Citation Nr: 21010450 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 08-12 991 DATE: February 24, 2021 ORDER Entitlement to the restoration of service connection for a cervical spine disability is granted. Service connection for a left hand and wrist disability is denied. Service connection for left shin splints is denied. Service connection for right shin splints is denied. Service connection for a left ankle disability is denied. Service connection for a right ankle disability is denied. Service connection for gastroesophageal reflux disease is denied. REMANDED Service connection for a low back disability is remanded. FINDINGS OF FACT 1. There was not clear and unmistakable error in the September 2011 rating decision granting service connection for a cervical spine disability. 2. A left hand and wrist disability was not incurred in service and is not related to service. 3. A left shin splints disability was not present during the appeal period. 4. A right shin splints disability was not present during the appeal period. 5. A left ankle disability was not incurred in service and is not related to service. 6. A right ankle disability was not incurred in service and is not related to service. 7. Gastroesophageal reflux disease (GERD) was not incurred in service and is not related to service. CONCLUSIONS OF LAW 1. The criteria for entitlement to the restoration of service connection for a cervical spine disability have been met. 38 C.F.R. § 3.105(d). 2. The criteria for service connection for a left hand and wrist disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 3. The criteria for service connection for left shin splints have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 4. The criteria for service connection for right shin splints have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 5. The criteria for service connection for a left ankle disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 6. The criteria for service connection for a right ankle disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 7. The criteria for service connection for GERD have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1991 to June 2005. The period from May 2003 to June 2005 is dishonorable service for VA purposes. The Veteran had service in Oman in support of Operations Enduring Freedom and Iraqi Freedom. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from August 2007 and July 2013 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Board finds that there is substantial compliance with its July 2010 directive to provide the Veteran with a notice letter describing how to substantiate his claims, and request that he provide authorization to enable VA to obtain his prison treatment records. This letter was provided in July 2011. There was substantial compliance with the Board’s directive to obtain the Veteran’s Vocational and Rehabilitation records because they were obtained and associated with his claims file. The Board finds that there is substantial compliance with Board remand directives to obtain treatment records from the federal prison system. VA made several requests for these records and contacted the Bureau of Prisons (BoP) to determine proper procedure. BoP explained that VA needed to submit an authorization signed by the Veteran. In February 2017, VA sent a letter to the Veteran requesting he submit an authorization. The Veteran did not do so. A claimant has the responsibility to present and support a claim for benefits under laws administered by the VA, 38 U.S.C. § 5107(a). While VA has a duty to assist the Veteran in substantiating his claim, that duty is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190 (1991). The Board finds there is also substantial compliance with this Board remand directives regarding Persian Gulf War undiagnosed illnesses or medically unexplained chronic multisymptom illnesses. Stegall v. West, 11 Vet. App. 268, 271 (1998). The August 2018 examiner diagnosed the Veteran with bilateral carpal tunnel syndrome with regard to the left hand and wrist. The examiner provided a diagnosis. Therefore, the opinion substantially complies with the September 2015 remand directives to address whether there are objective indications of symptoms that cannot be attributed to any known clinical diagnosis. The August 2018 examiner’s finding that the shins were normal indicates the examiner found no objective indications of shin symptoms. The 2018 examiner’s finding of no symptoms for the left ankle and a right ankle strain complied with the remand directives because the examiner identifies symptoms or provides a diagnosis. Similarly, the diagnosis of GERD satisfies the remand directives because it rules out symptoms that cannot be attributed to any known clinical diagnosis. Additionally, the April 2018 VA examinations substantially comply with the Board remand directives. The VA examiners reviewed the evidence of record and considered the Veteran’s actual history and statements. The examiners rendered opinions with reasoned medical explanations and analysis. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Therefore, the Board finds that the Veteran has been provided an adequate medical examination in conjunction with his claim. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Accordingly, there has been substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). 1. Whether the severance of service connection for a cervical spine disability based in clear and unmistakable error was proper. The Veteran asserts that the severance of service connection for a cervical spine disability was improper. A September 2011 rating decision granted service connection for degenerative disc disease of the cervical spine. In January 2013, severance of service connection for the cervical spine disability was proposed. Service connection was subsequently severed in the July 2013 rating decision on appeal, finding that evidence of record at the time of the award of service connection failed to show any indication of a cervical spine or neck injury during the Veteran’s honorable period of service. Service connection will be severed only where evidence establishes that it is clearly and unmistakably erroneous (CUE) (the burden of proof being on the Government). 38 C.F.R. § 3.105(d). When severance of service connection is considered warranted, a rating proposing severance will be prepared setting forth all material facts and reasons. The claimant will be notified at his or her latest address of record of the contemplated action and furnished detailed reasons therefor and will be given 60 days for the presentation of additional evidence to show that service connection should be maintained. Unless otherwise provided in paragraph (i) of this section, if additional evidence is not received within that period, final rating action will be taken and the award will be reduced or discontinued, if in order, effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires. 38 C.F.R. § 3.105(d). A change in diagnosis may be accepted as a basis for severance action if the examining physician or physicians or other proper medical authority certifies that, in the light of all accumulated evidence, the diagnosis on which service connection was predicated is clearly erroneous. This certification must be accompanied by a summary of the facts, findings, and reasons supporting the conclusion. 38 C.F.R. § 3.105(d). To establish that a grant of service connection was the product of CUE, VA must show that (1) either the correct facts as they were known at the time were not before the adjudicator, the adjudicator made an erroneous factual finding, or the statutory or regulatory provisions were incorrectly applied; (2) the alleged error was undebatable, not merely a disagreement as to how the facts were weighed or evaluated; and (3) the error manifestly changed the outcome of the prior decision. See Allen v. Nicholson, 21 Vet. App. 54, 58-59 (2007); Stallworth v. Nicholson, 20 Vet. App. 482, 487-88 (2006); cf. Bustos v. West, 179 F.3d 1378, 1380-81 (Fed. Cir. 1999); Damrel v. Brown, 6 Vet. App. 242, 245 (1994); Russell v. Principi, 3 Vet. App. 310, 313-14, 319 (1992) (en banc). A clear and unmistakable error is one about which reasonable minds could not differ. See, e.g., 38 C.F.R. § 20.1403(a). In most respects, the CUE standard for severing service connection under § 3.105(d) is equivalent to the CUE standard for reversing or revising a prior final decision under 38 C.F.R. § 3.105(a). See Baughman v. Derwinski, 1 Vet. App. 563, 566 (1991). Section 3.105(d) places at least as high a burden of proof on the VA when it seeks to sever service connection as § 3.105(a) places upon an appellant seeking to have an unfavorable previous determination overturned. Id. However, the determination is not limited to the law and the record that existed at the time of the original decision. The severance decision focuses-not on whether the original decision was clearly erroneous-but on whether the current evidence establishes that service connection is clearly erroneous. Stallworth v. Nicholson, 20 Vet. App. 482, 488 (2006). As such, VA may consider medical evidence and diagnoses that postdate the original award of service connection to demonstrate that the diagnosis on which service connection was predicated is clearly erroneous. Stallworth, 20 Vet. App. at 488. The Secretary’s burden is not to prove clear and unmistakable error in the original decision in the same manner a claimant would show CUE under sections 5109A or 7111. Id. A decision that is reversed or amended on the basis of CUE is revised to conform to the true state of the facts or the law that existed at the time of the original adjudication. Allen, 21 Vet. App. at 62 (internal quotations omitted). The question before the Board in this case is whether the grant of service connection for cervical spine degenerative disc disease was clearly and unmistakably erroneous. The Board concludes that the severance of service connection was improper because there is a medical opinion concluding that the current disability is at least as likely as not related to recurrent neck pains in service. This conflicts with the reason service connection was severed. The January 2013 and July 2013 rating decisions regarding severance found that evidence of record at the time of the award of service connection failed to show any indication of a cervical spine or neck injury during the Veteran’s honorable period of service. They also found that degenerative disc disease (DDD) was demonstrated by an August 2004, MRI, but that this was improperly used as a basis for the award of service connection because DDD is not arthritis. Therefore, the September 2011 rating decision improperly applied the chronic disease presumptions under 38 C.F.R. § 3.309 to grant service connection. Service treatment records during the honorable period of the Veteran’s service show that in August 2002, the Veteran was treated for neck and head pain. Cervical spine X-rays were ordered. August 2002 X-rays showed left-sided neural foraminal narrowing although vertebral height was maintained. An MRI later that month shows mild disc desiccation, which was reported normal for the Veteran’s age. There was no foraminal stenosis identified. These reports contradict the rating decision severing service connection in that there was evidence of cervical spine disability during service. Specifically, there was mild disc desiccation. During the dishonorable period of service, the Veteran was formally diagnosed with degenerative disc disease in August 2004. Tending to support a lack of in-service incurrence and nexus, a June 2014 VA medical opinion and a November 2015 VA addendum opinion concluded that that the September 2002 MRI showed a normal cervical spine without DDD or foraminal narrowing. The examiner further opined that an MRI is better than an X-ray, so the August 2002 X-ray showing no foraminal narrowing is overruled by the MRI. The examiner further noted that degenerative changes can be seen as early as the third decade of life and are related to the aging process. Tending to weigh against severance is a May 2018 VA medical opinion concluding that the Veteran’s degenerative disc disease is at least as likely as not related to recurrent neck pain in service. The rationale was stated as a review of the service treatment records documenting recurrent neck pain and narrowing of cervical disc space, as well as the current examination. The Board finds that the evidence in favor of severance is not clear and unmistakable. The June 2014 and November 2015 VA medical opinions did not address the September 2002 MRI finding of disc desiccation. Instead they relied solely on the conclusion of a normal study. Desiccation, whether normal for the Veteran’s age or not, was manifest in service. An August 2004 MRI confirming a diagnosis of DDD is a relatively short period of time after the Veteran’s last day of honorable service. It seems as though it is a short trip from disc desiccation to DDD. On the other hand, the May 2018 opinion correctly noted the Veteran’s complaints of neck pain in service. Although this opinion is fairly general, its accuracy in that regard combined with the failure of the June 2014 and November 2015 VA opinions to address the neck pains in service produces opinions that are roughly equal in probative value. Therefore, it cannot be said that the award of service connection, after reviewing all of the existing and current evidence, was clearly and unmistakably erroneous. In short, there is both positive supporting a nexus and negative evidence against service connection for a cervical spine disability. This evidence presents a reasonable disagreement as to such, and reasonable minds could disagree as to the ultimate determination. However, this determination, at this point, amounts to no more than a disagreement as to how to weigh the facts. In context of a severance case, a disagreement as to how to weigh the facts is legally insufficient to establish that the award of service connection was clearly erroneous. Accordingly, the severance of service connection was improper, service connection is restored, and the appeal is granted. Service Connection 2. Service connection for a left hand and wrist disability. The Veteran seeks service connection for a left hand and wrist disability. 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). 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 carpal tunnel syndrome (CTS), and evidence shows that he reported arm numbness in service and sustained a fracture to the 5th metacarpal of the left hand, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of CTS began during service or is otherwise related to an in-service injury, event, or disease. Service treatment records show an August 1993 report of left-hand tingling, due to hyperventilation with an anxiety attack. Then, the Veteran sustained a fracture to the left hand in February 1995. A March 1995 X-ray showed the injury had healed. In an April 1998 service examination, upper extremities were normal. The Veteran denied swollen and painful joints in his report of medical history at that time. In a March 2004 post post-deployment health assessment, the Veteran denied swollen, stiff and painful joints, as well as numbness or tingling in the hands or feet. In May 2005, he reported left arm numbness, however, this cannot qualify as an in-service incident due to the characterization of the Veteran’s service during this period. June 2011 VA treatment records show the Veteran reported a 5-week history of numbness and tingling from his elbows to his fingertips. He was diagnosed with CTS of the right hand in July 2011. In November 2011, he was seen by rheumatology to assess polyarthralgia with features of inflammatory arthritis. The onset in approximately March 2011 of CTS and polyarthralgia symptoms is years after his period of honorable service. In the August 2011 VA examination, the Veteran reported that his left ring and little fingers are numb with lack of use or upon waking in the morning. The numbness resolves with movement. He denied physical limitation to the left hand. The examiner reported that the Veteran had an EMG completed on both hands and CTS was noted on the right. The August 2011 examiner opined that the Veteran’s left-hand disability is not at least as likely as not related to an in-service injury, event, or disease. The rationale was that the left-hand examination was essentially normal, that the left 5th metacarpal fracture had healed by March 1995 (making injury to have occurred prior to February 1995), and that service treatment records were silent for any other left-hand trauma. The examiner concluded that the left-hand fracture was acute and transitory. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). A VA examination was also conducted in April 2018 diagnosed the Veteran with bilateral carpal tunnel syndrome. The examiner opined that left carpal tunnel syndrome by history are less likely related to arm numbness in service. The examiner reasoned that the neurology notes from June 2011 document a five-week history of numbness to the hands, which was many years after service. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the Veteran is competent to report having experienced symptoms of pain and numbness, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of carpal tunnel syndrome. The issue is medically complex, as it requires knowledge of interpretation of complicated diagnostic medical testing]. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board finds that the recorded medical history in service and in June 2011 are more probative than the Veteran’s general claim for service connection and reports of pain in his hand. The medical records are more detailed and specific and were recorded at or near the time of the incidents under review (i.e. service and the onset of the disability). Consequently, the preponderance of the evidence is against the claim, and it must be denied. The Board notes that the legal provisions regarding service in the Southwest Asia Theater of Operations during the Persian Gulf War under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 are not applicable. The Veteran’s left hand and wrist symptoms have been attributed to carpal tunnel syndrome. Accordingly, the disability does not qualify as an undiagnosed illness or a medically-unexplained chronic multisymptom illness. 38 C.F.R. § 3.317 (a)(1). 3. Service connection for left shin splints. 4. Service connection for right shin splints. The Veteran seeks service connection for left and right shin splints. The Veteran contends that he had them during his incarceration from 2005 to 2011. 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 shin splints 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). Moreover, the Board concludes that the Veteran’s reports of pain do not reach the level of functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1367-69 (Fed. Cir. 2018). The August 2011 VA examiner found that shin splints were not caused by service. The examiner reasoned that the current examination was normal and that there are no records to confirm a previous diagnosis of shin splints. The Veteran stated he experienced shin splints during his incarceration during the appeal period from 2005 to 2011. His medical records from his period of incarceration are not associated with his claims file. As noted above, he was provided with the authorization forms to permit VA to attempt to obtain them and he did not return them. The April 2018 VA examination found no shin splints. November 2011 VA treatment records pertaining to polyarthralgia do not include a report of shin pain. Although the Veteran reports that he is unable to stand more than one hour without taking a break and sitting and is not able to run more than 1 mile due to pain, there is no evidence that this rises to the level of a functional impact on earning capacity. While the Veteran believes he had shin splints during his incarceration and he is competent to report pain in his shins, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires knowledge of diagnostic criteria for the diagnosis. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Despite his report of having shin splints during his incarceration, his earnings capacity has not been impaired due to shin pain. There is no persuasive evidence of severity, frequency, and duration of shin pain that would result in this impairment. Consequently, service connection is not warranted. 5. Service connection for a left ankle disability. The Veteran seeks service connection for a left ankle disability. 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 reduced range of motion and some swelling, and evidence shows that the Veteran sprained the ankle in November 1991, the preponderance of the evidence weighs against finding that the Veteran’s left ankle disability began during service or is otherwise related to an in-service injury, event, or disease. Service treatment records show a left ankle sprain with no swelling, loss of range of motion or laxity in November 1991. In the report of medical history in April 1998, the Veteran denied swollen or painful joints. In the April 1998 Report of Medical Examination, the feet and lower extremities were normal. In an April 2001 medical questionnaire, the Veteran denied difficulty squatting to the ground and climbing stairs, and weakness in his legs or feet. In the November 2002 pre-deployment health assessment, the Veteran denied any concerns about his health. In a March 2004 post-deployment health assessment, the Veteran denied swollen stiff or painful joints. In a February 2005 Report of Medical Assessment, the Veteran denied having any concerns about his health other than those reported, which are not relevant here. The June 2011 VA treatment examination showed normal motor examination in the extremities. The August 2011 VA ankle examination showed a resolved left ankle sprain. The Veteran reported he may have some swelling in the left ankle with prolonged standing, which improves with rest. He states that the left ankle disability interferes with daily activities such as with standing over an hour and running more than one mile. The examiner noted the cardiac history which may cause some of the swelling. The examiner found the left ankle disability is less likely than not related to the in-service left ankle sprain in November 1991. The examiner reasoned that the Veteran’s annual firefighter physical examinations and pre- and post-deployment examinations on the ankle joints were normal. The examiner concluded that the left ankle sprain in service was acute and transitory. The current examination results were normal for the Veteran’s age and body habitus. The April 2018 VA ankle examination showed the Veteran denied left ankle pain. Treatment records show treatment for polyarthralgia in the ankle in July 2011 and thereafter. The symptoms prompting the polyarthralgia diagnosis had their onset five weeks prior. The medical records show that the in-service left ankle strain healed and did not recur. This is shown by the later affirmative denials of symptoms in the service treatment records. Moreover, the ankle pain in 2011, which is the first credible indication of post-service ankle disability began only five weeks prior. This is years after the honorable period of service. Additionally, the VA examiners’ opinions are highly probative evidence against the claim as they considered the Veteran’s history and provide an opinion based on sound reasoning. The Veteran believes his left ankle pain is related to an in-service injury, event, or disease. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of medical principles that is not readily observable by the lay person. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examiners’ opinions. The Board notes that the legal provisions regarding service in the Southwest Asia Theater of Operations during the Persian Gulf War under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 are not applicable. When the Veteran had left ankle symptoms in 2011, the VA examiner attributed them to known causes such as age and body habitus. In the most recent VA examination, the Veteran did not have left ankle symptoms. Accordingly, the disability does not qualify as an undiagnosed illness or a medically-unexplained chronic multisymptom illness. 38 C.F.R. § 3.317 (a)(1). 6. Service connection for a right ankle disability. The Veteran seeks service connection for a right ankle disability. 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 diagnosis of right ankle strain, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. Service treatment records show the Veteran denied swollen or painful joints in the report of medical history in April 1998. In the April 1998 Report of Medical Examination, the feet and lower extremities were normal. In an April 2001 medical questionnaire, the Veteran denied difficulty squatting to the ground and climbing stairs, and weakness in his legs or feet. In the November 2002 pre-deployment health assessment, the Veteran denied any concerns about his health. In a March 2004 post-deployment health assessment, the Veteran denied swollen stiff or painful joints. In a February 2005 Report of Medical Assessment, the Veteran denied having any concerns about his health other than those reported, which are not relevant here. June 2011 VA treatment examination showed normal motor examination in the extremities. At the August 2011 VA ankle examination, the examiner reported the ankle was normal (without a diagnosis), however, the range of motion testing resulted in reduced range of motion. The examiner attributed this to age. The examiner opined that the right ankle condition was not related to service because there was no in-service incurrence. The examiner relied upon normal pre- and post-deployment examinations as well as no report of ankle problems otherwise. The examiner found that the examination was normal for the Veteran's age and body habitus. The Board notes that the Veteran denied problems with the right ankle at that examination. The April 2018 VA ankle examination showed the Veteran reporting that right ankle pain began off and on since 2014, and that he was in a motor vehicle accident in December 2017. The examiner diagnosed the Veteran with a right ankle strain. The examiner opined that the current right ankle strain was less likely related to service. The rationale was that the history of onset of the right ankle pain was many years after service and his motor vehicle accident in 2017. The Board concludes the there was no in-service incurrence or manifestations of an ankle disability. This is shown by the later affirmative denials of symptoms in the service treatment records. Moreover, the ankle pain in 2011, which is the first credible indication of post-service ankle disability, is shown by the treatment records to have begun in 2011. This is years after the honorable period of service. Additionally, the VA examiners’ opinions are highly probative evidence against the claim as they considered the Veteran’s history and provide an opinion based on sound reasoning. While the Veteran believes his right ankle disability is related to service, the Board reiterates that the preponderance of the evidence weighs against findings that an in-service injury, event, or disease occurred. To the extent the service treatment records conflict with the Veteran’s reports, the Board assigns more probative value to the service treatment records because they were recorded near the time period relevant to the issue of whether there is an in-service incurrence. The Board notes that the legal provisions regarding service in the Southwest Asia Theater of Operations during the Persian Gulf War under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 are not applicable. When the Veteran had right ankle symptoms in 2011, the VA examiner attributed them to known causes such as age and body habitus. In the most recent VA examination, the Veteran had a right ankle strain, which the examiner attributed to a vehicle accident. Accordingly, the disability does not qualify as an undiagnosed illness or a medically-unexplained chronic multisymptom illness. 38 C.F.R. § 3.317 (a)(1). 7. Service connection for GERD. The Veteran seeks service connection for GERD. 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 evidence shows in-service gastrointestinal symptoms, 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. Service treatment records show that in March 1995, the Veteran had bouts of vomiting. The April 1998 report of medical examination showed a normal abdominal examination. In April 2001, an abdominal X-ray was suspicious for severe ileus versus early bowel obstruction. The X-rays were taken after the Veteran complained of chest pain. In November 2002, the Veteran denied having health concerns and was not referred for gastrointestinal problems after interview. In June 2003, the Veteran had flu symptoms with vomiting. In March 2004, the Veteran denied diarrhea, frequent indigestion, and vomiting. According to the August 2011 VA intestines examination, up until 2010 the Veteran had symptoms of inability to have a bowel movement after eating yet feeling an urge to do so. He also reported blood in the stool. The August 2011 VA examination showed a normal intestinal examination. The examiner opined that the service treatment records documented evaluation and treatment of intestinal symptoms, but that those symptoms were acute and transitory. Pre- and post- deployment examinations were normal. Thus, the Veteran’s intestinal condition is not related to service, the examiner opined. Furthermore, at the April 2018 VA examination, the Veteran said that he started having heart burn and an associated cough on and off for three years. The examiner diagnosed him with GERD. The examiner opined that GERD is less likely than not related to service. The rationale is that the totality of the service and post-service medical records do not document ongoing treatment for GERD. The Board interprets this, in light of the statement that the Veteran reported heart burn for three years, to mean there was no treatment for GERD in service or post-service until three years prior. The evidence thus shows that the in-service incurrences were isolated, as shown by the later normal reports and denials of symptoms in the service treatment records. GERD itself did not have its onset, according to the Veteran’s report in the 2012 VA examination, until 2015. This is years after service. While the Veteran is competent to report having experienced intestinal symptoms during his incarceration, and symptoms of GERD, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of, in the case of his symptoms through 2010, an ongoing disability as opposed to isolated instances of constipation or other acute problem, or GERD. The issue is medically complex, as it requires knowledge of medical diagnostic criteria, of disease characteristics, and of the etiologies of diseases. This requires specialized knowledge that is not capable of lay observation. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the VA examiners’ opinions. Nonetheless, service connection may be granted for a Persian Gulf veteran with objective indications of a qualifying chronic disability that manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). A qualifying chronic disability is a chronic disability that may result from an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2)(i). Here, the Veteran had active service in Oman from December 2002 to May 2003. Therefore, he is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). The April 2018 VA examination shows the Veteran has a diagnosis of 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. REASONS FOR REMAND 1. Service connection for a low back disability is remanded. While the Board sincerely regrets the additional delay, the Board cannot make a fully-informed decision on the issue of service connection for a low back disabililty because no VA examiner has opined whether the Veteran’s low back disability is related to his contention of wearing heavy firefighting equipment in service and to the mild thoracic spine scoliosis found in August 1993. In the April 2018 VA examination, the Veteran asserted that he started having back pain and radiating pains to the lower legs since service. He has been consistent about this contention since as early as 2011. The Veteran has a current diagnosis of degenerative arthritis of the spine and intervertebral disc syndrome as evidenced by the April 2018 VA thoracolumbar spine examination. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from a clinician regarding whether the Veteran’s lumbar spine degenerative arthritis of the spine and IVDS is at least as likely as not related to the mild thoracic spine scoliosis identified in August 1993, and to the Veteran’s use of heavy firefighting equipment carried on his back. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. If upon completion of the above action any benefit sought on appeal remains denied, the case should be returned to the Board after compliance with appellate procedure. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Rocktashel, 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.