Citation Nr: 21064905 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 16-44 617 DATE: October 21, 2021 ORDER Entitlement to an initial compensable rating for burn scars of the right and left arms is denied. Entitlement to service connection for a right forearm disability is denied. Entitlement to service connection for carpal tunnel syndrome of the right wrist is denied. Entitlement to service connection for bronchial asthma is denied. REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for a right elbow disability is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the appellant has had four scars attributable to welding sparks, two on the right forearm and two on the left forearm. The scars are not of the head, face, or neck. None of the scars is painful, unstable, associated with any underlying soft tissue damage, nonlinear, or causes any functional impairment. The total area of the scars is less than six square inches (39 square cm). 2. The most probative evidence establishes that the appellant does not currently have a right forearm disability which manifested during active duty or is otherwise causally related to his active service, or caused or aggravated by a service-connected disability. 3. The most probative evidence establishes that carpal tunnel syndrome of the right wrist did not have its onset in service, did not manifest within the one-year presumptive period, and is not otherwise related to the appellant's active service, or caused or aggravated by a service-connected disability. 4. Asthma clearly and unmistakably existed prior to the appellant's active service; and asthma clearly and unmistakably did not undergo an increase in severity beyond its natural progression during service. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial compensable rating for burn scars of the right and left arms have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, DCs 7801-7805. 2. The criteria for entitlement to service connection for a right forearm disability have not been met. 38 U.S.C. §§ 1110; 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 3. The criteria for entitlement to service connection for carpal tunnel syndrome of the right wrist have not been met. 38 U.S.C. §§ 1110; 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 4. The criteria for entitlement to service connection for bronchial asthma have not been met. 38 U.S.C. §§ 1111, 1153; 38 C.F.R. § 3.306. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty in the U.S. Navy from January 1977 to January 1981. This matter comes before the Board of Veterans' Appeals (Board) from a May 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The appellant was afforded a hearing by videoconference before the undersigned Veterans Law Judge (VLJ) in August 2019. A transcript is of record. Because portions of the hearing were unable to be transcribed in full, the appellant was offered the opportunity for an additional Board hearing in a December 2020 letter. It was explained that, if he did not respond to the letter within 30 days, it would be presumed that he does not wish to have an additional hearing. To date, no response or statement regarding an additional Board hearing has been received. Thus, as noted previously in the April 2021 decision, the Board presumes that the appellant does not desire an additional Board hearing. The Board, in pertinent part, remanded the issues of entitlement to an initial compensable rating for burn scars of the right and left arms and entitlement to service connection for sleep apnea, carpal tunnel syndrome of the right wrist, a right elbow disability, a right forearm disability, bronchial asthma, and basal cell carcinoma in April 2021. A May 2021 rating decision, in pertinent part, awarded entitlement to service connection for basal cell carcinoma with residual scarring of the posterior trunk, and assigned an initial noncompensable rating, effective May 7, 2015. The grant of service connection constitutes a full award of the benefit sought on appeal with respect to that claim. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). A Supplemental Statement of the Case (SSOC) was issued in July 2021. Initial Ratings Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if that disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the initial rating assigned following an award of service connection, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous. . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. The rating criteria for scars are provided generally under 38 C.F.R. § 4.118, Diagnostic Codes (DC) 7800, 7801, 7802, and 7804. The Board notes that the criteria under DC 7800 contemplate scars that are specifically of the head, face, or neck. Hence, DC 7800 is not for application in this case. VA published a final rule amending its regulations on skin disabilities, effective August 13, 2018. There are no changes to DCs 7800, 7804, 7805, and 7828 under the August 13, 2018 amended version of the skin criteria. In other words, DCs 7800, 7804, 7805, 7828 are exactly same both prior to and after August 13, 2018. C.f., 38 C.F.R. § 4.118 (October 23, 2008) with 38 C.F.R. § 4.118 (August 13, 2018). The pre-amended DC 7801 provided disability ratings for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear. 38 C.F.R. § 4.118, DC 7801 (2017). In contrast, the amended DC 7801 contemplates burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801 (August 13, 2018). Both the old and new criteria provide that a 10 percent rating is awarded when the area of the scar(s) covers at least 6 square inches (39 square centimeters), but less than 12 square inches (77 square centimeters). A 20 percent rating is warranted when the area of the scar(s) covers at least 12 square inches (77 square centimeters) but less than 72 square inches (456 square centimeters). A 30 percent rating is warranted when the area of the scar(s) covers at least 72 square inches (456 square centimeters), but less than 144 square inches (929 square centimeters). A 40 percent rating is assigned when the area of the scar(s) covers at least 144 square inches (929 square centimeters) or greater. 38 C.F.R. § 4.118, DC 7801. Note (1) to the pre-amended DC 7801 stated that a deep scar is one associated with underlying soft tissue damage. Prior to August 13, 2018, DC 7802 provided rating criteria for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear. 38 C.F.R. § 4.118, DC 7802. The amended version is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7802 (August 13, 2018). Both versions state that a 10 percent disability rating is warranted when the area of the scar covers 144 square inches (929 square centimeters) or greater. Under both the old and new rating criteria, DC 7804 provides disability ratings for scars that are unstable or painful. A 10 percent rating is warranted for one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful. A 30 percent rating is warranted for five or more scars that are unstable or painful. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, an additional 10 percent should be added to the evaluation based on the total number of unstable or painful scars. Note (3) states that scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118, DC 7804. Under both the old and new rating criteria, DC 7805 provides that any other disabling effects of scars which are not considered in a separate rating under diagnostic codes 7800 to 7804 should be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118, DC 7805. VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. The Board must apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. VA thus must consider the claim pursuant to the former and revised regulations during the course of this appeal. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). The Board finds that the revised version of the regulation is no more or less favorable than the version in effect prior to August 13, 2018, in the instant matter because the evidence does not indicate that there is any underlying soft tissue damage. 1. Entitlement to an initial compensable rating for burn scars of the right and left arms. For the reasons that follow, the Board finds that the preponderance of the evidence is against the award of entitlement to an initial compensable rating for burn scars of the right and left arms for any portion of the period on appeal. The appellant's burn scars, right and left arm, were assigned an initial noncompensable rating under DC 7805, effective May 7, 2015. As detailed in the May 2016 rating decision on appeal, this service-connected disability includes three scars: (1) left upper extremity burn scar, 0.1 square inches in area (0.4 square cm); (2) left upper extremity burn scar, 0.03 square inches in area (0.2 square cm); and (3) right upper extremity burn scar, 0.1 square inches in area (0.6 square cm), all three of which are superficial and linear, and are neither painful nor unstable. The appellant was afforded a VA scars/disfigurement examination in March 2016. The claims file was reviewed. Per the appellant's history, he had well-healed, hardly visible scars from welding on the chest, abdomen, and arm. Examination revealed two well-healed scars on the left forearm close to the wrist, and one tiny scar on the dorsum of the right hand. These were all due to burns, specifically from welding sparks. There were no visible scars on the upper chest. No scars were painful or unstable. The left upper extremity scars were linear and measured 4 cm and 2 cm, respectively. Both were less than deep partial thickness. The scar on the right upper extremity was also linear and measured 1 cm. There were no non-linear scars, superficial or deep. There was no functional impact. A scars/disfigurement disability benefits questionnaire was completed in July 2019 by a VA physician. A copy of this disability benefits questionnaire was submitted by the appellant and his representative in December 2019. The appellant reported, in pertinent part, welding burns to the trunk and arms. He also reported sunburns and acne of the arms. Scars were observed of the face and upper back, but were the result of acne scarring. Although other scars were reported to be painful, no welding scars were painful or unstable. Two scars observed upon examination were due to burns. The first was on the right distal forearm, measured 20 cm by 12 cm, was of less than deep partial thickness, and was patchy hypomelanosis. Such was superficial and non-linear. The second was on the left dorsal forearm, measured 4 cm by 12 cm, was of deep partial thickness, and was patchy hypomelanosis with some out pouching. This scar was deep and non-linear. The total area of superficial non-linear scars on the right upper extremity was 240 square cm. The total area of deep non-linear scars on the left upper extremity was 48 square cm. There was no functional impact. The disability benefits questionnaire stated that, for purposes of completing the form, superficial non-linear scars are not associated with underlying soft tissue damage, but deep non-linear scars are associated with underlying soft tissue damage. Also of record are black-and-white photographs of, inter alia, the appellant's right and left forearms. However, the Board is unable to discern the presence or size of any scars from these photographs. The March 2016 VA examination report notes two well-healed linear scars on the left forearm close to the wrist, measuring 4 cm and 2 cm, respectively, and one tiny linear scar on the dorsum of the right hand, measuring 1 cm. The July 2019 VA examination notes one scar on the right distal forearm, measuring 20 cm by 12 cm, and one scar on the left dorsal forearm, measuring 4 cm by 12 cm, both with patchy hypomelanosis. Because of the apparent discrepancies between the March 2016 and July 2019 disability benefits questionnaires, the appellant was afforded a contracted scars examination in May 2021. The claims file was reviewed. Following examination of the appellant and review of the claims file, five scars were identified. There were two linear scars on the right forearm from welding sparks. There were also two linear scars on the left forearm from welding sparks. The fifth scar was on the left upper back and was the result of basal cell carcinoma excision. The four welding scars were well-healed. No scar was painful. No scar was unstable with frequent loss of covering of skin. Each of the four forearm welding scars measured 0.5 cm by 0.1 cm. No scars had underlying soft tissue damage. No scars resulted in limitation of function. The clinician explained that, although the forearm scars may well have been due to sparks related to welding, they were not consistent with burns in relation to full thickness, deep partial thickness, and/or less deep partial thickness. As delineated above, the appellant has four scars attributable to welding sparks, two on the right forearm and two on the left forearm. The scars are not of the head, face, or neck. None of the scars is painful, unstable, associated with any underlying soft tissue damage, nonlinear, or causes any functional impairment. The total area of the scars is less than six square inches (39 square cm). As such, entitlement to an initial compensable rating would not be warranted under the old or new versions of DC 7802, 7804, or 7805. Although the scars are the result of burns, the Board affords great probative weight to the explanation of the May 2021 examiner that the scars were not consistent with burns in relation to full thickness, deep partial thickness, and/or less deep partial thickness. Additionally, because the scars were not deep and nonlinear, or associated with underlying soft tissue damage, an initial compensable rating under either version of DC 7801 likewise would not be warranted. Regarding the larger scars observed in July 2019, the May 2021 contracted clinician did not identify such as being due to welding burns. Rather, the May 2021 examiner clarified that there were four scars resulting from welding sparks and delineated the size and location of each. The Board affords great probative weight to the May 2021 contracted examiner's determination that the only current scars due to welding burns are the four identified and described above. There is no competent opinion of record that the additional scars of the right distal forearm, measuring 20 cm by 12 cm, the left dorsal forearm, measuring 4 cm by 12 cm, identified in July 2019, are the result of welding sparks or that such are part and parcel of the appellant's service-connected right and left arm scar disability. As noted by the Board in April 2021, the right forearm scar identified in July 2019 was on the distal forearm, although the right forearm welding scar observed in March 2016 was on the dorsum. The May 2021 contracted examination report confirmed the size and location of the two right forearm scars that are attributable to welding sparks. Thus, the scar identified in July 2019 on the right forearm is not part and parcel of the appellant's service-connected disability. Regarding the left forearm scars, the Board also finds that the left dorsal forearm scar identified in July 2019 is not the same as was identified in March 2016 or May 2021. The May 2021 examination report confirms that the two left forearm scars identified in March 2016 are still present and are due to in-service welding sparks. Although the two scars identified in July 2019 are due to burns, the competent evidence of record establishes that such were not welding spark burns. Thus, they are not part and parcel of the appellant's service-connected disability. In sum, the most probative evidence establishes that entitlement to an initial compensable rating for burn scars of the right and left arms is not warranted for any portion of the period on appeal. As delineated above, these scars, which are not of the head, face, or neck, are not painful, unstable, associated with any underlying soft tissue damage, nonlinear, or causes any functional impairment. The total area of the scars is less than six square inches (39 square cm). As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. "To establish a right to compensation for a present disability, a Veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service'the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis and other organic diseases of the nervous system, such as carpal tunnel syndrome, may also be established on a presumptive basis by showing that such a 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. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted for a disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). 2. Entitlement to service connection for a right forearm disability. 3. Entitlement to service connection for carpal tunnel syndrome of the right wrist. The Board finds that the most probative evidence is against the award of entitlement to service connection for a right forearm disability or carpal tunnel syndrome of the right wrist. There is no indication, nor is it contended, that carpal tunnel syndrome was noted in service or manifest to a compensable degree within one year of separation. Thus, service connection on a presumptive basis is not for application. 38 C.F.R. §§ 3.307, 3.309. A January 2003 VA urgent care note states that the appellant complained of occasional right hand numbness if he leans on it and also in association with right shoulder pain. The assessment was possible nerve damage to the right shoulder. June 2009 nerve conduction testing performed at the Henry Ford Health System revealed carpal tunnel syndrome on the right is more severe than of the left. A March 2011 clinical note from Henry Ford Health System states that there was no weakness or paresthesia of the right arm. An August 2019 EMG follow-up note from Henry Ford Health System states that the appellant has reported neurologic radiating symptoms into the right lower arm. F.N., M.D., noted that this would make sense even though the appellant did not have evidence of a brachial plexus injury. The appellant requested, and was afforded, a VA shoulder and arm examination in August 2019. The claims file was reviewed. Following examination of the appellant and review of the claims file, right shoulder tendinopathy was diagnosed. Radiating symptoms were not endorsed or observed. A January 2021 MRI of the cervical spine was ordered to rule out right upper extremity radiculopathy. The MRI revealed mild multilevel spondylotic degenerative changes, with no high grade spinal canal or foraminal stenosis. As discussed below with respect to the right elbow disability claim, following the Board's April 2021 remand, the RO apparently determined that a compensation and pension examination for the appellant's claimed right forearm disability was also warranted. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The appellant was thus afforded a contracted elbow and forearm examination in May 2021. The claims file was reviewed. Following examination of the appellant and review of the claims file, right elbow degenerative arthritis was diagnosed. It was determined that there was no right forearm pathology upon which to render a diagnosis, and that there was no functional impairment in earning capacity. The appellant reported that his arm pain began in 2000 when he was working and was told by a clinician at the time that he was stretching his arm too long and too far. The appellant reported that he has lost right arm mobility, including being unable to stretch his arm completely. He was not sure if there was any nerve damage. He also reported that he injured his right shoulder, which he thought may have an effect on his right elbow and forearm. The appellant complained of painful extension of the arm, but denied pain on forearm supination or pronation. There was no flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. Regarding functional impact, the appellant was unable to completely straighten out his arm due to his right elbow disability. There was no impact regarding the right forearm. The appellant was afforded a contracted wrist examination in May 2021. The claims file was reviewed. Following examination of the appellant and review of the claims file, bilateral carpal tunnel syndrome was diagnosed. The appellant reported that the onset of symptoms was 2007, when his right wrist became painful with working and repetitive motions. EMG studies performed in 2009 revealed bilateral carpal tunnel syndrome. The appellant stated that aching and throbbing pain travels up to the elbows and that his muscles feel tight. The contracted clinician opined that it was less likely than not that the appellant's right carpal tunnel syndrome was incurred in or otherwise causally related to his active service because there were no pertinent complaints or treatment during active service. The clinician also opined that there was no evidence or medical literature to support the contention that service-connected right shoulder tendinopathy aggravated carpal tunnel syndrome. It was explained that tendinopathy and carpal tunnel syndrome were not medically related. An additional medical opinion was obtained in June 2021 from a contracted physician. Following review of the claims file, the physician opined that it was less likely than not that the appellant's right carpal tunnel syndrome was caused or aggravated by service-connected right shoulder disability. It was explained that carpal tunnel syndrome was unequivocally unrelated to and not impacted by any right shoulder pathology. Such were anatomically separate and unrelated. Upstream conditions would not cause or impact the amount of impingement of the nerve in the wrist area, which is the indisputable cause of the carpal tunnel syndrome, as evidenced by EMG studies. Thus, right carpal tunnel syndrome was neither caused nor aggravated by the service-connected right shoulder disability. As delineated above, there is no competent evidence of right forearm pathology, or functional impairment in earning capacity, during the period on appeal. Thus, the current disability element of the service connection claim cannot be satisfied. The appellant is certainly competent to report symptoms and observations, including pain radiating down his right arm, because this requires only personal knowledge as it comes through an individual's senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The appellant in this case is not competent to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the appellant in this case, who has not been shown by the evidence of record to have medical training or skills. The evidence of record reveals that clinicians considered and investigated the appellant's claims of radicular-type symptoms of the right upper extremity. See e.g. August 2019 EMG follow-up note from Henry Ford Health System and January 2021 VA MRI report. Possible causes were the service-connected right shoulder disability or the nonservice-connected cervical spine arthritis. However, no diagnosis of a right upper extremity radicular or neurological disability was rendered. Further, to the extent that such competently-reported symptoms affect the right forearm, the most probative evidence establishes that the appellant has not experienced any functional impairment in earning capacity due to such. Indeed, during the May 2021 contracted elbow and forearm examination, the appellant himself denied any functional impact regarding the right forearm. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1131. Thus, where the collective lay and medical evidence indicates that, fundamentally, the appellant does not have a current disability for which service connection is sought, there can be no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gilpin v. West, 155 F.3d 1353, 1356 (Fed. Cir. 1998). The Board notes that "disability" as defined in 38 U.S.C. §§ 1110 and 1131 refers to the functional impairment of earning capacity, not the underlying cause of said disability, and that pain alone can reach the level of a functional impairment of earning capacity. Saunders v. Wilkie, 866 F.3d 1356 (2018). In this case, however, there is no indication, nor is it contended, that the appellant experiences any right forearm symptoms which cause a functional impairment in earning capacity. In summary, the Board finds that the most probative evidence shows that the appellant does not currently have a right forearm disability and the record contains no indication that any currently claimed right forearm disability was incurred in active service or is otherwise causally related to active service. Thus, the claim of service connection for a right forearm disability must be denied at this time. See 38 C.F.R. §§ 3.102, 3.303; McClain v. Nicholson, 21 Vet. App. 319 (2007) (the requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim... even though the disability resolves prior to the Secretary's adjudication of the claim."); Brammer, supra. Turning to carpal tunnel syndrome of the right wrist, the Board finds the May 2021 and June 2021 medical opinions, when read together, highly probative as to the crucial question of nexus. Indeed, such are well-reasoned, based upon consideration of the medical and lay evidence of record, and consistent with the competent evidence of record. Indeed, there is no competent opinion to the contrary. The Board has considered the appellant's lay history of symptomatology related to his claimed disorder throughout the appeal period. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through an individual's senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The appellant in this case is not competent to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the appellant in this case, who has not been shown by the evidence of record to have medical training or skills. The Board finds the May 2021 and June 2021 medical opinions to be of greater probative weight than the appellant's lay assertions as to the crucial question of etiology. In sum, the most probative evidence establishes that the appellant does not currently have a right forearm disability which manifested during active duty or is otherwise causally related to his active service, or caused or aggravated by a service-connected disability, and that carpal tunnel syndrome of the right wrist did not have its onset in service, did not manifest within the one-year presumptive period, and is not otherwise related to the appellant's active service, or caused or aggravated by a service-connected disability. As the evidence preponderates against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 4. Entitlement to service connection for bronchial asthma. For the reasons that follow, the Board finds that the most probative evidence establishes that entitlement to service connection for bronchial asthma is not warranted. Notably, the appellant himself does not dispute that he has had asthma his entire life. Rather, he contends that his active service aggravated such asthma. While the appellant endorsed asthma at the time of enlistment on his December 1976 Report of Medical History, and reported that his last asthma attack had been 14 years prior, a diagnosis of asthma was not noted on entry. Rather, the appellant's lungs and chest were examined and found to be normal. He was found to be qualified for enlistment into the United States Navy. Thus, the appellant is entitled to the presumption of soundness. The appellant's remaining service treatment records are otherwise negative for pertinent complaints or observations. The appellant was afforded a VA respiratory examination in March 2016. The claims file was reviewed. Following examination of the appellant and review of the claims file, asthma was diagnosed. The appellant reported that he had a history of asthma with onset at age 3 or 4. He had been on inhalers since then. He also endorsed having previously smoked cigarettes; however, he quit smoking in 1996. The VA examiner opined that the appellant's asthma clearly and unmistakably existed prior to service and was not aggravated beyond its natural progression by military service. However, no rationale was offered. During the August 2019 Board hearing, the appellant testified that, although he had been diagnosed with asthma prior to entry into active service, he had not experienced any asthma attacks or other asthma-related problems prior to service. He explained that the information in the March 2016 VA examination report regarding pre-service symptomatology was inaccurate. In light of the lack of rationale in the March 2016 medical opinion and the appellant's testimony, the matter was remanded in order to obtain a new etiological opinion. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The appellant was afforded a contracted respiratory examination in May 2021. The claims file was reviewed. Following examination of the appellant and review of the claims file, asthma was diagnosed. It was noted that such had first been diagnosed during the appellant's childhood. The appellant reported that, while on active duty, he had a hard time breathing concurrent with traveling on a ship and going overseas with changing climates. He sought treatment in service and was assessed with shortness of breath due to climate changes. The appellant also reported that he was a welder and was exposed to asbestos while on active duty. The contracted examiner noted that the appellant described his triggers as usually animals and weather changes. The contracted clinician observed that the appellant himself did not dispute that his asthma began as a child. The clinician also opined that the appellant's asthma clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated beyond its normal progression by an in-service injury, event, or illness. It was explained that the evidence revealed that the appellant's asthma continued while in service and that the severity and manifestations described by the Veteran during service were typical. A veteran is presumed to have been in sound condition when entering service, except as to defects, infirmities, or disorders noted at the time of the examination or where clear and unmistakable evidence demonstrates that the injury or disease existed prior to service and was not aggravated by such service. 38 U.S.C. §§ 1111, 1137. In order to rebut the presumption of soundness, the government must show by clear and unmistakable evidence that (1) a veteran's disability existed prior to service and (2) that the pre-existing disability was not aggravated during service. See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). The Federal Circuit has made clear that the Secretary may rebut the second prong of the presumption of soundness by demonstrating with clear and unmistakable evidence, either that (1) there was no increase in disability during service, or (2) any increase in disability was due to the natural progression of the condition. Wagner, 370 F.3d at 1096; see also Quirin v. Shinseki, 22 Vet. App. 390, 397 (2009). Clear and unmistakable evidence is defined as obvious or manifest. 38 C.F.R. § 3.306 (b). Clear and unmistakable evidence means that the evidence "'cannot be misinterpreted and misunderstood, i.e., it is undebatable.'" Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). Temporary or intermittent flare-ups during service of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002). Evidence of a veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). If the disorder becomes worse during service and then improves due to in-service treatment to the point that it was no more disabling than it was at entrance into service, the disorder has not been aggravated by service. Verdon v. Brown, 8 Vet. App. 529 (1996). With respect to the question of whether the appellant had asthma, which pre-existed his military service, the May 2021 contracted examiner determined that the appellant's asthma clearly and unmistakably pre-existed the appellant's active service. To this end, the examiner noted that the appellant did not dispute this and that the appellant himself had reported on multiple occasions that he was first diagnosed with asthma as a child. The May 2021 contracted clinician provided a thorough rationale based upon examination of the appellant, review of the lay and medical evidence of record, and relevant medical literature. There is no competent opinion to the contrary. Based on the above, the Board finds that the appellant suffered from asthma, which clearly and unmistakably existed prior to service. The Board accordingly finds that the evidentiary standard for establishing the asthma existed prior to service has been met. Even where the evidence clearly and unmistakably establishes, as it does in this case, that the disorder at issue existed prior to service, to rebut the presumption of soundness, the evidence must also clearly and unmistakably show that the disorder was not aggravated during or by service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. Thus, the question that remains is whether the appellant's asthma clearly and unmistakably was not aggravated beyond its normal progression by his active service. The Board finds that the evidence clearly and unmistakably shows that the pre-existing asthma disability was not aggravated beyond its natural progression by the appellant's active service. The Board finds the May 2021 contracted medical opinion particularly probative as to the question of aggravation, as it appears to have been based upon a thorough review of the record and thoughtful analysis of the appellant's entire history. Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). The May 2021 contracted examiner's rationale was substantial, thorough, and based on the overall record. The March 2016 VA medical opinion is entitled to minimal probative weight due to the lack of a rationale, as discussed above. The Board again observes that the appellant has disputed the characterization of his pre-service symptoms in the March 2016 examination report. The Board will also afford such minimal probative weight, without making a finding as to the credibility or accuracy of the lay reports as described in the examination report. Crucially, the outcome of the matter would not change even if the March 2016 examination report were considered. Although the appellant reports suffering from asthma symptoms during his active service, the evidence establishes that it is clear and unmistakable that his asthma was not aggravated beyond its natural progression and his reported in-service symptoms were typical of his condition. Here, there is no competent evidence to show that the appellant's disability was aggravated beyond its natural progression by the circumstances of his active service. There is no competent evidence that contradicts the conclusions of the May 2021 contracted examiner. Significantly, the findings of the May 2021 contracted examiner were thoroughly explained and fully supported by the evidence of record. To this end, the Board notes that the May 2021 medical opinion was based on interview and examination of the appellant, review of the record, including the lay statements and evidence submitted by the appellant, and the examiner explained the reasons for her conclusions based on an accurate characterization of the evidence of record. The Board therefore places significant weight on the findings of the May 2021 examiner. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Bloom, supra. Accordingly, the Board finds that service connection for bronchial asthma is not warranted. The Board has considered the appellant's contentions that his asthma was aggravated by his active service. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through an individual's senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The appellant in this case is not competent to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the appellant in this case, who has not been shown by the evidence of record to have medical training or skills. The Board finds the May 2021 contracted examination report and opinion to be of greater probative weight than the appellant's lay assertions. In other words, while the appellant is competent to describe his symptoms, he lacks the necessary expertise to state that those symptoms represent an aggravation of the underlying disability. In addition, the appellant's contentions are contradicted by the findings of the May 2021 contracted examiner who considered the appellant's lay statements in rendering her negative opinion. In short, the Board finds that the competent evidence, in the form of the service medical records, post-service medical records, and medical opinion evidence, demonstrates that aggravation did not take place. See 38 U.S.C. § 1153; 38 C.F.R. §§ 3.304, 3.306(b); see also Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002) (the mere occurrence of symptoms, in the absence of a demonstrated increase in the underlying severity, does not constitute aggravation of the disability). For these reasons, the Board finds that the evidence shows that the appellant's asthma pre-existed his active service, but was not aggravated during such service. Accordingly, entitlement to service connection for bronchial asthma is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea. The appellant contends that he developed a deviated septum from an in-service injury to the face, that such eventually required a septorhinoplasty in February 1994, that the surgical repair was unsuccessful, and that such caused him to develop his current obstructive sleep apnea. The appellant was diagnosed with deviated septum and a septorhinoplasty was thus performed in February 1994. The appellant contends that the surgical repair for breathing problems was unsuccessful, which then resulted in the development of sleep apnea. A January 2005 note from the Henry Ford Hospital and Medical Center states that the appellant endorsed problems breathing out his nose on the right side. He also reported repeated bouts with sinus infections which are particularly bothersome at night. These are associated with his history of asthma. A December 2014 clinical note states that the appellant reported that his wife told him that he stops breathing during sleep and that this has occurred for 10 years. He also reported 37 years of snoring. A diagnosis of obstructive sleep apnea based on clinical history of observed breathing pauses during sleep, choking arousals, snoring, obesity, and crowded oropharyngeal exam. Such was later confirmed by sleep study. During his August 2019 hearing, the appellant contended that unsuccessful nasal surgery to correct his breathing resulted in the development of sleep apnea. Received in December 2019 was a sleep apnea Disability Benefits Questionnaire (DBQ) completed by Dr. S.Z. in July 2019 and a medical opinion of M.A., M.D., completed in November 2019. Dr. M.A., who practiced pediatric and adult sleep medicine, opined that the appellant's current mild obstructive sleep apnea was at least as likely as not a direct or indirect result of the appellant's military service. It was noted that the appellant had been examined and his medical history, including service records, had been reviewed. Dr. M.A. explained that, in his personal experience and in medical literature, it is known that veterans of military service are at higher risk of developing sleep apnea. Dr. S.Z. also noted that the appellant's persistent daytime hypersomnolence was attributable to his sleep apnea. However, as noted by the Board in April 2021, this opinion is insufficient to award the benefit sought on appeal. Dr M.A.'s opinion is conclusory and appears to be primarily based on general correlations, rather than causation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The appellant requested, and was afforded, a VA sleep apnea examination in August 2019. The claims file was reviewed. Following examination of the appellant and review of the claims file, obstructive sleep apnea was diagnosed. The appellant was noted to have a BMI of 37 at the time of his February 2015 sleep study. The VA examiner explained that the pathophysiology of obstructive sleep apnea was collapse of the velopharyngeal and/or oropharyngeal airway during sleep. The most important risk factors were advancing age, male gender, obesity, and craniofacial or upper airway soft tissue abnormalities. Additional risk factors include smoking, nasal congestion, menopause, and family history. No etiological opinion was offered. In accordance with the Board's April 2021 remand directives, the appellant was afforded a contracted sleep apnea examination in May 2021. The claims file was reviewed. Following examination of the appellant and review of the claims file, obstructive sleep apnea was diagnosed. The appellant reported that, while serving on a ship, he was assigned a top bunk near heating ducts and asbestos pipes, which had an impact on his sleep. There were noises from such and the ship would toss and turn, which impacted his sleep. The appellant also reported that he would awaken due to his snoring and that others observed his snowing in service. The clinician opined that it was less likely than not that the appellant's sleep apnea was incurred in or was otherwise causally related to his active service. It was explained that, although the appellant reported sleep issues during service with sleeping and snoring, these were not signs or symptoms of sleep apnea. Rather, with sleep apnea, there is no problem falling or staying asleep. Snoring was not a sign of sleep apnea. It was explained that many factors increase the risk factor for developing obstructive sleep apnea, including obesity, craniofacial abnormalities, and upper airway soft tissue abnormalities. Obesity was the best documented risk factor. The prevalence of obstructive sleep apnea progressively increases as body mass index (BMI) and associated markers, such as neck circumference and waist to hip ratio, increase. However, the appellant has contended that he was struck in the face during active service which resulted in a deviated septum and the need for the February 1994 septorhinoplasty. Although the clinician noted that craniofacial abnormalities and upper airway soft tissue abnormalities can increase the risk factor for developing obstructive sleep apnea, the appellant's contention regarding an in-service injury to the face does not appear to have been considered. The Board notes that, in the April 2021 remand directives, the clinician was directed to: comment on the significance, if any, of the appellant's February 1994 diagnosis of deviated septum and the septorhinoplasty performed at that time, and the appellant's contentions that the surgical repair for breathing problems was unsuccessful, which then resulted in the development of sleep apnea. As such, the Board finds that this May 2021 opinion is inadequate and that remand is warranted to obtain a new medical opinion. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Stegall v. West, 11 Vet. App. 268 (1998). The Board makes no credibility finding as to the credibility of the appellant's reported in-service face injury at this juncture. 2. Entitlement to service connection for a right elbow disability. Following the Board's April 2021 remand, the RO apparently determined that a compensation and pension examination for the appellant's claimed right elbow disability was warranted. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The appellant was thus afforded a contracted elbow and forearm examination in May 2021. The claims file was reviewed. Following examination of the appellant and review of the claims file, right elbow degenerative arthritis was diagnosed. It was determined that there was no right forearm pathology upon which to render a diagnosis, and that there was no functional impairment in earning capacity. The appellant reported that his arm pain began in 2000 when he was working and was told by a clinician at the time that he was stretching his arm too long and too far. The appellant reported that he has lost right arm mobility, including being unable to stretch his arm completely. He was not sure if there was any nerve damage. He also reported that he injured his right shoulder, which he thought may have an effect on his right elbow and forearm. The appellant complained of painful extension of the arm, but denied pain on forearm supination or pronation. There was no flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. Regarding functional impact, the appellant was unable to completely straighten out his arm due to his right elbow disability. There was no impact regarding the right forearm. The contracted clinician opined that it was less likely than not that the appellant's current right elbow disability was incurred in or was otherwise causally related to his active service. It was explained that there was no evidence of an in-service injury or disease. However, although the appellant explained during the examination that he believed his right shoulder injury may have had an effect on his right elbow, the contracted clinician did not offer an opinion regarding service connection on a secondary or aggravation basis. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As such, the Board finds that the matter must be remanded in order to obtain a new medical opinion. The matters are REMANDED for the following action: 1. Obtain a medical opinion from an appropriate clinician as to the nature and etiology of the appellant's sleep apnea. Access to the claims file should be made available to the examiner for review. After reviewing the claims file, the examiner should opine as to the following: Is it at least as likely as not that sleep apnea had its onset in service or is otherwise related to the appellant's active service? In providing the requested opinions, the clinician should review the relevant evidence of record, to include the January 2005 note from the Henry Ford Hospital and Medical Center, the December 2013 clinical note, the July 2019 DBQ completed by Dr. S.Z., the November 2019 medical opinion of Dr. M.A., and the May 2021 contracted examination report and medical opinion. The clinician should comment on the significance, if any, of the appellant's February 1994 diagnosis of deviated septum and the septorhinoplasty performed at that time, and the appellant's contentions that the surgical repair for breathing problems was unsuccessful, which then resulted in the development of sleep apnea. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. In providing the requested opinions, the clinician should consider the appellant's reported symptoms in service and thereafter, including the nature, onset, progression and severity of the appellant's reported symptoms. If there is any medical reason to accept or reject the proposition that the appellant's reported symptoms in service and thereafter represented the onset of sleep apnea, this should be noted. Stated another way, do the appellant's reports about his symptoms align with how sleep apnea is known to develop or are the appellant's reports generally inconsistent with medical knowledge or implausible? The Board makes no credibility finding as to the credibility of the appellant's reported in-service face injury at this juncture. If the clinician determines that an examination of the appellant is necessary, one should be scheduled. 2. Obtain a medical opinion from an appropriate clinician as to the nature and etiology of the appellant's right elbow disability. Access to the claims file should be made available to the examiner for review. After reviewing the claims file, the examiner should opine as to the following: Is it at least as likely as not that a right elbow disability had its onset in service or is otherwise related to the appellant's active service? If not, is it at least as likely as that that a right elbow disability was proximately due to or the result of service-connected right shoulder disability? If neither, is it at least as likely as not that a right elbow disability was aggravated (made worse) by service-connected right shoulder disability? If aggravation is found, the examiner must attempt to establish a baseline level of severity prior to aggravation. In providing the requested opinions, the clinician should review the relevant evidence of record, to include the May 2021 contracted elbow and forearm examination report. (Continued on the next page) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the clinician determines that an examination of the appellant is necessary, one should be scheduled. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Behlen, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.