Citation Nr: 21072896 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 16-27 612A DATE: December 6, 2021 ORDER Entitlement to service connection for a cervical spine disorder, claimed as neck pain, is denied. Entitlement to service connection for a right ankle disorder is denied. Entitlement to service connection for bruised ribs and right kidney disorder is denied. Entitlement to service connection for pain in eyes to include seeing floaters is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for poor blood circulation (hands & feet blotchy) is denied. Entitlement to service connection for migraine headaches is denied. Entitlement to service connection for bilateral hand tremors is denied. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. FINDINGS OF FACT 1. At no time during the pendency of the claim does the Veteran have a diagnosis of a cervical spine disorder, and the record does not contain a recent diagnosis of such disability prior to the Veteran's filing of a claim. 2. At no time during the pendency of the claim does the Veteran have a diagnosis of a right ankle disorder, and the record does not contain a recent diagnosis of such disability prior to the Veteran's filing of a claim. 3. At no time during the pendency of the claim does the Veteran have a diagnosis of a bruised ribs and a right kidney disorder, and the record does not contain a recent diagnosis of such disability prior to the Veteran's filing of a claim. 4. At no time during the pendency of the claim does the Veteran have a diagnosis of pain in eyes to include seeing floaters, and the record does not contain a recent diagnosis of such disability prior to the Veteran's filing of a claim. 5. At no time during the pendency of the claim does the Veteran have a diagnosis of tinnitus, and the record does not contain a recent diagnosis of such disability prior to the Veteran's filing of a claim. 6. At no time during the pendency of the claim does the Veteran have a diagnosis of poor blood circulation, and the record does not contain a recent diagnosis of such disability prior to the Veteran's filing of a claim. 7. At no time during the pendency of the claim does the Veteran have a diagnosis of migraine headaches, and the record does not contain a recent diagnosis of such disability prior to the Veteran's filing of a claim. 8. At no time during the pendency of the claim does the Veteran have a diagnosis of a bilateral hand tremors, and the record does not contain a recent diagnosis of such disability prior to the Veteran's filing of a claim. 9. At no time during the pendency of the claim does the Veteran have a diagnosis of PTSD, and the record does not contain a recent diagnosis of such disability prior to the Veteran's filing of a claim. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical spine disorder, claimed as neck pain, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a right ankle disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for bruised ribs and right kidney disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. [The criteria for service connection for pain in eyes to include seeing floaters are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for tinnitus are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for poor blood circulation are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for migraine headaches are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for service connection for bilateral hand tremors are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for service connection for PTSD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from July 2002 to November 2002 and from December 2003 to April 2005. These matters come to the Board of Veterans' Appeals (Board) on appeal from September 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran was scheduled for a virtual hearing in October 2021. A notice of the hearing was sent in September 2021. The Veteran did not appear, such that he was marked as a "no-show" and his hearing request is considered withdrawn. 38 C.F.R. § 20.704(d). Therefore, the matter now returns to the Board. Service Connection Generally, service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). In addition to the general elements of service connection, PTSD may be granted if the evidence of record satisfies three basic elements. There must be: 1) medical evidence diagnosing PTSD in accordance with 38 C.F.R. § 4.125(a); 2) a link, established by medical evidence, between current symptoms of PTSD and an in-service stressor; and 3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304 (f). In this regard, the Board notes that, for cases certified to the Board after August 4, 2014, as is the case here, the diagnosis of PTSD must be in accordance with the criteria of American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders - 5th Edition (DSM-5). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for a cervical spine disorder, claimed as neck pain, is denied. 2. Entitlement to service connection for a right ankle disorder is denied. 3. Entitlement to service connection for bruised ribs and right kidney disorder is denied. 4. Entitlement to service connection for pain in eyes to include seeing floaters is denied. 5. Entitlement to service connection for tinnitus is denied. 6. Entitlement to service connection for poor blood circulation (hands & feet blotchy) is denied. 7. Entitlement to service connection for migraine headaches is denied. 8. Entitlement to service connection for bilateral hand tremors is denied. 9. Entitlement to service connection for PTSD is denied. The Veteran contends that his disabilities resulted from physical injuries incurred during training that he had to neglect as well as exposure to chemicals and burn pits. Furthermore, the Veteran claims that his PTSD stressor included constantly being fired upon and seeing children being injured. See October 2008 Claim. No specific arguments have been provided. In the Veteran's service treatment records, it is noted that in December 2003 he had a bruised kidney and in January 2004, he complained of right-side neck pain and headaches. In February 2004, there were complaints of severe coughing causes nose bleeds. In a May 2004 medical note, it was recorded that the Veteran twisted his right ankle and had bruised ribs and kidneys, furthermore he complained of nose bleeds. In March 2005, it was noted that the Veteran got into a car accident prior to deployment, and he complained of his ankle rolling. In January 2006, the Veteran complained of headaches and neck stiffness. The Veteran's post-service treatment records note the Veteran had general pain to back and joints in February 2006 and stated that he injured his right ankle while in service. It was also noted he reported symptoms consistent with PTSD in August 2007. However, no diagnosis was given. The Board notes that the Veteran has not been afforded VA examinations to determine the etiology of his claimed disabilities. In his March 2010 notice of disagreement, the Veteran reported that he was incarcerated and could not see a VA examiner because he maxed out of his leave. Although VA's ability to provide examinations to incarcerated veterans may be limited by the circumstances of the incarceration, the Court of Appeals for Veterans Claims (Court) has held that VA must "tailor [its] assistance to the peculiar circumstances of confinement. Such individuals are entitled to the same care and consideration given to their fellow veterans." Bolton v. Brown, 8 Vet. App. 185, 191 (1995), citing Wood v. Derwinski, 1 Vet. App. 190, 192 (1991). An October 2010 Deferred Rating requested medical records from a correctional facility and also instructed the Veteran to provide an appropriate authorization form to request medical records on his behalf. The Board notes that VA does not have the authority to require a correctional institution to release a Veteran so that VA can provide him the necessary examination at the closest VA medical facility. See 38 U.S.C. § 5711. Nevertheless, VA's duty to assist an incarcerated veteran includes: (1) attempting to arrange transportation of the claimant to a VA facility for examination; (2) contacting the correctional facility and having their medical personnel conduct an examination according to VA examination worksheets; or, (3) sending a VA or fee-basis examiner to the correctional facility to conduct the examination. See Bolton, 8 Vet. App. at 191. Accordingly, the RO must make reasonable efforts to accommodate the veteran with respect to his current incarceration by scheduling a VA examination, to the extent possible. If the veteran cannot be afforded a VA examination due to incarceration, the RO must document all attempts taken to schedule the veteran for a VA examination. The correctional facility responded in a December 2010 correspondence replying they could not furnish the medical records without a release form signed by the Veteran. The Veteran has not submitted such release. See Wood v. Derwinski, supra. The Board finds that VA examinations are not required and the VA has met the duty to assist. In determining whether the duty to assist requires that a VA medical examination be provided, or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, the Veteran does not have a current diagnosis of any of the disabilities that he is claiming and has not had one at any time during the pendency of the claims or recent to the filing of the claims. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As the record does not reflect diagnoses related to his disabilities, the cornerstone element of service connection has not been met, and service connection is not warranted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (stating that service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it; without this minimum level of proof, there can be no valid claim). No further discussion of the remaining elements is necessary. The Board acknowledges the Court's holding in Saunders but does not find a basis for determining that there is functional impairment related to a diagnosis of a lumbar spine disorder, a right ankle disorder, bruised ribs and right kidney disorder, a pain in eyes to include seeing floaters, tinnitus, poor blood circulation (hands & feet blotchy), migraine headaches, bilateral hand tremors and/or PTSD. See Saunders v. Wilkie, 886 F.3d. 1356 (2018). Moreover, the Veteran has not alleged manifestations of similar severity, frequency and duration as those VA has determined by regulation would cause impaired earning capacity in an average person. Wait v. Wilkie, 33 Vet. App. 8 (2020). In addition, the record does not reflect a diagnosis related to PTSD under the DSM-5. See Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). Although the Veteran had various complaints throughout his service treatment records, the available post-treatment records describe generalized pain, but do not provide any diagnosis for his specific complaints of neck pain, headaches, right ankle pain, neck pain, eye pain, tinnitus, poor blood circulation, bruised kidneys and ribs as well as bilateral hand tremors. Also, in the Veteran's service treatment records, it was noted that he was involved in a car accident prior to deployment that results in his ankle pain and bruised kidneys and ribs. In addition, in a July 2009 VA Memorandum, it was reported that the Veteran provided insufficient evidence to verify his PTSD stressor, to include not providing a VA Form 21-0781, Statement in Support of Claim for Service Connection for PTSD. Furthermore, the Veteran has not provided medical opinions to weigh in on these matters. In this regard, a mere conclusory generalized lay statement that service event or illness caused a current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Court has held that VA is not required to provide a medical examination when there is no credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Therefore, the Board finds that a VA examination and/or opinion is not necessary to decide claims as to direct service connection. In reaching this determination, the Board has also considered the lay assertions of record, including the contentions of the Veteran in support of a medical nexus. The Veteran contends that her lumbar spine disorder is due to his service. As a lay person, the Veteran is competent to report observable symptoms, such as back pain. See Washington v. Nicholson, 21 Vet. App. 191, 195 (2007) (holding that, "[a]s a layperson, an appellant is competent to provide information regarding visible, or otherwise observable symptoms of disability"); see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (Lay testimony is competent to establish the presence of observable symptomatology); Layno v. Brown, 6 Vet. App. 465 (1994). Lay evidence may be competent on a variety of matters concerning the nature and cause of disability. Jandreau, 492 F.3d at 1377 n.4. However, while the Veteran is competent to report having experienced symptoms of a lumbar spine disorder, a right ankle disorder, bruised ribs and right kidney disorder, a pain in eyes to include seeing floaters, tinnitus, poor blood circulation (hands & feet blotchy), migraine headaches, bilateral hand tremors and/or PTSD, he is not competent to opine on the etiology of the condition and/or to determine that these symptoms are somehow related to either her active service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Thus, the Board concludes that the preponderance of the evidence is against finding that the Veteran meets the criteria for service connection for his claimed disabilities. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claims, the doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Adeyemi, Associate 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.