Citation Nr: 21007577 Decision Date: 02/09/21 Archive Date: 02/10/21 DOCKET NO. 15-10 299A DATE: February 9, 2021 ORDER Entitlement to a compensable initial disability rating for bilateral hearing loss prior to May 15, 2018, and in excess of 10 percent, thereafter, is denied. Entitlement to service connection for obstructive sleep apnea, to include as secondary to a service-connected disability, is denied. Entitlement to service connection for right lower extremity peripheral neuropathy, to include as due to herbicide agent exposure, is denied. Entitlement to service connection for left lower extremity peripheral neuropathy, to include as due to herbicide agent exposure, is denied. FINDINGS OF FACT 1. Prior to May 15, 2018, the Veteran’s hearing loss has been manifested by no worse than Level I impairment in both ears. 2. As of May 15, 2018, the Veteran’s hearing loss has been manifested by no worse than Level II impairment in the right ear and Level VI impairment in the left ear. 3. The Veteran’s obstructive sleep apnea was not shown in service or for many years thereafter and is not otherwise etiologically related to active duty service, to include as secondary to a service-connected disability. 4. The Veteran’s right lower extremity neuropathy was not shown in service or for many years thereafter and is not otherwise etiologically related to active duty service. 5. The Veteran’s left lower extremity neuropathy was not shown in service or for many years thereafter and is not otherwise related to active duty service. CONCLUSIONS OF LAW 1. Prior to May 15, 2018, the criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.85, 4.86, Diagnostic Code (DC) 6100. 2. As of May 15, 2018, the criteria for a rating in excess of 10 percent for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.85, 4.86, DC 6100. 3. The criteria for service connection for obstructive sleep apnea, to include as secondary to a service-connected disability, have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.310. 4. The criteria for entitlement to service connection for right lower extremity peripheral neuropathy, to include as due to herbicide agent exposure, have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 5. The criteria for entitlement to service connection for left lower extremity peripheral neuropathy, to include as due to herbicide agent exposure, have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from April 1969 to January 1971. The Board of Veterans’ Appeals (Board) remanded the matter in October 2019 to obtain outstanding VA audiogram results with pure tone thresholds, obtain outstanding relevant VA and private medical records, and obtain medical opinions. The Board is now satisfied that there was substantial compliance with the remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-147 (1999). Increased Rating Disability evaluations are determined by applying a schedule of ratings which is based on average impairment of earning capacity based on the specific diagnostic codes identifying the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. 38 C.F.R. § 4.7. While the Board typically considers only those factors contained wholly in the rating criteria, it is appropriate to consider factors outside the specific rating criteria when appropriate in order to best determine the level of occupational and social impairment. See. Mauerhan v. Principi, 16 Vet. App. 436 (2002); Massey v. Brown, 7 Vet. App. 204, 208 (1994). In cases where the Veteran’s claim arises from disagreement with the initial evaluation following the grant of service connection, the Board shall consider the entire period of a claim to see if the evidence warrants the assignment of different ratings for different periods of time during these claims – a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999). 1. Entitlement to a compensable initial disability rating for bilateral hearing loss prior to May 15, 2018, and in excess of 10 percent thereafter The Veteran contends that he is entitled to a compensable disability rating for bilateral hearing loss prior to May 15, 2018, and in excess of 10 percent thereafter. He contends that the VA examinations do not accurately reflect his hearing loss because the room is quiet and does not reflect real world settings. Assignment of a disability rating for hearing loss is derived by a mechanical application of the rating schedule to the specific numeric designations assigned after audiology testing is completed. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Ratings for hearing loss, which range from noncompensable to 100 percent, are based on an organic impairment of hearing acuity as demonstrated by the results of speech discrimination tests together with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies of 1,000, 2,000, 3,000, and 4,000 Hertz (Hz). The degree of disability from service-connected hearing loss is rated based on 11 auditory acuity levels with Level I, representing essentially normal acuity, through level XI, representing profound deafness. See 38 C.F.R. § 4.85. Additionally, the schedule takes into account the effect of the Veteran’s hearing loss disability on occupational functioning and daily activities. Martinak v. Nicholson, 21 Vet. App. 447 (2007). An alternative rating method may be used when the pure tone threshold at each of the four specified frequencies (1,000, 2,000, 3,000, and 4,000 Hertz) is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1,000 Hz and 70 decibels or more at 2,000 Hz. 38 C.F.R. § 4.86. VA will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa based on whichever results in the higher numeral. Id. In hearing loss rating cases, an examination for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. Examinations are conducted without the use of hearing aids. 38 C.F.R. § 4.85(a). Prior to May 15, 2018 After a review of the record, the Board determines that a compensable rating is not warranted prior to May 15, 2018. Here, the clinical evidence fails to show that the Veteran had sufficient hearing loss to warrant the assignment of a compensable rating. A November 2012 VA examination reveals that the Veteran reported difficulty understanding speech in areas of background noise. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran’s Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 25 30 40 55 38 94 LEFT 25 40 50 60 41 94 Applying the results to Table VI, the findings yield a numeric designation of Level I in the right ear and Level I in the left ear. Entering the resulting bilateral numeric designation of Level I for the right ear and Level I for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a 0 percent disability rating under DC 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. Similarly, the Veteran underwent a September 2014 VA examination. He reported that he believed his hearing had worsened over the past two years and he depended heavily on his hearing aids to hear well. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran’s Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 20 40 50 55 41 92 LEFT 35 50 60 60 51 92 Applying the results to Table VI, the findings yield a numeric designation of Level I in the right ear and Level I in the left ear. Entering the resulting bilateral numeric designation of Level I for the right ear and Level I for the left ear to 38 C.F.R. § 4.85, Table VII, it again equates to a 0 percent disability rating under DC 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. The Veteran underwent a VA audiological evaluation in May 2016 and demonstrated the following pure tone thresholds:  HERTZ 1000 2000 3000 4000 Avg RIGHT 30 35 50 55 43 LEFT 35 40 55 55 46 However, this examination cannot be used to establish hearing loss on a statutory basis because, although speech recognition testing was used, it was conducted using the CID W-22 material rather than the appropriate Maryland CNC material. Next, the Veteran underwent a private audiological examination in November 2017, which showed the following pure tone threshold findings: HERTZ 1000 2000 3000 4000 Avg RIGHT 35 50 55 60 50 LEFT 35 50 60 60 51 However, this examination also cannot be used to establish hearing loss on a statutory basis because, the NU-6 material for speech recognition testing was used rather than the appropriate Maryland CNC material. Finally, the Veteran underwent a VA audiological evaluation in December 2017 and demonstrated the following pure tone thresholds: HERTZ 1000 2000 3000 4000 Avg RIGHT 25 35 45 55 40 LEFT 30 40 50 55 44 As with the May 2016 evaluation, the CID W-22 material for speech recognition was used rather than the appropriate Maryland CNC material, so this examination cannot be used to establish hearing loss on a statutory basis. Based on the evidence above, a compensable rating for the Veteran’s bilateral hearing loss prior to May 15, 2018 is not warranted. As of May 15, 2018 In an October 2020 rating decision, the Veteran was granted a 10 percent rating for bilateral hearing loss. After a review of the record, the Board determines that a rating in excess of 10 percent as of May 15, 2018 is not warranted. Specifically, the clinical evidence fails to show that the Veteran has sufficient hearing loss to warrant the assignment of a rating in excess of 10 percent. A May 2018 VA examination reveals that the Veteran reported that he wears binaural hearing aids and has difficulty understanding in both noisy and quiet situations, so he avoids them. He also reported having difficulty hearing on the telephone, he increases the volume on the television, and he frequently uses closed captioning. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran’s Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 35 50 60 65 38 86 LEFT 45 60 65 65 41 66 Applying the results to Table VI, the findings yield a numeric designation of Level II in the right ear and Level VI in the left ear. Entering the resulting bilateral numeric designation of Level II for the right ear and Level VI for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a 10 percent disability rating under DC 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. The Board expressly acknowledges its consideration of the lay evidence of record when adjudicating this claim, including the Veteran’s reports that his hearing has worsened, he has difficulty hearing others even in quiet situations, and that he has difficulty hearing the TV or while talking on the phone. The Veteran is competent to report difficulty with his hearing; however, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran describes is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran’s main complaint is reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Rossy v. Shulkin, 29 Vet. App. 142, 145 (2017). Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to a compensable rating prior to May 15, 2018 and a rating in excess of 10 percent for bilateral hearing loss thereafter. 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 claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Furthermore, service connection is warranted for a veteran who has been exposed to a toxic herbicide agent during active military service (subject to the requirements of 38 C.F.R. § 3.307(a)) for diseases such as chloracne or other acneform diseases consistent with ischemic heart disease, Type 2 diabetes, Hodgkin’s disease, non-Hodgkin’s lymphoma, porphyria cutanea tarda, multiple myeloma, prostate cancer, soft-tissue sarcomas, early-onset peripheral neuropathy, Parkinson’s disease, chloracne and respiratory cancers, and B-cell leukemias. 38 C.F.R. § 3.309(e). For diseases such as early-onset peripheral neuropathy, 38 C.F.R. § 3.307(a)(6)(ii) requires that the disease shall have become manifest to a degree of 10 percent or more within a year after the last date of active duty service. To determine whether a Veteran was exposed to herbicide agents, VA regulations state that a veteran who served in the Republic of Vietnam during the period from January 9, 1962 to May 7, 1975 shall be presumed to have been exposed during such service to certain toxic herbicide agents, with the most common being “Agent Orange,” unless there is affirmative evidence to the contrary. 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6). Therefore, if a Veteran served in-country in Vietnam, they are entitled to a presumption of herbicide exposure, and need not prove actual exposure to herbicides. The Veteran served in Vietnam during this time and is presumed to have been exposed to herbicide agents. 2. Entitlement to service connection for obstructive sleep apnea, to include as secondary to a service-connected disability The Veteran contends that he has had difficulty sleeping since service, but that his obstructive sleep apnea was caused or aggravated by his service-connected posttraumatic stress disorder (PTSD) or PTSD medication. After a review of the evidence, the Board concludes that while the Veteran has a current diagnosis of sleep apnea, the preponderance of the evidence weighs against finding that this disorder began during service or is otherwise etiologically related to an in-service injury, event, or disease, to include as secondary to a service-connected disability. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363. 1366 (Fed. Cir. 2009); 38 C.F.R. §§ 3.303(a), 3.304, 3.310. First, the service treatment records are silent for any complaints, symptoms, or a diagnosis related to sleep apnea. Specifically, the Veteran’s separation examination from January 1971was normal and he reported his medical condition as “good.” While the Veteran reports that he was first diagnosed with obstructive sleep apnea in 2012 and was experiencing sleep apnea symptoms for 10-15 years prior, a September 2012 sleep study was negative for sleep apnea and he was instead diagnosed with mild disordered sleeping. The Veteran was officially diagnosed with sleep apnea after a sleep study was performed in August 2014. Giving the Veteran the benefit of the doubt and determining that sleep apnea symptoms began 10-15 years prior to his first sleep study in 2012, the record demonstrates that the Veteran’s sleep apnea symptoms did not begin until at least 26 years after the Veteran separated from service. Therefore, continuity of symptoms has not been shown on a clinical basis. 38 C.F.R. § 3.303. The Board has considered the Veteran’s statements that his sleep apnea symptoms have persisted since service. However, the Board is unable to grant service connection purely on his statements alone. Specifically, while the Veteran has asserted continuous symptoms, the medical evidence of record weighs heavily against his testimony. The evidence does not show that his symptoms have persisted since service, and the Veteran’s contentions of continuous symptoms have not been consistent throughout the record. Specifically, the medical records first show complaints of difficulty sleeping and daytime fatigue beginning in December 2011, and while he stated he has had trouble sleeping since service, in 2014 he reported experiencing symptoms for the prior 10-15 years. Furthermore, the Board notes that the Veteran submitted claims for service connection in January 1971, August 2010, and July 2012, but did not file a claim for obstructive sleep apnea until December 2013. The Board can infer that the Veteran had knowledge of the VA benefits system at the time and had the opportunity to file a claim for obstructive sleep apnea. See generally, Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (Lance, J., concurring) (discussing the distinction between cases in which there is a complete absence of any evidence to corroborate or contradict the testimony, and cases in which there is evidence that is relevant either because it speaks directly to the issue or allows the Board as factfinder to draw a reasonable inference). Accordingly, service connection for obstructive sleep apnea is not warranted based on continuity of either the medical evidence or the Veteran’s statements. Next, despite the lack of continuous symptoms, service connection may still be warranted if the evidence otherwise indicates a relationship between the Veteran’s current disorder and his active duty service. However, the competent evidence fails to establish a nexus between active duty and the Veteran’s current sleep apnea. The medical treatment records between December 2011 and November 2020 detail treatment for sleep apnea that includes sleep studies, a CPAP machine, and recommendations on weight loss and reducing alcohol intake. A VA examination was scheduled to determine whether there is a nexus between the Veteran’s current disorder and an event or injury that occurred in service. In September 2014, the Veteran underwent a VA examination for obstructive sleep apnea. He reported that he was diagnosed with obstructive, central, and mixed sleep apnea in 1970, although there are no records of these diagnoses in evidence. He also reported that he began waking 2-3 times during the night in 1970 while on active duty in a combat zone in Vietnam, and that he began seeking treatment for these symptoms in 2004. He reported that he took over-the-counter Tylenol, which helped, although he continued to have difficulty staying asleep, which required him to take three naps per day for 15-20 minutes each. Lastly, he reported that he had difficulty driving and difficulty with concentration as a result of daytime fatigue. The September 2014 VA examiner did not provide a nexus opinion but noted that the Veteran suffered from persistent daytime hypersomnolence, took medication to treat his sleep apnea, and did not use a CPAP or other breathing machine. The Veteran underwent a second VA examination in April 2014. The examiner opined that the Veteran’s obstructive sleep apnea (OSA) is less likely than not proximately due to, the result of, or aggravated by his PTSD with depressive disorder. The examiner explained that while there are articles in the medical literature that report an association of obstructive sleep apnea with PTSD, “there are no controlled double blind prospective “gold standard” studies that have been completed that conclude PTSD causes OSA.” They further noted that there are “a host of retrospective statistical studies that…have marked limitations and selection biases.” They noted that there is no consensus that PTSD causes or aggravates OSA. Conversely, the examiner noted that it is clinically well-known that OSA is caused by anatomic upper airway obstruction and/or collapse and, in their opinion, it is impossible for a psychiatric condition to cause upper airway anatomic obstruction and/or collapse due to a lack of pathophysiologic mechanism. They further elaborated that obesity is the leading risk factor for OSA, and the Veteran’s sleep specialist recommended weight loss for the Veteran’s obesity level of a body mass index over 29. As such, they opined that it is more likely than not that the Veteran’s OSA was due to obesity post-service. The examiner reviewed the evidence of record and supported their opinion with well-supported and well-reasoned analysis, making it highly probative. Next, a medical expert in sleep medicine reviewed the file and provided an opinion in January 2019 at the request of the Board. The specialist opined that it is not likely that the currently diagnosed sleep apnea had its onset during the Veteran’s active service. First, the examiner noted that the Veteran’s reported sleep difficulties since service likely represent insomnia symptoms related to PTSD rather than sleep apnea symptoms, and that there was no documentation of symptoms suggestive of sleep apnea during the Veteran’s military service in the record. They noted that the Veteran reported in August 2014 that he began suffering sleep apnea symptoms 10-15 years prior to the 2014 sleep study. As such, the examiner noted that aging, which is one of the strongest predictors of sleep apnea, may have given rise to this disorder decades after service. Additionally, the examiner opined that it is not likely that the service-connected PTSD caused or aggravated the Veteran’s sleep apnea. They acknowledged that the Veteran submitted articles into evidence showing an association between sleep apnea and PTSD. However, the examiner noted that “the article only shows that patients with obstructive sleep apnea have an association of greater burden of mental health comorbidities than individuals without sleep apnea,” and that many veterans have both disorders, but that this is not evidence of causality. They also noted that further longitudinal studies that have not been carried out are required to examine this question. They concluded that there is no existing evidence that PTSD is a risk factor for the development of sleep apnea or that it worsens the severity of sleep apnea. Because the January 2019 examiner is a specialist in sleep medicine, reviewed the evidence of record, considered the Veteran’s contentions, reviewed the submitted articles associating sleep apnea and PTSD, and provided well-reasoned support for his opinions based on the medical literature, the Board finds this opinion highly probative. In response to this opinion, the Veteran asserted in an August 2019 letter that the article he submitted for review indicates that “pharmacologic therapy using hypnotic medication is the most common treatment for insomnia. However, some hypnotics, such as benzodiazepines, can have adverse effects on nocturnal respiration, thus exacerbating the OSA. Therefore, these should be used with caution for the patient with both OSA and insomnia.” The Board interprets the Veteran’s response as suggesting that his insomnia is a symptom of his PTSD, and treatment for insomnia with hypnotics such as benzodiazepines aggravates OSA, demonstrating that it is at least as likely as not that his PTSD treatment aggravated his OSA. However, the Board determines that this argument does not provide probative evidence that the Veteran’s PTSD treatment exacerbated his OSA because the records demonstrate that the Veteran was prescribed fluoxetine and sertraline (Zoloft) for his psychiatric symptoms, which are not hypnotics but are rather selective serotonin reuptake inhibitors. Nonetheless, the Veteran was provided a VA examination in March 2020 to opine whether the Veteran’s PTSD treatment caused or aggravated his sleep apnea. The examiner noted that the article submitted by the Veteran showing a connection between PTSD and OSA concluded that there are many errors in the study and “PTSD/depression/mood disorder do not cause sleep apnea.” After reviewing the evidence of record and the submitted article, the examiner opined that the Veteran’s PTSD treatment, specifically Zoloft, does not affect, cause, or aggravate the Veteran’s OSA. They opined that it is less likely than not that his sleep apnea is related to or affected by PTSD because sleep apnea is due to collapse or near collapse of the soft tissue cells of the pharynx when they relax in sleep. They further explained that “this is a physiologic condition unrelated to or affected by stress or emotional change or treatment of PTSD.” The examiner reviewed the record and the submitted article in forming their opinion while providing well-reasoned support, making their opinion highly probative. In arriving at these conclusions, the Board has considered the statements made by the Veteran asserting a causal connection between his sleep apnea and his active duty service. The Board also acknowledges that the Veteran contends that his sleep apnea was caused or aggravated by his service-connected PTSD. While lay statements may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his sleep apnea, especially given that the evidence fails to demonstrate the onset of sleep apnea in service, or any other in-service incident, illness, or injury to which such a condition may be presently linked. The Board concludes that the weight of the evidence is against the claim for service connection for obstructive sleep apnea and there is no doubt to be otherwise resolved. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The appeal is denied. 3. Entitlement to service connection for right lower extremity peripheral neuropathy, to include as due to herbicide agent exposure 4. Entitlement to service connection for left lower extremity peripheral neuropathy, to include as due to herbicide agent exposure The Veteran seeks service connection for bilateral lower extremity peripheral neuropathy which he contends is related to active duty service. Specifically, he asserts entitlement to presumptive service connection for early-onset peripheral neuropathy due to Agent Orange exposure during service in Vietnam. After reviewing all the evidence of record, the Board determines that service connection for peripheral neuropathy is not warranted. As an initial matter, the Board finds that the Veteran is not entitled service connection for early-onset peripheral neuropathy on a presumptive basis due to herbicide agent exposure per 38 C.F.R. § 3.307(a)(6)(ii). First, although the Veteran is presumed to have been exposed to herbicide agents, the evidence of record does not contain a diagnosis for early-onset peripheral neuropathy during or within one year of service. Specifically, his separation examination in January 1971 was normal and the Veteran reported his medical condition as “good.” Moreover, the record does not show treatment for complaints of neuropathy symptoms until October 2012, although the Veteran reported that he has been having tingling symptoms since 1994. This is approximately 23 years after the Veteran separated from service. Next, although the Veteran is nor entitled to presumptive service connection for peripheral neuropathy due to herbicide agent exposure per 38 C.F.R. § 3.307, he is not precluded from demonstrating that his peripheral neuropathy was proximately due to, the result of, or aggravated by his Agent Orange exposure or other in-service illness, event, or injury. See Combee v. Brown, 43 F3.d 1039, 1041-42 (Fed. Cir. 1994). However, the competent evidence fails to establish a relationship between active duty and the Veteran’s current neuropathy. First, the Veteran’s service treatment records do not contain evidence of any complaints of, treatment for, or clinical observations of peripheral neuropathy. Of note, the January 1971 separation examination noted normal feet, lower extremities, and neurologic functioning. Indeed, the records do not indicate diagnoses or treatment for neuropathy until October 2012. The Board notes that the Veteran concedes that he has not experienced peripheral neuropathy symptoms since service, but rather that he began experiencing tingling in his lower extremities in 1994, approximately 23 years after service. Therefore, service connection is not warranted based on continuity of symptoms. Next, service connection may be granted if the evidence otherwise reflects that his current peripheral neuropathy is related to service. However, after a review of all available evidence, service connection is also not warranted on this basis. Specifically, the Veteran underwent a VA examination in September 2014. While the examiner did not provide a nexus opinion, they noted the Veteran’s reports that he began experiencing on and off tingling in his upper thighs in 1994 that continued for years. He reported first seeking treatment in September 2012 after a marked increase in tingling and associated pain in the upper thighs while walking and standing often. He reported treatment with gabapentin but noted that the neuropathy had increased and spread to his bilateral lower legs and feet. He noted that it caused daily pain that lasted for a half hour. Furthermore, he reported limitations in standing, sitting, or walking too long or climbing stairs, and that he experienced flare-ups that caused numbness in his feet once per week. A VA examiner in March 2020 opined, based on the evidence of record, that the Veteran’s neuropathy was less likely than not caused by exposure to Agent Orange in service, because neuropathy must occur within one year of exposure to the herbicide agent to be considered a result of exposure. The examiner noted that the Veteran had normal examination findings from service through 2010 and 2011 and was not diagnosed with neuropathy until 2012. The examiner also noted that the article submitted by the Veteran only argues Agent Orange exposure in water but does not change the presumptive diseases. Additionally, it is already conceded that the Veteran was exposed to Agent Orange. Because the examiner reviewed the evidence of record, including articles submitted by the Veteran, considered the Veteran’s contentions, and provided well-reasoned support for their opinion, it is of great probative value. In support of his claim, the Veteran submitted a disability benefits questionnaire in September 2014, as well a statement from the same provider in April 2016, that states that the Veteran has mild sensory distal polyneuropathy with an etiology of prediabetes. However, the physician noted that there is no way to prove or not whether his neuropathy could be related to chemical exposure, and they could not eliminate that possibility. However, this is not an opinion on whether it is at least as likely as not that his neuropathy was related to herbicide agent exposure during service. As such, this opinion is of no probative value. In arriving at these conclusions, the Board has considered the statements made by the Veteran asserting a causal connection between his peripheral neuropathy and his active duty service. The Board also acknowledges that the Veteran contends that his peripheral neuropathy was caused by herbicide agent exposure, and that it could be a case of delayed onset due to Agent Orange exposure. The Board notes that the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his peripheral neuropathy, especially given that the evidence fails to demonstrate the onset of peripheral neuropathy in service, or any other in-service incident, illness, or injury to which such a condition may be presently linked. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board concludes that the weight of the evidence is against the claim for service connection for peripheral neuropathy and there is no doubt to be otherwise resolved. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The appeal is denied. 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. B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Veltri, Associate Counsel