Citation Nr: 21009455 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 15-13 302 DATE: February 22, 2021 ORDER Service connection for a gastrointestinal disorder, to include irritable bowel syndrome (IBS), is denied. Service connection for bilateral hearing loss is denied. Service connection for tinnitus is denied. Service connection for a respiratory condition is denied. Resolving reasonable doubt in the Veteran’s favor, service connection for obstructive sleep apnea is granted. FINDING OF FACT 1. The preponderance of the evidence is against finding that the Veteran has a currently diagnosed gastrointestinal disorder that began during active service or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence of record is against finding that the Veteran has had a bilateral hearing loss disability at any time during or approximate to the pendency of the claim. 3. The Veteran’s tinnitus was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 4. The preponderance of the evidence of record is against finding that the Veteran has had a respiratory condition at any time during or approximate to the pendency of the claim. 5. Sleep apnea is shown to be related to service by competent medical evidence. CONCLUSION OF LAW 1. The criteria for service connection for a gastrointestinal disorder, to include irritable bowel syndrome (IBS), are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 2. The criteria for service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for tinnitus are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for a respiratory condition are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 5. The criteria for service connection for sleep apnea are met. 38 U.S.C. §§ 1110, 1131, 1154(a) 5107; 38 C.F.R. §§ 3.102, 3.303, REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1988 to December 1992, including in the Southwest Asia Theater of Operations after August 1, 1990. These matters come before the Board of Veterans’ Appeals (Board) from August 2013, February 2015, and January 2018 rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA). This matter was previously before the Board in February 2019 but was remanded for further development. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.800 (c). 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). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be established for a Persian Gulf War veteran who exhibits objective indications of a qualifying chronic disability resulting from an undiagnosed illness or medically unexplained chronic multisymptom illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multisymptom illness that are defined by a cluster of signs or symptoms such as: (a) chronic fatigue syndrome, (b) fibromyalgia, (c) irritable bowel syndrome, or (d) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection. The term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, nonmedical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a). The term “Persian Gulf Veteran” means a Veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317 (d). The Veteran’s service records reflect service in the Southwest Asia theater of operations during the Persian Gulf War. Thus, the provisions of 38 C.F.R. § 3.317 are applicable. Consideration of a Veteran’s claim under this regulation does not preclude consideration of entitlement to service connection on a direct basis. 1. Service connection for a gastrointestinal disorder, to include irritable bowel syndrome (IBS), is denied. The Veteran seeks service connection for a gastrointestinal disorder, to include IBS. The Veteran contends his symptoms began in 1992 or early 1993. See January 2018 notice of disagreement. For the reasons that follow, the Board finds entitlement to service connection for a gastrointestinal disorder is not warranted. The Veteran had active service in the Arabian Sea and the Persian Gulf from August 1990 to January 1991 and from January 1991 to April 1991. Therefore, he is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). A June 2013 VA Gulf War examination reflects a diagnosis of gastroesophageal reflux disease (GERD). As the Veteran’s GERD is a diagnosed condition, it cannot be considered an undiagnosed illness. 38 C.F.R. § 3.317(a)(1)(ii). Moreover, GERD is a structural gastrointestinal disorder and therefore not considered a MUCMI. 38 C.F.R. § 3.317(a)(2)(i)(B)(3); 76 Fed. Reg. 41,696 (Jul. 15, 2011); see Atencio v. O’Rourke, 30 Vet. App. 74, 83 (2018). Thus, presumptive service connection for GERD under § 3.317 is not warranted. Although presumptive service connection for GERD under §3.317 is not warranted, VA must also consider the claim on a direct service-connection basis. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Thus, the question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of GERD, and he reports symptoms since 1992, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of GERD began during service or is otherwise related to an in-service injury, event, or disease. The Veteran’s service treatment records are silent for complaints of, treatment for, and/or a diagnosis of a gastrointestinal disorder. He denied a history of pain or pressure in chest; chronic cough; frequent indigestion; and stomach, liver, or intestinal trouble on his June 1988 enlistment report of medical history. His June 1988 enlistment and October 1992 separation reports of medical examination also note a normal clinical evaluation of the abdomen and viscera. Post-service, a September 2010 VA treatment record notes GERD and abdominal pain. A July 2011 VA treatment record notes a history of GERD. A February 2012 VA treatment record notes GERD on Prilosec, and an October 2012 VA treatment record notes GERD stable on proton pump inhibitor (PPI). The Veteran underwent a VA Gulf War examination in June 2013. The examiner diagnosed GERD with an unknown date of diagnosis. During the examination, the Veteran reported suffering from heartburn, burping, nausea, and vomiting after meals while deployed. He indicated that he went to the doctor and was prescribed medication but did not take them because of the side effects. An October 2017 report of consultation and examination by the Veteran’s private diagnostic consultant, P.Y., Doctor of Chiropractic (D.C.), notes a diagnosis of IBS. The physician noted the Veteran was diagnosed with IBS via intermittent constipation and diarrhea, which has been present since his Gulf War service without hiatus. The physician opined that it is as likely as not that his IBS is ‘directly and causally related to Gulf War Syndrome per the presumptions (undiagnosed illness) published in Gulf War. Spring 2015. www.publichealth.va.gov.’ He further opined that it is as likely as not that the Veteran’s IBS is directly and causally related to his military service. Finally, the physician noted that IBS is a permanent condition that had its onset during deployment to Desert Storm and has persisted to the present. The Veteran underwent a VA intestinal conditions examination in December 2017.The examiner indicated that the Veteran does not have an intestinal condition. The examiner noted current symptoms of stomachache, constipation, and having to avoid dairy products due to stomach cramps. The December 2017 examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, or event. The examiner noted that, based on examination and all available documentation, there is no evidence of irritable bowel syndrome, which is a disease with a clear and specific etiology and diagnosis. The examiner noted review of the Veteran’s claims file, including the October 2017 private report of consultation and examination, but reiterated that examination did not find any evidence of IBS and, thus, IBS is not corroborated as being related to a specific exposure event due to service in Southwest Asia. In compliance with the Board’s February 2019 remand directives, a VA addendum opinion was obtained in February 2020. The examiner opined that the Veteran’s GERD was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran reported suffering from heartburn, burping, nausea, and vomiting after meals during deployment; however, there is no evidence of a GERD diagnosis during active duty or within one-year of separation from service. His claims file notes heartburn in 2010 on a nutrition consult with 35-pound weight gain in one and a half to two years. The examiner noted that heartburn, burping, nausea, and vomiting are not diagnostic of GERD as the differential can also include H pylori, gastritis, peptic ulcer disease, and gastroenteritis. After a review of the evidentiary record, the Board finds the preponderance of the evidence weighs against finding entitlement to service connection for a gastrointestinal condition is warranted. Regarding the Veteran’s asserted diagnosis of IBS, the Board finds that the Veteran does not have a current diagnosis of IBS and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). While P.Y., a chiropractor and diagnostic consultant, stated in an October 2017 consultation and examination report that the Veteran had IBS, there is no indication that he performed a physical examination or any diagnostic tests to confirm the presence of IBS. Instead, the statement appears to be based on the Veteran’s self-reported medical history, which is inconsistent with medical treatment records that show no diagnosis of IBS prior to or after this evaluation. Consequently, this opinion is afforded little probative weight. While the Veteran believes he has a current diagnosis of IBS, he is not competent to provide such a diagnosis. IBS is medically complex, and rendering a diagnosis requires specialized medical education and knowledge and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Regarding the Veteran’s currently diagnosed GERD, the Board finds the preponderance of the evidence weighs against finding that the Veteran’s GERD onset in service or is otherwise related to service. His VA treatment records are silent for a diagnosis of a gastrointestinal disorder until 2010, years after his separation from service. While the Veteran is competent to report having experienced heartburn, burping, nausea, and vomiting since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of GERD. The issue is medically complex, as it requires knowledge and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Additionally, while the Veteran is competent to report symptoms observable to a lay person, such as burping, the Board finds the Veteran’s reports of such symptoms to be less probative than the competent medical evidence of record as the Veteran’s reports are inconsistent with his medical treatment records, which contain no complaints of such symptoms at separation from service. Further, the February 2020 VA examiner opined that the Veteran’s GERD is not at least as likely as not related to an in-service injury, event, or disease, including a specific exposure event in-service. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is not applicable. Accordingly, service connection for a gastrointestinal disorder is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 2. Service connection for bilateral hearing loss is denied. The Veteran seeks service connection for bilateral hearing loss. The Veteran reports in-service noise exposure from small arms fire, heavy artillery, grenades, helicopter, aircraft engines, tanks, and 120-milimeter cannons. For the reasons that follow, the Board finds that entitlement to service connection for bilateral hearing loss is not warranted. The Veteran’s DD Form 214 reflects a military occupational specialty of Tank Crewman. The circumstances of his military service are consistent with the reported noise exposure. As such, the Board concedes the Veteran had noise exposure in service. 38 U.S.C. § 1154 (a). Thus, the question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to such in-service noise exposure. The Board concludes that the Veteran does not have a current diagnosis of bilateral hearing loss and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). While in-service noise exposure is conceded, the Veteran’s service treatment records are silent for complaints of, treatment for, and/or a diagnosis of hearing loss. There is also no contemporaneous medical diagnosis of a bilateral hearing loss disability that meets the standard of 38 C.F.R. § 3.385 within a year of separation from service. The Veteran underwent a VA hearing loss examination in June 2013. Pure tone thresholds, in decibels (dB), were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 25 25 25 25 LEFT 25 25 30 30 25 Speech audiometry revealed bilateral speech recognition ability of 96 percent. In compliance with the Board’s remand directives, the Veteran’s February 2014 fee-based audiology results were requested. The request obtained a November 2014 VA audiology note that indicates pure tone thresholds obtained for both ears were deemed unreliable and will not be reported. The audiologist noted the Veteran answered her questions appropriately when asked through headphones at 50dB AU but did not respond to pure tone stimuli in the right ear at any presentation level at any frequency and the left ear pure tone average was 90dB. These results did not correspond with the otoacoustic emission (OAE) results obtained. The audiologist also noted speech discrimination scores obtained were deemed unreliable. In November 2015, the Veteran reported in-service noise exposure, including being constantly surrounded by tanks at each duty station. See November 2015 correspondence. In December 2015, the Veteran’s wife reported that the Veteran cannot hear. See December 2015 correspondence. An October 2017 private report of consultation and examination by the Veteran’s diagnostic consultant, P.Y., D.C., notes the Veteran was exposed to acoustic trauma of mortars, rockets, grenades, tank cannons, tank engines, and tank exhaust noise. He indicated the Veteran has suffered from progressive bilateral hearing loss. The physician reported the Veteran has bilateral hearing loss under normal conditions of 30 percent of the left ear and 30 percent for the right ear. The physician opined that it is as likely as not that the Veteran’s hearing loss is directly and causally related to the acoustic trauma. October 2017 audiometry results by J.A., hearing aid dispenser (HAD), were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 60 55 60 -- 65 LEFT 50 50 60 -- 60 Speech discrimination scores were not provided. The Veteran underwent another VA examination in December 2017 by an audiologist, who is competent to assess hearing loss disabilities. The examiner deemed the pure tone thresholds obtained for both ears unreliable and did not report them. The examiner similarly found that the use of speech discrimination scores was not appropriate for the Veteran because of language difficulties, cognitive problems, and/or inconsistent speech discrimination scores. An opinion on the etiology of the Veteran’s claimed bilateral hearing loss could not be provided. After a review of the evidentiary record, the Board finds the preponderance of the evidence weighs against finding entitlement to service connection for a bilateral hearing loss disability for VA purposes. The Board concludes the Veteran has not had a diagnosed bilateral hearing loss disability for VA purposes at any time during or approximate to the appeal period. In reaching this conclusion, the Board acknowledges the Veteran and his wife have reported he has experienced hearing loss. The Board recognizes that they are competent to describe impaired hearing, which is within the realm of their personal experience. 38 C.F.R. § 3.159. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir. 2007). Nonetheless, determining whether a hearing loss disability exists, as defined by 38 C.F.R. § 3.385, is not a simple medical condition or determination because the diagnosis is based on results of audiology testing. A hearing loss disability under 38 C.F.R. § 3.385 is also not a condition under case law that has been found to be capable of lay observation. For these reasons, the Veteran and his wife, as laypersons, are not competent to state that his level of impaired hearing reaches the level of the legal standards of a hearing loss disability for the purpose of VA disability compensation under 38 C.F.R. § 3.385. The Board also acknowledges that the October 2017 private audiometry results reflect pure tone thresholds consistent with a hearing loss disability for VA purposes; however, the Board notes that the October 2017 private audiometry testing was not conducted by a state-licensed audiologist. The results also fail to include a controlled speech discrimination test (Maryland CNC). See 38 C.F.R. § 4.85. Thus, the Board finds the results to be worth no probative value. As the competent evidence fails to show a hearing loss disability for VA purposes in service, within the presumptive period, or at any time during the current appeal, service connection for a bilateral hearing loss disability is not warranted. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The preponderance of the evidence is against the claim; there is no doubt to be resolved. Service connection for bilateral hearing loss is not warranted. 3. Service connection for tinnitus is denied. The Veteran seeks service connection for tinnitus. The Veteran contends his tinnitus is due to in-service noise exposure, including from small arms fire, heavy artillery, grenades, helicopter, aircraft engines, tanks, and 120-milimeter cannons. For the reasons that follow, the Board finds that entitlement to service connection for tinnitus is not warranted. As discussed above, the Board has conceded in-service noise exposure. 38 U.S.C. § 1154(a). A June 2013 VA examination also reflects a current diagnosis of recurrent tinnitus. Thus, the question for the Board is whether the Veteran’s currently diagnosed tinnitus began during service or is at least as likely as not related to his in-service noise exposure. While the Veteran has a current diagnosis and in-service noise exposure has been conceded, the Board finds the disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period and was not noted in service with attributable continuity of symptomatology. His service treatment records are silent for complaints of, treatment for, and/or a diagnosis of tinnitus. The Veteran denied a history of ear, nose, or throat trouble and/or hearing loss on his June 1988 enlistment report of medical history. His June 1988 enlistment and October 1992 separation reports of medical examination also reflect normal clinical evaluations of the ears. Post-service, a September 2010 VA treatment record reflects the Veteran denied tinnitus or vertigo. The evidence of record is otherwise silent regarding tinnitus until the Veteran’s application for service connection in January 2013. In January 2013, the Veteran reported never going to medical because being hurt was a sign of weakness. He indicated he experiences ringing in the ear from his service. The Veteran underwent a VA examination in June 2013. The examiner noted the Veteran reports recurrent tinnitus with recurrent left ear tinnitus over the past twenty-two years two or three times a day. The examiner indicated that the claims file was requested but was not made available for review such that an opinion could not be offered. A November 2014 audiology note reflects constant bilateral tinnitus with onset reported as unknown. A November 2014 VA examination notes the Veteran reports recurrent tinnitus but does not remember when he first noticed his constant bilateral tinnitus. The examiner noted that testing revealed unreliable puretone thresholds and speech discrimination results for both ears; therefore, the Veteran’s current hearing status is unknown. Due to the unknown status of the Veteran’s hearing, an opinion regarding the etiology of tinnitus could not be provided. In November 2015, the Veteran reported the ringing in his ear has been constant since 1989. He reported ear pain, headaches, itchy and watery eyes that are directly related to tinnitus and indicated he had similar symptoms on active duty. An October 2017 private report of consultation and examination from the Veteran’s diagnostic consultant, P.Y., D.C., notes the Veteran was exposed to the acoustic trauma of mortars, rockets, grenades, tank cannons, tank engines, and tank exhaust noise. The physician noted the Veteran suffers from bilateral tinnitus and opined that his tinnitus is as likely as not directly and causally related to the acoustic trauma incurred in service. The Veteran underwent a VA examination in December 2017. The examiner noted the Veteran reported recurrent tinnitus. The examiner noted tinnitus in both ears for the past 10 to 15 years with no specific cause. Tinnitus is intermittent and lasts for hours at a time. The examiner indicated that the Veteran’s current hearing status is not known such that the etiology of his tinnitus cannot be determined. A VA addendum opinion was obtained in November 2019. The examiner opined that the Veteran’s tinnitus was less likely than not incurred in or caused by the claimed in-service injury, event, or disease. The examiner noted that his 1988 enlistment and his 1992 separation examinations indicate hearing within normal limits. His service treatment records reflect no clinically significant increase in thresholds over time in service compared to his 1988 examination. The examiner further noted that while the Veteran’s reports of military noise exposure and/or reports of subsequent difficulties are noted, there is a lack of objective evidence of damage to the auditory system over time in service as evidenced by permanent clinically significant increases in threshold based on frequency specific audiological testing. The examiner indicated that the Institute of Medicine (IOM) carried out a study mandated by Congress and sponsored by the Department of Veterans Affairs to assess issues related to noise-induced hearing loss and tinnitus associated with service in the Armed Forces since World War II. In its report, “Noise and Military Service- Implications for Hearing Loss and Tinnitus,’ the IOM acknowledges that hearing loss can be associated with acoustic trauma/hazardous noise but points out that the likelihood of this is based on many factors. The examiner reported that, based on numerous studies, the IOM report indicated that ‘the evidence is not sufficient to determine the probability of acquiring noise-induced hearing loss associated with service in the military, or in specific branches of the military for a given individual. The probability of acquiring noise-induced hearing loss can only be determined precisely with well-controlled, longitudinal epidemiological studies.’ The examiner further indicated that the IOM report indicated that ‘the evidence was not sufficient to reach conclusions regarding the specific number or proportion of service members, overall or in specific branches or occupational groups, who report that tinnitus began or was exacerbated by noise exposure during military service.’ The examiner noted that it is not well-founded to state that any specific individual’s tinnitus is or is not due to noise exposure in military service based solely on his or her branch of service or military occupation when other direct evidence is available (i.e., adequate audiological examinations from time in service.) Finally, the examiner noted that, while research has continued since the publication of the IOM study, and while such research will no doubt lead to improved understanding and assessment tools, the most accepted clinical standard of evidence of damage to the auditory system due to acoustic trauma remains permanent clinically significant increase in thresholds as measured by audiological testing. An addendum opinion was obtained in January 2020. The examiner opined that the condition was less likely than not incurred in or caused by his claimed in-service injury, event, or disease. In addition to the November 2019 rationale, the examiner noted the Veteran’s 2013 examination indicated hearing within normal clinical limits for most frequencies but did indicate a clinical degree of hearing loss at 800Hz at the right ear and at 2000, 3000, and 8000Hz at the left ear. The examiner conceded the high likelihood of hazardous noise exposure related to the Veteran’s military occupational specialty but found that the Veteran’s current tinnitus is less likely than not related to noise exposure in active duty service. After a review of the evidentiary record, the Board finds the preponderance of the evidence weighs against finding entitlement to service connection for tinnitus. VA treatment records are silent for complaints of tinnitus until the Veteran’s 2013 application for service connection such that a diagnosis of tinnitus is not documented until his June 2013 VA examination, decades after his separation from service. His service treatment records do not show complaints of or treatment for ringing in the ears. At separation, he was found to have a normal clinical evaluation of the ears. The Veteran reports onset of tinnitus in service and continuity of symptoms since service; however, he denied tinnitus during treatment in 2010. While the Veteran is competent to report having experienced symptoms of ringing in the ears since service and consistently since service, his statements are found to be not credible because they are inconsistent with prior statement made to medical providers. Thus, the Board concludes that, while the Veteran has tinnitus, which is a chronic disease under 38 C.F.R. § 3.309 (a), it was not shown as chronic in service or within a presumptive period, did not manifest to a compensable degree within a presumptive period, and was not noted in service with credible evidence of continuity of symptomatology. Service connection on a direct basis - through a casual nexus between tinnitus and in-service noise exposure - is also not established. The most probative nexus opinions are the unfavorable November 2019 and January 2020 VA medical opinions. The examiner’s opinion was based on review of the Veteran’s service and post-service treatment records and his lay statements, and they were supported with a rationale that is factually consistent with the record. Moreover, the VA examiner is qualified through education, training, and experience to opine that the Veteran’s tinnitus is not related to service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). In reaching this conclusion, the Board acknowledges that the 2019 and 2020 VA examiner relied, in part, on the 2005 IOM report as a basis for providing a negative nexus opinion and, in June 2019, the U.S. Court of Appeals for Veterans Claims (Court) issued a decision in McCray v. Wilkie, 31 Vet. App. 243 (2019) discussing the above noted 2005 IOM report. The Court noted that the IOM report concluded, in part, that “based on current knowledge of cochlear physiology there was no sufficient scientific basis for the existence of delayed-onset hearing loss.” However, the IOM report also indicated that “[t]here is not sufficient evidence from longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one’s lifetime, long after the cessation of that noise exposure” and that “definitive studies to address this issue have not been performed.” The Court then held that if the Board finds that a medical text that serves as the basis for a medical opinion contains apparent qualifiers or contradictions, or if the veteran raises the issue or it is reasonably raised from review of the evidence of record, the Board must address that issue and explain whether those aspects of the medical text diminish the probative value of the medical opinion evidence or render the opinion inadequate, and if not, why not. Id. at 23-24. In this case, the Board acknowledges the 2005 IOM report relied on by the examiner is the same report the Court found contained contradictory findings in McCray; however; unlike in McCray, the examiner noted both that there was a lack of objective evidence of damage to the auditory system over time and that sufficient scientific investigation had not been conducted to rule out that such a connection was possible. Further, the examiner gave a cogent reason for why the IOM study should nonetheless be relied on. Thus, the Board finds the opinion sufficient because there was a personal examination of the Veteran and the examiner noted the Veteran’s personal medical history of tinnitus (or lack thereof), and his lay statements in reaching his conclusion. Thus, the examiner reached his conclusion not solely on the contradictory findings of the IOM study but by applying the relevant scientific knowledge to reach a conclusion regarding this specific Veteran’s tinnitus. The Board is also cognizant the October 2017 private audiologist opined that the Veteran’s bilateral tinnitus is at least as likely as not related to his in-service noise exposure. This opinion is based, at least, in part, on the lay statement that the Board has herein found to be not credible. Thus, it has minimal probative value and is insufficient to place the nexus evidence in this case in relative equipoise. In conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is not applicable. Accordingly, service connection for tinnitus is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 4. Service connection for a respiratory condition is denied. The Veteran seeks service connection for a respiratory condition. He contends that his respiratory condition onset in service or, alternatively is the result of his service in the Southwest Asia theater of operations. For the reasons that follow, the Board finds service connection for a respiratory condition is not warranted. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of a respiratory condition and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran’s service treatment records are silent for complaints of, treatment for, and/or a diagnosis of a respiratory condition. The Veteran denied a history of asthma, shortness of breath, pain or pressure in chest, and chronic cough on his June 1988 enlistment report of medical history. His June 1988 enlistment and October 1992 separation reports of medical examination also reflect normal clinical evaluations of the lungs and chest. Post-service, the Veteran denied pleurisy, shortness of breath, and/or cough in September 2010. The record is silent for a respiratory condition until October 2017. A June 2013 VA Gulf War examination only notes sleep apnea under respiratory conditions. The examiner noted no additional signs or symptoms not addressed through completion of an associated disability benefits questionnaire. An October 2017 private report of consultation and examination by the Veteran’s diagnostic consultant, P.Y., D.C., reflects diagnosis of respiratory insufficiency (dyspnea), chronic obstructive pulmonary disease (COPD), and bronchial asthma. In relation to his respiratory insufficiency, the physician noted he has a very poor aerobic capacity due to this progressive condition that began with his Gulf War service. In relation to his COPD and asthma, the physician noted he was exposed to the contaminated and toxic air generated from burn pits, which were situated in close proximity to the sleeping area. The physician indicated that he developed respiratory difficulties at the that time, which have intensified over the years and now manifest as a chronic cough, wheezing, dyspnea, and sleep apnea. The physician opined that the Veteran’s conditions are as likely as not directly and causally related to Gulf War syndrome and/or his military service. The Veteran underwent a VA examination in February 2020. The examiner indicated the Veteran does not now have nor has he even been diagnosed with a respiratory condition. The examiner indicated that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted the Veteran denied any respiratory condition other than sleep apnea. After a review of the evidentiary record, the Board finds the preponderance of the evidence weighs against finding entitlement to service connection for a respiratory condition is warranted. The Board concludes the Veteran has not had a diagnosed respiratory condition at any time during or approximate to the appeal period. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In reaching this conclusion, the Board recognizes that the Veteran has reported symptoms since service, and he is competent to describe those symptoms that are within the realm of his personal experience. 38 C.F.R. § 3.159. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, the Board finds any reports of onset of symptoms in service with continuity thereafter to be not credible as they are inconsistent with the Veteran’s contemporaneous treatment records, which indicate the Veteran denied respiratory symptoms in September 2010. While P.Y., a chiropractor and diagnostic consultant, stated in October 2017 that the Veteran has respiratory insufficiency (dyspnea), COPD, and bronchial asthma, there is no indication that he performed a physical examination or any diagnostic tests to confirm the presence of such conditions. Instead, the statement appears to be based on the Veteran’s self-reported medical history, which have been found to be inconsistent with his medical treatment records, which show no history of a respiratory condition or symptoms. Consequently, the October 2017 report is afforded no probative value. While the Veteran believes he has a current respiratory condition, he is not competent to provide such a diagnosis. Diagnosis a respiratory condition is medically complex as it requires specialized medical education and knowledge and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence of record, which establishes that the Veteran does not have a current respiratory condition. To the extent the Veteran has asserted his respiratory symptoms are due to his service in the Southwest theater of operations and a diagnosis has not been provided, the Board further finds that evidence of record does not reflect any respiratory symptoms beyond the October 2017 private examination. As the evidence does not establish symptoms from an undiagnosed illness or medically unexplained chronic multisymptom illness, the Board finds further consideration under 38 C.F.R. § 3.317 is unnecessary. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is not applicable. Accordingly, service connection for a respiratory condition is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 5. Service connection for obstructive sleep apnea is granted. The Veteran seeks service connection for obstructive sleep apnea, to include as secondary to a psychiatric disorder. A February 2020 VA examination reflects a diagnosis of obstructive sleep apnea. The Veteran’s service treatment records do not reflect a diagnosis of sleep apnea. Neither a post-deployment nor separation examination report are of record. A February 2020 VA examiner opined that the Veteran’s sleep apnea was at least as likely as not incurred in or caused by service based on documentation. The examiner based on this favorable opinion on the Veteran’s assertion that during service he snored loudly, and woke up out of his sleep several times a night, had day time sleepiness, and had to change jobs from being a driving tanks to loader because he was falling asleep at the wheel. The examiner also noted that sleep apnea was diagnosed in 2012 and there had been current, chronic, and continuous treatment and care since. Addendum opinions were obtained in August 2020 and October 2020. The first examiner opined that the sleep apnea is not proximately caused by the Veteran’s service-connected posttraumatic stress disorder. An opinion regarding aggravation was not provided. The second examiner noted that the available medical records are silent for a diagnosis of sleep apnea while in service, but indicated she unable to opine on the examination findings of another provider or on symptoms that may substantiate the previous examiner’s rationale. Accordingly, she did not provide the requested nexus opinion. Resolving all reasonable doubt in the Veteran’s favor on the matter of causal nexus, the Board notes that the VA examiner has considered the Veteran’s lay statements as to what symptoms he observed during service- snoring and fatigue. The Board is mindful that the service treatment records do not reflect a contemporaneous diagnosis of sleep apnea, nor evidence of snoring and fatigue complaints, but otherwise there is nothing directly contradicting the Veteran’s current recollection in this regard. The mere absence of contemporaneous medical documentation of treatment (or complaints) does not alone render lay testimony not credible. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2008). This is one such instance where the Veteran’s competent and credible lay evidence as to in-service symptoms is sufficient to establish in-service onset. The VA examiner, a medical professional has considered the Veteran’s current report of having experienced snoring and fatigue symptoms in service and determined such is sufficient to establish onset of sleep apnea in service. There being no competent medical opinion to the contrary, any reasonable doubt regarding causal nexus is resolved in the Veteran’s favor. Service connection for sleep apnea is granted. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.Aoughsten, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.