Citation Nr: 21016008 Decision Date: 03/19/21 Archive Date: 03/19/21 DOCKET NO. 15-37 760 DATE: March 19, 2021 ISSUES 1. Entitlement to service connection for hyperopia with astigmatism and presbyopia, claimed as loss of vision, to include as secondary to meningitis. 2. Entitlement to service connection for neck stiffness, to include as secondary to meningitis. 3. Entitlement to service connection for degenerative disc disorder of the lumbar spine, to include as secondary to meningitis. 4. Entitlement to service connection for a disorder of spitting blood, to include as secondary to meningitis. 5. Entitlement to service connection for chronic obstructive pulmonary disease (COPD), to include as secondary to meningitis. 6. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to meningitis. 7. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to meningitis. 8. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to meningitis. 9. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to meningitis. ORDER Entitlement to service connection for hyperopia with astigmatism and presbyopia, claimed as loss of vision, to include as secondary to meningitis is denied. Entitlement to service connection for neck stiffness, to include as secondary to meningitis is denied. Entitlement to service connection for degenerative disc disorder of the lumbar spine, to include as secondary to meningitis is denied. Entitlement to service connection for a disorder of spitting blood, to include as secondary to meningitis is denied. Entitlement to service connection for chronic obstructive pulmonary disease (COPD), to include as secondary to meningitis is denied. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to meningitis is denied. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to meningitis is denied. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to meningitis is denied. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to meningitis is denied. FINDINGS OF FACT 1. Hyperopia with astigmatism and presbyopia, claimed as loss of vision, is regarded as a refractive error, rather than a disability due to disease or injury for which VA compensation is available, and there is no other superimposed eye disability attributable to service. 2. Neck stiffness was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 3. Degenerative disc disorder of the lumbar spine was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 4. A disorder of spitting blood was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 5. Chronic obstructive pulmonary disease (COPD) was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 6. Peripheral neuropathy of the right upper extremity was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 7. Peripheral neuropathy of the left upper extremity was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 8. Peripheral neuropathy of the right lower extremity was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 9. Peripheral neuropathy of the left lower extremity was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. CONCLUSIONS OF LAW 1. Hyperopia with astigmatism and presbyopia, claimed as loss of vision, was not incurred in or aggravated by service, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1110, 1131, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 4.9 (2018). 2. Neck stiffness was not incurred in or aggravated by service, arthritis may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 3. Degenerative disc disorder of the lumbar spine was not incurred in or aggravated by service, arthritis may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 4. A disorder of spitting blood was not incurred in or aggravated by service, bronchiectasis may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 5. Chronic obstructive pulmonary disease (COPD) was not incurred in or aggravated by service, bronchiectasis may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 6. Peripheral neuropathy of the right upper extremity was not incurred in or aggravated by service, organic disease of the nervous system may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 7. Peripheral neuropathy of the left upper extremity was not incurred in or aggravated by service, organic disease of the nervous system may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 8. Peripheral neuropathy of the right lower extremity was not incurred in or aggravated by service, organic disease of the nervous system may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). 9. Peripheral neuropathy of the left lower extremity was not incurred in or aggravated by service, organic disease of the nervous system may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1984 to September 1992. This matter is before the Board of Veterans Appeals (Board) on appeal from September 2013 and August 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In an October 2016 Brief, the Veteran’s attorney stated, “While we continue to allege these conditions are related to service, we agree that until service connection for the primary condition is granted, service connection for the secondary conditions cannot be. We ask that when service connection for meningitis/encephalitis is granted, that VA provide examinations for the claimed secondary conditions.” The Board previously remanded these matters in September 2018 along with the issue of service connection for skin cancer, which was granted in an April 2020 rating decision. This constituted a complete grant of the benefit sought and the issue is no longer on appeal. The issues were again remanded by the Board in September 2020. As stated in the September 2018 and September 2020 Board remands, the Veteran and his attorney have asserted that the remaining claims for service connection on appeal still include as secondary to the Veteran’s meningitis and/or encephalopathy, which have now been service-connected. The Board previously highlighted in September 2020 that while the medical evidence of record is voluminous and complex, his primary care provider has suggested that the various symptoms and disorders are likely interrelated. In light of these contentions and evidence, and as the Veteran has been granted service-connection for meningitis with encephalopathy, the Board ordered new VA examinations in September 2020. These examinations were necessary to address the secondary service connection theory of entitlement. The appeals are now back before the Board. Significantly, during the pendency of his appeals, a January 2021 rating decision granted several claims dating back to July 6, 2012. These granted claims included service connection for migraine headaches, meningitis with encephalitis, and parkinsonism. The Veteran is now in receipt of a 100 percent combined schedular rating and a total disability rating based on individual unemployability (TDIU). AB v. Brown, 6 Vet. App. 35, 38 (1993). He is also in receipt of special monthly compensation (SMC). (Continued on the next page.) Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2018). The Veteran and his attorney were sent a January 2021 Supplemental Statement of the Case (SSOC) informing them of the critical evidentiary requirements necessary to substantiate their claims. The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct. 3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant’s failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection To establish service connection a Veteran must generally show: “(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). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b). We note that arthritis and organic disease of the nervous system are chronic diseases, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309. Under 38 C.F.R. § 3.303 (b), service connection may be established by demonstrating continuity of symptomatology. Continuity may be established if a claimant can demonstrate (1) that a condition was “noted” during 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. The provisions of 38 C.F.R. § 3.303 (b) only apply to diseases recognized by VA as “chronic.” See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303 (b), 3.309(a). Chronic diseases that become manifest to a degree of 10 percent or more within one year of termination of active duty may be presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 1. Entitlement to service connection for hyperopia with astigmatism and presbyopia, claimed as loss of vision, to include as secondary to meningitis The Board incorporates its discussion from the sections above by reference. By way of background, the Service Treatment Records (STRs) include an August 1992 Report of Medical Examination from separation. It disclosed a clinically normal evaluation of the eyes – general, ophthalmoscopic examination, pupils, ocular mobility, and neurologic system. In the contemporaneous Report of Medical History, the Veteran endorsed wearing glasses or contact lenses and having vision in both eyes. He also endorsed eye trouble. Still, he wrote “No acute/chronic medical problems” and signed the document. Later, an April 6, 1992 private medical opinion from the Eye Clinic of Fairbanks from Dr. B. J. W. shows an impression of hyperopia with anisometropia with farsightedness in the right eye than the left eye. The Veteran was seen for complaints of intermittent blurred vision from a stick in his right eye about one month prior. The physician concluded, “I do not feel that this is related to the injury but certainly the injury aggravated the symptoms.” In August 2013, the Veteran was afforded a VA eye conditions examination with medical opinion. The VA examiner explained: Veteran’s current “eye disability” noted to be hyperopic astigmatism/presbyopia OU, and ptosis OD. Veteran’s refractive error of hyperopia is related to the same condition first noted while he was on active duty in 1992. His presbyopia was not noted while he was on active duty since this is an age-related condition that normally does not present until individual is in his forties. Veteran’s history of ptosis OD which per history has been present since 2010 is not related to his active duty service. No history of it while he was on active duty. Recently, the Veteran was afforded a December 2020 VA eye conditions examination with medical opinion. The VA examiner identified only ptosis, right eyelid, with a date of onset of September 19, 2011. The VA examiner documented a lay history from the Veteran: Veteran states he had Ascetic meningitis in 2010 and noticed a decreased in his vision in both eyes since then. He also complains of his eyes being ‘droopy’ with his right eye more than his left. He was given an option of surgery but he declined because he states the “droopy eyelids helps him with his light sensitivity accompanied with his headaches.” He also states he suffered an injury in 1992 when he got a piece of wood in his right eye. He is also being currently monitored every 6 months because he is currently on Plaquenil treatment. He states as far as he knows, it has not affected his eyes. Upon physical examination, the Veteran had 20/20 vision or better for both eyes for corrected near and distance. The doctor wrote, “Veteran’s Hyperopia with Astigmatism and Presbyopia are refractive diagnosis and thus, do not warrant a diagnosis.” The VA examiner rendered a set of VA medical opinions. First, for direct service connection, the VA examine provided a negative nexus opinion. The VA examiner reasoned, “Veteran’s Hyperopia with Astigmatism and Presbyopia are refractive diagnosis and thus, do not warrant a diagnosis. These are developmental error of refraction and not related to his meningitis/encephalopathy.” Second, only for right eye ptosis, the VA examiner rendered a positive nexus opinion. The Board observes that the Veteran has since been separately service-connected for ptosis of the right upper eyelid. See January 2021 Rating decision. The Veteran contends that he is entitled to service connection for hyperopia with astigmatism and presbyopia, claimed as loss of vision, to include as secondary to meningitis. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). He is competent to report that he requires glasses to correct his vision. We have considered the Veteran’s lay assertions. However, they are outweighed by the more probative, contemporaneous treatment records, including the STRs. We also assign the most probative weight to the December 2020 VA examination results. Next, the Board observes that the claimed hyperopia with astigmatism and presbyopia or refractive error is not a service-connectable disability entity for VA purposes. Refractive errors of the eyes are congenital or developmental defects and not disease or injury within the meaning of applicable legislation. 38 C.F.R. §§ 3.303 (c), 4.9; McNeely v. Principi, 3 Vet. App. 357, 364 (1992). In the absence of superimposed disease or injury, service connection may not be allowed for refractive error of the eyes, including myopia, presbyopia, and astigmatism, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. Id. Indeed, VA regulations specifically prohibit service connection for refractory errors of the eyes unless such defect was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90 (July 18, 1990) (cited at 55 Fed. Reg. 45,711) (Oct. 30, 1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). The Veteran has not satisfied the evidentiary requirement identified in the January 2021 Supplemental Statement of the Case (SSOC) of a current disability for VA purposes. In this case, there is also no evidence that the Veteran’s claimed hyperopia with astigmatism and presbyopia has caused any impairment of earning capacity or is a manifestation of other disease or injury for which service connection may be granted at this time. The April 1992 medical opinion from Dr. B. J. W., while documenting a possible aggravating injury, shows refractive error correctable with reading glasses. Any other eye impairment is already encompassed by the recent grant for service connection for ptosis of the right upper eyelid. Consistently, the STRs disclosed a clinically normal examination of the reportedly impaired systems at separation. VA treatment records only establish wearing glasses many years removed from separation. To the extent the Veteran contends he has additional impairment of visual acuity, it would not be subject to compensation because it is still not a disease or injury within the law providing for compensation. 38 U.S.C. §§ 1110, 1131. While service connection may be granted, in limited circumstances, for superimposed disability on a constitutional or developmental abnormality, there is no allegation or evidence that such occurred in this case. See VAOPGCPREC 82-90, 55 Fed. Reg. 45,711 (1990); see also Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993). In other words, there is also no need to address aggravation because the weight of the evidence does not establish that a particular injury or disease resulting in disability was incurred coincident with service. 38 C.F.R. § 3.303. As such, a consideration of the presumption of soundness is not applicable. In the absence of proof of another current disability for which service connection may be granted, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Accordingly, the claim is denied as a matter of law. Additionally, any theory of secondary service connection for variously claimed symptoms would fail as a matter of law. Evening assuming the Veteran had an additional eye disability for VA purposes, though we do not concede this, any nexus to a refractive error would not allow for a grant of secondary service connection. The contemporaneous treatment records and VA examination results outweigh his lay assertions. Therefore, a secondary service connection theory of entitlement is precluded as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (where the law is dispositive, the claim must be denied due to a lack of legal merit). In reaching this conclusion, we have considered the lay contentions to the extent they are competent. We have applied the benefit of the doubt doctrine, however, there is no doubt to resolve. The VA law and regulations are clear. The most probative evidence is the contemporaneous treatment records, including the Report of Medical History from separation and December 2020 VA examination with negative nexus opinions. There is no hyperopia with astigmatism and presbyopia or other disability for VA purposes documented at separation. To the extent there is a private medical opinion documenting an injury in service, this is already contemplated by the recent grant of service connection for ptosis. The Veteran has been afforded a complete VA examination to assist with developing his claim. There is no doubt to resolve. Therefore, service connection for hyperopia with astigmatism and presbyopia is not warranted. (Continued on the next page.) 2. Entitlement to service connection for neck stiffness, to include as secondary to meningitis 3. Entitlement to service connection for degenerative disc disorder of the lumbar spine, to include as secondary to meningitis The Board incorporates its discussion from the sections above by reference. We note that arthritis and pain as organic disease of the nervous system are recognized chronic diseases, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). By way of background, the Report of Medical Examination from separation disclosed a clinically normal evaluation of the head, face, neck, and scalp, spine, other musculoskeletal system, and neurologic system. In the contemporaneous Report of Medical History, the Veteran denied a head injury, neuritis, paralysis, arthritis, rheumatism, or bursitis, and bone, joint, or other deformity. He endorsed recurrent back pain. Still, he wrote “No acute/chronic medical problems” and signed the document. Later, the Veteran was afforded an August 2013 VA medical opinion for the claimed lumbar degenerative disc disease (DDD) condition. It is uploaded as CAPRI on August 21, 2013 and located at the end of several other VA examinations conducted at the Tampa VA Medical Center (VAMC). The VA physician provided an extensive review and summary of the claims file. The physician ultimately rendered a negative nexus opinion implicitly encompassing all theories of direct and presumptive service connection for any lumbar spine disability. It reads: 1. Review of currently available medical records fails to document chronicity of claimed condition during service or after discharged from service. 2. Review of currently available medical literature (up-to-date) fails to support a causative etiology between low back pain from muscle spasms and lumbar spine DDD. “Degenerative disc disease in the lumbar spine, or lower back, refers to a syndrome in which a compromised disc causes low back pain. The intervertebral discs have a fluid-rich center (nucleus pulposus) that appears hyperintense on MRI T2-weighted images. With aging, the nucleus pulposus loses water, becoming progressively more hypointense, and the disc flattens. The often concurrent weakening of the annulus fibrosus raises the chance of annular tear and resultant disc abnormalities. Wear and tear can lead to degenerative disc disease, or the breakdown of the spinal discs, with small cracks and tears and/or loss of fluid in the discs. This can lead to other changes including the formation of bone spurs. Calling this condition a “disease” is somewhat misleading because these changes occur with normal aging and frequently cause no symptoms. Following the September 2020 Board remand, the Veteran was afforded a December 2020 VA neck conditions examination with medical opinion. The VA examiner reviewed the entire claims file, elicited a lay history from the Veteran, and performed a physical examination. The VA examiner identified cervical strain with a date of diagnosis of 2010. The Veteran reported neck stiffness since his meningitis diagnosis in 2010. The Veteran had daily pain, 5/10, from random daily activity. It happens once per month, lasts for weeks, and is relieved by medication. At the same time, the Veteran was afforded a December 2021 VA back conditions Disability Benefits Questionnaire (DBQ). The VA examiner identified degenerative disc disease (DDD) of the lumbar spine with a date of onset of 2010. It shows that Veteran reported that he began having back pain in 2012 after meningitis. The Veteran is in constant lower back pain, takes several medications, and uses a scooter. Next, the VA examiner offered a set of December 2020 medical opinions contained within the same document for both the neck and back. He provided a negative nexus opinion for direct and implicitly for presumptive service connection for both the neck stiffness and DDD of the lumbar spine. The rationales all read, “Veteran was in the U,S. Army from 1984-1992. All of the following condition started 18 years after the veteran was in service. Therefore, it is less than 50% that any of the claimed conditions are service related.” Turning to secondary service connection, the VA examiner similarly rendered negative nexus opinions. The Board observes that the examiner checked both boxes 4A and 4B for a positive and negative nexus, but concluded with negative nexus opinions in the rationale. The rationales cite other causal factors, which explains both checked boxes. First, for neck stiffness, the VA examiner concluded, “It is less than 50% that ENCEPHALOPATHY or MENINGITIS Would cause a chronic stiff neck. Neck stiffness is an acute symptom of active ENCEPHALOPATHY or MENINGITIS. But there is no literature to support a chronic stiff neck after having MENINGITIS.” Second, the VA examiner also opined in part, “DEGENERATIVE DISC DISORDER OF THE LUMBAR SPINE. It is less than 50% that MENINGITIS would not cause DEGENERATIVE DISC DISORDER OF THE LUMBAR.” (capitalization in original.) Additionally, the VA examiner indicated that the Veteran’s conditions were not aggravated beyond their natural progression. In short, these negative nexus opinions encompass all theories of secondary service connection. The following month, in January 2021, the Veteran was afforded a VA addendum medical opinion. The pain and neuropathies are addressed separately below. The January 2021 addendum medical opinion reads in part: 3- The Veteran uses a wheelchair because of the residuals from the meningitis or encephalopathy. Encephalitis can damage the brain which would cause chronic problems. Veteran also has Parkinsonism, chronic back problems, and neuropathy in both legs that all contribute to the veteran needing a wheelchair. 4- Back disability is less likely than not incurred in or caused by service and not secondary or aggravated by the meningitis with encephalopathy during service. Veteran’s symptoms did not start until 20 years after discharge from service There is no evidence or research to state that Degenerative Disc Disorder of the Lumbar spine is due/secondary to or aggravated by the meningitis and /or encephalopathy. This negative nexus opinion resolves any possible varying interpretation in the December 2021 VA medical opinion as it is written. Ongoing VA treatment records include a rheumatology consultation note from June 2019 indicating that the chief medical issue was relapsing polychondritis diagnosed in 2013. The Veteran is competent to report back pain and neck stiffness following meningitis after service. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is also competent to relate what he has been told by a professional. He is competent to report that he was diagnosed with DDD and cervical strain in 2010. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran’s own lay opinions as to the diagnosis and cause of any neck and back disability are not probative evidence, although the Veteran’s observed symptoms described may be useful to an expert in evaluating whether the Veteran has a disability and in determining the etiology thereof. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Because the record does not indicate that the Veteran has medical expertise, the Veteran’s lay opinion beyond a description of his symptoms is of limited probative value. Here, the most probative evidence is the contemporaneous treatment records, including the STRs, and the medical opinion of the December 2020 VA examiner bolstered by the January 2021 addendum. First, the STRs do not show any neck or back disability. Years later, the Veteran presented with complaints of neck and back pain in 2010. The Board assigns substantial probative weight to the contemporaneous treatment records. We address any neurological manifestations in the extremities in a separate section below. Second, the Board also assigns substantial probative weight to the comprehensive medical opinions of the December 2020 VA examiner. The VA examiner reviewed the entire claims file, and provided detailed reasons and bases in support of negative nexus opinions. The VA examiner rendered negative nexus opinions for all theories of direct and secondary service connection for the neck and back, which considered all neurological manifestations. The negative nexus opinions are supported by the objective evidence in the claims file, as cited to by the VA examiner. The VA examiner highlighted that the Veteran’s own lay history placed the onset of the disabilities to over 18 years after separation. The VA examiner reasoned, “Veteran was in the U.S. Army from 1984-1992. All of the following condition started 18 years after the veteran was in service. Therefore, it is less than 50% that any of the claimed conditions are service related.” The negative nexus opinions are supported by complete DBQs for both the neck and back, consideration of the Veteran’s lay history, and a review of the claims file. Therefore, we assign substantial probative weight to the negative nexus opinions of the December 2020 VA examiner. For direct and presumptive service connection, the Board finds that the Veteran did not have the characteristic manifestations necessary to identify the disease entities in service. Neck stiffness and DDD of the lumbar spine disabilities were not manifest in service or within one year from separation, and are not otherwise attributable to service. There is no probative evidence to the contrary. In addition, we find that while competent to report what he has been told by his physician and to report being told by his physician that he has a diagnosis of neck and back disability, the Veteran’s own lay opinion regarding identifying a potential chronic disease entity, such as arthritis, pales in probative weight when compared to the objective medical evidence of record. Additional causal evidence against the claims, and while not dispositive, is the lapse of so many years between discharge and the first documented reports of chronic conditions many years after discharge. This multi-year gap after service provides highly probative evidence against these claims. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). An alternative method of establishing the second and third Shedden element, under 38 C.F.R. § 3.303 (b), is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a). Consideration of entitlement to service connection via the demonstration of continuity of symptomatology is applicable in the present case. However, the most probative evidence in the contemporaneous treatment records and December 2020 medical opinion does not demonstrate such continuity. The December 2020 VA examiner described the Veteran’s lay and medical history showing the remote onset of the claimed disease entities years after separation in 2010. Consequently, service connection on a direct and presumptive basis for neck stiffness and DDD of the lumbar spine disabilities is not warranted. Next, it appears the Veteran’s central theory of entitlement to service connection for a neck stiffness and DDD of the lumbar spine disabilities is also one of secondary service connection. More specifically, he contends that neck stiffness and DDD of the lumbar spine disabilities are secondary to his service-connected meningitis. 38 C.F.R. § 3.310. The Board has considered the evidence of record, and finds that neck stiffness and DDD of the lumbar spine disabilities are not related to service, and are less likely than not proximately due to, the result of, or aggravated by any service connected disability. Indeed, the December 2020 VA examiner supported the negative nexus opinions for secondary service connection with very detailed reasons and bases citing to accepted medical knowledge and evidence in the claims file. For the neck, the Veteran identified a key timing issue in the secondary service connection theory of entitlement. Indeed, the VA examiner reasoned, “Neck stiffness is an acute symptom of active ENCEPHALOPATHY or MENINGITIS. But there is no literature to support a chronic stiff neck after having MENINGITIS.” (capitalization in original.) For the back, the VA examiner similarly and unequivocally clarified in January 2021: 4- Back disability is less likely than not incurred in or caused by service and not secondary or aggravated by the meningitis with encephalopathy during service. Veteran’s symptoms did not start until 20 years after discharge from service. There is no evidence or research to state that Degenerative Disc Disorder of the Lumbar spine is due/secondary to or aggravated by the meningitis and /or encephalopathy. In reaching these conclusions the VA examiner applied his medical expertise. There is also no other probative evidence establishing that any neck stiffness and DDD of the lumbar spine disabilities is due to any other service connected disease or injury. We have sympathetically considered the Veteran’s lay statements to the extent that he is competent to relate current pain in the neck and back. We have specifically considered that Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). The Federal Circuit found that 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.” There is no additional functional impairment due to pain alone as is addressed by Saunders related to service. It follows that the weight of the evidence is against any indication of a relationship to service for any neurological manifestations of a neck or back disability. Therefore, even after considering Saunders, service connection for a neck or back disability is not warranted. In sum, the Board has assigned the most probative weight to the contemporaneous medical records, including the STRs, and the findings of the December 2020 VA examiner. The VA examiner reviewed the STRs, VA treatment records, objective test results, private treatment records, and considered the Veteran’s lay history. The VA examiner rendered negative nexus opinions for all theories of entitlement. We have found these to be the most probative evidence of record. We have considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable. 38 C.F.R. §§ 3.303, 3.307, 3.309. The most probative evidence establishes the remote onset of any neck or back impairment. There is also no nexus to meningitis or other service-connected disability. 38 C.F.R. § 3.310. There was no aggravation by service connected disease or injury. There is no probative evidence to the contrary. The Board notes other factors, as cited in the August 2013 VA medical opinion. We acknowledge several of his conditions require the use of a wheelchair and scooter. There is no doubt to resolve. Therefore, service connection for neck stiffness and DDD of the lumbar spine disabilities is not warranted. 4. Entitlement to service connection for a disorder of spitting blood, to include as secondary to meningitis 5. Entitlement to service connection for chronic obstructive pulmonary disease (COPD), to include as secondary to meningitis We note that bronchiectasis is a recognized chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). By way of background, the Service Treatment Records (STRs) show April and May 1992 notations of a cold with painful coughing. Later, the Report of Medical Examination from separation disclosed a clinically normal evaluation of the lungs and chest, heart and vascular system. In the contemporaneous Report of Medical History, the Veteran denied heart trouble, and high or low blood pressure. He endorsed pain or pressure in chest, that he had coughed up blood, in addition to chronic or frequent colds and chronic cough. Still, he wrote “No acute/chronic medical problems” and signed the document. Ongoing VA treatment records from the Tampa VA Medical Center (VAMC) show the remote onset of respiratory impairment, diagnosed as COPD. They show that the Veteran has a respiratory disorder with acute respiratory failure, but which is not characterized by spitting up blood or bouts of bronchitis. The Veteran was seen in 2014 for acute bronchitis and treated with antibiotics. A pulmonary consultation from March 2014 revealed relapsing polychondritis with beginning hoarseness, normal spirometry and lung volumes, with history of mild obstructive sleep apnea. Next, the Veteran was afforded an August 2015 VA respiratory conditions examination. The VA examiner identified interstitial lung disease from 2014 and pulmonary embolism from 2015. The VA examiner noted a history of acute bronchitis, resolved without residuals. The VA examiner described the Veteran’s lay history, “Pt presents for eval of claimed COPD. Vet is poor historian with difficulty with memory and speech. He states he does not recall what happened during his military service regarding any breathing problems. States had pneumonia once in about 2005, was treated outpatient but had to stay home for 2 weeks.” The VA examiner reviewed he Veteran’s prior medical history showing the remote onset of any chronic respiratory disability. It shows in part, “PCP visits 1/29/2013, 3/12/2013, 4/24/2013, 5/14/2013, 7/16/2013, 8/12/2013 - no complaints of respiratory difficulties. 7/24/2012, 9/4/2012, 11/26/2012, 6/4/2013, 7/30/2013 Dr. [R.]-[N.]-, no c/o respiratory difficulties.” The staff physician documented the remote diagnosis of the diagnosed disease entities. Next, the VA examiner rendered a negative nexus opinion for direct service connection for COPD. The VA examiner reasoned in part: There is no documentation of any respiratory complaints/diseases/treatment from 1992-2014. [O]n New Pt H&P 11/5/2013 at James Haley VA, no respiratory complaints noted. Sent for sleep study in 1/2014 at which time found to have nocturnal hypoxemia and started on O2 at night only, but still no significant complaints of dyspnea. No significant respiratory complaints noted until 2015 (when had PEs). The staff physician concluded that there was no diagnosis of COPD. Subsequent VA treatment records showed a diagnosis of COPD with chronic respiratory failure, dated October 2, 2019, with need for home oxygen tank. The issue remained a nexus. Following the September 2020 Board remand, the Veteran was afforded a December 2020 VA Respiratory Conditions Disability Benefits Questionnaire (DBQ), received by VA in January 2021. The VA examiner reviewed the entire claims file, elicited a lay history from the Veteran, and performed a physical examination. The Veteran reported that he is constantly short of breath. The VA examiner identified chronic obstructive pulmonary disease (COPD) with a date of diagnosis of 2014. The VA examiner did not identify bronchiectasis, including no blood-tinged sputum at times. The VA examiner documented, “PFT from 2016 still accurately reflects the veteran current respiratory health. His % predicted are all low.” The VA examiner cited and reviewed a contemporaneous chest x-ray. Next, the VA examiner rendered a set of negative nexus opinions for all theories of direct, presumptive, and secondary service connection. The VA examiner reasoned in part: Veteran started having SOB around 2014 due to COPD. It is less than 50% that his lung diseases are service related. Meningitis is an inflammation of the fluid and membranes (meninges) surrounding your brain and spinal cord. The swelling from meningitis typically triggers signs and symptoms such as headache, fever and a stiff neck. Most cases of meningitis in the United States are caused by a viral infection, but bacterial, parasitic and fungal infections are other causes. Some cases of meningitis improve without treatment in a few weeks. Others can be life-threatening and require emergency antibiotic treatment. . . . . Encephalitis is inflammation of the brain. There are several causes, but the most common is a viral infection. Encephalitis often causes only mild flu-like signs and symptoms— such as a fever or headache— or no symptoms at all. Sometimes the flu-like symptoms are more severe. Encephalitis can also cause confused thinking, seizures, or problems with movement or with senses such as sight or hearing. Turning to secondary service connection, the VA examiner similarly rendered negative nexus opinions. The Board observes that the examiner checked both boxes 4A and 4B for a positive and negative nexus, but concluded with negative nexus opinions in the rationale. The rationales cite other causal factors, which explains both checked boxes. The VA examiner explained in part, “There is no evidence or research to suggest that Meningitis or Encephalitis would cause lung disease. It is less than 50% that his lung disease are (sic) service related.” The VA examiner provided links to Mayo Clinic literature. The VA examiner indicated that there is no aggravation beyond the diseases’ natural progression. He reiterated, “There is no evidence or research to suggest that Meningitis or Encephalitis would cause lung disease. It is less than 50% that his lung disease are (sic) service related.” Also from December 2020, several medical opinions in one document are of record. They encompass the Veteran’s contentions that he has a disorder manifested by spitting blood. The VA examiner similarly indicated negative nexus opinions for all theories of direct, presumptive, and secondary service connection. The VA examiner reasoned, “Denies spitting up blood. He says he’s cough up blood when only has a bad cough from his COPD. Does not cough up blood all the time.” Later, a January 19, 2021 VA addendum medical opinion was obtained. It shows a negative nexus opinion for COPD for any theory of aggravation. The VA examiner reasoned, “Since there is no evidence or research to suggest that Meningitis or Encephalitis would cause lung disease, there is also no evidence or research to suggest that Meningitis or Encephalitis could aggravate the COPD beyond its natural progression. Therefore it is less than 50% that his COPD was aggravated by the Meningitis/Encephalopathy.” The Veteran contends that he is entitled to service connection for chronic obstructive pulmonary disease (COPD) and a disorder manifested by spitting up blood, to include as secondary to meningitis. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is competent to report shortness of breath and spitting up blood. The Veteran is also competent to relate when he was diagnosed with COPD. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran’s own lay opinions as to the diagnosis and cause of any COPD disability are not probative evidence, although the Veteran’s observed symptoms described may be useful to an expert in evaluating whether the Veteran has a disability and in determining the etiology thereof. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Because the record does not indicate that the Veteran has medical expertise, the Veteran’s lay opinion beyond a description of his symptoms is of limited probative value. Here, the most probative evidence is the contemporaneous treatment records, including the STRs, and the medical opinion of the December 2020 VA examiner. First, the STRs do not show any clinically diagnosed blood spitting or respiratory disability at separation. The Veteran made lay indications of coughing up blood, but no further condition was diagnosed. The document ultimately shows “No acute/chronic medical problems.” More than two decades after separation, COPD was diagnosed in 2014. At the December 2020 VA examination, no bronchiectasis including any bloody sputum was identified. The Board assigns substantial probative weight to the contemporaneous treatment records. Second, the Board also assigns substantial probative weight to the comprehensive medical opinions of the December 2020 VA examiner. The VA examiner reviewed the entire claims file, and provided detailed reasons and bases in support of a negative nexus opinion. The VA examiner rendered negative nexus opinions for all theories of direct and secondary service connection for COPD and any blood spitting disorder, which considered all theories of entitlement. The negative nexus opinions are supported by the objective evidence in the claims file, as cited to by the VA examiner. The VA examiner highlighted that the Veteran’s own lay history of only coughing up blood related to COPD, but not spitting. The VA examiner concluded, “There is no evidence or research to suggest that Meningitis or Encephalitis would cause lung disease. It is less than 50% that his lung disease are (sic) service related.” Regarding direct and presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entities in service. COPD and a disorder manifested by spitting up blood disability were not manifest in service or within one year from separation, and are not otherwise attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report being told by his physician that he has a diagnosis of COPD from 2014, the Veteran’s own lay opinion regarding identifying a potential chronic disease entity, such as bronchiectasis, pales in probative weight when compared to the objective medical evidence of record. Additional causal evidence against the claims, and while not dispositive, is the lapse of so many years between discharge and the first documented reports of only COPD more than 20 years after discharge. This multi-year gap after service provides highly probative evidence against these claims. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). An alternative method of establishing the second and third Shedden element, under 38 C.F.R. § 3.303 (b), is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a). Consideration of entitlement to service connection via the demonstration of continuity of symptomatology is applicable in the present case. However, the most probative evidence in the contemporaneous treatment records and VA medical opinions does not demonstrate such continuity. The December 2020 VA examiner described the Veteran’s medical history showing the remote onset of one of the claimed disease entities several decades after separation. Consequently, we find that service connection on a direct and presumptive basis for COPD and a disorder manifested by spitting up blood is not warranted. Next, the Veteran through his attorney has asserted that his theory of entitlement to service connection for a COPD and a disorder manifested by spitting up blood is also one of secondary service connection. More specifically, he contends that these disabilities are secondary to his service-connected meningitis and related impairment. 38 C.F.R. § 3.310. The Board has considered the evidence of record, and finds that COPD and a disorder manifested by spitting up blood are not related to service, and are less likely than not proximately due to, the result of, or aggravated by any service connected disability. Indeed, the December 2020 VA examiner supported the negative nexus opinions for secondary service connection with very detailed reasons and bases citing to accepted medical knowledge and evidence in the claims file. For COPD, the VA examiner concluded, “There is no evidence or research to suggest that Meningitis or Encephalitis would cause lung disease. It is less than 50% that his lung disease are (sic) service related.” For any disorder manifested by spitting up blood, the VA examiner unequivocally documented that the Veteran denied spitting up blood at the time. His lay reports in this regard are probative, to the extent they are competent. For aggravation, the January 2021 VA addendum medical opinion is clear “Since there is no evidence or research to suggest that Meningitis or Encephalitis would cause lung disease, there is also no evidence or research to suggest that Meningitis or Encephalitis could aggravate the COPD beyond its natural progression. Therefore it is less than 50% that his COPD was aggravated by the Meningitis/ Encephalopathy.” There is also no competent and probative evidence establishing that any COPD and a disorder manifested by spitting up blood is due to any other service connected disease or injury. We have also considered the Veteran’s lay statements to the extent that he is competent to relate current pain from breathing or spitting blood. However, they are outweighed by the medical evidence of record. See Saunders v. Wilkie, 886 F.3d 1356 (2018). Subsequently, in Wait v. Wilkie, No. 18-4349, the United States Court of Appeals for Veterans Claims (CAVC) addressed the question of what is necessary for a claimant to demonstrate that his or her pain or other symptoms cause “functional impairment of earning capacity,” and therefore meet the current disability requirement under Saunders. The CAVC held that, to meet the current disability requirement under Saunders, “there must be competent evidence specific to the claimant tending to show that his or her impairment rises to a level to affect earning capacity, which may include showing manifestations of a similar severity, frequency, and duration as those VA has determined by regulation would cause impaired earning capacity in an average person.” The CAVC clarified that the Board must make the factual determination whether the appellant’s manifestations rise to the level of a functional impairment in earning capacity. Nonetheless, there is no additional functional impairment due to pain alone as is addressed by Saunders related to service. The weight of the evidence is against any indication of a relationship to service for any manifestations of any blood spitting disorder. Therefore, even after considering Saunders, service connection for COPD and a disorder manifested by spitting up blood is not warranted. In sum, the Board has assigned the most probative weight to the contemporaneous medical records, including the STRs, and the findings of the December 2020 VA examiner. The VA examiner reviewed the STRs, VA treatment records, objective test results, private treatment records, and considered the Veteran’s lay history. The VA examiner rendered negative nexus opinions for all theories of entitlement. Any current reports of spitting blood are attributable to COPD rather than a distinct disease entity. For any blood spitting, we note the existence of a current disability is the cornerstone of a claim for VA disability compensation. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). We have considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable. 38 C.F.R. §§ 3.303, 3.307, 3.309. Any reports of cough at separation did not rise to the level of a chronic disease. Any cough in service was acute, transitory, and resolved by separation. The most probative evidence establishes the remote onset of COPD over two decades after separation. There is also no nexus to meningitis or other service-connected disability. 38 C.F.R. § 3.310. Additionally, we considered Saunders for all theories of entitlement. There is no probative evidence to the contrary. There is no doubt to resolve. Therefore, service connection for COPD and a disorder manifested by spitting up blood is not warranted. 6. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to meningitis 7. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to meningitis 8. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to meningitis 9. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to meningitis The Board incorporates its discussion from the sections above by reference. We note that pain as organic disease of the nervous system is a recognized chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). By way of background, the Report of Medical Examination from separation disclosed a clinically normal evaluation of the upper extremities, lower extremities, spine, other musculoskeletal system, and neurologic system. In the contemporaneous Report of Medical History, the Veteran denied neuritis or paralysis. Ongoing VA treatment records from the Tampa VA Medical Center (VAMC) show that the Veteran developed neurological problems, including peripheral neuropathy after the onset of herpetic meningoencephalitis in 2010, per a Neurology Consultation Note dated January 2014. The issue remains a nexus. Following the Board’s September 2020 remand, the Veteran was afforded a December 2020 VA peripheral nerves examination. The VA examiner reviewed the entire claims file, elicited a lay history from the Veteran, and performed a physical examination. The Veteran described intermittent numbness and tingling in his left arm. He is in constant pain with numbness and tingling in both legs from his knee to his feet. The VA examiner identified neuropathy of both arms from 2010, and neuropathy of both legs since 2010. Next, the VA examiner rendered negative nexus opinions implicitly encompassing all theories of direct, presumptive, and secondary service connection for each of these claimed conditions. For direct and presumptive service connection, the VA examiner highlighted, “All of the following condition[s] started after 2010. Veteran was in the U.S. Army from 1984-1992. All of the following condition[s] started 18 years after the veteran was in service. Therefore, it is less than 50% that any of the claimed conditions are service related.” For secondary service connection, the examiner checked both boxes 4A and 4B for a positive and negative nexus, but concluded with negative nexus opinions in the rationale. The rationales cite other causal factors, which explains both checked boxes. It reads, “PERIPHERAL NEUROPATHY OF THE BILATERAL LOWER EXTREMITIES. It is less than 50% that MENINGITIS would cause PERIPHERAL NEUROPATHY. The veteran has DEGENERATIVE DISC DISORDER OF THE LUMBAR SPINE. The veteran[’]s DEGENERATIVE DISC DISORDER OF THE LUMBAR SPINE can cause PERIPHERAL NEUROPATHY” (capitalization in original.) Turning to the bilateral upper extremities, the VA examiner similarly opined, “PERIPHERAL NEUROPATHY OF THE BILATERAL UPPER EXTREMITIES. It is less than 50% that MENINGITIS would cause PERIPHERAL NEUROPATHY. The veteran has DEGENERATIVE DISC DISORDER OF THE LUMBAR SPINE. The veteran[’]s DEGENERATIVE DISC DISORDER OF THE LUMBAR SPINE can cause PERIPHERAL NEUROPATHY.” (capitalization in original.) The VA examiner elaborated on page 8 of 9. For example, he wrote, “Veteran has DEGENERATIVE DISC DISORDER OF THE LUMBAR SPINE. His PERIPHERAL NEUROPATHY OF THE LOWER EXTREMITIES is due to the back condition and not do to having meningitis or ENCEPHALOPATHY.” (capitalization in original.) For the upper extremities, the VA examiner explained, “Veteran has a pinched ulnar nerve in his left arm that is causing his neuropathy. It is not related to having meningitis or ENCEPHALOPATHY.” He clarified, “If his meningitis or ENCEPHALOPATHY was causing PERIPHERAL NEUROPATHY OF THE UPPER EXTREMITIES it would occur in both upper extremities. In his case he only has in left arm due to a pinched nerve.” (capitalization in original.) The VA examiner also indicated there was no aggravation. The following month, in January 2021, the VA examiner provided a clarifying addendum medical opinion. He explained in relevant part: 1- Veteran diagnosed with degenerative disc disorder of the lumbar spine. Degenerative disc disorder of the lumbar spine can cause compression of spine and caused pinched nerves that causes neuropathy in both legs. It is less than 50% that his meningitis and/or encephalopathy caused or aggravated neuropathy in both legs. There is no evidence or research to state that neuropathy in both legs was caused by or aggravated by meningitis and /or encephalopathy. It is less than 50% that his neuropathy in both legs is due to service. Symptoms did not start until 18+ years after discharge from service. 2- Diagnosed with pinched ulnar nerve. Which would cause intermittent numbness and tingling in his left arm. It is less than 50% likely that the meningitis and/or encephalopathy caused or aggravated the pinched ulnar nerve. If it was aggravated by the meningitis and/or encephalopathy, he would have numbness and tingling in both extremities. Pinched ulnar nerve is less likely than not due to or incurred in service. Onset of symptoms happened 18 years after discharge from service. Additional VA treatment records are substantially the same. The Veteran contends that he is entitled to service connection for peripheral neuropathy of the right and left upper and lower extremities, to include as secondary to meningitis. The Veteran is competent to report pain in both lower extremities and tingling in the left arm. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is also competent to report when he was diagnosed with peripheral neuropathy and ulnar nerve impingement, as told to him by a physician. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Here, the most probative evidence is the contemporaneous treatment records, including the STRs, and the medical opinions of the December 2020 VA examiner with January 2021 addendum. First, the STRs do not show any neurological disability, including any painful impairment of the extremities. Years later, the Veteran presented to VA with neurological complaints. Peripheral neuropathy was diagnosed after the onset of herpetic meningoencephalitis in 2010, per a Neurology Consultation Note dated January 2014. The Board assigns substantial probative weight to the contemporaneous treatment records. Second, the Board assigns the most probative weight to the wide-ranging medical opinions of the December 2020 VA examiner. This includes the January 2021 VA addendum medical opinion. The VA examiner reviewed the entire claims file, and provided detailed reasons and bases in support of negative nexus opinions. The VA examiner rendered negative nexus opinions for all theories of direct and secondary service connection for the peripheral neuropathy of the right and left upper and lower extremities. The negative nexus opinions are supported by the objective evidence in the claims file, as cited to by the VA examiner. The VA examiner highlighted that the Veteran’s own lay history placed the onset of the reported impairment due to pain several years after separation. The VA examiner summarized, “All of the following condition[s] started after 2010. Veteran was in the U.S. Army from 1984-1992. All of the following condition[s] started 18 years after the veteran was in service.” The negative nexus opinions that followed are supported by additional reasons and bases citing to evidence in the claims file. Therefore, we assign substantial probative weight to the negative nexus opinions of the December 2020 VA examiner. Regarding direct and presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. Peripheral neuropathy of the right and left upper and lower extremities was not manifest in service or within one year from separation, and are not otherwise attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report being told by his physician that he has a diagnosis of peripheral neuropathy, the Veteran’s own lay opinion regarding identifying a potential chronic disease entity, such as organic disease of the nervous system, pales in probative weight when compared to the objective medical evidence of record. Additional causal evidence against the claim, and while not dispositive, is the lapse of so many years between discharge and the first documented reports of chronic conditions years after discharge. This multi-year gap after service provides highly probative evidence against these claims. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (indicating that “evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the [V]eteran’s health and medical treatment during and after military service, as evidence of whether a pre-existing condition was aggravated by military service”). An alternative method of establishing the second and third Shedden element, under 38 C.F.R. § 3.303 (b), is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a). Consideration of entitlement to service connection via the demonstration of continuity of symptomatology is applicable in the present case. However, the most probative evidence in the contemporaneous treatment records and December 2020 VA medical opinion does not demonstrate such continuity. The VA examiner described the Veteran’s medical history showing the remote onset of the claimed disease entities years after separation. Consequently, we find that service connection on a direct and presumptive basis for peripheral neuropathy of the right and left upper and lower extremities is not warranted. Next, it appears the Veteran’s theory of entitlement to service connection for a peripheral neuropathy of the right and left upper and lower extremities is also one of secondary service connection. He contends that these disabilities are secondary to his service-connected meningitis and residual impairment. 38 C.F.R. § 3.310. The Board has considered this theory of entitlement. The most probative evidence is the December 2020 VA medical opinion with January 2021 VA addendum medical opinion. The Board finds that peripheral neuropathy of the right and left upper and lower extremities is not related to service, and is less likely than not proximately due to, the result of, or aggravated by any service connected disability. Indeed, the December 2020 VA examiner supported the negative nexus opinions for secondary service connection with detailed reasons and bases citing to accepted medical knowledge and evidence in the claims file. For example, for the bilateral lower extremities, the VA examiner was clear in the January 2021 addendum. “It is less than 50% that his meningitis and/or encephalopathy caused or aggravated neuropathy in both legs. There is no evidence or research to state that neuropathy in both legs was caused by or aggravated by meningitis and /or encephalopathy.” The VA examiner noted other factors. For the left upper extremity, the VA examiner elaborated in part: Diagnosed with pinched ulnar nerve. Which would cause intermittent numbness and tingling in his left arm. It is less than 50% likely that the meningitis and/or encephalopathy caused or aggravated the pinched ulnar nerve. If it was aggravated by the meningitis and/or encephalopathy, he would have numbness and tingling in both extremities. Pinched ulnar nerve is less likely than not due to or incurred in service. There is also no competent and probative evidence establishing that any peripheral neuropathy disability is due to any service connected disease or injury. To the extent the Veteran has non-service connected disabilities, we may not consider these. 38 C.F.R. § 3.310, Sabonis v. Brown, 6 Vet. App. 426 (1994). In reaching these conclusions, we have considered the Veteran’s lay statements to the extent that he is competent to relate current pain in the right and left upper and lower extremities. However, they are outweighed by the medical evidence of record. In this regard, we have specifically considered that Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). There is no additional functional impairment due to pain alone as is addressed by Saunders related to service. It follows that the weight of the evidence is against any indication of a relationship to service for any neurological manifestations of any peripheral neuropathy disability. Therefore, even after considering Saunders, service connection for peripheral neuropathy of the right and left upper and lower extremities is not warranted. In sum, the Board has assigned the most probative weight to the contemporaneous medical records, including the STRs, and the findings of the December 2020 VA examiner. The VA examiner reviewed the STRs, VA treatment records, objective test results, private treatment records, and considered the Veteran’s lay history. The VA examiner rendered negative nexus opinions for all theories of entitlement. He bolstered these in the January 2021 addendum medical opinion. We have found these to be the most probative evidence of record. We have considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable. 38 C.F.R. §§ 3.303, 3.307, 3.309. The most probative evidence establishes the remote onset of any peripheral nerve impairment many years after separation. There is also no nexus to meningitis or other service-connected disability. 38 C.F.R. § 3.310. We note other factors. Additionally, we considered Saunders for all theories of entitlement. There is no probative evidence to the contrary. There is no doubt to resolve. Therefore, service connection for a peripheral neuropathy of the right and left upper and lower extremities is not warranted. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). The Board is sympathetic the hardships the Veteran endures. He is in receipt of a 100 percent combined schedular rating, a total disability rating based on individual unemployability (TDIU), and special monthly compensation (SMC). AB v. Brown, 6 Vet. App. 35, 38 (1993). In reaching these conclusions, the Board finds that the preponderance of the evidence is against the claims. As such, the benefit of the doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Bodi, 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.