Citation Nr: A21020050 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 200527-88447 DATE: December 15, 2021 ORDER The claim for service connection and a separate 10 percent rating, but not higher, for a painful scar of the left knee throughout the claims period is granted. The claim for service connection for erectile dysfunction as secondary to service-connected hypertension is granted. The claim for service connection for a chronic respiratory disability, to include bronchitis, as due to asbestos exposure is denied. The claim for service connection for residuals of broken left hand is denied. The claim for service connection for a left hip disability is denied. The claim for service connection for a left leg disability is denied. The claim for service connection for a left ankle disability is denied. The claim for service connection for a right shoulder disability is denied. The claim for service connection for a right hip disability is denied. The claim for service connection for a right leg disability is denied. The claim for service connection for a right ankle disability is denied. The claim for service connection for bilateral pes planus is denied. The claim for service connection for bilateral plantar fasciitis is denied. The claim for service connection for neurological impairment of the left upper extremity is denied. The claim for service connection for neurological impairment of the left lower extremity is denied. The claim for service connection for neurological impairment of the right upper extremity is denied. The claim for service connection for neurological impairment of the right lower extremity is denied. The claim for service connection for irritable bowel syndrome (IBS) is denied. The claim for service connection for a head scar is denied. The claim for service connection for a left shoulder disability, to include as secondary to a service-connected disability, is denied. The claim for service connection for a cervical spine disability, to include as secondary to a service-connected disability, is denied. The claim for service connection for diabetes mellitus, to include glucose intolerance and hyperglycemia, is denied. The claim for service connection for a chronic skin disability other than tinea versicolor, claimed as eczema of the ankles and arms, is denied. The claim for service connection for folliculitis barbae is denied. The claim for service connection for an acquired psychiatric disorder, to include an anxiety disorder other than PTSD secondary to a service-connected disability, is denied. The claim for service connection for chronic fatigue, to include as secondary to a service-connected disability, is denied. The claim for service connection for insomnia, to include as secondary to a service-connected disability, is denied. REMANDED The claim for service connection for sleep apnea is remanded. FINDINGS OF FACT 1. The Veteran's left knee post arthroscopic surgery residuals manifest a single scar that is painful, stable, and superficial. 2. The Veteran's erectile dysfunction was incurred secondary to service-connected hypertension. 3. The Veteran does not have a chronic respiratory disability, to include bronchitis. 4. The Veteran does not have any chronic residuals of a broken left hand. 5. The Veteran does not have a chronic left hip disability. 6. The Veteran does not have a chronic left leg disability other than service-connected chondromalacia of the left knee. 7. The Veteran does not have a chronic left ankle disability. 8. The Veteran does not have a chronic right shoulder disability. 9. The Veteran does not have a chronic right hip disability. 10. The Veteran does not have a chronic right leg disability other than service-connected chondromalacia of the right knee. 11. The Veteran does not have a chronic right ankle disability. 12. The Veteran does not have bilateral pes planus. 13. The Veteran does not have bilateral plantar fasciitis. 14. The Veteran does not have chronic neurological impairment of the left upper extremity. 15. The Veteran does not have chronic neurological impairment of the left lower extremity, to include radiculopathy associated with a service-connected low back disability. 16. The Veteran does not have chronic neurological impairment of the right upper extremity. 17. The Veteran does not have chronic neurological impairment of the right lower extremity, to include radiculopathy associated with a service-connected low back disability. 18. The Veteran does not have IBS. 19. The Veteran does not have a scar of the head. 20. A left shoulder disability, currently diagnosed as a trapezoid strain and tendonitis, was not present in service or until years thereafter and is not etiologically related to any incident of active service and was not caused or aggravated by a service-connected disability. 21. A cervical spine disability, currently diagnosed as a trapezoid strain and tendonitis, was not present in service or until years thereafter and is not etiologically related to any incident of active service and was not caused or aggravated by a service-connected disability. 22. The Veteran does not have diabetes mellitus and glucose intolerance and hyperglycemia were not present in service or until years thereafter and are not etiologically related to any incident of active service. 23. The Veteran is service-connected for tinea versicolor; his reports of skin abnormalities are symptoms of his service-connected disability and do not manifest as a separate and distinct disability to include eczema and folliculitis barbae. 24. The Veteran is service-connected for PTSD; anxiety, fatigue, and insomnia are symptoms of his service-connected disability and do not manifest as separate and distinct disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection and a separate 10 percent rating, but not higher, for a painful scar of the left knee are met. 38 U.S.C. §§ 1110, 1131, 1155; 38 C.F.R. §§ 3.303, 4.7, 4.118, Diagnostic Code 7804. 2. The criteria for service connection for erectile dysfunction as secondary to service-connected hypertension are met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. 3. A chronic respiratory disability, to include bronchitis, was not incurred or aggravated due to asbestos exposure during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 4. Chronic residuals of a broken left hand were not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 5. A chronic left hip disability was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 6. A chronic left leg disability was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 7. A chronic left ankle disability was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 8. A chronic right shoulder disability was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 9. A chronic right hip disability was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 10. A chronic right leg disability was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 11. A chronic right ankle disability was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 12. Bilateral pes planus was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 13. Bilateral plantar fasciitis was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 14. Neurological impairment of the left upper extremity was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 15. Neurological impairment of the left lower extremity was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 16. Neurological impairment of the right upper extremity was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 17. Neurological impairment of the right lower extremity was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 18. IBS was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 19. A head scar was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 20. A left shoulder disability was not incurred in or aggravated by active service and was not proximately due to or the result of a service-connected disability. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. 21. A cervical spine disability was not incurred in or aggravated by active service and was not proximately due to or the result of a service-connected disability. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. 22. Diabetes mellitus, to include glucose intolerance and hyperglycemia, was not incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 23. A chronic skin disability other than tinea versicolor was not incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 24. Folliculitis barbae was not incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 25. An acquired psychiatric disorder other than PTSD, to include an anxiety disorder, was not incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 26. The criteria for a disability manifested by chronic fatigue are not met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. 27. The criteria for a disability manifested by insomnia are not met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1980 to November 2000. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2020 Higher-Level Review (HLR) decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's claims were developed in accordance with VA's modernized appeals system. They were initially denied in a February 2019 decision by the agency of original jurisdiction (AOJ). In January 2020, the Veteran filed a VA Form 20-0996 (Decision Review Request: Higher-Level Review) and requested readjudication of his claims via the HLR process. The AOJ issued the May 2020 HLR decision on appeal, which considered the evidence of record at the time of the prior February 2019 decision. In May 2020, the Veteran submitted a VA Form 10182, Decision Review Request: Board Appeal, and elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the original February 2019 rating decision on appeal. 38 C.F.R. § 20.301. Evidence was added to the claims file during a period of time when new evidence was not allowed. The Board may not consider this evidence in its decision. 38 C.F.R. § 20.300. The Veteran may file a Supplemental Claim and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. With respect to the remanded claim for service connection for sleep apnea, the additional evidence will be considered by the RO in the adjudication of the claim. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 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). Service connection may also be granted on a secondary basis for a disability which is proximately due to, or the result of an established service-connected disability. 38 C.F.R. § 3.310. Similarly, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. Allen v. Brown, 7 Vet. App. 439 (1995). In the latter instance, the nonservice-connected disease or injury is said to have been aggravated by the service-connected disease or injury. 38 C.F.R. § 3.310. In cases of aggravation of a veteran's nonservice-connected disability by a service-connected disability, such veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.322. 1. Entitlement to service connection for a painful scar of the left knee. The Veteran contends that service connection is warranted for a painful scar of the left knee. He is currently service-connected for a left knee scar as a residual of arthroscopic surgery and left knee chondromalacia. Service connection for the scar was awarded in the February 2019 rating decision on appeal with an initial noncompensable evaluation assigned from June 29, 2018. The Board finds that service connection and a separate 10 percent evaluation is warranted for the left knee scar to account for the Veteran's competent reports of pain associated with the scar. The Veteran's left knee scar is currently rated under Diagnostic Code 7802 pertaining to burn scars or scars due to other causes not of the head, face, or neck, that are not associated with underlying soft tissue damage. The Board finds that a separate 10 percent evaluation is appropriate under Diagnostic Code 7804 for scars that are unstable or painful. 38 C.F.R. § 4.118. The Veteran has provided competent lay evidence that he experiences pain in the left knee scar. Although the scar was described as not painful during a December 2018 VA examination, the Board will resolve any doubt in favor of the Veteran and finds that a separate 10 percent rating based on the lay evidence of pain is appropriate throughout the claims period. A higher rating under this diagnostic code requires more than two scars that are unstable or painful, but the Veteran's surgical residuals clearly manifest only one scar. A higher rating is also possible under Note (2) of Diagnostic Code 7804 which provides for an additional 10 percent evaluation for a scar that is both unstable and painful. Note (1) clarifies that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. In this case, there is no lay or medical evidence that the Veteran's left knee scar is unstable, and a higher rating is therefore not warranted. As a final matter, the Board notes that the assignment of a separate rating based on a painful scar does not violate VA's rule against pyramiding. See 38 C.F.R. § 4.14. The two relevant diagnostic codes in this case (7802 and 7804) pertain to separate and distinct symptomatology, i.e., the presence of a superficial scar without underlying tissue damage and pain associated with the scar. Thus, the Veteran is separately rated for distinct symptoms of the scar and the award of service connection and a second rating for pain is appropriate. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994) (Separate disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability). 2. Entitlement to service connection for erectile dysfunction, to include as secondary to a service-connected disability. The Board finds that service connection is warranted for erectile dysfunction as secondary to service-connected hypertension. Erectile dysfunction is first noted in the Veteran's medical records in September 2012, when the Veteran reported a history of the condition to his physician at the Naval Hospital Pensacola (NHP). The September 2012 naval physician also linked the Veteran's erectile dysfunction to medication used to treat hypertension. The competent evidence therefore establishes that erectile dysfunction was incurred secondary to service-connected hypertension and service connection is warranted. 3. Entitlement to service connection for a chronic respiratory disability, to include bronchitis, as due to asbestos exposure. 4. Entitlement to service connection for residuals of a broken left hand. 5. Entitlement to service connection for a left hip disability. 6. Entitlement to service connection for a left leg disability. 7. Entitlement to service connection for a left ankle disability. 8. Entitlement to service connection for a right shoulder disability. 9. Entitlement to service connection for a right hip disability. 10. Entitlement to service connection for a right leg disability. 11. Entitlement to service connection for a right ankle disability. 12. Entitlement to service connection for bilateral pes planus. 13. Entitlement to service connection for bilateral plantar fasciitis. 14. Entitlement to service connection for neurological impairment of the left upper extremity. 15. Entitlement to service connection for neurological impairment of the left lower extremity. 16. Entitlement to service connection for neurological impairment of the right upper extremity. 17. Entitlement to service connection for neurological impairment of the right lower extremity. 18. Entitlement to service connection for IBS. 19. Entitlement to service connection for a head scar. The Veteran contends that service connection is warranted for a chronic respiratory disability, residuals of a broken left hand, disabilities of the bilateral hips, legs, ankles, right shoulder, bilateral pes planus, bilateral plantar fasciitis, neurological impairment of the upper and lower extremities, IBS, and a scar of the head. The Veteran contends that the disabilities were incurred due to in-service injuries, or in the alternative, were incurred secondary to service-connected disabilities. The question for the Board is whether the Veteran has the current disabilities claimed. The Board concludes that the Veteran does not have the disabilities claimed, and has not had the conditions at any time during the pendency of the claims or recent to the filing of the claims. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). Service treatment records document several complaints relevant to the current claims, but the complaints are all acute in nature without evidence of chronic disabilities. For example, in January 1986, the Veteran was seen for left arm pain following a motor vehicle accident and was found to have a left arm soft tissue injury. Similarly, the Veteran twisted his left ankle in December 1986 playing basketball, sprained his right wrist in November 1989, and injured his left forearm after falling on some glass in April 1993. The Veteran also reported having an upset stomach in September 1982 and was seen for an acute episode of gastritis in July 1994. Regarding the claimed residuals of a broken left hand, there are no contemporaneous complaints in the service records, but the Veteran was noted to have a pre-service history of an unspecified left arm fracture on the December 1979 enlistment examination and a previous left wrist fracture in July 1984. Service records are negative for any complaints or treatment pertaining to the claimed respiratory, bilateral hip, bilateral leg, right ankle, right shoulder, bilateral foot, neurological, and scar disabilities. There are also no relevant abnormalities on the August 2000 separation examination. The separation report of examination and the report of medical history only document findings related to already service-connected conditions including disabilities of the knees, low back, stomach, hearing loss, and skin. Thus, the Veteran's service records do not document the presence of any chronic disabilities relevant to the current claims. Additionally, the Board observes that injuries and conditions documented during active service are not sufficient to establish the presence of a current disability. The requirement of a current disability is met by evidence of symptomatology at the time of filing or at any point during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319, 323 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013) (finding that the Board must address pre-claim evidence in assessing whether a current disability existed, for purposes of service connection, at the time the claim was filed or during its pendency). Thus, while service records may show some complaints of symptoms related to the current claims, they cannot serve to establish the presence of a current disability as they pertain to a period almost 20 years prior to receipt of the Veteran's claims in June 2018. The post-service evidence also does not establish the presence of the disabilities claimed by the Veteran. The record does not contain any post-service medical records documenting treatment for the claimed disabilities. Additionally, VA examiners in December 2018 and January 2019 concluded that the Veteran did not have disabilities of the bilateral legs other than service-connected chondromalacia of the knees, did not manifest neurological impairment of the lower extremities, and did not have disabilities of the bilateral hips or ankles, to include arthritis. The Veteran received consistent treatment for low back pain throughout the claims period, but denied any radiating pain or associated neurological impairment of the lower extremities in November 2010, December 2010, August 2011, and January 2019. There is also no post-service lay or medical evidence pertaining to the other claimed disabilities. In short, the post-service record does not contain evidence establishing the presence of the chronic disabilities claimed by the Veteran. The Board further observes there is no lay or medical evidence of actual functional impairment related to the Veteran's claimed disabilities. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018) (holding that the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and that "pain alone can serve as a functional impairment and therefore qualify as a disability."). In this case, the Veteran has not described any impairment during the applicable claims period related to the claimed conditions. Thus, the record does not establish any actual impairment associated with the claimed disabilities. The Board has also considered the Veteran's statements, but notes that he has not provided any specific lay evidence in support of the claims. In general, the Veteran lacks the expertise to specifically diagnose himself with any chronic disability. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) (finding veteran competent to testify as to ringing in the ears (tinnitus); Jandreau v. Nicholson, 492 F.3d 1372, 1377, Note 4 (Fed. Cir. 2007). The Veteran is competent to describe the symptoms he experiences, but has not provided any specific lay evidence in support of his claims, to include a description of any current symptoms or a report that a clinician has diagnosed him as having any of the currently claimed disabilities. Therefore, the record establishes that the Veteran does not have the disabilities claimed. Absent proof of the existence of the disability, there can be no valid claim. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Degmitech v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Accordingly, the preponderance of the evidence is against the claims and they are denied. 20. Entitlement to service connection for a left shoulder disability, to include as secondary to a service-connected disability. 21. Entitlement to service connection for a cervical spine disability, to include as secondary to a service-connected disability. 22. Entitlement to service connection for diabetes mellitus, to include glucose intolerance and hyperglycemia. The Veteran contends that service connection is warranted for a left shoulder disability, cervical spine disability, and diabetes mellitus. The Veteran specifically contends that service connection is warranted as directly due to service, or in the alternative, that his left shoulder and cervical spine conditions are secondary to service-connected knee and/or low back disabilities. The question for the Board is whether the Veteran has current disabilities that began during service or are at least as likely as not related to an in-service injury, event, or disease or are incurred or aggravated by a service-connected disability. While the Veteran has the disabilities claimed (or closely related conditions) and the evidence documents some injuries during service, the preponderance of the evidence weighs against a finding that the Veteran's shoulder, cervical, and diabetes-related disabilities began during service or are otherwise related to an in-service injury or service-connected disability. As a preliminary matter, the Board finds that the Veteran does not have diabetes mellitus. The Veteran's service and post-service medical records are entirely absent for findings of diabetes mellitus, though the Veteran reported a family history of the disease in August 2011. There is also no lay evidence of diabetes; the Veteran never reported receiving a diagnosis of the condition by any of his VA or military healthcare providers. However, while the Veteran has not been diagnosed with diabetes mellitus, the record contains findings of conditions that may be indicative of future diabetes. In August 2011, the Veteran's VA doctor noted the presence of impaired fasting glucose and hyperglycemia was identified by a naval hospital doctor in April 2016. A glucose intolerance was also diagnosed in January and February 2013. The Board has therefore expanded the Veteran's claim to include the findings of glucose intolerance and hyperglycemia. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (when a Veteran seeks benefits for a specific condition and is then diagnosed with a different but potentially related condition while the claim is being processed, VA may not reflexively treat the different conditions as separate claims). The Board finds that the first two elements of service connection are present. Post-service medical records document diagnoses of a left trapezoid muscle strain and tendonitis in connection with complaints of left shoulder and cervical pain. Additionally, as noted above, glucose intolerance and hyperglycemia have also been identified by various healthcare providers during the relevant claims period. Regarding the presence of an in-service injury, service treatment records show that the Veteran was treated for left arm injuries in January 1986 (following a motor vehicle accident) and in April 1993 when he fell cutting his arm on some glass. Laboratory results also showed that the Veteran's glucose level was elevated in July 1998. While there are no specific complaints related to the Veteran's cervical spine, the Veteran's neck was examined in connection with the January 1986 motor vehicle accident and an X-ray was ordered, indicating that an injury was suspected. The Board will therefore resolve any doubt in favor of the Veteran and finds that an in-service injury is established for all three claims. The Board must now determine whether the third element of service connectiona link between the current diagnoses and in-service injuriesis present. The Board notes that service and post-service records do not indicate such a link. Service records, while documenting treatment for acute left arm injuries and elevated glucose, do not establish chronic disabilities. The Veteran's left shoulder was not specifically involved in his two left arm injuries, and the July 1998 notation of elevated glucose was an isolated finding associated with a urinary tract infection. Furthermore, while the Veteran's neck was X-rayed in connection with the January 1986 motor vehicle accident, the Veteran denied experiencing any neck pain at that time and the X-ray of the cervical spine was normal. The Veteran's upper extremities, spine, and laboratory sugar levels were all normal at the August 2000 separation examination, and the Veteran specifically denied a history of pain in the shoulder or sugar in his urine on the accompanying report of medical history. Thus, service records do not support the claims for service connection. The post-service medical records also weigh against the claims. The earliest evidence of the claimed conditions dates from January 2010, almost 10 years after discharge, when the Veteran was seen at NHP with complaints of left shoulder and neck pain dating back only one to two months. He additionally complained of neck pain on two occasions in August 2018 and September 2018, but there is no indication of a link with service. There is also no competent medical evidence supporting the claim for service connection on a direct or secondary basis. None of the Veteran's treating healthcare providers have identified a relationship between active service and any left shoulder, neck, or glucose conditions. There is also no competent medical evidence supporting the Veteran's claims for service connection on a secondary basis. Based on the above, the Board finds that the competent medical evidence is against the claims of service connection. The Board has also considered the Veteran's contentions regarding service connection, but notes that as a lay person, he is not competent to opine as to medical etiology or render medical opinions in that respect. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Grover v. West, 12 Vet. App. 109, 112 (1999). The Board acknowledges that the Veteran is competent to report observable symptoms, but finds that his opinion as to the cause of these symptoms simply cannot be accepted as competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1131, 1336 (Fed. Cir. 2006). The Board also notes that the Veteran has not reported a continuity of symptoms since service to support his claims for direct service connection. In sum, the record shows that the first evidence of the Veteran's claimed disabilities was years after separation from service. In addition, there is no medical evidence indicating that the Veteran's claimed disabilities may be associated with active duty or are caused or aggravated by a service-connected disability. The Board therefore concludes that the evidence is against a nexus between the claimed disabilities and active service or any service-connected disability. Accordingly, the Board must conclude that the preponderance of the evidence is against the claims and they are denied. 38 U.S.C. § 5107(b). 23. Entitlement to service connection for a chronic skin disability other than tinea versicolor, claimed as eczema of the ankles and arms. 24. Entitlement to service connection for folliculitis barbae. 25. Entitlement to service connection for an acquired psychiatric disorder other than PTSD, to include an anxiety disorder as secondary to a service-connected disability. 26. Entitlement to service connection for chronic fatigue, to include as secondary to a service-connected disability. 27. Entitlement to service connection for insomnia, to include as secondary to a service-connected disability. The Veteran contends that service connection is warranted for various skin and psychiatric symptoms as manifestations of chronic disabilities. With respect to the claimed anxiety, fatigue, and insomnia, the Veteran contends these symptoms are manifested by separate chronic disabilities that warrant service connection on a secondary basis. The Board finds that all the symptoms described by the Veteran are manifestations of already service-connected disabilities and are not separate and distinct disabilities. Service connection for tinea versicolor was awarded in a November 2000 rating decision effective December 1, 2000. A VA examination in August 2000 showed "significant" tinea versicolor (de-pigmented areas of the skin) on the upper trunk. Service connection for PTSD was also awarded in a July 2020 rating decision from February 11, 2020, based on symptoms including anxiety and chronic sleep impairment. These grants of service connection account for the Veteran's complaints of skin, anxiety, and sleep disturbance symptoms. The competent medical and lay evidence does not establish the presence of other conditions to account for the Veteran's reported symptoms. Regarding his skin complaints, records from the NHP and VA Medical Center (VAMC) include atopic dermatitis and dermatophytosis on the Veteran's problem list in February 2014 and September 2018, respectively. However, the Board notes that the medical records on these dates are negative for actual skin abnormalities; in fact, the examination of the Veteran's skin in February 2014 was negative with no lesions or ecchymosis. A VA skin examination in December 2018 also specifically related dermatophytosis to the Veteran's service-connected tinea versicolor, specifying that tinea versicolor is a type of dermatophytosis currently affecting the Veteran's left forearm. No other skin conditions were identified or diagnosed, including folliculitis barbae. Thus, treatment records do not establish the presence of any additional skin conditions other than the service-connected tinea versicolor, to include any complaints or treatment of folliculitis affecting the Veteran's face and beard area. Similarly, there are no findings of acquired psychiatric disorder other than service-connected PTSD which specifically includes the Veteran's reports of anxiety, fatigue, and insomnia. In August 2018, the Veteran was seen at NHP with complaints of nightmares and anxiety. He requested medication for sleep and a mental health referral. He was referred to mental health for anxiety and PTSD with nightmares and was provided medication for anxiety, nightmares, and insomnia. A month later, in September 2018, the Veteran sought treatment with a private therapist with complaints of fatigue, depression, and trauma issues. He was specifically found to exhibit anxiety, sleep disturbance, and fatigue. Finally, review of the rating decisions pertaining to the award of service connection and compensation for PTSD clearly shows that the Veteran's current rating is based on his symptoms of anxiety, fatigue, and sleep disturbance/insomnia. In sum, the Board finds that the Veteran's complaints related to his skin, anxiety, fatigue, and insomnia are all fully contemplated by the service-connected tinea versicolor and PTSD. As he does not manifest disabilities that are separate and distinct from the already-service connected conditions, service connection on a direct or secondary basis is not warranted. As such, the claims for skin disabilities, an acquired psychiatric disorder, and fatigue and insomnia are denied. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea. The Board regrets further delay in this case, but finds that a remand is necessary to correct an error in the development of the claim for entitlement to service connection for sleep apnea that occurred prior to the February 2019 rating decision. Specifically, a remand is necessary to obtain a copy of a February 2017 sleep study performed by a VA contractor. Treatment records show that the Veteran was seen by his primary care provider at the VAMC in December 2016 with complaints of feeling tired and breathing cessation in his sleep. He requested a sleep study. The Veteran was referred to an outside sleep specialist and a sleep study was performed at Choice 30 Sleep Study in February 2017. A copy of the sleep study report was uploaded to VA's Vista Imaging system in September 2017, but a copy of the actual sleep study report is not included in the Veteran's claims file and is not available for review by the Board. The absence of the sleep study report (which is specifically referenced in the May 2020 HLR decision) is a violation of VA's duty to assist the Veteran in the development of evidence to support his claim. (Continued on the next page) The matter is REMANDED for the following action: Obtain a copy of the Veteran's February 15, 2017 sleep study report from the Biloxi's VAMC's Vista Imaging system. VA treatment records show that the private sleep study was added to VISTA Imaging on September 13, 2017. R. Behlen Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Department of Veterans Affairs 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.