Citation Nr: 21068584 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 14-32 295 DATE: November 10, 2021 ORDER Entitlement to service connection for hypertension, to include as due to in-service exposure to herbicide agents, and to include as secondary to a service-connected disability, is granted. Entitlement to service connection for coronary artery disease (CAD), to include as due to in-service exposure to herbicide agents, is granted. Entitlement to service connection for supraventricular tachycardia (SVT), to include as due to in-service exposure to herbicide agents, and to include as secondary to a service-connected disability, is granted. Entitlement to service connection for left ventricular hypertrophy (LVH), to include as secondary to a service-connected disability, is granted. Entitlement to service connection for a disability manifested by dizziness, to include as due to in-service exposure to herbicide agents, and to include as secondary to service-connected disability, is denied. REMANDED Entitlement to service connection for headaches, to include as due to in-service exposure herbicide agents, and to include as secondary to a service-connected disability, is remanded. FINDINGS OF FACT 1. Resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that his currently diagnosed hypertension was caused by his in-service exposure to herbicide agents. 2. Resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that his currently diagnosed CAD was caused by his in-service exposure to herbicide agents. 3. Resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that his currently diagnosed SVT was caused by his hypertension. 4. Resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that his currently diagnosed LVH was caused by his hypertension. 5. The competent and credible evidence does not demonstrate that the Veteran has a current diagnosis for a disability manifested by dizziness. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension, to include as due to in-service exposure to herbicide agents, and to include as secondary to a service-connected disability, have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. 2. The criteria for entitlement to service connection for CAD, to include as due to in-service exposure to herbicide agents, have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 3. The criteria for entitlement to service connection for SVT, to include as due to in-service exposure to herbicide agents, and to include as secondary to a service-connected disability, have been met. 38 U.S.C. §§ 1110, 1113, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. 4. The criteria for entitlement to service connection for LVH, to include as secondary to a service-connected disability, have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 5. The criteria for entitlement to service connection for a disability manifested by dizziness, to include as due to in-service exposure to herbicide agents, and to include as secondary to service-connected disability, have not been met. 38 U.S.C. §§ 1110, 1113, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from June 1967 to May 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Most recently, in May 2021, the Board, in pertinent part, remanded the issues on appeal for additional development. As the actions specified in the remand have been substantially completed, the matters have been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Although the issue certified to the Board was for entitlement to service connection for supraventricular tachycardia, in light of Clemons v. Shinseki, 23 Vet. App. 1 (2009), the issue has been recharacterized as entitlement to service connection for a heart disorder, to include coronary artery disease, supraventricular tachycardia, and left ventricular hypertrophy, to comport with the record. In September 2021, the Veteran submitted additional evidence in support of his appeal along with a signed waiver of RO consideration of evidence. The Board accepts this evidence for inclusion in the record. See 38 C.F.R. § 20.1305. Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Service connection may be granted 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(a). Generally, service connection requires: (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. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic diseases, such as hypertension and arteriosclerosis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. That presumption is rebuttable by probative evidence to the contrary. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection when the requirements for application of the presumption are not met. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Continuity of symptomatology may establish service connection if a claimant can demonstrate (1) that a condition was "noted" during service; (2) there is post-service evidence of the same symptomatology; and (3) there is medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). VA regulations provide that a veteran who, during active military, naval, or air service, served between April 1, 1968, and August 31, 1971, in a unit that, as determined by the Department of Defense (DOD), operated in or near the Korean DMZ (i.e. demilitarized zone) in an area in which herbicides are known to have been applied during that period, shall be presumed to have been exposed during such service to an herbicide agent unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. See 38 C.F.R. § 3.307(a)(6)(iv). The term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, specifically: 2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram. 38 C.F.R. § 3.307(a)(6)(i). Furthermore, VA regulations provide for presumptive service connection for specific diseases associated with exposure to herbicide agents. Those diseases that are listed at 38 C.F.R. § 3.309(e), including ischemic heart disease, shall be presumptively service-connected if there are circumstances establishing herbicide agent exposure during active military service, even though there is no record of such disease during service. 38 C.F.R. § 3.307(a). Note 2 provides that the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. 38 C.F.R. § 3.309(e). Generally, the regulation applies where an enumerated disease becomes manifest to a degree of 10 percent or more at any time after service. 38 C.F.R. § 3.307(a)(6)(ii). In addition, service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Notwithstanding the provisions relating to presumptive service connection, a Veteran may establish service connection for a disability with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). 1. Entitlement to service connection for hypertension, to include as due to in-service exposure to herbicide agents, and to include as secondary to a service-connected disability The Veteran asserts that hypertension developed due to his active duty service. He contends that his hypertension was caused by his exposure to herbicide agents during service. He said that his private physicians told him in the 1970's or 1980's that he had high blood pressure. Because the Veteran felt like he was healthy, he said that he did not seek a lot of medical attention and initially declined taking blood pressure medications. He said that he preferred to jog three or four miles a day three days a week to control his blood pressure. See October 2011 and July 2013 statements and December 2013 Decision Review Officer (DRO) hearing transcript. The question before the Board is whether the Veteran's hypertension is etiologically related to his active duty service. Based on a careful review of all the subjective and clinical evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for hypertension is warranted. In a March 2013 Administrative Decision, the RO conceded that the Veteran served in or near the Korean DMZ, and that exposure to Agent Orange is conceded. The evidence demonstrates that the Veteran has a current diagnosis for hypertension. See June 2019 VA examination. The Veteran's service treatment records (STRs) document that the Veteran entered service with a blood pressure reading of 120/84. At a March 1969 separation examination, the Veteran's blood pressure reading was 126/80. On the March 1969 associated report of medical history, the Veteran did not report any blood pressure problems. VA treatment records from 1994 to 2017 document the Veteran's history of high blood pressure problems. A July 1994 VA clinical record reflects that the Veteran sought treatment following a single episode of musculoskeletal chest pain in April 1994. The impression was negative graded exercise for ischemia, but abnormal secondary to hypertensive blood pressure response. The VA physician recommended treatment of hypertension by the Veteran's primary medical doctor. Subsequent VA treatment records from 1996 to 1999, including VA Hypertension Screening Forms, document the Veteran's elevated blood pressure readings and use of antihypertensive medication (August 1996 VA Hypertension Screening Form and June 1999 VA Progress Note). The Veteran's hypertension continued to be monitored and treated at VA facilities. Now, the Board recognizes that the record includes conflicting medical opinions concerning whether the Veteran's current hypertension is etiologically related to his active duty service, to include as due to his in-service herbicide agent exposure. With regard to the medical opinions obtained, as with all types of evidence, it is the Board's responsibility to weigh the conflicting medical evidence to reach a conclusion as to the ultimate grant of service connection. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board may favor the opinion of one competent medical expert over another if its statement of reasons and bases is adequate to support that decision. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Stated another way, the Board decides, in the first instance, which of the competing medical opinions or examination reports is more probative of the medical question at issue. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). In a March 2014 opinion, the Veteran's private treating physician, Dr. D.H., listed hypertension as one of the Veteran's conditions. Dr. D.H. stated that the Veteran "suffers from a multitude of symptoms that could be attributed to exposure to Agent Orange during his deployment." No explanation or rationale was provided. In a June 2019 VA opinion, the VA examiner opined that the Veteran's hypertension was less likely than not incurred in or caused by herbicide exposure. The VA examiner discussed his review of the National Academy of Sciences (NAS) Institute of Medicine's Veterans and Agent Orange: Update 2010 (2012). The June 2019 VA examiner found that the Veterans and Agent Orange: Update 2010 (2012) made no changes in that the association of hypertension and Agent Orange was still listed as "Limited of Suggestive Evidence of Association," and based on this the VA secretary did not recommend making hypertension a presumptive disease for Agent Orange exposure. Citing the Veterans and Agent Orange: Update 2010 (2012), the VA examiner noted that "the available evidence does not at this time establish a positive association between herbicide exposure and hypertension." No further rationale was provided. In August 2021, the Veteran underwent an independent medical evaluation, which was conducted by a board certified and residency trained occupational or environmental physician. Following a review of the Veteran's medical records, the independent physician discussed how the Veteran had longstanding hypertension with elevated blood pressure in 1994 and a definitive diagnosis in 1996, when he was placed on medication. Further, the independent physician found that the Veteran was a non-smoker, drank modestly, and did not utilize recreational drugs, and he had no other risk factors for hypertension. The independent physician stated that despite the fact that VA had not established hypertension as a presumptive disease for herbicide exposure, there is an abundance of evidence that hypertension is causally related to herbicide exposure. Discussing the Veterans and Agent Orange: Update 2006 (2007), the independent physician explained that the Institute of Medicine Committee (Committee) had reviewed new studies and revisited all the studies related to ischemic heart disease and hypertension that had been discussed in previous updates and concluded that there was limited or suggestive evidence to support an association between exposure to the herbicides used in Vietnam and hypertension. The independent physician found that the studies showed a stronger association between Agent Orange and hypertension than for ischemic heart disease. In the Veterans and Agent Orange: Update 2010 (2012), the independent physician stated that the Committee reaffirmed the Veterans and Agent Orange: Update 2006 (2007) conclusion of limited or suggestive evidence of an association between herbicide exposure and hypertension. In the Veterans and Agent Orange: Update 2012 (2014), the independent physician noted that the Committee had reviewed new studies not previously available for review and described their findings. Several studies in Korean Vietnam War veterans show a statistically significant increase in incidence of hypertension in these veterans versus non-Vietnam War veterans. Multiple studies indicate a consistent pathway for how TCDD and similar compounds cause hypertension. The independent physician found that since 2006, hypertension is one of the few conditions listed in the limited or suggestive evidence that are not presumptively service-connected to exposure to Agent Orange, despite earlier and stronger evidence of an association than ischemic heart disease. In the latest Veterans and Agent Orange: Update 11 (2018), the independent physician stated that hypertension had moved from limited or suggestive of association to the sufficient evidence of association. Thus, the independent physician concluded that there is unequivocal evidence that exposure to herbicides causes hypertension. After reviewing all the relevant evidence, the independent physician opined that it was more likely that the Veteran's hypertension was caused by exposure to herbicides while serving in Korea. The Board finds that the August 2021 independent physician's opinion is the most probative evidence regarding the etiology of the Veteran's hypertension. On that basis, the August 2021 independent physician provided an opinion based on a comprehensive review of the Veteran's medical history, his in-service exposure to herbicides, and relevant medical literature concerning the relationship between hypertension and herbicide exposure, and supported by a thorough rationale for the conclusions. By contrast, the March 2014 private opinion was speculative and did not provide a rationale for its conclusion. Further, the June 2019 VA opinion relied solely on the findings of the Veterans and Agent Orange: Update 2010 (2012) without discussing the recent change in the Veterans and Agent Orange Update 11 (2018). Additionally, the June 2019 did not discuss the Veteran's medical history, to include any risk of factors he had for hypertension, other than his herbicide exposure. Because the March 2014 private opinion and June 2019 VA opinion did not include sufficient rationales for the opinions, the Board finds that these opinions are inadequate. Therefore, the Board concludes that the August 2021 independent physician's opinion provides the most persuasive etiological opinion. Taking into consideration the totality of the evidence, the Board finds that resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that his hypertension was caused by his in-service exposure to herbicide agents. Therefore, the Veteran's service connection claim for hypertension must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for a heart disorder to include CAD, SVT, and LVH, to include as due to in-service exposure to herbicide agents, and to include as secondary to a service-connected disability The Veteran asserts that his SVT was caused by his exposure to herbicide agents, or alternatively, that his SVT was caused by a service-connected disability. The Veteran described how since 1994, he had experienced years of episodes of heart arrhythmias or heart beating too fast. He said that his private physician diagnosed him with SVT, and he had an ablation in 2011. A few years later, the Veteran said that his doctor told him that his heart condition was returning. He underwent another ablation in 2015. The Veteran suggested that his sleep apnea caused his SVT. See October 2011, July 2013, and August 2014 statements and December 2013 DRO hearing transcript. The question before the Board is whether the Veteran has a heart disorder that is etiologically related to his active duty service or a service-connected disability. Based on a careful review of all the subjective and clinical evidence, and resolving all reasonable doubt in favor of the Veteran, service connection for a heart disorder is warranted. The Veteran's STRs do not document any findings related to any complaints, treatment, or diagnosis for any cardiac problems. At a March 1969 separation examination, the Veteran had normal heart clinical evaluation results and a negative chest x-ray. On his associated report of medical history, no cardiac issues were reported. VA and private treatment records from 1999 to 2017 document the Veteran's complaints and treatment for heart problems. A June 1999 VA progress note documents that the Veteran was positive for palpations. In August 2011, the Veteran presented to the emergency room complaining of a rapid heart rate. He described having this sensation several times a month "for years." See August 2011 private treatment record. At an October 2011 private clinic visit, the Veteran was diagnosed with SVT, a condition that the Veteran reported had been going on for years, but was becoming more frequent. Subsequent VA treatment records document that the Veteran had undergone ablations to treat his SVT in 2011 and 2015. See April 2016, March 2017, and October 2017 VA treatment records. An October 2012 private treatment documents that the Veteran's echocardiogram revealed mild left ventricular hypertrophy, an ejection fraction with an estimated range of 55 to 65 percent, and mild aortic valve regurgitation and mitral regurgitation. In May 2014, the Veteran underwent a VA examination. Following an objective evaluation, the Veteran was diagnosed with SVT. The May 2014 VA examiner determined that the etiology of the Veteran's SVT was unknown. The May 2014 VA examiner's opinion provided an unfavorable nexus opinion, but only addressed the Veteran's service-connected fascial discoid dermatitis consistent with systemic lupus, which was his only service-connected disability at the time. In June 2020, the Veteran underwent another VA examination. Following an objective evaluation, the Veteran was diagnosed with CAD and SVT. The June 2020 VA examiner found that the Veteran's CAD qualified within the generally accepted medical definition of ischemic heart disease and that the etiology of his CAD was Agent Orange. The etiology of the Veteran's SVT was unknown. In the June 2020 VA examiner's opinion, the VA examiner opined that the Veteran's SVT was less likely than not proximately due to, the result of, or aggravated by his nonservice-connected sleep apnea. No other opinion was provided. As previously discussed above, the Veteran underwent an August 2021 independent medical evaluation. Following a review of the Veteran's relevant medical records, the August 2021 independent physician noted that the Veteran was diagnosed with hypertension in 1996, that his SVT was initially diagnosed in 2011 and that he had a LVH diagnosed by echocardiogram in 2012. Citing a consensus document by the European Heart Rhythm Association, the independent physician discussed how hypertensive heart disease can manifest as many cardiac arrhythmias, most commonly being atrial fibrillation. Furthermore, both supraventricular and ventricular arrhythmias may occur in hypertensive patients, especially in those with LVH or heart failure. The independent physician stated that according to the consensus document, SVT occurs frequently in hypertensive patients with LVH, such as the Veteran. In addition, the consensus document stated that LVH is the most important predictor for developing SVT and that patients with LVH have a 3.4 fold greater odds of developing SVT than those without LVH. Citing a 2008 study, the independent physician explained that there is a recognized association between hypertension and LVH and a finding that prolonged hypertension increased the mass of the heart and was associated with LVH. Finally, the independent physician found that the Veteran had no other risk factors for LVH or SVT, because he was a non-smoker, drank modestly, and did not utilize recreational drugs. Overall, the independent physician opined that the Veteran's LVH and SVT were more than likely caused by his prolonged hypertension. The evidence demonstrates that the Veteran has current diagnoses for CAD, SVT, and LVH. See October 2012 private treatment record and June 2020 VA examination. Despite the record showing that the Veteran had claimed service connection for SVT, the Board finds that given the additional heart diagnoses in the record, it would be prejudicial to the Veteran to limit the scope of his claim. Therefore, the Board finds it is appropriate to expand the Veteran's service connection claim under Clemons v. Shinseki, 23 Vet. App. 1 (2009) as a claim for a heart disorder. First, the Board has considered whether service connection for CAD is warranted. VA conceded that the Veteran was exposed to a herbicide agent during service. As noted above, to establish service connection on a presumptive basis, the Veteran must have a presumptive disease for exposure to herbicide agents. See 38 C.F.R. §§ 3.306(a), 3.309(e). Ischemic heart disease is a presumptive disease associated with exposure to herbicide agents. 38 C.F.R. § 3.309(e). At the Veteran's June 2020 VA examination, the VA examiner found that the Veteran's diagnosis for CAD qualified within the generally accepted medical definition of ischemic heart disease. Accordingly, the Board finds that resolving all reasonable doubt in favor of the Veteran, his currently diagnosed CAD was caused by his in-service exposure to herbicide agents. Next, the Board has considered whether service connection for SVT is warranted. On that basis, the Board finds that the August 2021 independent physician's opinion provides the most probative evidence regarding the etiology of the Veteran's SVT. The August 2021 independent physician provided an opinion based on a thorough review of the relevant medical records, consideration of relevant medical literature, and discussion of the Veteran's medical history, and supported by a through rationale for the conclusions. Although the record includes unfavorable nexus opinions provided by the May 2014 and June 2020 VA examiners, the Board also notes that neither the May 2014 VA examiner nor the June 2020 VA examiner discussed whether there was any relationship between the Veteran's SVT and his hypertension. Accordingly, the Board finds that the August 2021 independent physician's opinion is more persuasive. Therefore, the Board concludes that resolving all reasonable doubt in favor of the Veteran, his SVT was caused by his now service-connected hypertension. Finally, the Board has considered whether service connection for LVH is warranted. Similar to the determination above, the Board finds that the August 2021 independent physician's opinion provides the most probative evidence regarding the etiology of the Veteran's LVH. The August 2021 independent physician provided an opinion based on a thorough review of the relevant medical records, consideration of relevant medical literature, and discussion of the Veteran's medical history, and supported by a thorough rationale for the conclusions. Notably, the record does not include any evidence to the contrary. Accordingly, the Board finds that resolving all reasonable doubt in favor of the Veteran, his LVH was caused by his now service-connected hypertension. In summary, resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that service connection for CAD, SVT and LVH are warranted. Accordingly, the Veteran's service connection claims for CAD, SVT, and LVH must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for a disability manifested by dizziness, to include as due to in-service exposure to herbicide agents, and to include as secondary to service-connected disability The Veteran asserts that his dizziness occurred during his episodes of heart arrhythmias. He also contends that his dizziness was related to his sleep apnea and hypertension. See October 2011, June 2013, and August 2014 statements. The question before the Board is whether the Veteran has a current diagnosis for a disability manifested by dizziness. Based on a careful review of all the subjective and clinical evidence, the Board finds that the preponderance of the evidence weighs against finding service connection for a disability manifested by dizziness is warranted. The Veteran's STRs do not document any findings related to any complaints, treatment, or diagnosis for dizziness or any condition related to dizziness. At a March 1969 separation examination, the Veteran had normal clinical evaluation results for his ears and had a normal neurologic clinical evaluation. No pertinent symptomatology was reported on his associated report of medical history. VA and private treatment records document the Veteran's complaints of dizziness. At a February 2001 VA clinic visit, the Veteran reported that he felt dizzy while he was taking antihypertensive medications several years ago. In 2011, the Veteran sought treatment for his SVT, where he had associated symptoms of dizziness. See August 2011, October 2011, and November 2011 private treatment records. At a September 2013 VA clinic visit, the Veteran reported sometimes having difficulty standing, which was attributed to his dizziness. In November 2015, the Veteran underwent a private neurological evaluation during which he reported having dizziness and difficulty maintaining his balance on "bad days" associated with his central and obstructive sleep apnea. No diagnosis associated with his dizziness was provided by either his VA or private treatment health providers. In June 2019, the Veteran underwent a VA examination for his sleep apnea. At the examination, the Veteran reported that he was having issues with fatigue, blurred eyes, dizziness, and rapid heart rate. He indicated that his doctors did not know the cause, but they thought his symptoms could be related to his sleep apnea. In June 2020, the Veteran underwent a VA examination for ear conditions. The June 2020 VA examiner noted that the Veteran made no complaints of dizziness related to a vertigo, and when he was questioned about his dizziness, he said, "sometimes I don't know where my feet are and I trip." Following an objective evaluation, the June 2020 VA examiner found that there was no objective evidence to render a diagnosis for an ear condition at this time. At a June 2020 VA examination for heart conditions, the VA examiner noted that in 2015, before his cardiac ablation which brought his heart back to a normal rhythm, the Veteran underwent another episode of dizziness and lightheadedness. During the examination, the VA examiner conducted an interview-based METs test. The June 2020 VA examiner noted that the Veteran had symptoms of dizziness during activity. Furthermore, the June 2020 VA examiner explained that the Veteran's dizziness occurred when he went into SVT. In a June 2021 VA opinion, the VA examiner noted that a diagnosed vestibular condition by a treating provider or on the VA examination reports could not be found. The June 2021 VA examiner explained that the records showed that the Veteran's dizziness had been a symptom of low blood pressure in 2001, rapid heart rate, according to the Veteran's lay statements, or related to sleep apnea as documented in 2015. Overall, the June 2021 VA examiner found that no standalone diagnosis of a vestibular condition had been diagnosed. The Veteran is certainly competent to report his history of dizziness. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the Veteran has not demonstrated that he has the requisite specialized knowledge or training to attribute his dizziness to a separate and distinct diagnosis rather than as a symptom of his sleep apnea, hypertension, or SVT. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Veteran has not presented any competent and credible evidence of current diagnosis for a disability manifested by dizziness, and the available evidence does not support that the Veteran has any persistent symptomatology that would suggest that he has an underlying chronic disability, other than those for which he has already been diagnosed (i.e., sleep apnea, hypertension, and SVT). Accordingly, the Veteran's assertions that he may have an additional disability manifested by dizziness have little probative value. No underlying disability has been clinically diagnosed during the appeal period or proximate thereto. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). In summary, the preponderance of the evidence weighs against finding in favor of the Veteran's service connection claim for a disability manifested by dizziness. Therefore, the benefit-of-the-doubt rule does not apply, and the service connection claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for headaches, to include as due to in-service exposure herbicide agents, and to include as secondary to a service-connected disability, is remanded. The Veteran is seeking service connection for headaches. The evidence includes conflicting medical evidence regarding whether the Veteran has a current diagnosed headache disability. At a June 2020 VA examination, the Veteran was diagnosed with migraines. However, in a June 2021 VA opinion, the VA examiner found that the Veteran's headache diagnosis was not supported by treatment notes. Furthermore, at an August 2012 private clinic visit, the Veteran's neurologist discussed how the etiology of the Veteran's complaints, including symptoms of intermittent headaches and retro-orbital pain associated with his memory problems remained unclear. However, the private neurologist suggested that the episodic nature of the symptoms would be more consistent with paroxysmal disorders such as migraines or epilepsy. Additionally, the private neurologist found that a headache disorder such as atypical migraine or even postural orthostatic tachycardia syndrome would be a more plausible explanation if the frequency and severity of the symptoms were to increase. Because the Veteran's treatment records include multiple reports of headaches, but no definitive diagnosis, the Board finds that the currently available record is insufficient to decide the claim. Accordingly, the Board finds that a remand to obtain a new VA examination to confirm the Veteran's diagnosis is required. The matter is REMANDED for the following actions: 1. Obtain all the outstanding treatment records for the Veteran's headaches that are not currently of record. 2. Schedule the Veteran for a VA examination for his headaches by an appropriately qualified clinician (M.D.). The examiner must resolve the conflicting medical evidence in the April 2012 private treatment record, June 2020 VA examination, and June 2021 VA opinion regarding the Veteran's headache diagnosis. The examiner must explain whether the Veteran has a current headache diagnosis. If so, please identify. In providing the above opinion, the examiner must address the Veteran's documented complaints of headaches in his treatment records as well as his lay reports of headaches. If a diagnosed headache disability is established, the examiner is requested to opine whether it is at least as likely as not (50 percent or greater probability) that such disability is related to service, to include herbicide exposure, or is related to or aggravated by a service-connected disability. To the extent, the examiner finds that the Veteran does not have a separate diagnosis for headaches, the examiner must explain whether the headaches are a symptom of another disability. Then, the examiner must specifically identify that disability. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. (Continued on the next page) 3. To avoid another remand, the Agency of Original Jurisdiction (AOJ) must review the requested development and ensure that the Board's specific instructions have been completed in full. If any development is found to be inadequate, it must be returned to the providing examiner for corrective action. If such corrective action is not requested, then the Board will be required to return the case to the AOJ for substantial compliance with its remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). 4. After ensuring the above development has been completed, readjudicate the issue on appeal. If the benefit sought on appeal is not granted to the Veteran's satisfaction, send the Veteran and his representative a supplemental statement of the case and provide an opportunity to respond. Then, return the case to the Board for further appellate review. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Journet Shaw, 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.