Citation Nr: 21012165 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 17-32 143 DATE: March 3, 2021 ORDER The claim of entitlement to an initial disability rating in excess of 30 percent from May 28, 2014, and in excess of 50 percent from January 7, 2020, posttraumatic stress disorder (PTSD) with depressive disorder, is denied. The claim of entitlement to service connection for a lumbar spine disorder, to include degenerative arthritis, is denied. REMANDED The claim of entitlement to service connection for sarcoidosis, to include as due to herbicide exposure, is remanded. The claim of entitlement to service connection for a heart disorder, to include ischemic heart disease (IHD), and to include as due to herbicide exposure, is remanded. FINDINGS OF FACT 1. Prior to January 7, 2020, the severity, frequency, and duration of the Veteran’s psychiatric symptoms did not more closely approximate occupational and social impairment with reduced reliability and productivity. 2. From January 7, 2020, the severity, frequency, and duration of the Veteran’s psychiatric symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas. 3. The Veteran’s lumbar spine disorder was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology has not been established; and the disability is not otherwise etiologically related to an in-service injury or disease. CONCLUSIONS OF LAW 1. Prior to January 7, 2020, the criteria for a disability rating in excess of 30 percent for PTSD with depressive disorder were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. From January 7, 2020, the criteria for a disability rating in excess of 50 percent for PTSD with depressive disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, DC 9411. 3. The criteria for entitlement to service connection for a lumbar spine disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active service with the United States Army from June 1966 to June 1968. The Veteran received, among other commendations, the Vietnam Service Medal and the Vietnam Campaign Medal. These matters come before the Board of Veterans’ Appeals (Board) from a December 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in April 2019. A written transcript of that hearing has been prepared and is associated with the evidence of record. The Veteran’s claim of entitlement to service connection for ischemic heart disease has been expanded to encompass any heart disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009); Brokowski v. Shinseki, 23 Vet. App. 79 (2009); see also August 2019 Board remand. In August 2019, the Board remanded these matters to the RO for additional development. The Board concludes that there has been substantial compliance with its prior remand directives only as to the psychiatric conditions and the lumbar spine disorder. Although regrettable, additional remand is required as to the claims of entitlement to service connection for sarcoidosis and a heart disorder in order to obtain substantial compliance with the Board’s previous remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). This appeal has been advanced on the Board’s docket pursuant to 38 U.S.C. § 7107(a)(2) and 38 C.F.R. § 20.900(c). 1. The claim of entitlement to an initial disability rating in excess of 30 percent from May 28, 2014, and in excess of 50 percent from January 7, 2020, for PTSD with depressive disorder. The Veteran contends entitlement to increased ratings for his PTSD with depressive disorder. During the April 2019 Board hearing, the Veteran testified that his psychiatric symptoms had worsened since his last VA examination, which had occurred in November 2014. He described panic attacks, as well as increased flashbacks and nightmares. See Board hearing transcript. Disability ratings are determined by application of a ratings schedule which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In general, the degree of impairment resulting from a disability is a factual determination and generally the Board’s primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Nonetheless, separate, or staged, ratings can be assigned for separate periods during the initial rating period on appeal based on the facts found. See O’Connell v. Nicholson, 21 Vet. App. 89, 91-92 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate for initial rating and increased rating claims when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Each service-connected disability is rated based on specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran is generally presumed to seek the maximum benefit allowed by law and regulation. See AB v. Brown, 6 Vet. App. 35, 39 (1993). Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Mental disorders are rated under the General Rating Formula for Mental Disorders (General Formula) pursuant to 38 C.F.R. § 4.130, and the Veteran’s PTSD is rated under DC 9411. Under the General Formula (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating in excess of 30 percent prior to January 7, 2020 and in excess of 50 percent thereafter. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Prior to January 7, 2020 The Board concludes that during this period, the Veteran’s symptoms did not cause the level of impairment required for a disability rating of 50 percent or higher. Instead, the Veteran’s symptoms more closely approximated the symptoms associated with a 30 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 30 percent rating. The Veteran’s initial VA examination was conducted in November 2014 by a VA clinical psychologist. The examiner noted the Veteran’s symptoms to include depressed mood, anxiety, chronic sleep impairment and mild memory loss, such as forgetting names, directions or recent events. At the time of this examination, the Veteran was observed to have good grooming and hygiene, and hs psychomotor activity was normal. His speech was clear and fluent, his mood appeared euthymic, and his affect was appropriate and broad. His thought processes appeared logical to the examiner and his immediate and remote memory intact. The examiner included many references to supplemental information contained in the Veteran’s claim file, noting that the Veteran had retired in 2011 to care for his wife of 42 years after she became ill and ultimately passed away. As of May 2014, the Veteran was still working six hours per day at the same facility he had worked before retiring. He had reported to his mental health provider that he went to the gym at his work and was in a “pretty good” dating relationship with a new person. He reported positive relationships with his children, who lived several hours away, and he had future plans to visit them. It is evident to the Board from the clinician’s examination report, that she reviewed and thoroughly considered the Veteran’s lay report of symptoms and the available treatment records from his VA provider in formulating her clinical conclusions and in linking the etiology of the Veteran’s PTSD and depressive disorder to his military service. The Board therefore assigns significant probative value to this examination and to the clinical evidence highlighted by the examiner in her report. However, while the examiner concluded that the Veteran’s conditions resulted in only occupational and social impairment in line with a 10 percent rating due to mild or transient symptoms, the Board concludes that the symptoms described in this and other evidence of record most closely aligns with a 30 percent rating during this period. The level of psychiatric functioning noted in mental health treatment notes created throughout the period on appeal, along with the Veteran’s lay statements made to providers during this period, further confirm that the Veteran’s PTSD and depressive disorder was manifested by symptoms associated with a 30 percent rating such as chronic sleep impairment, depressed mood, anxiety, panic attacks (weekly or less often), and mild memory loss, which caused the Veteran 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 normal conversation). For example, while May 2014 and November 2016 counseling records from the Vet Center show that the Veteran reported flared symptoms after talking about the war, most records show at least generally satisfactory functioning. One May 2015 pulmonary consultation record shows that the Veteran took a week-long cruise to the Bahamas in December 2014. Other records throughout this period also show a relatively consistent disability picture in line with a 30 percent rating, but no higher. Mental health outpatient treatment notes from March 2015 reflect the Veteran’s report that he felt he was “hanging in there” and was “about the same as” his last appointment. He reported “only a little depression, nothing persistent. Usually related to stressors.” He reported an improvement in his temper and noted that he was “still dating some.” A February 2017 mental health outpatient treatment note similarly indicates that the Veteran was doing “pretty good,” still had “flashbacks now and then, intrusive memories. Some nightmares.” His mental status examination on that date showed that he was alert and oriented, had good eye contact, and his affect was “full with normal intensity.” His mood was euthymic but with underlying anxiety. The Veteran’s psychiatrist noted that the Veteran was “doing alright” and they discussed the possibility of decreasing his psychotropic medications. According to an October 2019 mental health outpatient note, the Veteran reported he had continued working part time from his retirement in 2011 until June 2019, when he decided not to renew his “CDL” driving license, though he maintained his regular license. He did report increased feelings of loneliness and feeling that some of his symptoms had flared as he had more time on his hands. Still, he continued to engage in therapy and reported having recently enjoyed a trip to visit the D-Day memorial with seven other veterans as arranged by his Vet Center provider. Mental status examination on this date reflected behavioral markers in line with a 30 percent rating, but no higher. The Veteran did experience symptoms during this period that are not listed with a specific rating, such as feeling that he could not “go out and do things like a normal person,” and of feeling on “guard.” The Board further acknowledges statements made by the Veteran in support of his claim (such as those contained in his December 2018 Form 9 appeal) which include his report that, among other things, he had panic attacks every day, severe nightmares, and difficulties with his relationships. However, while the Veteran is competent to report such symptoms, the Board considers the Veteran’s ongoing mental health treatment records to provide the most credible and probative evidence regarding the severity of the Veteran’s psychiatric condition throughout this period on appeal. Cumulatively, these VA psychiatric treatment and Vet Center counseling records show some fluctuation in the severity of the Veteran’s symptoms, but also clearly indicate that the Veteran was able to maintain family relationships and satisfactorily meet work responsibilities while he remained employed. Although the Veteran did experience some symptoms contemplated by the higher 50 percent rating—such as disturbances of mood, and intermittent periods of feeling alone or the need to isolate from others—the evidence does not demonstrate that these symptoms met the level of impairment associated with a 50 percent rating given his general functioning. The Board further finds the severity, frequency, and duration of the Veteran’s unlisted symptoms more closely approximate the symptoms contemplated by a 30 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 50 percent rating. See 38 C.F.R. § 4.126. In sum, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms resulted in the level of impairment required for a 50 percent rating. As the criteria for a 50 percent or higher rating are not met, the appeal as to a rating in excess of 30 percent disabling during this period must be denied. From January 7, 2020 The issue during this period is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher. The Board concludes that the Veteran’s symptoms resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent evaluation and no higher. As noted earlier in this decision, a 70 percent rating is assigned where symptoms cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 70 percent rating may include symptoms such as suicidal ideation; obsessional rituals (which interfere with routine activities); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or an inability to establish and maintain effective relationships. During this period, the Veteran received an updated VA examination in January 2020. This examiner concluded that the Veteran’s functioning at that time again matched only a 30 percent rating. However, viewing the evidence in a light most favorable to the Veteran, the Board concludes that the Veteran’s overall functioning during this period approximated a 50 percent rating due to prevalent symptoms such as flattened affect; panic attacks more than once a week; impairment of short and long-term memory; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships which caused him occupational and social impairment with reduced reliability and productivity. According to May 2020 progress notes from the Vet Center, the Veteran described “having flashbacks and nightmares lately.” He still struggled with sleep disturbances but denied suicidal or homicidal ideation. April 2020 treatment notes showed that the Veteran was attending a PTSD group twice per month, and reported “having cabin fever and feeling tired” related to a discussion about the Coronavirus. The Veteran struggled with nightmares, anxiety, increased hypervigilance, and isolation (see e.g., individual contact note dated January 29, 2020). During this period, the Veteran’s overall disability picture did not more closely approximate a 70 percent rating. The Board acknowledges that the Veteran’s VA and private treatment records and some of the Veteran’s lay statements of record show that the Veteran’s PTSD and depressive disorder did include some symptoms associated with a 70 percent rating, such as difficulty in adapting to stressful circumstances, such as those brought on by COVID-19. Further, the Veteran did have symptoms that are not listed with a specific rating, such as easy startling and difficulty in crowds. However, the Board finds the severity, frequency, and duration of the Veteran’s listed and unlisted symptoms more closely approximate the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. See 38 C.F.R. § 4.126. The January 2020 VA examiner did not identify in the Veteran symptoms that could reach a 70 percent rating, such as intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; or impaired impulse control. Further, the Veteran’s own statements made to treatment providers indicate that he experienced relative stability in his level of functioning during this period (see e.g., April 2020 mental health outpatient note reporting no worsening nightmares and panic attacks, with nightmares occurring once per week and flashbacks every few months; Veteran reported, “I feel like I’m in a good place to be honest.”). Socially, during this period the Veteran maintained supportive contact with a daughter who lived near him and stayed in touch with two other children who lived out of town. He maintained a relationship with a girlfriend for over 5 years, and attended church regularly. While he stated he did not have any close friends, he also reported being “bored but content with his social network.” See April 2020 Mental Health Outpatient Note. A Mental status examination on this same date reflected that the Veteran’s speech was normal in rate, rhythm, and tone, his thought process logical and coherent, and his attention, concentration and judgment was good. His mood reflected underlying anxiety but with suicidal ideation, no delusions or hallucinations. His memory was “intact in all spheres.” His treating psychiatrist on this date noted that “[o]verall arc of treatment is the patient is improving.” According to the January 2020 VA examination, the Veteran attended monthly “VFW” meetings and ate at restaurants about once a week. In light of this probative evidence, the Board finds a 70 percent rating not warranted. Having fully considered the evidence of record throughout the period on appeal, the Board concludes that the preponderance of the competent, credible and probative evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms resulted in the level of impairment required for a 50 percent rating prior to January 7, 2020, and in excess of 50 percent from that date, have not been met. As such, the Veteran’s appeal for an increased rating for his PTSD and depressive disorder must be denied. 2. The claim of entitlement to service connection for a lumbar spine disorder, to include degenerative arthritis. The Veteran asserts that his lumbar spine disorder was caused by his active service. Specifically, he asserts that his military duties involved walking long distances while carrying heavy equipment. He also asserts that he completed strenuous work clearing fields and obstacles and that his back pain started while in service. See October 2015 Statement in Support of Claim. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases, including arthritis, may be presumed related to service if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). To show chronicity there is a requirement of a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “chronic.” 38 C.F.R. § 3.303(b). In these types of cases the disease is presumed under the law to have had its onset during service even though there is no evidence of that disease during service. 38 C.F.R. § 3.307(a). This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. § 1113; 38 C.F.R. § 3.307(d), 3.309(a). Pursuant to 38 C.F.R. § 3.309(a) if a disease is not shown to be chronic during service or the one-year presumptive period, then service connection may also be established by showing a continuity of symptomatology after service. 38 C.F.R. § 3.303(b). Continuity of symptomatology may be established by demonstrating: (1) that a condition is shown in service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Id. Nevertheless, when service connection cannot be granted on a presumptive basis, a veteran may still establish service connection on a direct basis. See Combee v. Brown, 34 F.3d 1039,1042 (Fed. Cir. 1994). VA shall consider all information and lay and medical evidence of record in a case and make appropriate determinations as to competence, credibility, and weight. 38 U.S.C. § 5107; Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); 38 C.F.R. § 3.303. Additionally, lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that whether lay evidence is competent and sufficient in a particular case is a factual issue). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In this case, the Board notes that the Veteran has a current diagnosis of degenerative arthritis of the spine (as well as radiculopathy of the lower left extremity and status post-lumbar fusion), as evidenced by the back conditions disability benefits questionnaire (DBQ) dated February 2020. As noted above, arthritis is an enumerated condition under 38 C.F.R. § 3.309(a) and is eligible for presumptive service connection. Review of the remaining evidence of record, however, reveals that the Veteran’s disability was not shown as chronic in service, did not manifest to a compensable degree within the presumptive period, and was not noted in service with attributable continuity of symptomatology. The Veteran’s service treatment records (STRs) are silent for complaint of, or treatment for, a back condition or back pain during his active service. Further, the Veteran’s Reports of Medical Examination and History at his separation in April 1968 include no indication of a spine condition or back pain. The Board acknowledges the Veteran’s lay statements of record that he “started having minor back pain” during his service but that did not seek medical attention because he was in “a war zone” and back pain was considered a very low priority. See October 2015 Statement in Support of Claim. The Veteran also testified that he did not recall ever having a physical examination at his separation. On their own, such statements could provide a reasonable explanation for why the Veteran’s service records do not contain complaint of back pain, however, the Board finds these lay reports to lack credibility and probative value when viewed along with the Veteran’s actual separation records and the considerable amount of post-service medical treatment evidence. For example, the evidence of record contains copies of the Veteran’s April 1968 Report of Medical History and Report of Medical Examination conducted for his separation at Fort Belvoir, Virginia. In these Reports, an examiner noted no spine conditions and, while the Veteran reported having other physical ailments such as frequent colds and a chronic cough (which were not reported at his induction), he did not complain of back trouble in his medical report at separation. Further, this same record indicates that an examiner made additional comments about each of the ailments of which the Veteran complained and is silent for discussion of a spine condition. Additionally, the Veteran’s signature appears on both the Veteran’s April 1968 Report of Medical History and on a separate Statement of Medical Condition signed in May 1968, declaring that to the best of his knowledge, there had been no change in his medical condition since his last separation examination. Post-service medical treatment records show that the first documented complaint of back pain is contained in a May 1990 emergency room treatment note, where the Veteran was seen for “pain in his lower mid back, injured while lifting …[t]oday.” The Veteran was assessed on that date with low back strain, and the treatment note further indicated that the Veteran had “no prior” back injury. Subsequent private medical treatment records from the late 1990’s indicate that the Veteran sought additional treatment for low back pain, but these records do not provide a link between the Veteran’s back pain and his military service and instead point to work-related activities as causing the Veteran’s symptoms. For example, a January 1998 record states that the Veteran sought treatment for “intermittent discomfort in his right lower back and radiation around to the right groin area.” The note states that the Veteran had been “lifting quite a bit at work.” He was assessed at this time with mild low back pain. Other notes from these records reflect the Veteran’s complaints of chronic low back pain. See e.g., records from March and October 1998; January and June 2000. The Board finds these historical medical treatment records to be credible and probative evidence showing that the Veteran did not seek medical attention for back pain until several decades after his active service and outside of the applicable presumptive period for arthritis. Further, when he did eventually seek medical attention, he reported pain following work-related activities and lifting. The Board acknowledges the Veteran’s contention that his back pain began in service and continued after; however, the Veteran’s other lay statements contradict this assertion and reduce the credibility and probative value of his contentions. During his hearing before the Board, the Veteran stated that he actually first started noticing problems with his back while working on the back of a trash truck in the District of Columbia. The Board understands this work to have post-dated his active service as, according to his testimony, it was following the start of this work that he sought medical treatment from a hospital, which is consistent with the emergency room treatment evidence of record from 1990. These reports place the onset of the Veteran’s symptoms decades outside of the presumptive period and do not support a continuity of symptomatology for several decades following his service. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Next, the Board has also considered whether service connection for a low back condition could still be granted on a direct basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s degenerative arthritis and an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. Following the Board’s remand of this appeal, the Veteran was provided a VA medical examination in February 2020, with an addendum report provided in October 2020. According to this examination and addendum report, the Veteran’s low back disability was not at least as likely as not related to an in-service injury, event, or disease, noting the long gap of time between discharge from service and his first complaint of back pain. Further the examiner noted that the medical records related to the Veteran’s eventual back pain identified lifting activities at work as a precipitating cause of the symptoms. The Board finds these opinions probative as they are consistent with the medical treatment evidence and with the Veteran’s contemporaneous lay reports of symptoms that he made to medical providers. Even if the Board were to accept the Veteran’s assertion that he began having some back pain during service, which he is competent to observe, he is not competent to provide a diagnosis in this case or determine that his back pain symptoms were manifestations of his current low back condition (here, degenerative arthritis), as the Veteran has not demonstrated that he has the necessary medical expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Accordingly, the Board gives more probative weight to competent medical evidence of record, which establishes that the Veteran’s lumbar spine symptoms were less likely than not related to his military service. Lastly, the Board notes that when considering whether or not to grant a claim for service connection, the Board may take into consideration the passage of a lengthy period of time in which the Veteran did not complain of the disorder at issue. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Here, there is a significant period of time between when the Veteran separated from active duty, and the first documented complaints of low back condition. Upon review of the entire record, the Board finds that the competent, credible, and probative evidence weighs against the Veteran’s claim of entitlement to service connection for low back condition, to include degenerative arthritis, and to include as presumptively related to service. Because the preponderance of the evidence weighs against the Veteran’s claim, the benefit of the doubt doctrine is inapplicable, and the appeal is denied. 38 U.S.C. § 5107(b). REASONS FOR REMAND 1. The claim of entitlement to service connection for sarcoidosis, to include as due to herbicide exposure, is remanded. The Veteran seeks service connection for sarcoidosis, which he asserts is the result of his exposure to Agent Orange and/or other toxins. The Board finds remand necessary as the medical examination evidence of record has not addressed whether exposure herbicides or other toxins could be related to the claimed condition. As noted in the Board’s prior remand decision, the Veteran’s service treatment records do not contain any treatment related to sarcoidosis, and his Report of Medical Examination does not note any complaints or symptoms related to a heart condition. However, his April 1968 report of medical history noted a history of chronic or frequent colds and a chronic cough. Post-service private treatment records noted that the Veteran complained of cough, shortness of breath, and weight loss since 1989. In February 1990, he received a diagnosis of sarcoidosis. On remand, the Veteran received a VA examination in February 2020 (with corresponding addendum report provided in October 2020). The opining clinicians concluded that the Veteran’s sarcoidosis was less likely than not proximately due to or caused by his in-service exposures to herbicides and toxins based on the “medical fact that the cause of sarcoidosis in the vast majority of patients is not known” and that “chronic or frequent colds and a chronic cough are not known risk factors for this disease.” The reports also indicated reliance on the fact that the Veteran was “diagnosed with sarcoidosis more than 20-years after his release from active duty” and there was no objective evidence in the Veteran’s claims file that his sarcoidosis was “in any way related to any in-service exposure.” As this opinion failed to specifically address whether there is any potential link between herbicides (to include Agent Orange and other toxins to which the Veteran may have been exposed during his service in Vietnam) and sarcoidosis, the Veteran’s claim must be remanded for an addendum medical opinion. 2. The claim of entitlement to service connection for a heart disorder, to include ischemic heart disease, and to include as due to herbicide exposure, is remanded. The Veteran asserts that service connection is warranted for a heart disorder, to include ischemic heart disease. He contends that his heart disorder was caused by exposure to Agent Orange during service. As the Board noted in its August 2019 remand, the Veteran’s personnel records documented his service in the Republic of Vietnam, and he is therefore presumed to have been exposed to herbicides during his service. The Board finds that remand is again necessary as the medical opinion evidence of record did not adequately address conflicting medical evidence of record indicating that the Veteran may have coronary artery disease, a condition presumptively related to herbicide exposure. Further, the medical opinion evidence shows that the Veteran’s diagnosed “heart block” condition may be secondarily related to his sarcoidosis. As the Board is remanding his sarcoidosis claim for additional medical development, and as service connection for the identified heart block condition appears to be dependent on the Veteran’s sarcoidosis claim, the Board finds remand is additionally warranted to address any secondary link between the heart block condition and sarcoidosis, if sarcoidosis is determined to be related to herbicide exposure. The matters are REMANDED for the following action: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s claims. If the RO determines that any relevant records do not exist or that any additional attempts to obtain these records would be futile, the record should be annotated to reflect such and the Veteran should be notified in accordance with 38C.F.R. §3.159(e). 2. Then, the RO should obtain an addendum medical opinion by a VA clinician with sufficient expertise, to provide an opinion as to the following: (a.) Whether it is at least as likely as not that the Veteran’s sarcoidosis is directly related to his active duty exposure to Agent Orange and other toxins. All pertinent evidence of record must be made available. If the RO or clinician determine that an in-person or telemedicine examination is necessary to evaluate this claim, one should be scheduled. In providing this opinion, the examiner should consider and discuss the Veteran’s April 1968 report of medical history noting chronic colds and a chronic cough, as well as the Veteran’s October 2015 statement in support of claim regarding his in-service exposures to various toxins. 3. Then, the RO should obtain an addendum medical opinion by a VA clinician with sufficient expertise, to determine the nature and etiology of the Veteran’s heart disorders. All pertinent evidence of record must be made available. If the RO or clinician determine that an in-person or telemedicine examination is necessary to evaluate this claim, one should be scheduled. Following a review of the relevant medical records and lay statements, the VA clinician is to do the following: (a.) Identify all heart disorders present during the period of the claim on appeal. (b.) For each identified heart disorder present during the period of the claim, please explain fully whether each disorder qualifies as ischemic heart disease pursuant to 38 C.F.R. § 3.309(e), which defines the condition as, “Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina).” (c.) If the examiner concludes that the Veteran did not have ischemic heart disease (as defined above) at any period during the pendency of the claim, the examiner must address the conflicting evidence of record that show the Veteran’s historical diagnosis of coronary artery disease or a coronary artery condition. See e.g., February 2015, May 2019, November 2019, and June 2020 VA treatment records. (d.) For each identified condition that does not meet the above definition of ischemic heart disease, the examiner must opine whether is it is at least as likely as not (50 percent probability or greater) that the disorder was incurred in, caused by, or is otherwise etiologically related to the Veteran’s military service, to include as directly related to the Veteran’s in-service exposure to herbicide agents. It would be particularly helpful to the Board if the clinician would support their opinions with current medical research regarding any potential links between all non-IHD heart conditions and herbicide exposure. The rationale for all opinions expressed should also be provided. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. The RO or should then readjudicate the issues on appeal. If the benefit sought on appeal is not granted to the Veteran’s satisfaction, the Veteran should be furnished an appropriate supplemental statement of the case and be afforded the an opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Hart, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.