Citation Nr: 21009836 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 19-16 855 DATE: February 23, 2021 ORDER Prior to June 8, 2020, entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. From June 8, 2020, through November 9, 2020, entitlement to an increased initial rating from 50 percent to 70 percent, but no higher, for PTSD is granted. On and after November 9, 2020, entitlement to an initial rating in excess of 70 percent for PTSD is denied. Entitlement to a higher initial rating for bilateral hearing loss, evaluated as 0 percent disabling prior to June 20, 2019, and as 10 percent disabling on and after that date, is denied. Entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD, is denied. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for seborrheic keratosis is denied. FINDINGS OF FACT 1. Prior to June 8, 2020, the Veteran’s PTSD was manifested by occupational and social impairment with reduced reliability and productivity, but not by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 2. On and after June 8, 2020, the Veteran’s PTSD has manifested in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but not in total occupational and social impairment. 3. Prior to June 20, 2019, the Veteran’s bilateral hearing loss manifested in hearing impairment no greater than Level II in the right ear and Level II in the left ear. 4. On and after June 20, 2019, the Veteran’s bilateral hearing loss manifested in hearing impairment no greater than Level IV in the right ear and Level V in the left ear. 5. The preponderance of the evidence is against finding that sleep apnea began during active service or is otherwise related to an in-service injury, disease, or service-connected disability. 6. The Veteran did not exhibit a low back disability in service; degenerative arthritis of the spine did not manifest to a compensable degree within one year after discharge from service; and a low back disability is not otherwise shown to be associated with service.  7. The preponderance of the evidence is against finding that seborrheic keratosis began during active service or is otherwise related to an in-service injury, disease, or exposure. CONCLUSIONS OF LAW 1. Prior to June 8, 2020, the criteria for entitlement to an initial rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107, 7104; 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. 2. From June 8, 2020, through November 8, 2020, the criteria for entitlement to an initial higher rating from 50 percent to 70 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107, 7104; 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. 3. On and after November 9, 2020, the criteria for entitlement to an initial rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107, 7104; 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. 4. The criteria for entitlement to a higher initial rating for bilateral hearing loss, evaluated as 0 percent disabling prior to June 20, 2019, and as 10 percent disabling on and after that date, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(b), 4.85, 4.86, Diagnostic Code 6100. 5. The criteria for entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 6. The criteria for entitlement to service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a).  7. The criteria for entitlement to service connection for seborrheic keratosis have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1962 to August 1966. This matter comes before the Board on appeal from a March 2017 Regional Office (RO) rating decision. In June 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. Increased Rating Disability ratings are determined by comparing a veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. “Staged ratings,” or different percentage evaluations for separate periods based on the facts found, may also be awarded. Fenderson v. West, 12 Vet. App. 119, 126-7 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). 1. Entitlement to a higher initial rating for PTSD, evaluated as 50 percent disabling prior to November 9, 2020, and as 70 percent disabling on and after that date, is denied. The Veteran’s PTSD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9433. Disabilities that are evaluated under 38 C.F.R. § 4.130 are to be rated pursuant to VA’s General Rating Formula for Mental Disorders. A 0 percent (noncompensable) rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent rating is assigned when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and the inability to establish and maintain effective relationships. A 100 percent evaluation is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held “that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). In particular, the Federal Circuit has expressly rejected interpreting 38 C.F.R. § 4.130 in such a manner that would render specific symptomatology a secondary consideration at the 70 percent level. Id. Turning to the evidence of record, the Veteran underwent VA examinations in connection with this claim in February 2017 and November 2020. In relevant part, the February 2017 VA examiner determined that the Veteran’s PTSD most closely approximates “Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication.” This level of impairment corresponds to a 10 percent rating. He reported that his relationships with his sisters are fine. He denied difficulty making or keeping friends at any time. He and his current wife have been together since 1974, and he reported that they have a good relationship. He and his wife are friends with his first wife. His relationships with his two sons from his first marriage are fine, and his relationships with his five grandchildren are good. He used to golf, but he had to stop because of problems with his back. He watched television and goes to performances of the New Jersey Ballet with his wife. He reported that he refrains from aggressively acting out, but he does not take a lot from others, walking away as a way of containing his temper. Of the enumerated PTSD criteria, the examiner noted that the following symptoms actively apply to his PTSD: depressed mood, chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; flattened affect; and difficulty in establishing and maintaining effective work and social relationships. During examination, the Veteran’s eye contact was fair at times, seemingly in response to distress. He was open and cooperative. Speech was within normal limits for rate and articulation. Thought processes were clear, coherent, and goal-directed. No evidence of delusions were elicited, and auditory and visual hallucinations were denied. In terms of mood, he appeared irritable and mildly depressed. He began crying when talking about his symptoms and war. Affect was constricted and appropriate. Suicidal and homicidal ideation were convincingly denied. Sleep disturbance was reported, with delayed onset, frequent awakening, and early morning awakening. He reported that he gets three to five hours of sleep a night. Appetite disturbance was denied. Short-term memory impairment was evident. Judgment and insight were adequate. The Veteran did not have any other symptoms attributable to PTSD. A March 2020 VA initial evaluation for outpatient PTSD psychotherapy notes that the Veteran’s symptoms include decreased sleep, nightmares, isolation, hypervigilance, and some temper issues, although those are not as bad as when he was younger. VA medical records dated in April 2020 and subsequent months note that the Veteran’s mood is stable with occasional PTSD exacerbations. The Veteran testified at a personal hearing on June 8, 2020. At that time, the Veteran noted that he attends therapy sessions at the VA. He reported that he still has nightmares. (See Board hearing transcript, page 9.) It was noted that he has depression and anxiety and that he occasionally has issues with anger and irritability. He reported that he spends time with his family but not too many other people. He reported he was spending a lot of time at home even before COVID. He reported that he has thought about suicide. His representative noted that the Veteran has had suicidal thoughts and ideation. The Veteran’s wife also testified concerning the Veteran’s PTSD at the Board hearing. She reported that the Veteran talks in his sleep and sometimes acts violently. She reported that, “during the last ten years, the fun loving, daytime guy became very withdrawn, had little contact with friends, and often at the last minute, he would decide not to attend an event with me or participate and I frequently would go it alone.” (See Board hearing transcript, page 37.) She reported that “Hygiene would be infrequent without my intervention and assistance.” (See Board hearing transcript, page 37.) A July 2020 VA medical record notes that the Veteran had no suicidal thoughts or behavior. In a July 29, 2020, statement, the Veteran’s wife noted that the Veteran has nightmares that disrupt his sleep at night. She stated that “Recently, hygiene has become an overwhelming task for [the Veteran]. He is at the point where he will not shower if left to his own will.” She stated that “He has become unkempt, his hair and beard have not been cut in over a year. I must intervene to be sure he tends to his cleanliness.” She noted that “After hours of procrastination on his part and begging and negotiating on my part, at least twice a week I am able to convince him to get into our small shower with me so I can wash his body and hair.” She stated that, after years, she and some friends were finally able to convince him to talk to a therapist, and he has been in therapy for 2.5 years. A September 2020 private medical record notes that mental status examination showed that the Veteran was oriented to person, place, and time. His recent and remote memory were normal. His attention span and concentration were normal. Language was fluent with normal comprehension and repetition. His fund of knowledge was normal. The November 2020 VA examination report notes that the Veteran’s level of occupational and social impairment is best summarized as “Occupational and social impairment with reduced reliability and productivity.” He again reported that his relationships with his wife, children, grandchildren, and two sisters are fine. He reported that his relationships with his friends are okay. He reported that his wife’s aunt lives with him and that his relationship with her is fine. He reported that he spends his time watching television and reading. The examiner noted that the following symptoms actively apply to the Veteran’s PTSD: depressed mood; chronic sleep impairment; disturbances of motivation and mood; difficulty adapting to stressful circumstances, including work or a worklike setting; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner noted that the Veteran was open and cooperative during the interview. Speech was within normal limits for rate and articulation but limited in productivity. Thought processes were clear, coherent, and goal-directed. No evidence of delusions was elicited. Auditory and visual hallucinations were denied. Mood was described as all right, and he appeared mildly depressed. Affect was somewhat constricted and appropriate. Suicidal and homicidal ideation were convincingly denied. Sleep disturbances were reported, with delayed onset and frequent awakening. Appetite and sleep disturbance was denied. Memory was grossly intact. Judgment and insight were fair. The Veteran did not have any other symptoms that were attributable to PTSD. Based on the above, the Board finds that a rating in excess of 50 percent is not warranted prior to the date of the June 8, 2020, Board hearing, but that a rating of 70 percent, but no higher, is warranted on and after that date. This assignment constitutes no increase of the currently-assigned 50 percent rating prior to June 8, 2020; an increase from 50 percent to 70 percent from June 8, 2020, through November 9, 2020; and no increase of the currently-assigned 70 percent rating on and after November 9, 2020. Prior to June 8, 2020, the evidence of record does not warrant the assignment of a rating in excess of 50 percent. Specifically, the Board finds that the evidence of record does not demonstrate occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to the symptoms that are enumerated in the rating criteria or those that are of similar severity, frequency, and duration. With regard to the period prior to June 8, 2020, the Board notes that none of the evidence from this period reflects suicidal ideation. The February 2017 VA examination report notes that the Veteran convincingly denied suicidal and homicidal ideation. Otherwise, the medical records from this period do not indicate suicidal ideation or similar feelings of wanting to harm himself or others. There is no evidence from this period of obsessional rituals that interfere with routine activities. Nor is there an indication of any obsessive thoughts or behaviors of similar severity, frequency, and duration that interfere with routine activities. The Board notes that the Veteran did experience nightmares during this period and may have acted these nightmares out in his sleep on occasion. However, such impairment is not demonstrated to be of such severity, frequency, and duration as to result in deficiencies in most areas. The Veteran’s speech was normal. Similarly, the Veteran’s thought processes were within normal limits and were not of such severity, frequency, and duration to contribute to deficiencies in most areas. In addition, his judgment and insight were not shown to be deficient. The evidence does reflect that the Veteran experienced depression, but it was not noted to be of such severity as to affect his ability to function independently, appropriately and effectively. During this period, the Veteran was still seeing friends and was participating in social activities. The Veteran did not demonstrate impaired impulse control. As noted above, while he would not put up with mistreatment by others and did demonstrate irritability, he would walk away to control his temper. Nor does the evidence from this period demonstrate spatial disorientation. The Veteran did not demonstrate difficulty in adapting to stressful circumstances such that it resulted in deficiencies in most areas. The Veteran maintained good relationships with friends and family and was able to participate in public activities. While the Veteran did not work during this period, he does not allege, and the evidence does not reflect, that this is due to his PTSD. Likewise, the evidence during this period does not reflect an inability to establish and maintain effective relationships. He has had good relationships with his family during this period, and he also had friends. In short, the Board finds that the evidence from this period does not demonstrate occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Therefore, the Board finds that, prior to June 8, 2020, the criteria for a rating in excess of 50 percent were not met. However, the Board finds that the criteria for an increased rating from 50 percent to 70 percent is warranted for the period from June 8, 2020, through November 8, 2020. The Board notes that the findings that justified the assignment of a 70 percent rating are evident in the record as early as the June 8, 2020, Board hearing. In particular, the June 2020 hearing testimony and the July 2020 personal statement from the Veteran’s wife indicate the presence of the 70 percent criterion of neglect of personal appearance and hygiene. This evidence also notes that the Veteran has becoming increasingly isolated and withdrawn from social activities. Significantly, the Veteran testified to thoughts of suicide, and his representative’s statements strongly suggest that he and the Veteran have discussed suicidal ideation. The Board finds that these symptoms result in deficiencies in most areas, including family relations, judgment, thinking, and mood. Therefore, based on the above, the Board finds that entitlement to an increased, 70 percent rating is warranted from June 8, 2020, through November 8, 2020. Finally, the Board finds that the criteria for entitlement to a 100 percent rating are not met at any point on and after June 8, 2020. Specifically, the Board finds that there is not total occupational and social impairment. The evidence reflects that, even though he has withdrawn socially, the Veteran has relationships with his family and friends, reflecting less than total social impairment. He did not demonstrate any deficiencies in thinking are of such severity as to result in gross impairment in thought processes, and he did not demonstrate delusions or hallucinations. His speech and ability to communicate were impaired but not grossly so. While the evidence does reflect suicidal ideation, it does not reflect that the Veteran is a persistent danger of hurting himself or others. His memory impairment is not nearly so severe to approximate memory loss for names of close relatives, his own occupation, or his own name. As noted above, the evidence does indicate an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene) but this does not result in total functional impairment. Neglect of personal appearance and hygiene is contemplated in a 70 percent rating. The overall level of occupational and social impairment that is demonstrated during this period does not rise to the level of total occupational and social impairment. In short, the Board finds that entitlement to a rating in excess of 50 percent is not warranted prior to June 8, 2020; an increased rating from 50 percent to 70 percent, but no higher, is warranted from June 8, 2020, through November 8, 2020; and a rating in excess of 70 percent is not warranted on and after November 9, 2020. To the extent that the Veteran seeks entitlement to higher ratings than those that have been awarded, the Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, entitlement to even higher ratings must be denied. 2. Entitlement to a higher initial rating for bilateral hearing loss, evaluated as 0 percent disabling prior to June 20, 2019, and as 10 percent disabling on and after that date, is denied. The Veteran has claimed entitlement to a higher initial rating for bilateral hearing loss. He is currently in receipt of a 0 percent rating prior to June 20, 2019, and a 10 percent rating on and after that date. This disability is rated pursuant to 38 C.F.R. § 4.85, Tables VI, VIA, and VII, Diagnostic Code 6100. In evaluating hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The ratings schedule provides a table for ratings purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment. Level I indicates essentially normal acuity, while Level XI indicates profound deafness. 38 C.F.R. § 4.85, Tables VI, VII. An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone test. For each ear, the percent of speech discrimination and the puretone threshold average (which is the sum of the puretone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four) are combined on Table VI to produce a Roman numeral designation. See 38 C.F.R. § 4.85. The Roman numeral designations for hearing impairment of each ear are combined on Table VII to determine the percentage evaluation. Table VIA is used when the examiner certifies that the use of speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of 38 C.F.R. § 4.86. 38 C.F.R. § 4.85(c). When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, Table VI or Table VIA is to be used, whichever results in the higher numeral. 38 C.F.R. § 4.86(a). Additionally, when the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, Table VI or Table VIA is to be used, whichever results in the higher numeral. Thereafter, that numeral will be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). The Veteran underwent a VA examination in February 2017. The resulting examination report shows puretone thresholds, in decibels, as follows:          HERTZ           500  1000  2000  3000  4000  RIGHT   25 25 25 85 90 LEFT  25 25 25 85 90   The puretone threshold average was 56 decibels in the right ear and 56 decibels in the left ear.  The Maryland CNC speech discrimination test revealed speech recognition ability of 96 percent in the right ear and 96 percent in the left ear. In terms of functional impairment, it was noted that the “Veteran notes difficulty with group situations.” The above audiological findings show Level I hearing acuity in the right ear and Level I hearing acuity in the left ear under Table VI. Under Table VII, these findings warrant a 0 percent rating. The Veteran underwent an audiology evaluation in October 2019. The resulting report shows puretone thresholds, in decibels, as follows:          HERTZ           500  1000  2000  3000  4000  RIGHT   25 30 35 90 95 LEFT  25 30 35 90 95   The puretone threshold average was 62.5 decibels in the right ear and 62.5 decibels in the left ear.  The Maryland CNC speech discrimination test revealed speech recognition ability of 92 percent in the right ear and 92 percent in the left ear. The above audiological findings show Level II hearing acuity in the right ear and Level II hearing acuity in the left ear under Table VI. Under Table VII, these findings warrant a 0 percent rating. The record reflects that the Veteran picked up hearing aids in November 2019. At his June 2020 hearing, the Veteran testified that his wife has to constantly repeat herself, that he misunderstands people, and he has to turn the sound way up on the television. In a July 2020 statement, the Veteran’s wife noted that she and the Veteran do not go to theaters to see movies anymore because the Veteran constantly has to ask what is being said. She stated that they cannot watch television together because the volume is too loud for her. She also noted that they rarely go to restaurants because of the background noise. She also stated that the Veteran sometimes does not understand what she has said and then accuses her of not having told him something that she actually had told him. The record contains a July 2020 statement from a private audiologist. The Board cannot use the resulting audiological evaluation, however, as there is no indication that the testing satisfied the VA standards of 38 C.F.R. § 4.85. The Veteran underwent a VA examination in November 2020. The resulting examination report shows puretone thresholds, in decibels, as follows:          HERTZ           500  1000  2000  3000  4000  RIGHT   25 25 30 95 95+ LEFT  25 30 45 95 100   The puretone threshold average was 61 decibels in the right ear and 68 decibels in the left ear.  The examiner could not test speech discrimination in either ear. In terms of functional impairment, it was noted that the Veteran “has to tune my guitar by vibrations rather than by hearing the sounds” and that “Conversation can be a problem.” Because speech discrimination could not be tested, the Board will apply the puretone findings to Table VIA. This chart results in Level IV hearing acuity in the right ear and Level V hearing acuity in the left ear. Under Table VII, these findings warrant a 10 percent rating. The Board acknowledges the Veteran’s reports of functional impairment as described above. However, because disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometry evaluations are rendered, there is no doubt as to the proper evaluations to assign. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992); 38 C.F.R. § 4.85, Tables VI, VIA, and VII, Diagnostic Code 6100. Therefore, when applying the audiological examination test results, the Board is compelled to conclude that the preponderance of the evidence is against granting entitlement to increased ratings. The Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against this claim, the claim is not in equipoise. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, entitlement to a compensable disability rating for bilateral hearing loss prior to June 20, 2019, and entitlement to a rating in excess of 10 percent on and after that date is not warranted. Service Connection Service connection is warranted where the evidence of record establishes that an injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran 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, or nexus, between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for listed chronic diseases, such as arthritis, if such were shown as chronic in service; manifested to a compensable degree within a presumptive period (usually one year) after separation from service; or were noted in service with continuity of symptomatology since service. 38 U.S.C. §§ 1112, 1113; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). A disability that is proximately due to, or results from, a service-connected disease or injury shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection on the basis of aggravation is permitted. 38 C.F.R. § 3.310(b). Compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability and not due to the natural progress of the nonservice-connected disease. Allen v. Brown, 7 Vet. App. 439 (1995). 3. Entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD, is denied. The Veteran testified at his Board hearing that he, like many others in his tent, snored on active duty. (See Board hearing transcript, pages 17-18.) However, he was not diagnosed with obstructive sleep apnea (OSA) until approximately 2017. (See Board hearing transcript, page 21.) His service treatment records reflect that he neither complained of nor sought treatment for symptoms that have been attributed to obstructive sleep apnea. The Veteran’s accredited representative also presented the contention that “the Board should consider [the Veteran’s sleep apnea] as a proximate issue secondary to PTSD.” He discussed a study from the National Institute of Sleep Science that “says 98 out of 107 Veterans said sleep apnea was related to the PTSD.” (See Board hearing transcript, page 40.) In a February 2017 VA PTSD examination report, a VA psychologist noted that “It is beyond the scope of this exam and this examiner’s expertise to diagnose OSA.” She stated that, “Should a diagnosis of OSA be established, for example as a result of the evaluation scheduled for March 2017, it would be within a reasonable degree of medical certainty to conclude that veteran’s OSA could be related to his PTSD….” In explaining the rationale for her opinion, the examiner discussed multiple relevant academic studies that she suggests are supportive of finding such a link. For example, she noted that: In a recent review article, Gupta, M.A., & Simpson, F.C. (2015). Obstructive Sleep Apnea and Psychiatric Disorders: A Systematic Review. Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine, 11(2), 165-175. http://doi.org/10.5664/jcsm.4466, found “for the studied populations with … PTSD, it appears that there is an elevated prevalence of OSA in these disorders … A number of factors may play a role in the association between psychiatric disorders such as … PTSD with OSA.” While the nature of the relationship remains to be elucidated, they hypothesized the association could be due to PTSD-related factors such as changes in neurotransmitters, obesity and other metabolic disruptions, and dysregulation in CNS [central nervous system] functioning. The Veteran submitted a July 2020 opinion in which Dr. M.B. noted that the Veteran was under his care for OSA and COPD. Dr. M.B. provided the following: The patient suffers from PTSD, and i[t] negatively influences his ability to manage both of these medical disorders, along with his other medical issues. While the precise relationship between sleep apnea and PTSD is not clear in the medical literature, PTSD has well-known negative impact on sleep quality, sleep continuity, and restorative nature of sleep. In combination with sleep apnea, even i[n] situations where it has been appropriately treated with Pap therapy, as is the case with [the Veteran], there is a strong likelihood that these two conditions negatively impact each other, and will contribute to non-restorative, often suboptimal sleep quality. This will have obvious negative impact on the patient’s dilute function during the day, along with his overall health and sense of well-being. In its September 2020 remand, the Board noted that OSA is essentially caused by recurrent collapse of the pharyngeal airway during sleep, resulting in substantially reduced or complete cessation of airflow despite ongoing breathing efforts. It is a mechanical obstruction of the airways during sleep. The Board observed that the February 2017 VA opinion and Dr. M.B.’s opinion are inadequate because they do not explain how a mental health condition causes an anatomical or physiological change of the airway. It also noted that the Veteran is diagnosed with obstructive sleep apnea, not central sleep apnea. The Board further observed that the opinions note an association or correlation of PTSD and obstructive sleep apnea, but not causality. The Board additionally stated that Dr. M.B.’s opinion is insufficient to establish aggravation. Noting that “there is a strong likelihood that these two conditions negatively impact each other” is not a definitive statement that the Veteran’s PTSD aggravated his OSA beyond its natural progression. Noting that they “contribute to non-restorative, often suboptimal sleep quality” shows that the Veteran’s PTSD causes sleep impairment and his co-existing OSA causes sleep impairment which in the aggregate cause sleep impairment but is not a definitive statement that the Veteran’s PTSD aggravated his OSA beyond its natural progression. For these reasons, the Board remanded this case so that the Veteran could be afforded a VA examination and an opinion could be obtained to appropriately address the Veteran’s theory of entitlement. In a July 2020 statement, the Veteran’s wife noted that she had to videotape the Veteran’s body jerking, snoring, and struggling to breathe at night before the Veteran would agree to go to a sleep specialist. She stated that he has been using a CPAP machine for about two years. In November 2020, on remand, the Veteran underwent a VA video telehealth examination and an etiology opinion was obtained. Based on review of the record and interview and examination of the Veteran, the examiner opined that the Veteran’s sleep apnea is not at least as likely as not caused by or aggravated beyond its natural progression by his service-connected PTSD. With respect to the direct theory of service connection, the examiner noted that the Veteran’s service treatment records show “no visits in the record where sleep problem was a primary complaint, where sleep issues were further evaluated or [the Veteran was] diagnosed to have sleep apnea.” The examiner noted that “Further Exit exam on 8/11/66, prior to discharge from service has no mention of any sleep problems, to suggest his sleep apnea occurred [during] service. His weight in 1966 was 185lbs.” The examiner acknowledged the Veteran’s wife’s July 2020 statement but noted that “She stated that they lived together since 1974, [8 years after discharge from service].” She was not sure when she noticed the Veteran snoring and struggling to breathe. The examiner noted review of the February 2017 opinion and Dr. M.B.’s July 2020 statement. The examiner noted that the Veteran’s sleep apnea was diagnosed in March 2017, 51 years after his separation from service, and that his weight in 2019 was 211 pounds with a BMI of 30. The examiner stated that the time that has elapsed since separation from service and the diagnosis of sleep apnea makes a connection between sleep apnea and service unlikely. The examiner stated that “Age-related changes over 50 years that are not specific to military service such as weight gain and older age are more likely causes for his obstructive sleep apnea.” The examiner noted that “Obesity is the number one cause for Obstructive sleep apnea. Sleep apnea occurs significantly more often in older adults.” The examiner stated that “Men are two to three times more likely to have sleep apnea than are women. Having family members with sleep apnea might increase the risk.” With respect to the question of whether the Veteran’s service-connected PTSD has caused or aggravated his sleep apnea, the examiner stated the following: There are many theories of the association of sleep problems (mostly Insomnia) with PTSD. PTSD which is [a] psychological condition[], has not been shown to cause or aggravate sleep apnea. The existing literature does not support this connection. To state that PTSD causes or aggravate[s] sleep apnea would be speculative. With respect to the question of the mechanics of obstructive sleep apnea, the examiner noted the following: Obstructive sleep apnea is most common type of sleep apnea. It occurs when the muscles in the back of the throat and tongue relax, as a result airway narrows or closes and can’t get enough air. Brain senses inability to breathe and briefly rouses the person from sleep so that [they] can reopen airway and breath[e]. This pattern can repeat itself several times, all night, impairing ability to reach the deep, restful phases of sleep. The examiner then described the mechanics of central sleep apnea, which need not be further discussed in this decision. The examiner concluded that the “Veteran’s Obstructive sleep apnea is not likely incurred in or caused by service and is less likely caused by or aggravated beyond the nature progression by his service-connected PTSD.” The Board finds this opinion to be highly probative, as it was authored by a physician who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). It is based on review of the claims file and interview of the Veteran. It provides a thorough rationale that cites to the facts of the Veteran’s case and pertinent medical principles. It is also responsive to the questions that the Board asked in its September 2020 remand. Specifically, it explains the nature of obstructive sleep apnea versus central sleep apnea, and it addresses the lay contentions of the Veteran’s spouse. It also considers the medical literature that was cited in the February 2017 VA examination report and the July 2020 opinion from Dr. M.B. The examiner specifically noted that Dr. M.B. “did not say PTSD causes or aggravated sleep apnea,” while noting that “existing literature does not support this connection. To state that PTSD causes or aggravate[s] sleep apnea would be speculative.” The Board finds that the February 2017 VA examination report and Dr. M.B.’s July 2020 opinion are of diminished probative value for the reasons discussed above. Specifically, the Board finds that these opinions do not actually determine that the Veteran’s PTSD caused or aggravates his obstructive sleep apnea. The only remaining contrary opinion comes from the Veteran himself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the question posed by this claim is of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. In short, the Board finds that entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD, is not warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 4. Entitlement to service connection for a low back disability is denied. The Veteran contends that he has a current low back disability that is related to back injuries he suffered in service. At his Board hearing, he described a back injury in service “Carrying heavy equipment.” (See Board hearing transcript, page 23.) He also described having fallen off of the loading dock trying to get out of the way of a forklift. (See Board hearing transcript, pages 23-24.) He described having sought medical treatment, at which time he was put on bed rest and given pain medication and something to rub on his back. (See Board hearing transcript, page 25.) He testified that he continued to have lower back problems after separation from service. (See Board hearing transcript, page 26.) He reported that he had a double laminectomy in 1990. (See Board hearing transcript, pages 27-28.) Turning to the Veteran’s service treatment records, the Veteran’s spine was clinically normal when examined at the times of his March 1962 enlistment examination and his August 1966 separation examination. A November 1963 record notes that the Veteran had a low back strain. A record from later that month notes that the Veteran had a mild back strain. Another November 1963 record notes that the Veteran had strained his back three days earlier and was seen by a doctor and then sent to duty. It notes that the Veteran had “chronic, recurrent low back strain.” A December 1963 record notes that the Veteran “complains of sore back. Prevalent for past three months worse this past week. Pain in small of back.” There was no neurological deficit and lumbosacral spine x-rays were negative. A provisional diagnosis notes “[rule out] congenital defect.” It again notes a three-month history of low back pain. A March 1964 record notes the following: “X-ray examination of the L-Spine taken this date for the following reason: Auto accident 26 NOV 63 with chronic low back pain; now hurting in [right] S-1 joint and [right] L-S paraspineous [sic] region. Check disc spaces R/O bony patre places. RESULT: NEGATIVE.” A later March 1964 record notes a chronic complaint of back pain with an impression of “chronic low back & minimal objective findings.” An April 1964 orthopedic consultation record notes that the Veteran was injured in an auto accident in November 1963 in San Diego. At that time, physical examination and x-rays were negative. It was noted that, “Since [] then he has had repeated episodes of attack of acute, low back pain.” A provisional diagnosis of chronic low back pain was made. He had an orthopedic consultation in April 1964, and a notation of “No Duty – Bed Rest – No Liberty” was made. A June 1964 record notes that the Veteran had been involved in an automobile accident that morning. A December 1965 record notes a past history of back pain. Post-service, a May 1982 VA medical record notes that the Veteran sought treatment through VA for chronic low back pain. He noted at the time that he had had chronic low back pain for the past eight weeks. A radiology report from that time notes an impression of “[v]ery minimal degenerative osteoarthritis changes involving L4 and L5. Otherwise essentially normal lumbo sacral spine.” Current VA and private medical records from recent years reflect that the Veteran has been seeking treatment for low back problems. They do not provide a more specific timeline on past medical history and treatment than that which is mentioned elsewhere in this decision. The Veteran underwent a VA examination in February 2017 and an etiology opinion was obtained. The examination report notes diagnoses of degenerative arthritis of the spine and intervertebral disc syndrome. With respect to relevant history, the examiner noted that the Veteran “[h]ad back surgery in 1990, no trauma.” Based on review of the record and interview and examination of the Veteran, the examiner opined that the Veteran’s “back condition is due to back surgery he had over 20 years ago. No major back injuries in the service.” The examiner also noted that, “As far as the [motor vehicle accident] in service, his injuries were minor and he did not sustain any chronic injuries, he was able to finish his term.” The Board found that the probative value of this statement is diminished in that the Veteran’s service treatment records contain multiple entries concerning the Veteran’s low back, and it was unclear that the examiner’s notation of “No major back injuries in the service” contemplated all of the above service treatment records. The Board further noted that the May 1982 VA medical records were neither discussed nor referenced in the February 2017 VA examiner’s medical opinion. The Board directed that this evidence be discussed in the new opinion. In a July 2020 statement, the Veteran’s wife noted that the Veteran “has had chronic low back pain from an injury during his time in service, further exacerbated by carrying radio relay equipment on his back with in Viet Nam.” She also noted that “Mostly he just dealt with the pain. But during the years, as the pain progressively worsened, he sought conservative treatment first with chiropractic treatment, physical therapy, injections, surgery and now we are at the stage where he is on pain management.” The Veteran underwent a VA examination in November 2020, and an etiology opinion and rationale were obtained. The examination report notes diagnoses of degenerative arthritis of the spine and intervertebral disc syndrome. In response to a request to “Describe the history (including onset and course) of the Veteran’s thoracolumbar spine (back) condition (brief summary),” the examiner stated that the Veteran “[h]ad back surgery 1990, no trauma, has had [physical therapy], and pain [management] over the years with injection and pain meds, pain is daily, with activity.” Based on review of the record and interview and examination of the Veteran, the examiner opined that the Veteran’s current back disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In the rationale, the examiner noted that “Any injuries in the service were minor, soft tissue injuries which resolved and could not cause any chronic condition.” The examiner noted that the Veteran “had some minor back pain in 1980, many years post discharge.” He also noted that the Veteran’s “back condition is due to back surgery he had over 20 years ago, 1990. No major back injuries in the service.” The Board finds this opinion to be highly probative, as it was authored by an individual who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). It is based on review of the record and interview and examination of the Veteran. The opinion notes the relevant facts of the case, including those that had not been mentioned in the February 2017 opinion, and discusses the pertinent medical principles. Specifically, the examiner discussed the nature of the in-service injuries and noted that the 1982 back pain occurred many years following his discharge from service. The examiner found a medical reason to reject the proposition that the Veteran’s current back disability had its onset in service, that the Veteran's assertions are generally inconsistent with medical knowledge or implausible, and that the Veteran's reports do not align with how his current back disability is known to develop. The examiner maintained that any injuries in the service were minor, soft tissue injuries which could not cause any chronic condition. Therefore, the Board finds this opinion to be highly probative. The only remaining contrary opinion comes from the Veteran himself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the questions posed by this claim are of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. There is no persuasive medical evidence or persuasive credible lay evidence that the Veteran's claimed disorder manifested to a compensable degree within a year of his separation from service or had its onset in service and continued ever since service. The Veteran's lay perception that the symptoms he experienced over the years are part of a continuing disease process that had its onset during service has been rendered unfounded by the medical expert who carefully considered the Veteran's contentions but ultimately was not able to link any current condition to the Veteran's military service. Therefore, service connection based on presumptive service connection for a chronic disease or based on a theory of continuity of symptomatology is not warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 5. Entitlement to service connection for seborrheic keratosis is denied. A veteran who had active service in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. See 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). Herbicide exposure is presumed in this case. A veteran who was exposed to herbicides during service and develops certain diseases, listed in 38 C.F.R. § 3.309(e), will be service-connected for such disorder on a presumptive basis. There is no presumed positive association between exposure to herbicides and any condition that is not listed in 38 C.F.R. § 3.309(e). See Notice, 59 Fed. Reg. 341-46 (1994); Notice, 61 Fed. Reg. 41, 442-49 (1996); Notice, 72 Fed. Reg. 32,395-32,407 (Jun. 12, 2007); Notice, 74 Fed. Reg. 21,258-21,260 (May 7, 2009); Notice, 75 Fed. Reg. 32540 (June 8, 2010). Where the evidence does not warrant presumptive service connection, an appellant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran, through his spouse, has suggested that he may have a current skin condition that is due to Agent Orange exposure. (See July 2020 statement from Veteran’s spouse.) (Seborrheic keratosis is the only skin condition that is before the Board at this time, while all other skin conditions have been remanded in an August 2020 Board decision that was addressed under the Appeals Modernization Act (AMA).) The Board notes that seborrheic keratosis is not one of the conditions that is listed under 38 C.F.R. § 3.309(e) that is subject to presumptive service connection based on herbicide exposure. The Board will thus turn to the question of whether there is a direct relationship between the Veteran’s seborrheic keratosis and service, to include as due to his presumed Agent Orange exposure on a direct basis. In July 2017, the Veteran was sent a letter requesting that he submit scientific or medical evidence indicating an association between seborrheic keratosis and Agent Orange exposure. The Veteran has not submitted any such evidence. Turning to the evidence of record, the Veteran’s service treatment records reflect that he was treated for a rash on the right side of his buttock in July 1963. This record notes that the Veteran “[h]as an apparent neurodermatitis of R buttox [sic] area about tatoo [sic] in this area.” No diagnosis was made, and no further treatment is noted. An August 1966 separation examination report notes that the Veteran’s skin was clinically normal on examination. Service treatment records reflect that the Veteran never complained of or sought treatment for seborrheic keratosis, or for a skin condition that was not diagnosed during service. (The record does contain multiple instances of the Veteran seeking treatment for foot fungus. However, those complaints are not relevant to the Veteran’s seborrheic keratosis claim.) Post-service medical records include a March 1981 VA Agent Orange/toxic chemicals exposure questionnaire and examination notes that the Veteran identified “skin rash from hip down” as a symptom of the alleged exposure. There was no skin rash at the time of this examination. A May 1982 VA medical record notes that the Veteran complained of “intermittent skin lesions- dx @ one time as pittyscaris rosea (?) [sic] allergic to tetanus toxoid.” (The Board notes that the diagnosis may have been “pityriasis rosea.”) In recent years, private medical records note a diagnosis of “[i]nflamed seborrheic keratosis” and “[o]ther seborrheic keratosis.” (See, e.g., September 2015, January 2016, and July 2016 private medical records.) The September 2015 record constitutes the earliest diagnosis of seborrheic keratosis of record. The Veteran underwent a VA examination in connection with this claim in March 2017. Based on review of the record and interview and examination of the Veteran, the examiner diagnosed seborrheic keratosis and estimated a diagnosis date in 2017. The examiner noted that the Veteran reported a history of skin growths on his back for the past four to five years. It notes that he was not on any medication and complained of occasional pain and irritation. The examiner opined that this condition was less likely than not incurred in or caused by service. In her rationale, the examiner noted that the Veteran has had seborrheic keratosis for the last four to six years and that the Veteran was never diagnosed with or treated for this condition in service. In November 2020, the Veteran underwent a VA telehealth examination. In relevant part, the Veteran reported that he had had “‘a pencil eraser-head sized’ skin lesion on his left chest, which he thought arose when he was in RVN [the Republic of Vietnam].” He noted that “The lesion size has remained steady throughout the years, … except for the ‘last 1-2 years,’ where he has noticed an increase in its diameter.” He reported that he recently saw a dermatologist who diagnosed seborrheic keratosis. The examiner noted that “The veteran and his wife described a similar lesion present on the veteran’s back which was noted within the ‘last year or so and has been getting bigger.’” The VA examiner noted that the Veteran’s service treatment records “reveal he had a ‘rash over his right buttock’” in August 1963. His August 1966 separation examination report “noted a ‘normal’ skin and lymphatic examination.” The examiner noted that post-service medical records contain a September 2015 record noting that the Veteran “had a biopsy of a skin lesion affecting his back, the pathology report revealing seborrheic keratosis.” Seborrheic keratosis was also revealed on a November 2016 skin biopsy of the right upper eyelid and a February 2017 biopsy of the right inner arm and left foot. On examination, the examiner found seborrheic keratosis on the Veteran’s “anterior left upper chest” and “posterior, right mid-back.” The examiner opined that the Veteran’s seborrheic keratosis was less likely than not incurred in or caused by service. In his rationale, the examiner noted that the in-service rash over the Veteran’s right buttock “was temporary and resolved, since there are not further descriptions, present in the [service treatment records], for a chronic rash affecting the Veteran’s right buttock, after its initial occurrence in [August 1963].” The examiner also cited the normal separation examination. He noted that “No evidence of a chronic rash affecting the veteran’s right buttock, anterior chest or posterior back is described.” He further noted that the rashes that were found on the current examination were neither present nor described in the service treatment records. He noted that “There is a lack of evidence, in the [service treatment records], for signs and symptoms of chronic skin lesion or rash, affecting the veteran’s anterior chest or posterior back.” He further noted that “There is no evidence, in the [service treatment records], for chronic skin lesion(s), consistent with seborrheic keratosis (SK) (also known as seborrheic dermatitis), affecting the veteran while he was in military service.” The examiner also noted that “The diagnosis of SK was established approximately 45 years after the veteran’s discharge from military service.” He noted that medical literature, specifically in UpToDate, indicates that “‘SK usually develops after the age of 50.’” The examiner noted that “The veteran was 71 years of age when he was diagnosed with SK, which is consistent with the pathogenesis and the risk factor of advancing age for SK.” He noted that “There is no evidence, in the medical literature, that military service in the RVN, is a risk factor for the development of SK.” Therefore, “A nexus cannot be established between the veteran’s skin lesions (present on his anterior chest and posterior back, and diagnosed in [September 2015]), with any event, injury, disease, or skin lesion that was present while the Veteran was enrolled in military service.” The Board finds these opinions to be highly probative, as they were authored by physicians who possess the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). They are based on review of the record and interview and examination, and they contain etiology opinions with citation to the Veteran’s pertinent history. In particular, the Board finds that the November 2020 opinion is highly probative, as it contains a detailed rationale that includes a thorough discussion of the facts of the Veteran’s case and pertinent medical principles. It also addresses all of the claimed theories of entitlement, including entitlement to service connection based on herbicide exposure. The only remaining contrary opinion comes from the Veteran and his spouse. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the question posed by this claim, the question of whether the Veteran’s current seborrheic keratosis, specifically, is related to service from approximately 50 years earlier, is of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. In short, the Board finds that entitlement to service connection for seborrheic keratosis has not been established, either as presumptively related to the Veteran’s presumed in-service Agent Orange exposure, as directly related to such exposure, or as originating during or otherwise directly related to service itself. (continued on next page) The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Elizabeth Jalley, 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.