Citation Nr: 21064032 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 14-28 360A DATE: October 18, 2021 ORDER Entitlement to service connection for residual scarring, status post bilateral breast reduction, for substitution or accrued benefits purposes, is granted. Entitlement to service connection for prostate cancer for substitution or accrued benefits purposes is granted. Entitlement to service connection for an acquired psychiatric disorder for substitution or accrued benefits purposes is granted. Entitlement to service connection for a left shoulder disorder for substitution or accrued benefits purposes is denied. Entitlement to service connection for a right shoulder disorder for substitution or accrued benefits purposes is denied. Entitlement to service connection for a liver disorder for substitution or accrued benefits purposes is denied. Entitlement to service connection for an ulcer disorder for substitution or accrued benefits purposes is denied. Entitlement to service connection for a gastrointestinal disorder for substitution or accrued benefits purposes is denied. REMANDED Entitlement to service connection for a heart disorder for substitution or accrued benefits purposes is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) for substitution or accrued benefits purposes is remanded. Entitlement to assignment of a combined disability rating greater than 60 percent, prior to January 9, 2012, and greater than 80 percent, thereafter, for substitution or accrued benefits purposes is remanded. FINDINGS OF FACT 1. The Veteran underwent breast reduction surgery during active duty service, in February 1985 and March 2009, with residual surgical scarring at the location of the of bilateral reduction. 2. Resolving reasonable doubt in the appellant's favor, the Veteran's prostate cancer had onset within one year of active duty service. 3. Resolving any reasonable doubt in the appellant's favor, the Veteran's psychiatric disorder was caused or aggravated by prostate cancer. 4. A shoulder disability was not shown during a period of active service, shoulder arthritis was not shown within a year of discharge therefrom; it was not shown during a period of active duty for training, nor is it shown to be related to injury incurred during inactive duty for training, and arthritis of the joints is not shown to be secondary to a service-connected disability. 5. A liver disorder did not have onset during active duty or active duty for training; liver cysts were initially noted between his first and second periods of active service, but they are not shown to be due to injury during a period of inactive duty for training, and; the claimed liver disability did not increase in severity during active duty or active duty for training. 6. A gastrointestinal disorder and ulcer was not caused or aggravated during active duty, active duty for training or inactive duty for training. 7. An ulcer was not caused or aggravated during active duty, active duty for training or inactive duty for training. CONCLUSIONS OF LAW 1. The criteria for service connection for status post bilateral breast reduction with residual scarring for substitution or accrued benefits purposes have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38C.F.R. §§ 3.102, 3.303. 2. The criteria to establish service connection for prostate cancer for substitution or accrued benefits purposes have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for establishing service connection for an acquired psychiatric disorder for substitution or accrued benefits purposes have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for entitlement to service connection for a right shoulder disability for substitution or accrued benefits purposes have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 5. The criteria for entitlement to service connection for a left shoulder disability for substitution or accrued benefits purposes have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 6. The criteria for entitlement to service connection for a liver disorder for substitution or accrued benefits purposes have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 7. The criteria for entitlement to service connection for a gastrointestinal disorder for substitution or accrued benefits purposes have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 8. The criteria for entitlement to service connection for an ulcer for substitution or accrued benefits purposes have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Navy from September 1982 to February 1986 and October 2008 to April 2009. He had additional periods of inactive duty for training (INACDUTRA) and active duty for training (ACDUTRA) in the United States Naval Reserve from February 1986 and September 2010. The Veteran died in February 2018. The appellant is his surviving spouse who has been substituted for him in this matter in accordance with 38 U.S.C. § 5121A. This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2011 rating decisions of the Department of Veterans Affairs (VA),Regional Office (RO). This matter was previously before the Board in May 2019 and March 2021, at which time it was remanded for additional development. SERVICE CONNECTION Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting service, was aggravated therein. 38 C.F.R. § 3.303 (a). 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). To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Shedden, 381 F.3d at 1167; Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain chronic diseases may be presumed to have been incurred in service by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). Such a chronic disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307 (a). When a chronic disease is shown in service, sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). To be "shown in service," the disease identity must be established and the diagnosis must not be subject to legitimate question. Walker v. Shinseki, 708 F.3d 1331, 1335 (Fed. Cir. 2013); see also 38 C.F.R. § 3.303 (b). There is no "nexus" requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease. Walker, 708 F.3d at 1336. Certain evidentiary presumptions - such as the presumption of service incurrence for certain diseases, which manifest themselves to a degree of disability of 10 percent or more within a specified time after separation from service - are provided by law to assist veterans in establishing service connection for a disability or disabilities. 38 U.S.C. §§ 101, 1112; 38 C.F.R. § 3.304 (b), 3.306, 3.307, 3.309. Reserve and National Guard service generally means ACDUTRA and/or INACDUTRA. ACDUTRA is full-time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101 (22); 38 C.F.R. § 3.6 (c). INACDUTRA includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101 (23); 38 C.F.R. § 3.6 (d). The term active military service includes active duty, any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 C.F.R. § 3.6 (a). The presumption of service connection outlined in 38 C.F.R. § 3.307 and § 3.309 only applies to periods of active duty and not to the veteran's ACDUTRA or INACDUTRA with the Army National Guard because, by definition, the presumption of service connection applies where there is no evidence that a condition began in or was aggravated during the relevant period of service. With regard to a claimant whose claim is based solely on a period of ACDUTRA or INACDUTRA, however, there must be some evidence that the condition was incurred or aggravated during the relevant period of service. See Smith v. Shinseki, 24 Vet. App. 40, 45 (2010). Service connection may also be granted on a secondary basis for a condition that is not directly caused by the veteran's service. 38 C.F.R. § 3.310. In order to prevail under a theory of secondary service connection, the evidence must demonstrate an etiological relationship between (1) a service-connected disability or disabilities and (2) the condition said to be proximately due to the service-connected disability or disabilities. Buckley v. West, 12 Vet. App. 76, 84 (1998); see also Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, secondary service connection may also be found in certain instances when a service-connected disability aggravates another condition. See Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310 (b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). It is noted that some of the Veteran's service treatment records may be unavailable. The United States Court of Appeals for Veterans Claims (Court) has held that in instances where a claimant's service department records are unavailable, the Board is under a heightened obligation to explain its findings and to carefully consider whether the evidence is in equipoise, and if so, to resolve the matter in the claimant's favor. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991); Pruitt v. Derwinski, 2 Vet. App. 83, 85 (1992). But, this does not lower threshold for an allowance of a claim, for example where the evidence almost but not quite reaches the positive-negative balance. In other words, the legal standard for proving a claim is not lowered; rather, the obligation to discuss and evaluate evidence is heightened. Russo v. Brown, 9 Vet. App. 46 (1996). Moreover, the absence of some of the service treatment records in a fire does not create an adverse-presumption rule. Cromer v. Nicholson, 19 Vet. App. 215 (2005). 1. Entitlement to service connection for residual scarring, status post bilateral breast reduction The Veteran asserted that he had a chest condition that was related to active service. In February 2013, he described symptomatic scarring over the right and left breast due to a March 2009 surgical procedure. In correspondence received in September 2020, the appellant asserted that in written testimony the Veteran indicated that increasing pain and irritation of the condition impacted his daily activities, including but not limited to shirt friction. Indeed, he had to undergo a subsequent bilateral gynecomastia in March 2009 as a result of the aggravation of the residuals of the initial surgical procedure, that included avoidance of physical contact of people or objects with the chest due to pain and sensitivity. Enlistment physical examination dated in December 1980 noted that the Veteran had gynecomastia on entrance that was not considered disqualifying. Additional service treatment records reflect that he underwent surgical procedures in February 1985 and March 2009 for bilateral gynecomastia and had scarring from those procedures. A July 1985 service treatment record reflects a diagnosis of suspect surgical neuromas. A history of bilateral mastectomy for benign gynecomastia in February 1985 was noted showing a full recovery. The Veteran had reported persistent tenderness, bilaterally. The symptoms, which were exacerbated three to four weeks earlier, included shirt friction. Physical examination revealed thickening of the right periareolar and inverted left nipple. An August 1985 service treatment record noted a scar following the February 1985 gynecomastia surgical procedure. An October 1987 report noted a history of reduction of bilateral gyneomatics with no sequelae. An October 1996 mammogram revealed no abnormalities. February 2009 service treatment records reflect diagnoses of breast appearance hypertrophy. His nipples and surrounding breast tissue were enlarged bilaterally. The Veteran reported that the condition had been present since he was a teenager and remained essentially unchanged. In his 30s he had surgery, which slightly improved, but did not take care of condition. The treatment providers noted a history of surgical correction of gynecomastia more than ten years earlier and his symptoms had returned. The Veteran wanted a referral for another procedure to resolve his condition. A March 2009 private treatment record reflects a normal mammogram and ultrasound of the breasts. March 2009 private treatment records reflect that he underwent a surgical procedure for bilateral gynecomastia. Post-service treatment records reflect that the Veteran continued to have scarring from the February 1985 and March 2009 surgical procedures. An October 2014 VA treatment report recorded a diagnosis of gynecomastia. Physical examination revealed bilateral gynecomastia with horizontal surgical scars slightly spread. He was scheduled for a bilateral chest/breast gynecomastia with suction assisted lipectomy and possible reduction mammoplasty in January 2015, but had to undergo a different. In March 2016, the Veteran complained of bilateral breast pain. It was noted that a mammogram in August 2014, showed gynecomastia, most likely due to the Eligard used to treat advanced prostate cancer. A VA medical opinion dated in May 2020 shows that a VA examiner opined that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner explained that the Veteran's chest scars from surgeries for gynecomastia constituted the usual effects of ameliorative surgery. The debulking done for relief (amelioration) of gynecomastia involved cutting the skin and fatty layer of the chest wall, leading to the scars noted in the Veteran's claims file. The examiner could not identify in-service injury, incident or other evidence of any aggravation of the scar. There was no evidence that service somehow led to scar instability, growth or other evidence of unnatural aggravation. On VA examination in May 2021, following a review of the claims file, a VA examiner opined that was less likely than not that the Veteran's chest disorder was related to active military service. The examiner explained that the Veteran clearly had evidence of gynecomastia before enlistment to initial term of active duty service in 1982. The Entrance examination in December 1980 confirmed the gynecomastia at time of enlistment, and the Veteran reported gynecomastia since his teen years as well. The Veteran then requested surgical resection of the excess breast tissue during active duty service, accomplished in February 1985. No residuals or sequelae developed during that term of service or in the year thereafter, except surgical scarring. In 1996, 10 years after initial term of active duty service, mild obesity and gynecomastia were identified on periodic Reserve service examination. During active duty service from October 2008 to April 2009, the Veteran complained to General Surgery of persistent gynecomastia since teen years, largely unchanged despite the resection in February 1985. The Veteran again requested surgical resection of the excess bilateral breast tissue during final term of active duty service, which was performed in March 2009. In 2014, the Veteran reported that gynecomastia once again became problematic and he requested another resection of the tissue. Given his two previous gynecomastia surgeries, his treating physicians did not recommend a third procedure, and rather liposuction was recommended. The examiner opined that the Veteran's gynecomastia clearly and unmistakably preexisted all of Veteran's time in active duty service. Because the Veteran initially underwent surgery for gynecomastia during active duty service in 1985, the resulting surgical scarring did not preexist Veteran's initial term of active duty service. The examiner indicated that it was not possible to determine how much each condition contributed to the final gynecomastia recurrence without resorting to mere speculation. The Veteran's gynecomastia that preexisted active duty service. The condition persisted through both terms of his active duty service, and recurred over time as expected, despite appropriate surgical interventions in service. The examiner opined that the Veteran's gynecomastia, as it progressed and recurred over decades, was not exacerbated by any time or event in service over those years. The Veteran's gynecomastia was ultimately exacerbated in 2011 due to hormone treatments for prostate cancer, but that was unrelated to any time or event in service. Accordingly, as the service treatment records reflect that the Veteran underwent surgical procedures for bilateral gynecomastia during his two periods of active duty service in February 1985 and March 2009, and as the evidence also supports a finding of residual surgical scarring from those procedures, entitlement to service connection for residual scarring is warranted. Here, we note that generally service connection is warranted for disability resulting from disease or injury. Nothing in this record suggests that breast size was due to a disease or injury. A voluntary procedure is usually not a disease or injury. Furthermore, the ameliorative effect of surgery for a preexisting condition, including scars, will not be considered service connected unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306. Here, we find the report of painful scarring to be credible. Painful scarring is not considered an ameliorative effect. Accordingly, service connection for residual scarring, status post bilateral breast reduction, is warranted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55-56. 2. Entitlement to service connection for prostate cancer The Veteran asserted that his prostate cancer was etiologically related to his period of active service. In September 2011, he stated that he had been treated for prostate cancer that had been diagnosed within one month of his discharge from active service. Treatment records show that on September 2008 prostate specific antigen (PSA) was 0.71. In February 2011 his PSA was 3.2. In March 2011, the Veteran was diagnosed with elevated PSA. A June 2011 CT scan of the abdomen revealed mildly enlarged prostate gland. He was subsequently diagnosed with prostate cancer in August 2011. A June 2014 private treatment record contained a diagnosis of adenocarcinoma of the prostate, that was definitely diagnosed with a biopsy in 2011. The treatment provider opined that the Veteran's PSA levels had been steadily rising since 2007, and that it was more likely than not that he had an existing undiagnosed prostate cancer in the years preceding his 2011 biopsy. A VA examiner in May 2020 opined that the Veteran's prostate cancer was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran had an enlarged prostate in 2004 before service, thus, there was a strong likelihood the condition existed prior to service. The examiner added that there was no evidence it manifested or existed during active service, and there was no evidence that the cancer somehow manifested or grew due to service. The examiner added that the preexisting prostate cancer was not aggravated beyond the natural progression of such disorder during service. A VA examiner in May 2021 opined that it was less likely than not that the Veteran's prostate cancer was related to active military service. The examiner explained that while the evidence did document a slow increase in PSA from 2007 through 2011, the Veteran's total PSA was in the Normal range with only a slow rate of rise until October 2010, more than one year after his last term of active duty service. Once the Veteran's PSA started rising at a fast rate from 2010 to 2011, urology recommended prostate biopsy that confirmed an aggressive prostate cancer. The finding of an aggressive prostate cancer on biopsy in 2011 was consistent with the high velocity of change for Veteran's PSA from 2010 to 2011. Therefore, based on Veteran's normal PSA levels with normal rate of rise from 2007 to 2010, and the Veteran's biopsy-proven aggressive prostate cancer manifested by rapid rise of PSA from October 2010 to January 2011, the Veteran's prostate cancer developed late in 2010, rather than months or years earlier, as suggested in the June 2014 private medical opinion. As prostate cancer was diagnosed shortly after his last period of active duty service and there is competent medical evidence that supports a finding that the condition may have become initially manifested during service or within one year of discharge therefrom in 2010, it is reasonable to conclude that the Veteran's prostate cancer had its onset within one year of discharge from active duty service in April 2009. In making this determination, the Board notes that although his PSA readings prior to 2011 were within normal limits, he had increasingly PSA readings during service and leading to the diagnosed prostate cancer, reasonably shortly following active-duty service. In resolving all reasonable doubt in favor of the appellant, the Board finds that the Veteran's prostate arguably arose at least during the one-year following discharge from active duty service. The Board thus finds that service connection for prostate cancer is warranted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55-56. 3. Entitlement to service connection for an acquired psychiatric disorder The Veteran asserted that he had manifested symptoms associated with a psychiatric disorder during his period of active service. He additionally contended that he had been experiencing such symptoms secondary to his service-connected disabilities. In January 2012, he attributed his symptoms to emotional trauma associated with his prostate cancer diagnosis, treatment, medication and its side-effects, asserting that the condition affected his quality of life. In support of his claim, he submitted an article that noted posttraumatic stress disorder could be related cancer. In correspondence received in September 2020, the appellant asserted that the Veteran experienced understandable anxiety concerning his prostate cancer and other medical conditions. He was prescribed various antidepressants and psychotropic medications to cope with his anxiety. He was said to have limited his social interactions due to his anxiety, depression and occasional paranoia. Service treatment records from periods of Reserve service dated from 1993 to 2007 show that the Veteran was taking Valium and also experiencing sleep disturbance. Post-service VA outpatient treatment records confirm intermittent assessments of major depressive disorder and anxiety related to his declining physical condition. Treatment records in June 2011, reflect that the Veteran complained of depression associated with the diagnosis of prostate cancer in 2011, which impacted daily living. He was diagnosed with major depressive disorder in December 2012. Subsequent treatment records reflect complaints of anxiety and depression associated with his health condition. On VA examination in May 2021, while a VA examiner did not address the Veteran's claim for service connection for a psychiatric disorder on a secondary basis, the examiner determined that the Veteran's major depressive disorder fluctuated in severity in correlation to his prostate cancer, whether in remission and then recurrence. Therefore, the opinion weighs in favor of a finding that the Veteran's psychiatric disability was caused or aggravated by the now service connected prostate cancer. There is no evidence that contradicts the VA examiner's opinion. Therefore, the Board finds that the preponderance of the evidence supports awarding service connection for a psychiatric disorder, as being of service origin as secondary to the herein granted service-connected prostate cancer. See 38 C.F.R. § 3.310. As the Board has granted secondary service connection it need not address direct service connection, or any other theories for service connection, in this matter. Thus, after resolving any reasonable doubt in favor of the appellant, the evidence in favor of the claims is at least in a state of equipoise with the evidence that weighs against the claim. Therefore, service connection is granted. See 38 C.F.R. §§ 3.102, 3.310; Gilbert, supra. 4. Entitlement to service connection for a left shoulder disorder 5. Entitlement to service connection for a right shoulder disorder The Veteran asserted that he had left and right shoulder disorders that were first manifested during his period of active service. In August 2012, he stated that left and right shoulder disorders developed due to 28 years of doing push-ups in service. In correspondence received in September 2020, the appellant suggested that the shoulder disorders were secondary to the claimed chest disorder. In this regard, it was posited that the scarring, chest contraction and pain was a major inhibitor of use of the shoulders. An undated service treatment record, which appeared to have been written in the early 1990s, noted a diagnosis of back upper strain. The service treatment records for the periods of active duty fail to document arthritis of the shoulder, and in reports of medical history, the Veteran denied a history of arthritis, or painful or "trick" shoulder. Additionally, there was no evidence of shoulder injuries while in service. An August 2012 private treatment record contained a diagnosis of left shoulder impingement syndrome and right shoulder pain possibly due to cervical strain. Treatment records in 2013 noted cervical spine pain that radiated to the shoulders. Accordingly, the record does not reflect a shoulder disability during the Veteran's periods of active duty service and arthritis was not shown within one year following discharge from either of his two periods of active duty service. Additionally, there is no indication that the claimed condition developed during a period of ACDUTRA, nor were joint injuries recorded during INACDUTRA. On the question of a nexus between the right and left shoulder disorders and service and/or a service-connected disability, the weight of the evidence is against the claims. On VA examination in May 2020, the examiner noted the Veteran's statements that he had a bilateral shoulder condition due to 28 years of doing push-ups in the military. The examiner also noted that a service treatment note recorded a diagnosis of back upper strain. Following a review of the claims file, the examiner opined that that the Veteran's bilateral shoulder condition was less likely than not incurred during or caused by an in-service injury, event, or illness. The examiner noted that there was no record of chronic or recurrent bilateral shoulder problems reflecting the Veteran's ultimate diagnoses of right shoulder rotator cuff tear, tendonitis, bursitis, and arthritis and left shoulder impingement beginning during the Veteran's military service. The examiner indicated that these conditions also did not manifest within a year following the Veteran's separation from service. The examiner found no evidence to support findings of in-service origin or chronicity between service and the ultimate bilateral shoulder diagnoses post service discharge. The examiner further noted that there was no evidence that the upper back strain during service had anything to do with the ultimate development of the Veteran's left shoulder impingement which began in or around 2010, or his right shoulder pathology noted in the 2013 magnetic resonance imaging (MRI) study. The examiner also provided the opinion that the Veteran's left shoulder impingement and right shoulder rotator cuff tear, tendonitis, bursitis, and arthritis were clearly and unmistakably not aggravated beyond natural progression by an in-service injury, event, or illness. The examiner concluded that there was no evidence of any unnatural aggravation of the bilateral shoulder condition by or during service. A VA examiner in May 2021, following a review of the claims file, opined that is less likely than not that the Veteran's right and left shoulder disorders were not related to service, nor were they caused or aggravated by the chest disorder, status post chest surgeries for gynecomastia. The examiner explained that the Veteran had no evidence for any chest disorder, status post chest surgeries for gynecomastia, other than well healed superficial scars that had no effect on shoulder function. Scars of the chest had no direct or indirect effect on the joint function or wear of the shoulders. The Veteran's bilateral shoulder conditions were degenerative in nature, due to wear and tear over time, not due to any specific injury or other condition, and unrelated to superficial scars of the chest from gynecomastia surgery. The examiner concluded that the Veteran's shoulder conditions slowly progressed since December 2010, as expected for degenerative joint disorder and were not aggravated beyond normal course of the disease. The VA examiners in May 2020 and May 2021, provided evidence against the claims on a direct and secondary basis. The Board finds the opinion of the VA examiners in 2020 and 2021 to be highly persuasive and probative in finding that the evidence does not support a conclusion that the bilateral shoulder disorders were caused or aggravated by service or the now service-connected residual scarring, status post bilateral breast reduction. The examiners' findings were based on a review of the evidence, including the service treatment records and examination reports. The examiners considered the complete record and the Veteran's contentions, and provided reasoning that is supported by the record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). Significantly, there is no competent medical opinion of record linking the right or left shoulder disability to service or a service connected disability. The Board has considered the statements from the Veteran and the appellant asserting that his bilateral shoulder disorders had onset during active-duty service or were caused or aggravated by residual scarring, status post bilateral breast reduction disability. The Veteran and appellant are certainly competent to report as to the observable symptoms the Veteran experienced and their history, but they cannot self-diagnose because of the medically complex nature of such a diagnosis. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). The ultimate questions in this case are related to an internal medical process which extends beyond an immediately observable cause and effect relationship. Id. Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to service or a service or a connected disability is a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the Veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). The Board finds that the specific, reasoned opinion of the VA examiners of greater probative weight than the more general lay assertions in this regard. The examiners have training, knowledge, and expertise on which they relied to form the opinion, and the examiners provided rationale for the conclusions reached. As noted, there is no competent medical evidence that supports the claims. The Board cannot ignore the evidence of the VA examiners. Additionally, to the extent the Veteran and the appellant asserted continuity of symptomatology from active duty service (which is not entirely clear), the Board finds such statements inconsistent with the overall record. In this regard, treatment records during service failed to document any complaints of arthritis or shoulder pain until after 2012, and the service treatment records and medical records contemporaneous with service, the Veteran consistently denied a history of arthritis or shoulder problems in reports of medical history. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the Veteran). Finally, to the extent the Veteran claims entitlement to service connection for the right or left shoulder disability as secondary to a back upper strain recorded in service, as service connection for a thoracic/cervical spine disability has not been established, there is no legal basis upon which to award service connection on a secondary basis. 38 C.F.R. § 3.310. Simply stated, both the best medical evidence in this case, and the facts of this case, provide highly probative evidence against his claims for service connection for right and left shoulder disabilities. As the preponderance of the evidence weighs against the Veteran's claims, there is no reasonable doubt to be resolved, and the claims for service connection for bilateral shoulder disorders must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 6. Entitlement to service connection for a liver disorder The Veteran asserted that he had liver cysts that were etiologically related to his periods of active service. The service treatment records show that in an October 1991 report of medical history the Veteran indicated that he had stomach, liver, or intestinal trouble. An October 2002 computed tomography (CT) scan of the lumbar spine revealed a small hypodensity in the periphery of the liver. A November CT scan revealed subcentimeter hypodensity in liver. An October 2004 abdominal ultrasound demonstrated no abnormalities other than a 1.2 cm cyst in seg 4 of the liver. A May 2011 CT scan of the abdomen revealed a subcentimeter cyst involving the right lobe of the liver. A January 2015 CT scan of the abdomen and pelvis revealed subcentimeter hypodensities noted within the liver that were too small to characterize. The treatment provider opined that they likely represented cysts. The record does not reflect that a liver disability was shown during the Veteran's first period of service. Additionally, there is no indication that the condition developed during a period of ACDUTRA, or as due to injury during INACDUTRA. The Court has indicated that the normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service is probative evidence against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board where it found that Veteran failed to account for the lengthy time period after service for which there was no clinical documentation of low back condition); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (A prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability.). Important for this case, he was discharged from his first period of active duty in 1986, and liver cysts were initially noted in 2002, 16 years after the Veteran's first period of service and six years before this second period of active duty service. The gap is significant. The evidence does show that the Veteran's liver cysts existed prior to his second period of service from October 2008 to April 2009. However, despite the Veteran's contentions, the evidence fails to show that the condition worsened during his second period of service. A VA examiner in May 2020 noted that an October 2002 CT scan of the lumbar spine revealed a small hypodensity in the periphery of the liver. A May 2011 CT scan of the abdomen showed a subcentimeter cyst involving the right lobe of the liver, and in January 2015 a CT scan of the abdomen and pelvis revealed subcentimeter hypodensities noted within the liver which were too small to characterize. The treatment provider opined that they likely represented cysts. The examiner opined that it was less likely than not that any liver cyst manifested during active service, or was otherwise causally or etiologically related to a period of active service. The examiner explained that imaging done from 2002 showed a small hypodensity in the liver as an incidental finding. The lesion was noted to be still too small to characterize in 2015, after his separation from his second period of service. The examiner noted no evidence of growth in the lesion in the interim. It was also reported that there was no evidence that the Veteran's service somehow caused "unnatural aggravation" of the lesion. The examiner opined that the Veteran's liver cysts, which clearly and unmistakably existed prior to his entry into his second period of service, were clearly and unmistakably not aggravated beyond natural progression by an in-service injury, event or illness. In support of the opinion, the examiner noted that imaging studies in from 2002 and 2015, essentially showed the same findings, thus supporting a conclusion against a finding that the Veteran's military service caused any aggravation beyond natural progression of his liver cysts. Thereafter a VA examiner in May 2021, following a review of the claims file, opined that was less likely than not that the Veteran's liver disorder manifested during, or was otherwise causally or etiologically related to, or aggravated by, a qualifying period of active duty service and/or ACDUTRA. The examiner stated that Veteran's liver cysts were identified, incidentally, on imaging studies conducted for a lumbar condition in 2002, and were confirmed as liver cysts in 2003, many years after the initial term of active duty service. The examiner noted that the Veteran's liver cysts were very small and few in number. These did not progress over time and did not affect liver function. Therefore, the Veteran's liver cysts were clinically not significant and conferred no disability. As the condition never progressed, the Veteran's liver cysts were not aggravated caused or aggravated during service, including his second period of active duty service from October 2008 to April 2009. The VA examiners in May 2020 and May 2021, provided evidence against the claim. The Board finds the opinion of the VA examiners to be highly persuasive and probative in finding that the evidence does not support a conclusion that a liver disorder was caused or aggravated by service. Specifically, the evidence weighs against a finding that the Veteran's liver cysts, which preexisted his second period of active duty service, were aggravated therein. The examiners' findings were based on a review of the evidence, including the service treatment records and examination reports. The examiners considered the complete record and the Veteran's contentions, and provided reasoning that is supported by the record. See Nieves-Rodriguez, 22 Vet. App. at 304. Significantly, there is no competent medical evidence that contradicts the VA examiners' opinions. The Board has considered the statements from the appellant and the Veteran asserting that a liver disorder was caused or aggravated during service. The Veteran and the appellant are certainly competent to report as to the observable symptoms they experience/witness and their history, but they cannot self-diagnose because of the medically complex nature of such a diagnosis. See Layno, supra; Buchanan, supra; Jandreau, supra. The ultimate questions in this case are related to an internal medical process which extends beyond an immediately observable cause and effect relationship. Id. In any event, there is no indication the condition began during a given period of active duty service or ACDUTRA. Simply stated, both the best medical evidence in this case, and the facts of this case, provide highly probative evidence against the claim. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim for service connection for a liver disability. As such, that doctrine is not applicable in the instant appeal, and the claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 7. Entitlement to service connection for an ulcer disorder 8. Entitlement to service connection for a gastrointestinal disorder The Veteran asserted that he had an ulcer and a gastrointestinal (GI) disorder that were related to his periods of active service. Service treatment records show that in October 1984, the Veteran reported vague complaints of mild pain in the epigastric region, nausea, fever and diarrhea. An upper GI/OCG series was negative. An assessment of abdominal pain of unknown etiology was recorded. An October 1991 report of medical history shows that the Veteran indicated that he had stomach, liver or intestinal trouble. In September 1994, he reported that he took Tagamet for his stomach. An October 1996 report of medical history showed that the Veteran indicated that he had stomach, liver or intestinal trouble. VA outpatient treatment records dated in October 2002 reflect a history of peptic ulcer disease in 1969 and 1995. The Veteran had an active prescription of Ranitidine. In October 2003, he reported he had been treated for an ulcer in 1986 with Zantac. In November 2006, the Veteran presented with complaints of black tarry stool. He was treated for melena. Imaging studies in May 2007 revealed a slight deformity of the duodenal bulb consistent with chronic peptic disease. No evidence of an active ulcer crater was demonstrated. In October 2010, the Veteran provided a history of having been treated for an ulcer in 1986. In January 2012, the Veteran stated that he took Ranitidine daily to control flare-ups for multiple years. A February 2012 VA treatment record reflects a diagnosis of esophagitis. The treatment provider noted that the Veteran had occasional reflux. A March 2016 VA treatment record reflects a diagnosis of gastroesophageal reflux disease (GERD). In January 2017 an assessment of gastroenteritis was recorded. He was prescribed Omeprazole and famotidine. In June 2017 a clinician reported no history of diverticulosis of peptic ulcer. On VA examination in May 2020, the examiner noted the Veteran's statements that he was treated for an ulcer in 1986. The service treatment records showed that the Veteran complained of nausea and diarrhea from at least October 1984 and post-service treatment records showed that he was prescribed medication for his stomach since at least October 2002. Post-service treatment records contained a diagnosis of esophagitis in February 2012 and GERD in 2016. The examiner opined that the claimed esophagitis, gastritis and hiatal hernia were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The conditions were initially recorded post-service discharge. The service treatment records were negative for any evidence of chronic esophagus or stomach problems that correlated with the findings identified in the 2012 esophagogastroduodenoscopy. The examiner also concluded that the claimed esophagitis, gastritis and hiatal hernia clearly and unmistakably existed prior to the Veteran's second period of active duty service, and were clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. Concerning the claimed ulcer condition, the examiner opined that that the Veteran's claimed ulcer condition was not incurred during, caused by, or aggravated by an in-service injury, event, or illness. The examiner explained that the Veteran did not have a stomach ulcer and that there was never any imaging performed confirming an ulcer. A VA examiner in May 2021, opined that was less likely than not that the Veteran's GI disorder was related to service, nor was it caused or aggravated by a qualifying period of active duty service and/or ACDUTRA. While the Veteran was competent to report symptoms, including abdominal pain, nausea, dyspepsia and reflux, none of these symptoms were diagnostic for a specific GI disorder. Therefore, no specific or single GI disorder could be extrapolated from the symptoms the Veteran reported over time. Despite a history of peptic ulcer disease (PUD) suggested by EGD in 2007, PUD was never clinically confirmed definitively, and even if the condition was present, date of onset was unclear due to varying reports. Therefore, it could not be confirmed that Veteran developed PUD during a qualifying period of service. Moreover, if Veteran had PUD, it appeared to have completely resolved based on EGD findings in 2007 and 2012. Therefore, there was no evidence that the condition increased in severity during his second period active duty service or ACDUTRA. The examiner noted that gastritis was diagnosed based on EGD in 2007, years after initial term of active duty service. As Veteran's GI complaints had been non-specific and not consistent overtime during and since time in service, no relationship could be established between Veteran's gastritis and isolated GI complaints in service or otherwise until 2007. There was no evidence of gastritis during his first period of active duty service and/or ACDUTRA. While the Veteran's gastritis preexisted his second period of active duty service, the condition was not aggravated by it. The evidence showed that gastritis persisted and progressed as expected from the time of diagnosis in 2007 until the EGD in 2012, following the typical course for the disorder. There was no evidence that it progressed beyond the natural course of the condition during service. The examiner also noted diagnoses of esophagitis and GERD. The conditions were diagnosed based solely on symptom reports. In any event, they did not manifest until many years after final term of active service and thus were not clearly incurred during service or aggravated by any qualifying period of service. Concerning the claimed ulcer disability, the examiner noted that the record did not support a finding that Veteran had an ulcer in 1986. VA records in the years before 2008 to 2009 active duty service repeatedly documented PUD in 1969 and 1995, before and after initial term of active duty service, based solely on history provided by the Veteran. The service treatment records noted abdominal pain unknown etiology in October 1984, which was not treated as an ulcer. The only evidence of the existence of an ulcer was provided by history reported by the Veteran. General GI complaints could not be verified as due to an ulcer without imaging or scope results. The Veteran's belief that he may have been treated for an ulcer did not establish the diagnosis. An EGD in 2007 did reveal irregularities of the duodenal bulb consistent with chronic PUD, but no active ulcers were identified at that time or at any other time. Therefore, while PUD was suggested by the 2007 EGD, it was not confirmed. Initially, the Board notes that the record reflects a diagnosed GI disorder, including GERD. While it is unclear whether the Veteran suffered from an ulcer and/or PUD, assuming, without conceding, for purposes of this decision only, that a diagnosis of ulcer and/or PUD is adequate, the most probative evidence weighs against the claims. Here there is no evidence that a GI disorder or ulcer was diagnosed during a qualifying period of service. Additionally, there is no indication that the condition developed during a period of ACDUTRA, or as due to injury during INACDUTRA. Moreover, the probative evidence of record, does not show that the Veteran's GI, ulcer or PUD underwent an increase in severity during the period of active duty service or ACDUTRA. Notably, the VA examiners in May 2020 and May 2021 opined that there was no evidence that the claimed disorders were aggravated by active service to include ACDUTRA. The VA examiner in 2021 specifically found that if the Veteran ever had an ulcer/PUD, the condition appeared to have completely resolved based on EGD findings in 2007 and 2012. Therefore, there was no evidence that the condition may have increased in severity during a period active duty service or ACDUTRA. To the extent gastritis was noted on EGD in 2007, there was no evidence of gastritis during his first period of active duty service and while it preexisted his second period of active duty service, the condition was not aggravated by it. There was also no evidence that gastritis progressed beyond the natural course of the condition during service. Finally, esophagitis and GERD did not manifest until many years after final term of active service and thus were not clearly incurred during service or aggravated by any qualifying period of service. The VA examiner's opinion was based on a thorough review of the evidence in the claims folder and history provided by the Veteran; and the opinion was supported by sound and clear rationale. Accordingly, the Board finds that the VA examiner's opinion is entitled to great probative weight. In deciding the claim, the Board considered the lay assertions from the appellant and the Veteran that a GI disorder and an ulcer were caused or aggravated by a qualifying period of service. However, while lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case falls outside the realm of common knowledge of a lay person. See Jandreau, supra. The specific disabilities at issue, are not conditions that is readily amenable to mere lay diagnosis and neither the Veteran or the appellant have been shown she possesses the requisite medical expertise to determine the etiology of his GI and epigastric complaints. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Accordingly, the lay evidence does not constitute competent medical evidence and lacks probative value. Moreover, the lay statements are also outweighed by the existing medical evidence of record that did not find a nexus between the claimed GI disorder and ulcer and the Veteran's service. Accordingly, the preponderance of the evidence is against the claims, there is no reasonable doubt to be resolved, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. REASONS FOR REMAND 1. Entitlement to service connection for a heart condition is remanded. The Veteran asserted that he had a heart disorder that was first manifested during his periods of active service. In its March 2021 remand, the Board directed a VA examiner to expressly address whether it was at least as likely as not that the diagnosed left ventricular hypertrophy noted in a March 2009 echocardiogram, during a period of active duty, and which appeared to have resolved by 2017, had been manifested at any time since January 2012. If so, the examiner was asked to determine whether it is at least as likely as not etiologically related to the in-service findings in 2009. Unfortunately, there has not been compliance with the Board's remand directives. The Veteran underwent an examination in May 2021. The examiner noted that left ventricular hypertrophy was not shown during active duty/active duty training or within one year of separation from military service, and concluded that the condition was not permanently aggravated beyond their natural progression by any period of military service. Therefore, the examiner failed to address this question as specifically requested by the Board. Thus, for this reason, an addendum opinion is needed on remand to ensure substantial compliance with the Board's March 2021 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). 2. Entitlement to a TDIU is remanded. 3. Entitlement to assignment of a combined disability rating greater than 60 percent, prior to January 9, 2012, and greater than 80 percent, thereafter, for substitution or accrued benefits purposes is remanded. The appellant seeks a TDIU for substitution or accrued benefits purposes. VA treatment records throughout the appeal period provide contradicting evidence regarding the Veteran's employment status prior to his death. While he reported being retired as a Social Security Administration (SSA) judge, he also reported that he remained employed as a judge for the federal government through at least 2017. In a statement in July 2021, the appellant noted that the in the last years of his life, the Veteran worked as an Administrative Law Judge for the SSA, which afforded him the opportunity to work from home, and when that became untenable due to his health problems, he used his considerable sick and annual leave. Eventually, he was hospitalized and moved to hospice care for a prolonged period. The appellant indicated that to suggest the Veteran was employable would be illogical. The Board observes that no VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, has been filed in this case. As such, the Veteran's work history is unclear from the record. Without further information regarding the Veteran's occupational history and last employment, the evidence of record is insufficient to adjudicate the TDIU claim. For this reason, the Board finds a remand is warranted to obtain a completed VA Form 21-8940. Finally, the claim for a TDIU and the claim of entitlement to assignment of a combined disability rating greater than 60 percent, prior to January 9, 2012, and greater than 80 percent, thereafter, are inextricably intertwined with the Board's grant of service connection for status post bilateral breast reduction with residual scarring, prostate cancer and an acquired psychiatric disability, and the pending assignment of its corresponding rating percentage by the AOJ. Consideration of the TDIU and increased combined rating claims must be deferred pending implementation of the award granted herein. In this regard, the Board must note that "Entitlement to assignment of a combined disability rating greater than 60 percent, prior to January 9, 2012, and greater than 80 percent, thereafter, for substitution or accrued benefits purposes" is not an "issue" under VA law. The disability evaluations changes based on each disability, not as a whole. However, because this issue was in a prior remand the Board believes it should be left within the decision. The matters are REMANDED for the following action: 1. Implement the Board's grant of service connection for status post bilateral breast reduction with residual scarring, prostate cancer and an acquired psychiatric disability. Adjudicate the claims for entitlement to a TDIU and increased combined disability rating. 2. Solicit a completed VA Form 21-8940 (Application for Increased Compensation Based on Unemployability) from the appellant, addressing the Veteran's employment history, in addition to any other evidence relevant to the issue of entitlement to a TDIU. 3. Submit the claims file to the May 2021 VA examiner, if available, for an addendum opinion. If the original VA examiner is unavailable, a new examiner may be assigned to address the requested opinion. The claims file, including a copy of this remand, should be made available to the examiner, who should indicate a review of the file in the examination report. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the diagnosed left ventricular hypertrophy noted in 2009, and appeared to have resolved by 2017, had been manifested at any time since January 2012. If so, the examiner is requested to opine as to whether it is at least as likely as not etiologically related to the in-service findings in 2009. The examiner should consider all evidence, including lay statements regarding onset and continuity of symptoms, and must provide a complete rationale for all opinions expressed. John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Azizi, T. 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.