Citation Nr: 21076036 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 17-33 834 DATE: December 22, 2021 ORDER Entitlement to a compensable rating of 30 percent from May 23, 2012, but no higher, for pseudofolliculitis barbae (PFB) with scarring is granted. Entitlement to a rating in excess of 30 percent from May 17, 2018, for PFB with scarring is denied. New and material evidence having been received, the claim for service connection for a bilateral knee condition is reopened. New and material evidence having not been received, the claim for service connection for hypertension, to include as secondary to diabetes and herbicide exposure, remains denied and the appeal is not reopened. Entitlement to service connection for arthritis of the legs, to include as due to herbicide exposure, is denied. Entitlement to service connection for a bilateral knee condition is denied. FINDINGS OF FACT 1. The Veteran's PFB from May 23, 2012 was manifested by residual hyperpigmented scarring of the face and neck exceeding six square inches (39 square centimeters). 2. From May 17, 2018, the Veteran's PFB was asymptomatic with no painful or unstable scars or additional ratable signs or symptoms. 3. In an unappealed December 2008 rating decision, the Regional Office (RO) denied the Veteran's claim for service connection for hypertension, and arthritis of all joints, to include bilateral knee arthritis, finding no evidence of a nexus to service, to include herbicide exposure. 4. The evidence received since the December 2008 denial pertaining to hypertension is cumulative or redundant and does not relate to the unestablished facts in which this claim was previously denied. 5. Additional evidence received since the December 2008 denial is not cumulative or redundant of the evidence of record at the time of that decision, relates to an unestablished fact necessary to substantiate the claim for service connection for a bilateral knee condition, and raises a reasonable possibility of substantiating the claim. 6. The preponderance of the evidence is against finding that arthritis of the legs or a bilateral knee condition was chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomology is not established; and the disability is not otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for entitlement to a compensable rating of 30 percent from May 23, 2012, but no higher, for pseudofolliculitis barbae with scarring have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7806. 2. The criteria for entitlement to a rating in excess of 30 percent from May 17, 2018 for pseudofolliculitis barbae with scarring have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7806. 3. The December 2008 rating decision denying service connection for a bilateral knee condition and hypertension, is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.200, 20.201, 20.1103 4. New and material evidence has not been received for the claim for service connection for hypertension; thus, the claim is not reopened and remains denied. 38 U.S.C. §§ 5107, 5108; 38 C.F.R. §§ 3.102, 3.156. 5. New and material evidence has been received to reopen the claim for service connection for a bilateral knee condition. 38 U.S.C. §§ 5107, 5108; 38 C.F.R. §§ 3.102, 3.156. 6. The criteria for entitlement to service connection for arthritis of the legs have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for entitlement to service connection for a bilateral knee condition have not been 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 in the United States Army from August 1966 to August 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision issued by a VA Regional Office (RO), which denied an increased rating for the Veteran's PFB, denied service connection for bilateral arthritis of the legs, as well as declined reopening his claims for service connection for hypertension and arthritis of bilateral knee condition. Regardless of the RO's decision pertaining to reopen or not reopen the claims, the Board is obligated to consider the issue of new and material evidence and make an independent determination. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Thereafter, the RO granted an increased rating for his PFB at 30 percent disabling effective May 17, 2018. The Board notes, this increased rating constitutes a partial grant of the benefits sought on appeal; therefore, the issue remains on appeal and is for consideration by the Board. See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). The Board further notes that the issue of a total disability rating based on individual unemployability (TDIU) has been raised by the record, to include the Veteran's claims for an increased rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). However, this issue was recently adjudicated by the Board in a September 2021 decision. Ultimately, the Board denied entitlement to TDIU after considering all evidence of record dating back to 2007. See September 2021 Board Decision P.2. As this recent Board decision considered all applicable evidence during the period on appeal, the issue of entitlement to TDIU will not be further addressed in this decision. In July 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is of record. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The veteran's entire history is reviewed when making disability evaluations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; separate ratings may be assigned for distinct disabilities resulting from the same injury only where the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. See 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Veteran was granted service connection for PFB with a noncompensable rating under 38 C.F.R. § 4.118, DC 7813, effective May 20, 2008. He submitted a claim for increase in March 2010. Thus, the Board will consider the severity of his PFB disability from March 2010, as well as whether there was a factually ascertainable increase in severity within the year preceding his increased rating claim. See 38 C.F.R. § 3.400(o)(2). As noted above, subsequent to further development undertaken by the RO, the Veteran was granted a separate 30 percent rating for a painful facial scar secondary to his PFB under 38 C.F.R. § 4.118, DC 7800, pertaining to scars of the head, face, or neck, effective May 17, 2018. Throughout the appeal period, the Veteran's PFB has been rated under varying diagnostic codes under 38 C.F.R. § 4.118, pertaining to ratings of the skin, including DC 7813 and DC 7806-7800. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating, with the first code representing the underlying condition and the second code representing the residuals. 38 C.F.R. § 4.27. Here, his PFB was original rated based on dermatophytosis including tinea barbae of the beard area. (DC 7813). As of a July 2018 rating decision, the PFB disability is rated under the criteria of DC 7806-7800. The hyphenated diagnostic codes indicate that his PFB is currently rated based on dermatitis or eczema, (DC 7806) and scars or disfigurement of the head, face, or neck (DC 7800). The Board will consider rating the service connected PFB under all applicable diagnostic codes. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Here, the Veteran submitted his claim for increase in March 2010. As such, the pre-amended criteria will be considered throughout the entire appeal period and the amended criteria will be considered from August 13, 2018. Under both the amended and pre-amended criteria of DC 7800, which contemplates scars or disfigurement of the head, face, or neck, a 10 percent rating is warranted for one characteristic of disfigurement. A 30 percent rating is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with two or three characteristics of disfigurement. A scar with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with four or five characteristics of disfigurement warrants a 50 percent rating. A scar with visible or palpable tissue loss and either gross distortion of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with six or more characteristics of disfigurement warrants an 80 percent rating. Note (1) following DC 7800 identifies 8 characteristics of disfigurement, for the purposes of evaluation under § 4.118: (1) scar 5 or more inches (13 or more cm.) in length; (2) scar at least one-quarter inch (0.6 cm.) wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and (8) skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Under both the amended and pre-amended criteria of DC 7804, which contemplates unstable or painful scars, a 10 percent rating is provided for one or two scars that are unstable or painful, a 20 percent rating is provided for three or four scars that are unstable or painful, and a 30 percent rating is provided for five or more scars that are unstable or painful. Note (1) provides 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, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under DC 7804, when applicable. Prior to August 13, 2018, under DC 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. Prior to August 13, 2018, DC 7813 instructed to rate dermatophytosis (of beard area, tinea barbae) as disfigurement of the, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), or dermatitis (7806) depending on the predominant disability. Prior to August 13, 2018, DC 7820 provides that infections of the skin not listed elsewhere in the rating schedule are to be rated as disfigurement of the head, face, or neck (DC 7800), scars (DC 7801-7805), or dermatitis (DC 7806), depending upon the predominant disability. "Corticosteroids or other immunosuppressive drugs" refers to any oral or parenteral medication(s) prescribed by a medical professional to treat the underlying skin disorder. For claims filed prior to August 13, 2018, the Court held that compensation is available for all systemic therapies that are "like or similar to corticosteroids or other immunosuppressive drugs." Warren v. McDonald, 28 Vet. App. 194, 197-99 (2016). A topical corticosteroid could be administered on a large enough scale to affect the body as a whole, thus meeting the definition of "systemic therapy." Johnson v. Shulkin, 862 F.3d 1351, 1354-56 (Fed. Cir. 2017). A systemic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 13, 2018, a new General Rating Formula for the Skin applies to DCs 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is assigned for at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. Additionally, effective August 31, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Turning to the evidence of record, the Veteran was afforded a VA skin examination in May 2012. At which time the Veteran's diagnosis was confirmed as PFB located on the face, chin, and neck. The examiner noted that there were no medications used for treatment nor any procedures conducted within the past 12 months. There were no reported debilitating or non-debilitating episodes. Upon physical examination, the examiner noted that less than 5 percent of the Veteran's total body area and less than 5 percent of exposed area were affected. However, the examiner noted that the Veteran's PFB "causes scaring". Lastly, no functional impact was reported as a result of the Veteran's skin condition. In May 2018, the Veteran was afforded another VA skin examination. Once more the Veteran's condition was diagnosed as PFB. The condition was noted as causing scarring however, at the time of examination the Veteran's skin condition was noted as "asymptomatic". Due to reports by the May 2018 examiner regarding scarring, the Veteran was afforded a VA scar examination that same month. It was noted by the examiner that the Veteran has two scars resulting from his PFB. The scars were located under the chin and on the neck measuring 13 by 7 centimeters and 18 by 7 centimeters respectively with a combined total affected area of 217 square centimeters. The scars were not painful or unstable however hyperpigmentation in both scars was noted. In July 2021, the Veteran testified that he has had "razor bumps" since service and currently still has the same issues however that are not as bad but "it is still irritable". See July 2021 Hearing, P. 6. 1. Entitlement to a compensable rating of 30 percent from May 23, 2012, but no higher, for pseudofolliculitis barbae with scarring is granted. 2. Entitlement to a rating in excess of 30 percent from May 17, 2018 for pseudofolliculitis barbae with scarring is denied. At the outset, the Board finds that the Veteran's condition is best rated under either the criteria of DC 7800 pertaining to scars or disfigurement of the head, face, or neck; DC 7804 pertaining to unstable or painful scars; and/or DC 7806 pertaining to dermatitis or eczema. Because his PFB affects his face and neck, rating under DC 7801 or 7802 is not warranted, and because DC 7805 is a catchall directing to rate under DC 7800-7804, rating under that criteria is not supported. Beginning with the May 2012 VA examination, the Veteran's PFB was noted as causing scarring and impacting less than 5 percent of his total body area. VA treatment records do not contain reports of scaring other than to note an ongoing history of PFB. There is no evidence of the use of medical treatments to include corticosteroids or immunosuppressive medications. As such, under the criteria of DC 7806 the Veteran's PFB met the criteria for a noncompensable rating under both the pre and post August 2018 amendments to DC 7806. As such, the Veteran's PFB is best rated under the criteria of DC 7800 for scars. Unfortunately, a VA scar examination was never conducted to ascertain the severity of the Veteran's scaring until after the May 2018 VA skin examination even though the May 2012 examiner noted that the Veteran's PFB caused scarring. The Veteran has testified that his symptoms have progressively gotten better since service once the need to shave frequently has stopped even if some irritation is still ongoing. The Board finds the Veteran's residual scarring caused by his PFB to be consistent throughout the period on appeal as first noted by scarring in the May 2012 VA examination, later reflected, and described in detail during the May 2018 VA scar examination and supported by the Veteran's July 2021 testimony. As such, resolving all reasonable doubt in favor of the Veteran, the Board finds a 30 percent rating under DC 7806 for residual scarring caused by his PFB is warranted from May 23, 2012, reflecting the first recorded notation of scarring resulting from PFB. Additionally, entitlement to an increased rating in excess of 30 percent under the criteria of DC 7800 has not been demonstrated at any time during the pendency of this appeal. According to the May 2018 VA examination, the Veteran's face and neck had scarring which resulted in hyperpigmentation and which were at least 0.6 cm. in width and 13 cm. or more in length, resulting in three characteristics of disfigurement. Four or five characteristics of disfigurement were not demonstrated as his PFB did not result in indurated and inflexible skin, missing underlying soft tissue, abnormal skin texture, adherence to underlying tissue, or elevated or depressed scar contour. Further, there was no visible or palpable tissue loss and either gross distortion or assymetry of two features or paired sets of features. As such, a rating in excess of 30 percent under the criteria of DC 7800 is not warranted. Furthermore, no scars were noted as painful or unstable. As such, a rating under DC 7804 is not applicable. Based on the foregoing, a rating of 30 percent for the Veteran's PFB from May 23, 2012 is warranted, and no higher, under the criteria of DC 7806-7800. The Board finds that the Veteran's disability is fully capable of evaluation under the rating schedule. New and Material A previously denied claim may be reopened by the submission of new and material evidence. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Evidence is new if it has not been previously submitted to agency decision makers. Id. Evidence is material if it, either by itself or considered in conjunction with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence cannot be cumulative or redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. Id. The phrase "raises a reasonable possibility of substantiating the claim" is meant to create a low threshold that enables, rather than precludes, reopening. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). For purposes of determining whether new and material evidence has been received to reopen a finally adjudicated claim, the evidence will be presumed credible. See Kutscherousky v. West, 12 Vet. App. 369, 371 (1999). 3. New and material evidence having been submitted, the claim for service connection for a bilateral knee condition is reopened. The RO, by a decision entered in December 2008, denied the Veteran's original claim for service connection for bilateral knee condition. Specifically, the RO denied on grounds that there was no evidence in service treatment records (STRs) for a diagnosis or treatment for arthritis or a knee condition. The RO further noted that arthritis is not a presumptive condition for herbicide exposure, no evidence of a diagnosis within one year of discharge from service, nor is there any evidence of a nexus otherwise linking the conditions to service. The RO notified the Veteran of its decision, and of his appellate rights, but he did not initiate an appeal of the RO's decision within one year. Nor was any new and material evidence received within a year. 38 C.F.R. § 3.156(b). As a result, the RO's decision became final. 38 U.S.C. § 7105 (West 2012); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103. Subsequently, the Veteran filed to reopen his claim for a bilateral knee condition in March 2010. The RO denied his request in July 2012. Accordingly, the claim may now be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a) (2018); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). At the time of the December 2008 rating decision, the record contained service treatment records that were silent as to any complaints, treatment or diagnoses relevant to the legs or knees, but do confirm the Veteran's service in Vietnam. The record also contained lay statements contending during service, the Veteran was issued combat boots that were two sizes too large causing aching in his feet, ankles, and knees. He contended that after service he needed knee surgery and developed arthritis in his legs. Treatment records indeed showed treatment for knee and leg complaints, to include knee surgery in 2008, but none of these records relate any knee or leg condition to any incident of service. Since December 2008, the new evidence includes, significantly, a July 2021 Board hearing transcript where the Veteran elaborated as to in-service training exercises that he believed caused injury to his knees and legs and ultimately resulted in four knee surgeries. For purposes of reopening a claim, the Board presumes the credibility of the evidence and because the testimony pertains to nexus, it is both new and material in that it relates to the unestablished fact from the prior denial. As such, the claim is deemed reopened and can be considered on the merits. 4. New and material evidence having not been submitted, the claim for service connection for hypertension, to include as secondary to diabetes and herbicide exposure, remains denied. The RO, by a decision entered in December 2008, denied the Veteran's original claim for service connection for hypertension. Specifically, the RO denied on grounds that there was no documented treatment for or diagnosis of hypertension during service nor evidence of such within one year of discharge. Also, there was no evidence of a secondary nexus between hypertension and his service-connected diabetes. The RO notified the Veteran of its decision, and of his appellate rights, but he did not initiate an appeal of the RO's decision within one year. Nor was any new and material evidence received within a year. 38 C.F.R. § 3.156(b). As a result, the RO's decision became final. 38 U.S.C. § 7105 (West 2012); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103. Subsequently, the Veteran filed to reopen his claims for hypertension in March 2010. The RO denied his request in July 2012. Accordingly, the claim may now be considered on the merits only if new and material evidence has been received since the prior final denial (i.e., the December 2008 decision). 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a) (2018); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). At the time of the December 2008 rating decision, the file included the Veteran's service treatment records, which were not indicative of hypertension, but did confirm the Veteran's Vietnam service. The record also included the Veteran's lay statements contending various theories such as his hypertension related to diabetes and/or incurred in service due to herbicide exposure. Since 2008, evidence added to the claims file indicate the Veteran's treatment records showing the Veteran is no longer on medication for hypertension and, indeed, does not appear to have a confirmed diagnosis of hypertension any longer. The Veteran testified before the Board in July 2021 that he did not have hypertension. Thus, the Board concludes the evidence received since the December 2008 rating decision is new, but it is not material. The evidence is considered "new" because it has not been reviewed by an agency decision maker; however, it is not "material" because it does not support an unestablished fact necessary to substantiate the Veteran's claims. Specifically, the Veteran's claim was denied for lack of a disability associated with his military service. While the newly associated evidence includes reference to past treatments for hypertension, it in fact supports the prior findings that the Veteran lacks a current diagnosis and therefore no nexus to service. Accordingly, the evidence received since the December 2008 rating decision is not new and material; thus, the Veteran's claim seeking service connection for hypertension remains denied. Service Connection Generally, a veteran is entitled to service connection for a disability resulting from a disease or injury incurred or aggravated during active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disease diagnosed after discharge may still be service connected if all the evidence establishes that it was incurred in service. 38 C.F.R. § 3.303 (d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Certain chronic diseases, including hypertension, may be presumed to have been incurred during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303 (b). The theory of continuity of symptomatology under 38 C.F.R. § 3.303 (b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A veteran, who during active military, naval or air service, served in the Republic of Vietnam during the Vietnam Era shall be presumed to have been exposed during his or her service to an herbicide agent, to include Agent Orange, unless there is affirmative evidence to the contrary. 38 U.S.C. § 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii). The following diseases will be deemed service connected if the requirements of 38 C.F.R. § 3.307(a) are met, even if there is no record of such disease during service: AL amyloidosis, chloracne or other acneform disease consistent with chloracne; type 2 diabetes (also known as Type II diabetes mellitus); Hodgkin's disease; chronic lymphocytic leukemia (CLL); multiple myeloma; Non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma), chronic B-cell leukemias, Parkinson's disease, and ischemic heart disease. 38 C.F.R. § 3.309(e). The absence of a specific disability on the list of enumerated diseases for which service connection due to in-service herbicide exposure is presumed, does not preclude the Appellant from establishing service connection based on a medical nexus between the disability and the Veteran's service (a direct basis). McLendon v. Nicholson, 20Vet. App.79 (2016); See Combee v. Brown, 34 F. 3d 1039, 1043-1044 (Fed. Cir. 1994). In other words, the mere absence of the disability on the presumptive list is not an adequate basis for denial of a service connection. To substantiate a claim of secondary service connection there must be evidence of (i) a current chronic disability for which service connection is sought; (ii) an already service-connected disability; and (iii) that the already service-connected disability (a) caused or (b) aggravated the disability for which service connection is sought. See Allen v. Brown, 7 Vet. App. 439 (1995). 5. Entitlement to service connection for arthritis of the legs, to include as due to herbicide exposure, is denied. 6. Entitlement to service connection for a bilateral knee condition is denied. The Veteran generally contends that his claimed arthritis of the legs and bilateral knee condition, however diagnosed, are related to service. Specifically, he asserts that his arthritis is caused by exposure to herbicides while serving in Vietnam and that he has had symptoms since service. The Veteran also contends that he injured his knees during basic training while performing required exercises to include "low crawl" with machine gun fire over his head. See July 2021 Board Hearing P. 3. At the outset, the Board notes, that the Veteran's DD-214 verifies that he served in Vietnam as a radio mechanic where he was awarded, along with other decorations, the Vietnam Service Medal with four bronze service stars. Therefore, the presumption of herbicide exposure attaches. However, arthritis is not a presumptive condition associated with Agent Orange exposure. See 38 C.F.R. § 3.309(e). Even so, a nexus can still be established on a direct basis for any disease not included on the list of presumptive diseases. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran's service treatment records (STRs) are silent for any treatment, complaints, or diagnosis of any bilateral knee condition or arthritis. Post service treatment records indicate a lengthy history of knee and lower leg injuries beginning in 1992 with a tibial plateau fracture and resulting surgery. In 2001 and again in 2003 the Veteran underwent a right knee meniscectomy. Lastly, the Veteran had a total left knee replacement in 2008. The Veteran was afforded a VA examination for his knees and lower legs in December 2012. The Veteran was diagnosed with bilateral degenerative joint disease. During the examination the Veteran reported stiffness and pain with ambulation however no swelling or locking. Range of motion testing was normal with no objective evidence of painful motion. Functional loss was noted with contributing factors of deformity, disturbance of locomotion and interference with sitting, standing and weight bearing. Muscle strength and stability test were normal with no additional conditions. Examiner noted the Veteran's lengthy history of knee surgeries and procedures. The Veteran was noted as regularly using a can and knee braces. Diagnostic testing confirmed presence of degenerative arthritis. The examiner ultimately opined that the Veteran's knee and lower leg arthritis was less likely than not related to service. He explained that the Veteran's STRs were silent for any evidence of knee problems. The examiner explained that the Veteran's tibial plateau fracture in 1992 was the result of an acute fall and he did not begin to report problems in the right knee until the late 1990's after "acute meniscus tear" with resulting surgery in 2001. Lastly, the examiner explained that due to the lack of any injuries or notations of knee or leg issues in his STRs, there is no indication that an incident in service would have caused his meniscus tear. The Board finds the December 2012 VA examiner's opinions to be persuasive. The examiner did not solely rely on the fact that arthritis is not a presumptive disease, but rather considered the results of an in-person examination, the Veteran's specific military and medical history, as well the Veteran's lay statements in developing his medical opinion. Cf. Polovick v. Shinseki, 23 Vet.App. 48 (2009). The Board acknowledges the Veteran's belief that there is such a causal connection, but finds the Veteran lacks the competency to render such a medically complex opinion. See Layno v. Brown, 6 Vet. App. 465, 469(1994). It is well established that a layperson without medical training is not qualified to render a medical opinion regarding the diagnosis or etiology of certain disorders and disabilities. See 38 C.F.R. § 3.159 (a)(1). It is not shown that the Veteran is otherwise qualified through specialized education, training, or experience to offer a medical opinion as to the etiology of his skin conditions. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Thus, with respect to a nexus between the Veteran's current degenerative arthritis and in-service occurrence, the Board assigns more probative weight to the December 2012 VA examiner's opinions which denied service connection after thorough review of the Veteran's file, medical history, lay reports of onset in service, and consideration of conceded herbicide exposure. Furthermore, these findings are consistent with the medical evidence of record and supported by a through rationale. As such, the Board finds no causal connection between the disease or injury in service and the current disabilities. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Board has also considered whether the Veteran is entitled to service connection for arthritis as "chronic disease." See 38 C.F.R. § 3.303 (b). The Board notes, that arthritis is considered a "chronic disease, however the Veteran was diagnosed with degenerative arthritis at the earliest, over four decades after his separation from active service. Other knee issues began in the 1990's after an acute fall as indicated by the December 2012 VA examiner which occurred over thirty years after service. The earliest reported injury or complaint to his lower legs and knees was in 1976, seven years after service, in which the Veteran testified that a car slipped into neutral and knocked him to the ground, afterwards "a doctor told me I had to have surgery". See July 2021 Board Hearing P. 4. None of these reported injuries occurred during service. Thus, the record does not show that the Veteran's disability manifested to a compensable degree within one year of separation as required under 38 C.F.R. § 3.303 (b) nor was it the result of an injury suffered during active-duty service. While the Veteran has reported onset of symptoms in and since service, the prolonged period from separation from service until, at the earliest 1976, without complaints and/or treatments for his alleged disabilities is evidence for consideration in determining continuity of symptomatology and weighs against a claim herein. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). Additionally, the Veteran has not submitted any evidence to contradict or discount the findings of the November 2012 VA examiner. In the absence of credible evidence of degenerative arthritis within one year after separation or credible evidence of continuity of symptomatology, service connection is not warranted on a presumptive basis under the provisions of 38 C.F.R. §§ 3.303 (b), 3.307, and 3.309. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. F. Minnitte, Attorney Advisor 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.