veteran’s own statements, comments, and medical examination findings do not support an early onset. Even further, the examiner explained that the Veteran’s neuropathies are not due to presumed Agent Orange exposure because they have clear etiologies, namely his neck and back disease and shoulder issues. Thus, presumptive service connection for peripheral neuropathy of the bilateral upper and lower extremities based on exposure to Agent Orange is not warranted as the Veteran does not have early onset peripheral neuropathy and his peripheral neuropathy is instead attributable to other non-service-connected conditions. Service connection for peripheral neuropathy may still be granted on a direct basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s peripheral neuropathy of the bilateral upper and lower extremities, and an in-service injury, event or disease. 38 U.S.C. § 1110; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. To reiterate, the August 2015 VA examiner opined that the Veteran’s peripheral neuropathy is not at least as likely as not related to an in-service injury, event, or disease, rather it was instead due to his current neck and back disease and shoulder issues. The Veteran is not service connected for any neck, back, or shoulder disability.   While the Veteran believes his peripheral neuropathy is related to an in-service injury, event, or disease, including exposure to Agent Orange or other chemicals, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires specialized medical education and knowledge of the interaction between multiple systems in the body. Jandreau, 492 F.3d at 1377 n.4. Consequently, the Board gives more probative weight to the competent medical evidence, including especially the August 2015 VA examiner’s opinions and rationales. As such, the Board finds that entitlement to service connection on a direct or presumptive basis for neuropathy of the bilateral upper and bilateral lower extremities is not warranted. KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Pak 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.