Citation Nr: 21064564 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 16-60 279 DATE: October 20, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for degenerative changes of the right shoulder is granted. Entitlement to service connection for a COPD, also claimed as pneumonia, is denied. Entitlement to service connection for a skin cancer is denied. Entitlement to service connection for a back disability is denied. Entitlement to service connection for a heart disability is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran's current tinnitus or bilateral hearing loss had onset in service, they did not manifest to a compensable degree within one year of discharge, and tinnitus and hearing loss are not shown to be causally or etiologically related to any disease, injury, or incident in service. 2. Resolving all reasonable doubt in his favor, the Board finds that the Veteran's right shoulder disability had onset in service. 3. The preponderance of the evidence is against finding that COPD, also claimed as pneumonia, began during active service, or is otherwise related to any aspect of the Veteran's service. 4. The preponderance of the evidence is against finding that skin cancer, back disability and/or heart disability began during active service, they did not manifest to a compensable degree within one year of discharge, nor are not shown to be causally or etiologically related to any disease, injury, or incident in service, or a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. The criteria for service connection for degenerative changes of the right shoulder have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for COPD and pneumonia have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 5. The criteria for service connection for skin cancer have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 6. The criteria for entitlement to service connection for a back disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 7. The criteria for entitlement to service connection for a heart disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1977 to February 1984. The Veteran was scheduled to testify at a hearing before a Veterans Law Judge in July 2021, but he failed to report. Accordingly, his request for a hearing is deemed withdrawn. 38 C.F.R. § 20.704 (e). Following the issuance of the most recent supplemental statement of the case in 2016, additional private and VA treatment records were added to the claims file without a waiver of Agency of Original Jurisdiction review. The additional evidence is duplicative of evidence already of record, and it does not have a bearing on the appellate issues herein decided, as it does not provide competent medical evidence of a nexus between the Veteran's claimed disabilities and service. Therefore, the Board finds that referral of the additional evidence to the RO for initial consideration is not necessary. See 38 C.F.R. § 20.1304 (c). 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; 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 v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 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. 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). 1. Service connection for tinnitus 2. Service connection for bilateral hearing loss The Veteran seeks service connection for hearing loss and tinnitus due to military noise exposure. He asserts that during the performance of his duties as an armor crewmember he was exposed to excessive noise. Impaired hearing is defined as a disability under VA law when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels (dB) or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The threshold for normal hearing is from 0 to 20 decibels; higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). A VA examination report in June 2014 showed that the Veteran has a bilateral hearing loss disability as defined by 38 C.F.R. § 3.385. With regards to tinnitus, the Veteran reported on VA examination that he had tinnitus and the audiologist appeared to have found the Veteran's account of current tinnitus credible. Moreover, the Veteran is considered competent to report the presence of tinnitus, and there is no indication from the record that his account of current tinnitus is not credible. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) ("ringing in the ears is capable of lay observation"). Thus, the first criterion for establishing service connection for hearing loss and tinnitus, current disabilities, has been met. The Veteran's personnel form DD-214, documents his military occupational specialty (MOS) was armor crewmember and the RO conceded his exposure to hazardous noise in service. However, even when conceding that the Veteran was exposed to acoustic trauma during service, this is not the same as having sustained the type of injury that causes chronic hearing disability, including tinnitus. In other words, even if he was exposed to acoustic trauma during service, this does not automatically mean there were chronic residuals. In other words, even if he was exposed to acoustic trauma during service, this does not automatically mean there were chronic residuals, including a hearing loss by VA standards and/or tinnitus, which were caused thereby. The service treatment records contain no complaints, history or findings consistent with hearing loss or tinnitus. On separation from service in February 1984, the Veteran denied a history of hearing loss or ear trouble, and audiometric testing showed the puretone thresholds in decibels at the tested frequencies of 1000, 2000, 3000, and 4000 Hertz were 10, 5, 5, and 5, in the right ear; and in the left ear were 10, 10, 5, and 5. Here, there is no evidence of record with respect to chronic symptoms of hearing loss or tinnitus during service, nor has the Veteran reported experiencing chronic symptoms of hearing loss or tinnitus during service or continuously since service separation. Rather the Veteran has contended only that the in-service noise exposure caused the subsequent development of hearing loss and tinnitus well after service. As such, the Board finds that the Veteran did not experience chronic symptoms of sensorineural hearing loss or tinnitus during service. 38 C.F.R. § 3.303 (b). On the contrary, the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of bilateral hearing loss or tinnitus since service separation. He has not reported continuous symptoms since service during the course of this appeal or to health care professionals. VA treatment records initially noted complaints of impaired hearing after 2011. This multi-year gap between treatments is one factor, among others, weighing against a finding of continual symptoms since service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as one factor in resolving a claim); Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where Veteran failed to account for lengthy time period between service and initial symptoms of disability). The Board acknowledges that symptoms, not treatment, are the essence of any evidence of continuity of symptomatology. However, as noted above, the Veteran has not reported continuous symptoms of hearing loss or tinnitus since service separation. For these reasons, the Board finds that the weight of the evidence is against a finding of chronic symptoms in service or continuity of symptomatology after service. Id. The post-service record provides particularly negative evidence against these claims, sometimes from the Veteran himself. In addition, as discussed above, neither bilateral hearing loss nor tinnitus was shown within the first year of discharge and the presumptions 38 U.S.C. §§ 1112, 1113, 1137 and 38 C.F.R. §§ 3.307, 3.309 do not apply. The Board further finds that the weight of the evidence demonstrates that the current bilateral hearing loss and tinnitus are not otherwise related to active service, to include the in-service noise exposure. On VA examination in June 2014, the Veteran reported struggling to hear and understand when background noise was present. Important in this case, the Veteran endorsed occupational noise exposure as a carpenter, as well as recreational noise exposure from motorcycles and hunting. Reportedly, he wore hearing protection the last ten years of occasional recreational shooting. The examiner diagnosed bilateral sensorineural hearing loss and opined that the condition was less likely than not caused or aggravated by military noise exposure. The opinion was based on the fact that his separation from service the Veteran's hearing was normal for both ears. Therefore, his current hearing loss had to begin after he was discharged from the service. The examiner cited to the medical literature indicating that noise induced hearing loss occurred immediately and there was no scientific support for delayed onset sensorineural hearing loss weeks, months, or years after the exposure event. Therefore, his current hearing loss had to begin after he was discharged from the service. Regarding tinnitus, the Veteran reported onset of the condition 20 years after having been discharged from service. Like hearing loss, the Veteran has never indicated he has had this problem since noise exposure in service. Additionally, while the medical literature allowed for the possibility of a delay in onset of tinnitus due to noise exposure, as the interval between a noise exposure and the onset of tinnitus lengthens, the possibility that tinnitus would be triggered by other factors increased. Given the Veteran's reported onset of tinnitus many years after leaving military service, it was less likely than not caused by or a result of military service. The examiner further opined that the Veteran's tinnitus was likely a symptom associated with hearing loss, as tinnitus is known to be a symptom associated with hearing loss. The Board finds that the June 2014 VA examination report was adequate for evaluation purposes and highly probative. Specifically, the VA examiner reviewed the claims file, interviewed the Veteran, and conducted audiometric testing. There is no indication that the VA examiner was not fully aware of the Veteran's past medical history and in-service noise exposure or misstated any relevant fact. The VA examiner acknowledged the in-service noise exposure, the service treatment records and audiometric testing conducted therein, and provided adequate rationale in support of the opinion. The opinion is internally consistent and consistent with other evidence of record. Moreover, the VA examiner had the requisite medical expertise to render a medical opinion regarding the etiology of the bilateral hearing loss and tinnitus and had sufficient facts and data on which to base his conclusions. As such, the Board accords the June 2014 VA examination report great probative weight. The Veteran has contended throughout the course of this appeal that the current bilateral hearing loss and tinnitus were caused by the in-service noise exposure. Under the facts of this case that include no continuous post-service symptoms with a history of significant occupational noise exposure for many years, as well as recreationally, the Board finds that the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of medically complex disorders such as bilateral sensorineural hearing loss, as defined by VA regulations, or tinnitus. Bilateral hearing loss and tinnitus can have various etiologies, such as acoustic trauma, head trauma, diseases, ototoxic drugs, etc. The ultimate questions in this case are related to an internal medical process which extend beyond an immediately observable cause and effect relationship. While the Veteran is competent to attest to hearing problems, as a lay person, it has not been shown that he had specialized training sufficient to determine the etiology of bilateral hearing loss or tinnitus, especially when the onset date is many decades after service. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Such competent evidence has been provided by the VA examiner. The Board finds the medical opinion rendered by the VA examiner to be significantly more probative than the Veteran's lay assertions. Simply stated, both the best medical evidence in this case, and the facts of this case, provide highly probative evidence against the claims. 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 claims for service connection for bilateral hearing loss and tinnitus. As such, that doctrine is not applicable in the instant appeal, and the claims must be denied. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, 1 Vet. App. at 55-56. 3. Entitlement to service connection for a right shoulder disability The Veteran seeks service connection for a right shoulder disability. He asserts that his right shoulder problems are residuals of injuries in service and had onset therein. Unlike the above, the service treatment records reflect multiple complaints of right shoulder pain and trauma. In August 1979, the Veteran reported audible pop with relaxation while playing sports. The clinician noted a possible dislocation of the right shoulder. In November 1979, the Veteran was seen for complaints of right shoulder pain after playing football. Examination showed limited range of motion with pain and loss of strength. The clinician noted tenderness over the right shoulder anterior aspect at the bicipital tendon insertion, probably secondary to a contusion. In July 1980, he was seen again for right shoulder pain. In October 1983 and January 1984, the Veteran was seen for right shoulder pain after lifting a heavy object. The examiner noted edema and possible joint arthritis. On separation from service in February 1984, the clinician noted painful right shoulder during and after physical requirement test (PRT) and while lifting. After service, the Veteran was seen for right shoulder pain in 2011. Imaging studies in August 2011 revealed mild degenerative arthritis of the right shoulder joint. He provided a history of right shoulder pain for many years. In June 2012, the Veteran reported that he believed he initially dislocated his right shoulder 30 years earlier, during service. He reinjured it in a fall off of a ladder a couple of years prior and fractured his collar bone. An MRI showed a rotator cuff rupture. On VA examination in June 2014, the Veteran reported constant pain in the right shoulder. After service, he initially sought treatment for his right shoulder symptoms in 2000. The examiner diagnosed severe right rotator cuff tear and opined that the Veteran's right shoulder condition was less likely than not incurred in or caused by service. The examiner explained that there was no evidence of a chronic right shoulder disability related to service. The examiner found it significant that the Veteran was able to work in construction and as a fisherman for many years after service. Resolving all doubt in favor of the Veteran, the Board finds that the evidence is in relative equipoise and satisfactorily establishes that the shoulder problems originated during his active service. In reaching this decision, the Board notes that his lay statements consistently and credibly indicated that he sustained repeated traumas to the right shoulder during active duty service. The Veteran's service treatment records further corroborate his contentions. Thus, he has credibly stated that the onset of his right shoulder problems occurred during service. Although the VA examiner in June 2014 opined that the Veteran's right shoulder disability was not caused or aggravated by his military service, and the examiner acknowledged the Veteran's contentions of chronicity since service, the opinion nonetheless appears to rely on the lack of documentation of a chronic disorder or in service, despite multiple instances of documented shoulder trauma and related complaints throughout the Veteran's active duty service, to include on separation from service. Significantly, the Board herein conceded that the Veteran was experienced right shoulder injuries in service and intermittently sought treatment for his shoulder on numerous occasions. Although the VA examiner pointed to the Veteran's occupational history of physical labor as a possible factor contributing to his right shoulder disability, and indeed, there is evidence of right shoulder trauma post service discharge, it is safe to assume that repeated right shoulder trauma in service played a role in the development of right shoulder arthritis. Therefore, the Board finds the reports given by him regarding in-service occurrence, as well as the service treatment records, and the Veteran's own statements provided in connection with treatment which reported onset of intermittent right shoulder pain in service, to be the most probative evidence in this instance. As such, reasonable doubt is resolved in the Veteran's favor and the claim is granted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for COPD also claimed as pneumonia The Veteran claims that service connection for COPD also claimed as pneumonia is warranted because it was incurred in service or otherwise a result of service. Initially, the Board notes that at no time during the pendency of the claim does the evidence reflect a diagnosis of pneumonia. The threshold requirement for service connection is competent evidence of the existence of the claimed disability at some point during the appeal. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013); Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018). While the Board recognizes the Veteran's sincere belief in his claim, the most competent evidence of record do not show that he has been diagnosed with pneumonia at any time during the current appeal. Next, the Board notes that the Veteran has been diagnosed with COPD. The service treatment records show that in April 1977 the Veteran was treated for an upper respiratory infection. In July 1980, he was seen for coughing blood, attributed to hemoptysis. Physical examination revealed no abnormalities and the lungs were clear to auscultation and percussion. The Veteran was advised to stop smoking. On separation from service in February 1984, the Veteran denied a history of shortness of breath. On examination no abnormalities of the Veteran's lungs and/or chest were noted. Accordingly, the respiratory complaints in service appear to have been transitory in nature and to have resolved with treatment. The Board finds that the service treatment records lack sufficient observation or even notation to establish any disability onset in service. Following service discharge, an August 2011 CT scan showed findings suggestive of COPD, with no signs of pneumonia. Subsequent treatment records document a diagnosis of and treatment for COPD associated with a 40+ year history of smoking cigarettes. On VA examination in June 2014, the examiner noted that the Veteran reported that in 1977 he was treated for pneumonia and hospitalized for 15 days, after which he was returned to full duty. He was diagnosed with COPD in 2011. His history was significant for smoking 1/2 pack per day since 2013, prior to that he smoked a pack a day since the age of 14, with intermittent period of abstinence. Following a review of the evidence and an examination of the Veteran, the examiner diagnosed COPD and opined that the Veteran's claimed pneumonia and COPD were less likely than not caused by the in-service upper respiratory infection. The examiner explained that there was no scientific or objective evidence to support a finding that COPD could be etiologically related or caused by an upper respiratory infection. As for pneumonia, this was an acute illness that resolved with treatment with no residuals, as opposed to a chronic respiratory disorder. For claims received by VA after June 9, 1998, as is the case here, a disability or death will not be considered service-connected on the basis that it resulted from injury or disease attributable to the veteran's use of tobacco products during service, including cigarettes, unless the disability or death resulted from a disease or injury that is otherwise shown to have been incurred or aggravated during service. 38 U.S.C. § 1103; 38 C.F.R. § 3.300. "Otherwise shown" means, in pertinent part, that (i) the disability or death can be service-connected on some basis other than the veteran's use of tobacco products during service; (ii) the disability became manifest or death occurred during service; (iii) the disability or death resulted from a disease or injury that appeared to the required degree of disability within any applicable presumptive period under 38 C.F.R. §§ 3.307, 3.309, 3.313, or 3.316. The evidence does not show that the Veteran's COPD manifested during service or can be linked to service on a basis other than the Veteran's use of tobacco products. Significantly, the VA examiner explained that it was less likely as not that the currently diagnosed COPD was related to the respiratory complaints in service because there was no scientific or objective evidence to support a finding that COPD could be etiologically related or caused by an upper respiratory infection. Instead, the examiner noted that COPD initially noted many years after service, was associated with the Veteran's tobacco abuse disorder. Accordingly, the preponderance of the evidence shows that the Veteran's COPD did not manifest during service, and there is no indication that it resulted from a chronic disease or injury that manifested within a presumptive period under 38 C.F.R. §§ 3.307, 3.309, 3.313, or 3.316. See 38 C.F.R. § 3.300. To the extent the Veteran's COPD is attributable to his use of tobacco products, and is not otherwise linked to service, service connection may not be awarded as a matter of law. See id. The Board acknowledges the Veteran's contentions that his COPD should be service connected. The Board finds that the Veteran has not offered probative and competent evidence establishing a nexus between his COPD and service. Lay evidence may be competent to establish medical etiology or nexus. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to." See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). A diagnosis of a pulmonary disorder requires specialized training for determinations as to diagnosis and causation, and is therefore, not susceptible to lay opinions on etiology. Therefore, the Board finds that the lay assertions proffered by the Veteran lack probative value. As there is sufficient evidence to conclude that the Veteran's COPD which developed after service as a result of tobacco use, further medical examination or opinion on this issue is not warranted. Absent competent, credible, and probative evidence of a nexus between the Veteran's service and his COPD, the Board finds that COPD was not incurred in service and it is not otherwise related to service. Accordingly, service connection for COPD is not warranted. See 38 U.S.C. § 5107 (b); Gilbert, supra. 5. Entitlement to service connection for skin cancer The Veteran claims that service connection for skin cancer is warranted because it was incurred in service or otherwise a result of service. Specifically, he claim he developed basal cell carcinoma and squamous cell carcinoma due to sun exposure in service. The service treatment records show that the Veteran was treated for dry skin and a rash. In January 1980 he was seen for irritative contact dermatitis. He was also treated for a plantar wart in May 1981, and in 1982 he was seen for a skin rash with scaling. The service treatment records do not show any complaints related to skin cancer, nor was treatment for sunburn documented. On separation from service in February 1984, the Veteran denied a history of skin diseases, tumor or cancer, and on examination no skin abnormalities were noted. Personnel records reflect that the Veteran was stationed in Germany from August 1977 to February 1984. He also served at Fort Knox, Kentucky. Treatment records after 2011, documented treatment for skin lesions, including basal cell carcinoma and squamous cell carcinoma. Based on the evidence noted above, the Board finds that cancer was not shown in service or within one year following discharge from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Accordingly, competent evidence linking the current disability to service is needed to substantiate the claim. On the question of medical causation, the weight of the evidence is against the claim. On VA examination in June 2014, the Veteran related a history of surgery for basal cell carcinoma in 2013. He also reported treatment for squamous cell carcinoma, in situ, on the left anterior shoulder and right inferior central forehead. Both lesions were excised. Following a review of the claims file and an examination of the Veteran, the examiner opined that the Veteran's skin condition was less likely than not incurred in or caused by dry skin that occurred in service. The examiner explained that the service treatment records failed to document any evidence of severe sun exposure while on active duty. Moreover, the Veteran worked as a carpenter for more than 20 years and as a fisherman for three years, which presumably involved some sun exposure. Significantly, the Veteran was not diagnosed and/or treated for his skin cancer until many years after service. Although the Veteran has expressed his belief in a connection between his time in service and his skin cancer, including sun exposure during service, he lacks the knowledge and training required to diagnose a disability as complex as skin cancer, or to render a nexus opinion on a cause and effect relationship unobservable to a lay person. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Further, he has simply asserted his opinion, without a clear rationale or support; no probative value is given his statements beyond their worth as physical observations. Accordingly, the Board assigns more weight to the competent medical evidence which establishes the Veteran's skin cancer, initially noted more than a decade after service, was less likely than not related to his military service. The Board finds the opinion of the VA examiner in to be highly persuasive and probative in finding that the evidence does not support a conclusion that the Veteran incurred skin cancer due to active duty service. The examiner considered the complete record and the Veteran's contentions, and provided an explanation as to why the evidence does not support his contentions. The VA examiner provided adequate rationale in support of the opinion rendered and the opinion was internally consistent and consistent with other evidence of record, including the service treatment records and clinical findings reported by the Veteran's treatment providers after service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). Significantly, there is no competent medical opinion of record linking the skin cancer to service. Accordingly, the preponderance of the evidence is against the Veteran's claim for service connection for skin cancer, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); See Gilbert, 1 Vet. App. at 54. 6. Entitlement to service connection for a back disability 7. Entitlement to service connection for a heart disability The Veteran seeks service connection for back and heart disabilities. The service treatment records show that in July 1980, the Veteran complained of chest pain. Examination revealed no heart abnormalities and the clinician noted regular rhythm. The Veteran's chest pain was attributed to tracheitis. The remainder of the service treatment records contain no complaints, history or findings consistent with a heart or back disability. On separation from service in February 1984, the Veteran denied a history of recurrent back pain or heart trouble, and no chest, heart, vascular system or spine abnormalities were noted. In May 2012, a clinician noted that in April 2012, the Veteran suffered a myocardial infarction and was hospitalized. Cardiac risk factors for the Veteran included hypertension, hyperlipidemia, non-insulin-dependent diabetes mellitus, and a 40+ year history of tobacco use disorder. The Veteran also had a strong family history of myocardial infarctions, including his father, mother, sister and a brother. An impression of coronary artery disease status post NSTEMI. In May 2012 the Veteran complained of back pain. Subsequent treatment records showed x-ray findings of moderate degenerative changes in the lower lumbosacral spine. Thus, the evidence does not reflect a chronic back and/or heart disability in service or within one year following discharge from service. The Board notes that back and heart complaints were initially noted more than two decades after the Veteran's discharge from service. In so noting, the Board recognizes that the mere absence of medical records is not dispositive as to the question of continuity; the lay evidence must be considered as well. See Buchanan v. Nicholson, 451 F.3d at1335. If, however, it is determined based on reliable evidence, that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson, supra. To the extent the Veteran is asserting continuity of symptomatology from service, the Board finds such statements inconsistent with the overall record, to include the service treatment records. Thus, the Veteran has not adequately shown that his present complaints of back and heart problems continued since service. Here, there is no competent and credible evidence of a nexus between the Veteran's current back and/or heart disability and service. The only evidence of record in support of such a nexus is the Veteran's lay opinion. To the extent the Veteran believes that his current back and heart disability are related to service, to include any injuries incurred therein, as a lay person, the Veteran does not have the specialized training sufficient to render such an opinion. Jandreau, 492 F.3d at 1377. The diagnoses and/or etiology of lumbar spine or heart disorders require medical testing and expertise to determine. Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to his current claimed disorders, 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."). Thus, the Veteran's assertions regarding the etiology of the back and/or heart disability, diagnosed many years after service, and service, are of little probative value. In this regard, it is important for the Veteran to understand that the post-service treatment records provide particularly negative evidence against this case. A VA examination or medical opinion regarding the etiology of his currently diagnosed back and/or heart disability is not indicated as there is no suggestion that the Veteran's current disorders may be associated with service. Again, there is no competent evidence of chronic back or heart disability in service or within one year following discharge from service. Moreover, there is no competent and probative evidence to show that the Veteran had a low back and/or heart disability, during or contemporaneous with service and no competent and probative evidence that his current disorders are related to his service. Finally, to the extent the Veteran claims entitlement to service connection for a heart disability as secondary to COPD, as service connection for has not been established for COPD, there is no legal basis upon which to award service connection for a heart disability on a secondary basis. 38 C.F.R. § 3.310. Given the foregoing, the Board finds that the preponderance of the evidence is against the claim for service connection for a back and/or heart disability and that the claims must be denied. See 38 U.S.C. § 5107 (b); Gilbert, supra. 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.