Citation Nr: 21013614 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 15-44 683 DATE: March 10, 2021 ORDER Entitlement to a compensable rating for allergic rhinitis is denied. Entitlement to service connection for dizziness is denied. Entitlement to service connection for migraine headaches is denied. Entitlement to service connection for erectile dysfunction is denied. Entitlement to service connection for a gastrointestinal disorder, including irritable bowel syndrome, is denied. Entitlement to special monthly compensation (SMC) due to loss of use of a creative organ is denied. FINDINGS OF FACT 1. The Veteran canceled the VA examinations scheduled in September 2019, and has not presented good cause for his failure to respond to such attempts or expressed a willingness to attend such VA examinations. 2. For the entire period on appeal, the Veteran’s rhinitis was not manifested with a 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. 3. The Veteran’s dizziness was not manifested in service or for many years thereafter, and the preponderance of the evidence is against a finding that such disability is etiologically related to a disease or injury in service. 4. The Veteran’s migraine headaches were not manifested in service or for many years thereafter, and the preponderance of the evidence is against a finding that such disability is etiologically related to a disease or injury in service. 5. The Veteran’s erectile dysfunction was not manifested in service or for many years thereafter, and the preponderance of the evidence is against a finding that such disability is etiologically related to a disease or injury in service. 6. The Veteran’s gastrointestinal disorder was not manifested in service or for many years thereafter, and the preponderance of the evidence is against a finding that such disability is etiologically related to a disease or injury in service. 7. The Veteran’s erectile dysfunction is not a service-connected disability nor shown to be due to a service-connected disability; hence, entitlement to special monthly compensation based on the loss of use of a creative organ is not warranted. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for rhinitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.655, 4.1—4.14, 4.97, Diagnostic Code 6522. 2. The criteria for service connection for dizziness have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.655. 3. The criteria for service connection for migraine headaches have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.655. 4. The criteria for service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.655. 5. The criteria for service connection for a gastrointestinal disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.655. 6. The criteria for establishing entitlement to SMC are not met; SMC for loss of use of a creative organ is not warranted. 38 U.S.C. §§ 1114(k), 5107; 38 C.F.R. §§ 3.102, 3.350, 3.655. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from May 1975 to May 1997, to include service in Southwest Asia. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a November 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) St. Petersburg, Florida. Jurisdiction of this appeal is currently with the RO in Atlanta, Georgia. This case was most recently before the Board in November 2018, at which time the appeal was remanded to the Agency of Original Jurisdiction (AOJ) for further development. Specifically, the Board directed the RO to afford the Veteran VA examinations with regard to the Veteran’s claims. On remand, in compliance with the November 2018 Board remand directives, the RO requested the additional examinations for the Veteran’s claims. The record indicates the Veteran cancelled the scheduled examinations in September 2019, without explanation. The record does not indicate that the Veteran provided any reasoning for cancelling the examination nor has he requested that the examinations be rescheduled. Thus, the Board finds that the RO substantially complied with the November 2018 Board remand directives. See 38 U.S.C. § 5103A(b); Stegall v. West, 11 Vet. App. 268, 271 (1998); D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). The case has now been returned to the Board for appellate action. Pursuant to 38 C.F.R. § 3.655, when entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination or reexamination and a claimant, without good cause, fails to report for such an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. Under 38 C.F.R. § 3.655(b), when a claimant fails to report for an examination scheduled in conjunction with a claim for increase, the claim shall be denied. VA case law states that when a veteran refuses to participate or cooperate during a VA examination it is akin to failure to report for a VA examination without good cause. See Wood v. Derwinski, 1 Vet. App. 190 (1991). The Veteran contacted the VA clinic and requested the examinations be cancelled; therefore, as he refused to cooperate with reporting for the scheduled examinations, the Board finds that he failed to report to the scheduled VA examinations without good cause and the claim shall be rated based on the evidence of record. See 38 C.F.R. § 3.655. VA’s duty to assist is not a one-way street. If the Veteran wants help, she cannot passively wait for it in those circumstances where her own actions are essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 191 (1991); Hayes v. Brown, 5 Vet. App. 60, 68 (1993). Therefore, the Board will decide this matter based on the evidence of record as it is currently developed. Increased Rating - Allergic Rhinitis The Veteran generally contends that he is entitled to a compensable rating for rhinitis as his symptoms are more severe than reflected by the rating currently assigned. Specifically, he asserts that his symptoms include fatigue, general malaise, and lack of concentration; as well as significant drowsiness from antihistamine usage. See VA Form 21-4138 Statement in Support of Claim, April 26, 2012. Additionally, the Veteran asserts that his rhinitis is manifested with year-round allergies, severe nasal congestion, sinus pressure, migraine headaches, irritation after moving to Florida, and difficulty sleeping due to his rhinitis and fractured nose and/or deviated septum. See VA Form 21-4138 Statement in Support of Claim, April 23, 2012. Moreover, the Veteran reported he was always tired and run down, most likely due to the side effects of his medication. Id; see also Notice of Disagreement, December 5, 2012. Disability evaluations are determined by comparing a Veteran’s symptoms with criteria set forth in VA’s Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. While the Veteran’s entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where entitlement to compensation has already been established and an increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased rating claim 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, 509 (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Allergic rhinitis is rated under the criteria found at 38 C.F.R. § 4.97, Diagnostic Code 6522, for allergic or vasomotor rhinitis. While Diagnostic Code 6522 does not provide for a noncompensable rating, 38 C.F.R. § 4.31 provides for zero percent ratings in every instance where the schedule does not provide a zero percent rating for a diagnostic code and the requirements for a compensable evaluation are not met. Under Diagnostic Code 6522, a 10 percent rating is warranted for allergic or vasomotor rhinitis without polyps, but with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side. Of record is an April 2012 private evaluation by G.U. At this time, the provider found the Veteran’s allergic rhinitis, in combination with nonservice-connected disabilities, “may collectively have a significant impact on his ability to adequately function during employment activities.” Specifically, with regard to allergic rhinitis, she noted the physiological response of histamine release lead to fatigue and general malaise and significant drowsiness from medication that would result in difficulty with fatigue and lack of concentration. Additionally, she noted that the Veteran’s fractured nose, with septal deviation could aggravate his allergic rhinitis and prevent adequate drainage, and thus promote nasal congestion. At an October 2012 VA examination, the Veteran was diagnosed with allergic rhinitis, and residuals of a nasal bone fracture. The Veteran reported that his allergic rhinitis was progressively worse. There was no greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis. There was not complete obstruction on one side due to rhinitis. There was no permanent hypertrophy of the nasal turbinates. There were no nasal polyps. The Veteran did not have any granulomatous conditions. Other pertinent physical findings showed normocephalic, no sinus tenderness; pupils reactive to light, clear, no injection; ears within normal limits on the right ear, and wax buildup in the left ear; no nasal discharge; nasal membranes pink; no nasal inflammation; throat not congested; throat membranes pink; no throat inflammation; and no lymphadenopathy. The examiner noted the Veteran’s allergic rhinitis did not impact his ability to work. Further review of the record shows that the Veteran receives treatment at the VA Medical Center for various disabilities, to include his allergic rhinitis. However, there is no indication from the treatment notes of record that the Veteran has reported symptoms that are worse than those noted in the VA examination reports of record. The Board finds that the Veteran is not entitled to a compensable rating for his rhinitis. A compensable rating would require evidence that the Veteran’s allergic rhinitis was manifested by polyps; or, without polyps, but with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side. In this case, the VA examiner specifically noted that the Veteran did not have obstruction of 50 percent or greater on both sides, or complete obstruction on one side. Further, it was specifically noted that he did not have polyps. Additionally, the April 2012 private evaluation did not address the criteria required for a higher rating. Therefore, entitlement to a compensable rating for allergic rhinitis is not warranted. 38 C.F.R. § 4.97, Diagnostic Code 6522. The Board has considered other potentially applicable rating criteria but finds that a higher rating is not warranted for the Veteran’s allergic rhinitis because the Veteran does not have 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side due to traumatic septum nasal deviation; nor did he have any loss of part of the nose or scars; permanent hypertrophy of turbinates and with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side; nor other types of granulomatous infection. 38 C.F.R. § 4.97, Diagnostic Codes 6502, 6504, 6523, 6524. Therefore, a higher or separate rating is not warranted under alternative diagnostic codes. The Board acknowledges that the Veteran is competent to report observable symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). He is not, however, competent to identify a specific level of disability. Competent evidence concerning the nature and extent of the Veteran’s service-connected disability has been provided by VA medical professionals who have examined him. The medical findings adequately address the criteria under which the disability is evaluated and clearly demonstrate that the degree of impairment attributable to the service-connected disability. The Board accords these findings records greater weight than the Veteran’s complaints as to symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Nevertheless, the Board acknowledges the Veteran’s statements regarding symptoms of allergic rhinitis that include fatigue, general malaise, lack of concentration, side effects from medication, allergies, severe nasal congestion, sinus pressure, migraine headaches, irritation, difficulty sleeping, and feeling rundown. The Board finds, however, that neither the Veteran’s statements, nor medical evidence demonstrates that the criteria for higher ratings have been met during the period on appeal. Specifically, as noted above, the Veteran’s allergic rhinitis is described at an October 2012 VA examination, and the Veteran has not been shown to have nasal obstruction nor polyps at any time. The Board also acknowledges that the Veteran’s VA treatment records note complaints of and treatment for his allergic rhinitis. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. This argument is therefore without merit. Accordingly, the Veteran’s belief that he is entitled to a higher rating for his rhinitis is outweighed by the objective medical findings of record. That is, the Board assigns greater probative value to the pertinent objective findings on the VA examination report and treatment records that were recorded following examinations of the Veteran, than to the Veteran’s general belief that he is entitled to a higher rating. Consideration has been given to assigning a staged rating. However, at no time during the period in question has the disability warranted a higher schedular rating than that assigned, and the disability has been stable throughout the appeal period. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). Additionally, the Board has considered whether an inferred claim for a TDIU has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran’s current employment status is unknown. The Veteran has also not alleged, and the record does not suggest, that he is unable to obtain and maintain employment due solely to his service connected allergic rhinitis. As such, a Rice claim is not raised. In sum, the Board finds that the available evidence does not support a higher disability rating at any point during the appeal period. Accordingly, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and entitlement to a compensable rating for rhinitis is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Service Connection - Dizziness, Migraine Headaches, Erectile Dysfunction and Gastrointestinal Disorder The Veteran seeks to establish service connection for dizziness, migraine headaches, a gastrointestinal disorder and erectile dysfunction. Specifically, with regard to dizziness, the Veteran asserts the condition is intermittent and began during active service, when he experienced episodes of dizziness, lightheadedness, and vertigo. See VA Form 21-4138 Statement in Support of Claim, April 30, 2012; see also Notice of Disagreement, December 5, 2012. Specifically, with regard to migraine headaches, the Veteran asserts that his headaches began during active service, and have continued since. Id. Specifically, with regard to erectile dysfunction, the Veteran asserts that the condition causes marital problems; and that the condition is secondary to high cholesterol that began during active service, resulting in damaged penile arteries. Id. Moreover, the Veteran asserts in his April 2012 Notice of Disagreement that the statement submitted by his wife is not lay evidence. Rather, he provided her license as a registered nurse, and argues that she is entitled to submit a professional opinion on his erectile dysfunction condition, status, and symptoms. I. Legal Criteria Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1131; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Pertinent to a claim for service connection, such a determination requires a finding of a current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Under applicable regulation, the term “disability” means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § § 4.1; see also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (the term “disability” as used in 38 U.S.C. § 1110 “refers to the functional impairment of earning capacity, not the underlying cause of said disability,” and held that “pain alone can serve as a functional impairment and therefore qualify as a disability”). II. Pertinent Evidence Service treatment records show the Veteran complained of, and was treated for, elevated cholesterol, cholesterolemia, ulcer, stomachache, stomach trouble, abdominal pain, lightheadedness, nausea, diarrhea, abdominal cramping, headaches, constipation, impacted cerumen, and dizziness. See e.g. May 1975, July 1975, November 1976, January 1979, August 1980, July 1981, July 1983, April 1986, November 1990, February 1991, July 1995, October 1996, and December 1993. Post service treatment records document complaints of, treatment for, and diagnoses of dizziness, headaches, vertigo, recurring abdominal pain, a probable diagnosis of irritable bowel syndrome, and erectile dysfunction. See e.g. July 2005, April 2007, May 2007, February 2008, August 2008, and December 2008 private treatment records. Of record are April 2012 private opinions by G.U. At this time, the provider opined that the Veteran’s erectile dysfunction was at least as likely as not a continuation of, related to, or aggravated by his military service. In this regard, she noted documented elevated cholesterol and triglyceride lab results in active service, and stated that medical literature reports that this condition induces erectile dysfunction by increasing oxidative stress and impairing endothelial function of the penis. Additionally, she noted that hyperlipidemia causes atherosclerotic disease in the small penile arteries by depositing fatty plaque, narrowing the arterial diameter, preventing full blood engorgement and erectile capability. The provider opined that it was at least as likely as not that the Veteran’s dizziness condition was a continuation of, related to, or aggravated by his military service, in-service injuries and/or treatment. In this regard, she noted that the Veteran’s service treatment records documented episodic lightheadedness and dizziness associated with upper respiratory congestion and ear cerumen impactions; and complaints of benign positional vertigo. She noted the Veteran continued to intermittently report these symptoms, and therefore it is more likely due to inner ear disturbances. Additionally, the provider noted the Veteran’s annual examination noted “equilibrium problems,” related to ear cerumen; and the dizziness seems to be from the inner ear and an intermittent problem. The provider opined that it was at least as likely as not that the Veteran’s migraine headaches were a continuation of, related to, or aggravated by his military service, in-service injuries and/or treatment. In this regard, she noted that the Veteran reported psychological conditions, related to stress, and headaches on numerous occasions, sometimes associated with his sinus condition and nasal congestion. His headaches seemed to be chronically recurrent, and he has more headaches during episodic stress. Additionally, she noted that his low back pain medication may help control a migraine headache condition. Of record is an April 2012 statement submitted by the Veteran’s wife, F.M. At this time, she stated that the Veteran had difficulty obtaining and maintaining an erection in order to participate in sexual activity. She stated that due to his medical conditions, he lacks the energy or motivation to participate in sexual activity, resulting in marital tensions. At an October 2012 VA examination, the Veteran was diagnosed with a migraine headache condition. He reported symptoms included dizziness, feeling as though he would stagger, without vertigo, nausea, or vomiting; occurring about once a month. The Veteran reported that the migraines began in the military, and he believed they had their onset due to stress and a bad marriage. The headaches had continued, and occurred about two to three times per month, lasting a few hours in duration. The Veteran would lie down and take medication to alleviate his headaches. The examiner opined the Veteran’s migraine headaches were less likely than not incurred in or caused by his reports of headaches shown in service. In this regard, the examiner noted that the headaches in service were not described, nor diagnosed as migraine headaches; service treatment records were silent with regard to migraine headaches; the Veteran was diagnosed with anterior cephalgia; and chronicity for the headaches could not be established. Given the lack of objective evidence, the examiner found a nexus could not be made for the claimed migraine headaches and headaches noted during active service. The October 2012 VA examiner also opined the Veteran’s dizziness was less like than not incurred in or caused by his reports of headaches shown in service. In this regard, the examiner noted that the Veteran complained of dizziness during active service; had bilateral cerumen impaction; and then 13 years later in 1996, the Veteran reported dizziness with stomach problems, and experienced dizziness for three days. The examiner found there was no objective evidence to provide a level of chronicity for the Veteran’s dizziness due to service, nor evidence to establish a nexus for the claimed dizziness to service. Therefore, the examiner opined the Veteran’s dizziness was less likely than not incurred in or caused by active service. At an October 2012 VA examination for male reproductive system conditions, the examiner diagnosed erectile dysfunction. The Veteran reported that he had elevated sugars in the military and that he had “borderline” diabetes according to his primary care physician; and that the erectile dysfunction was due to his diabetes. The Veteran also reported that his primary care physician indicated he had elevated blood sugars, high triglycerides, and cholesterol, and that those conditions had contributed to his erectile dysfunction. The examiner opined that it was less likely than not that the Veteran’s erectile dysfunction was due to diabetes, nor incurred in or caused by his diagnosis of elevated cholesterol shown in service. In this regard, the examiner noted that it would be speculative to opine whether the Veteran’s erectile dysfunction incurred in or was caused by his diagnosis of elevated cholesterol shown in service. The examiner also noted the Veteran did not have a diagnosis of diabetes mellitus; erectile dysfunction could not be due to a condition that did not exist. Regarding whether the erectile dysfunction was due to elevated cholesterol shown in service, the current medical literature provided that erectile dysfunction could be due to elevated cholesterol. However, the literature also noted that erectile dysfunction is possibly due to several other medical or psychological conditions; there was insufficient objective evidence to provide for a diagnosis of erectile dysfunction due to high cholesterol. Thus, the examiner found that an opinion as to whether erectile dysfunction is due to elevated cholesterol would be speculative. III. Analysis - Dizziness Based on the foregoing, the Board finds that service connection is not warranted for dizziness. The record does not establish a causal link between the Veteran’s service and his dizziness. Turning to the question of whether there is an etiological relationship between the Veteran’s dizziness and service, the Board notes that the record contains two contradicting opinions which must be considered and weighed. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (stating that the probative value of medical evidence is based on the physician’s knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board will consider each of these opinions below. Applying 38 C.F.R. § 3.655(a) and (b) to the facts of this case, as the Veteran failed to report for VA examination without good cause, the regulation states that the Veteran’s claim “shall be rated based on the evidence of record.” The Veteran’s claim for service connection for dizziness was an original compensation claim and will be decided based on the evidence of record. First, the Board considers the April 2012 private etiology opinion submitted by G.U. The Board finds the April 2012 private etiology opinion inadequate to decide the claim because the opinion failed to provide supporting rationale for the conclusions reached, and was internally conflicting. Specifically, G.U. found the Veteran’s dizziness was as a result of an inner ear problem, and not due to his active service. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). This opinion is therefore afforded little, if any, probative weight. Next, the Board considers the October 2012 VA opinion. The Board finds that this opinion has clear conclusions and supporting data, as well as reasoned medical explanations that the Veteran’s dizziness did not have chronicity nor evidence to support a nexus between his dizziness and service. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Notably, the VA examiner noted the Veteran’s complaints of dizziness had a 13 year gap between his complaints in service and after. This opinion is therefore afforded great probative weight. The Board notes the Veteran’s assertions that his dizziness was intermittent, beginning in service and continuing since. However, as discussed above, the contemporary evidence contradicts this assertion, and there are no medical findings of record related to dizziness until over 13 years after his period of service, despite numerous complaints and extensive treatment for other parts of the body and conditions. Thus, to extent Veteran asserts that he experienced intermittent dizziness continuously beginning in service and after, the Board finds such assertions not credible. Additionally, the Board notes that lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, supra. Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, “VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to” and a mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran’s dizziness and any instance of his service to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Specifically, while the Veteran is competent to describe his current dizziness symptoms, the Board accords his statements regarding the etiology of such a disorder little probative value as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, and requires the administration and interpretation of diagnostic testing. In the instant case, there is no suggestion that the Veteran has had any medical training. Hence, the Board finds that he is not competent to provide a medical opinion to support this claim on the basis of his assertions alone. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinion of the Veteran is nonprobative evidence. In sum, the Board finds that the only probative medical evidence of record, the findings and October 2012 VA opinion, to be of greater probative value than the Veteran’s lay contentions and the April 2012 private etiology opinion by G.U. Upon review of the evidence, the Board finds the preponderance of the evidence is against the claim. Consequently, service connection for such disorder is not warranted. As the preponderance of the evidence is against the Veteran’s claim, the benefit of the doubt doctrine is not applicable to this claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. IV. Analysis - Migraine Headaches Based on the foregoing, the Board finds that service connection is not warranted for migraine headaches. The record does not establish a causal link between the Veteran’s service and his migraine headaches. Turning to the question of whether there is an etiological relationship between the Veteran’s migraine headaches and service, the Board notes that the record contains two contradicting opinions which must be considered and weighed. See Hayes v. Brown, supra (citing Wood v. Derwinski, supra)). See also Guerrieri v. Brown, supra. When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, supra, citing Owens v. Brown, supra. The Board will consider each of these opinions below. Applying 38 C.F.R. § 3.655(a) and (b) to the facts of this case, as the Veteran failed to report for VA examination without good cause, the regulation states that the Veteran’s claim “shall be rated based on the evidence of record.” The Veteran’s claim for service connection for migraine headaches was an original compensation claim and will be decided based on the evidence of record. First, the Board considers the April 2012 private etiology opinion submitted by G.U. The Board finds the April 2012 private etiology opinion inadequate to decide the claim because the opinion failed to provide supporting rationale for the conclusions reached. Barr v. Nicholson, supra; Stefl v. Nicholson, supra; Nieves-Rodriguez v. Peake, supra. This opinion is therefore afforded little, if any, probative weight. Next, the Board considers the October 2012 VA opinion. The Board finds that this opinion has clear conclusions and supporting data, as well as reasoned medical explanations that the Veteran’s migraine headache condition were no described nor diagnosed as migraine headaches in service; service treatment records did not show migraine headaches; and that a chronicity for migraine headaches was not established. Barr v. Nicholson, supra; Stefl v. Nicholson, supra; Nieves-Rodriguez v. Peake, supra. This opinion is therefore afforded great probative weight. The Board notes the Veteran’s assertions that his headaches began in service and continuing since. However, as discussed above, the contemporary evidence contradicts this assertion, and there are no medical findings of record related to migraine headaches during active service. The Board notes that lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, supra. Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, supra. However, “VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to” and a mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, supra. In the instant case, the Board finds that the question regarding the potential relationship between the Veteran’s migraine headaches and any instance of his service to be complex in nature. Woehlaert v. Nicholson, supra. Specifically, while the Veteran is competent to describe his current headache symptoms, the Board accords his statements regarding the etiology of such a disorder little probative value as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, supra. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, and requires the administration and interpretation of diagnostic testing. In the instant case, there is no suggestion that the Veteran has had any medical training. Hence, the Board finds that he is not competent to provide a medical opinion to support this claim on the basis of his assertions alone. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinion of the Veteran is nonprobative evidence. In sum, the Board finds that the only probative medical evidence of record, the findings and October 2012 VA opinion, to be of greater probative value than the Veteran’s lay contentions and the April 2012 private etiology opinion by G.U. Upon review of the evidence, the Board finds the preponderance of the evidence is against the claim. Consequently, service connection for such disorder is not warranted. As the preponderance of the evidence is against the Veteran’s claim, the benefit of the doubt doctrine is not applicable to this claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. V. Analysis - Erectile Dysfunction Based on the foregoing, the Board finds that service connection is not warranted for erectile dysfunction. The record does not establish a causal link between the Veteran’s service and his erectile dysfunction. Turning to the question of whether there is an etiological relationship between the Veteran’s erectile dysfunction and service, the Board notes that the record contains three contradicting opinions which must be considered and weighed. See Hayes v. Brown, supra (citing Wood v. Derwinski, supra). See also Guerrieri v. Brown, supra. When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, supra, citing Owens v. Brown, supra. The Board will consider each of these opinions below. Applying 38 C.F.R. § 3.655(a) and (b) to the facts of this case, as the Veteran failed to report for VA examination without good cause, the regulation states that the Veteran’s claim “shall be rated based on the evidence of record.” The Veteran’s claim for service connection for erectile dysfunction was an original compensation claim and will be decided based on the evidence of record. First, the Board considers the April 2012 private etiology opinion submitted by G.U. The Board finds the April 2012 private etiology opinion inadequate to decide the claim because the opinion failed to provide supporting rationale for the conclusions reached. Barr v. Nicholson, supra; Stefl v. Nicholson, supra; Nieves-Rodriguez v. Peake, supra. Specifically, G.U. notes the Veteran had elevated triglyceride and cholesterol levels in service that medical literature reports could induce erectile dysfunction, and hyperlipidemia that could cause atherosclerotic disease in the small penile arteries. However, G.U. did not provide an opinion with supporting rationale for this specific Veteran. This opinion is therefore afforded little, if any, probative weight. Next, the Board considers the April 2012 statement submitted by the Veteran’s wife in her capacity as a nurse. The Board finds this opinion inadequate to decide the claim because an opinion as to the nature and etiology of his erectile dysfunction was not provided. Rather, F.M. discussed the symptoms exhibited by the Veteran of inability to obtain and maintain an erection, and the lack of energy or motivation to participate in sexual activity. This statement is therefore afforded little, if any, probative weight. Finally, the Board considers the October 2012 VA opinion. The Board finds that this opinion has clear conclusions and supporting data, as well as reasoned medical explanations that the Veteran’s erectile dysfunction was not as a result of elevated sugars in the military, “borderline diabetes,” high triglycerides, nor cholesterol. Barr v. Nicholson, supra; Stefl v. Nicholson, supra; Nieves-Rodriguez v. Peake, supra. In this regard, the October 2012 VA examiner noted that the Veteran did not have diabetes mellitus, and that there were other causes of erectile dysfunction aside from high cholesterol, and that there was insufficient evidence to provide a diagnosis of erectile dysfunction due to high cholesterol. This opinion is therefore afforded great probative weight. The Board notes the Veteran’s assertions that his erectile dysfunction is as a result of active service. However, as discussed above, the contemporary evidence contradicts this assertion. The Board notes that lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, supra. Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, supra. However, “VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to” and a mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, supra. In the instant case, the Board finds that the question regarding the potential relationship between the Veteran’s erectile dysfunction and any instance of his service to be complex in nature. Woehlaert v. Nicholson, supra. Specifically, while the Veteran is competent to describe his current symptoms, the Board accords his statements regarding the etiology of such a disorder little probative value as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, supra. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, and requires the administration and interpretation of diagnostic testing. In the instant case, there is no suggestion that the Veteran has had any medical training. Hence, the Board finds that he is not competent to provide a medical opinion to support this claim on the basis of his assertions alone. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinion of the Veteran is nonprobative evidence. In sum, the Board finds that the only probative medical evidence of record, the findings and October 2012 VA opinion, to be of greater probative value than the Veteran’s lay contentions and the April 2012 private etiology opinion by G.U.; and the lay statement provided by the Veteran’s wife in her capacity as a nurse. Upon review of the evidence, the Board finds the preponderance of the evidence is against the claim. Consequently, service connection for such disorder is not warranted. As the preponderance of the evidence is against the Veteran’s claim, the benefit of the doubt doctrine is not applicable to this claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. VI. Analysis – Gastrointestinal Disorder The Veteran seeks to establish service connection for a gastrointestinal disorder. Specifically, the Veteran asserts that he manifested symptoms of irritable bowel syndrome that went undiagnosed during his active service. Applying 38 C.F.R. § 3.655(a) and (b) to the facts of this case, as the Veteran failed to report for VA examination without good cause, the regulation states that the Veteran’s claim “shall be rated based on the evidence of record.” The Veteran’s claim for service connection for erectile dysfunction was an original compensation claim and will be decided based on the evidence of record. At a March 1999 VA examination, the Veteran was not shown to have a gastrointestinal disorder, and did not have any diagnoses related to a gastrointestinal disorder. Notably, the Veteran denied all symptoms of nausea, vomiting, or dysphagia. Of record is an April 2012 private opinion by G.U. At this time, G.U. opined that the Veteran’s irritable bowel condition was at least as likely as not a continuation of, related to, or aggravated by his military service, in-service injuries and/or treatment. In this regard, she noted that the Veteran’s service treatment records document complaints of abdominal pain, cramping, intermittent nausea, constipation, gas, and diarrhea, and generalized tenderness. She noted that an etiology was never determined, and that he was always treated conservatively. She noted the Veteran’s diagnosis of irritable bowel syndrome, and stated that those symptoms correlate with the symptoms he experienced in the military. Therefore, she found that he seemingly continued to have this chronic gastrointestinal disorder. Additionally, she noted the Veteran’s gastrointestinal disorder led to developing hemorrhoids, were associated with feelings of anxiety, and that his suicidal and homicidal ideation “could have exacerbated his condition.” At an October 2012 VA examination for gastrointestinal disorders, the examiner found the Veteran did not have, nor had ever been diagnosed with an intestinal condition. The Veteran reported he was not diagnosed with irritable bowel syndrome in the military, but he had problems from constipation to diarrhea, and was prescribed different medications. The Veteran stated he was told he may have irritable bowel syndrome. The examiner noted that there was no objective evidence to diagnose irritable bowel syndrome, and indicated that a more precise diagnosis cannot be rendered. Turning to the question of whether there is an etiological relationship between the Veteran’s gastrointestinal disorder and service, the Board notes that the record contains two contradicting opinions which must be considered and weighed. See Hayes v. Brown, supra (citing Wood v. Derwinski, supra). See also Guerrieri v. Brown, supra. When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, supra, citing Owens v. Brown, supra. The Board will consider each of these opinions below. First, the Board considers the April 2012 private etiology opinion submitted by G.U. Specifically, G.U. found the etiology of his gastrointestinal disorder was never determined in service, and that he had a post-service diagnosis of irritable bowel syndrome with symptoms that correlated to his symptoms in the military; and that he “seemingly continued” to have a chronic gastrointestinal disorder. Further, she stated that his gastrointestinal disorder could have been exacerbated by hemorrhoids, anxiety, suicidal ideation, and homicidal ideation. However, G.U. failed to provide any supporting rationale for the conclusions reached or well-reasoned medical rationale. Barr v. Nicholson, supra; Stefl v. Nicholson, supra; Nieves-Rodriguez v. Peake, supra. This opinion is therefore afforded little, if any, probative weight. Next, the Board considers the October 2012 VA opinion. The Board finds that this opinion has clear conclusions and supporting data, as well as reasoned medical explanations that the Veteran did not have a diagnosis of a gastrointestinal disorder in service, nor was there evidence to diagnosed irritable bowel syndrome thereafter. Barr v. Nicholson, supra; Stefl v. Nicholson, supra; Nieves-Rodriguez v. Peake, supra. Notably, the VA examiner noted the Veteran’s symptoms during active service, and that he was told that he “may have” irritable bowel syndrome, and indicated that a more precise diagnosis could not be rendered. However, no opinion as to any etiology of the claimed gastrointestinal disorder was provided, nor was there an explanation as to why a diagnosis could not be rendered. This opinion is therefore afforded probative weight. Additionally, neither the private April 2012 opinion nor the October 2012 VA opinion addressed whether the Veteran’s claimed gastrointestinal disorder, to include irritable bowel syndrome, is an undiagnosed illness as a result of his service in Southwest Asia; nor did either opinion address the March 1999 VA examination finding that the Veteran did not have a gastrointestinal disorder, and denied all symptoms of nausea, and dysphagia. In November 2018, the Board remanded this matter for a more comprehensive VA examination. However, the Veteran did not appear for the scheduled examination. 38 U.S.C. § 3.655. The Board notes the Veteran’s assertions that his gastrointestinal disorder is as a result of active service. However, as discussed above, the contemporary evidence contradicts this assertion. The Board notes that lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, supra. Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, supra. However, “VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to” and a mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, supra. In the instant case, the Board finds that the question regarding the potential relationship between the Veteran’s erectile dysfunction and any instance of his service to be complex in nature. Woehlaert v. Nicholson, supra. Specifically, while the Veteran is competent to describe his current symptoms, the Board accords his statements regarding the etiology of such a disorder little probative value as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, supra. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, and requires the administration and interpretation of diagnostic testing. In the instant case, there is no suggestion that the Veteran has had any medical training. Hence, the Board finds that he is not competent to provide a medical opinion to support this claim on the basis of his assertions alone. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinion of the Veteran is nonprobative evidence. In sum, the Board finds that the only probative medical evidence of record, the findings and October 2012 VA opinion, to be of greater probative value than the Veteran’s lay contentions and the April 2012 private etiology opinion by G.U.; and the lay statement provided by the Veteran’s wife in her capacity as a nurse. Upon review of the evidence, the Board finds the preponderance of the evidence is against the claim. Consequently, service connection for such disorder is not warranted. As the preponderance of the evidence is against the Veteran’s claim, the benefit of the doubt doctrine is not applicable to this claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. SMC VA law provides that special monthly compensation is warranted if a veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of one or more creative organs. 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a). The record indicates the Veteran has a diagnosis of erectile dysfunction. However, since it is not been shown that erectile dysfunction is due to a service-connected disability nor service-connected, the claim for SMC for loss of use of a creative organ lacks legal merit. In Sabonis v. Brown, 6 Vet. App. 426, 430 (1994), the Court of Appeals for Veterans Claims (Court) held that in a case where the law is dispositive of the claim, it should be denied because of lack of legal entitlement under the law. Therefore, the Veteran’s claim for SMC based on loss of use of a creative organ is denied as a matter of law. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mariah N. Sim, 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.