Citation Nr: 21022542 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 17-40 037 DATE: April 16, 2021 ORDER New and material evidence has not been submitted to reopen a claim of entitlement to service connection for a prostate disorder and the claim remains denied. New and material evidence has not been submitted to reopen a claim of entitlement to service connection for a hypertension and the claim remains denied. New and material evidence has not been submitted to reopen a claim of entitlement to service connection for hearing loss and the claim remains denied. Entitlement to service connection for the residuals of a right knee disability is denied. Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied. Entitlement to service connection for urinary incontinence is denied. Entitlement to service connection for erectile dysfunction is denied. Entitlement to service connection for a respiratory disorder is denied. Entitlement to service connection for the residuals of a head injury is denied. FINDINGS OF FACT 1. In a final April 2012 rating decision, the RO declined to reopen the claim for service connection for a prostate disorder and denied service connection for hypertension and hearing loss; the Veteran did not timely perfect an appeal on any of these matters. 2. Evidence received since the April 2012 rating decision, while new, is cumulative or redundant of the evidence previously of record or does not relate to an unestablished fact necessary to substantiate the claims for service connection a prostate disorder, hypertension and hearing loss. 3. The weight of the probative evidence is against a finding that the Veteran’s right knee disability had its onset in service or is otherwise related to injury during active duty, nor was arthritis shown to have initially manifested within a year of discharge from active duty. 4. The preponderance of the evidence is against finding that GERD began during active service or for many years thereafter, and the condition is otherwise shown to be related to service. 5. The Veteran’s urinary incontinence was not present in service or for many years thereafter and is not shown to be etiologically related to active service, including his presumed exposure to herbicides while serving in the Republic of Vietnam. 6. The Veteran’s erectile dysfunction was not present in service or for many years thereafter and is not shown to be etiologically related to active service, including his presumed exposure to herbicides while serving in the Republic of Vietnam. 7. The Veteran’s respiratory disorder was not present in service or for many years thereafter and is not shown to be etiologically related to active service, including his presumed exposure to herbicides while serving in the Republic of Vietnam. 8. The Veteran did not have any residuals of a head injury in service and has not at any time during the pendency of this claim. CONCLUSIONS OF LAW 1. New and material evidence has not been received to reopen the claim for service connection for a prostate disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(c). 2. New and material evidence has not been received to reopen the claim for service connection for hypertension. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(c). 3. New and material evidence has not been received to reopen the claim for service connection for hearing loss. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(c). 4. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303, 3.307, 3.309. 5. The criteria for service connection for GERD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 6. The criteria for service connection for urinary incontinence have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309 7. The criteria for service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 8. The criteria for service connection for a respiratory disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 9. The criteria for service connection for residuals of a head injury have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1968 to April 1970, and during this period he served in the Republic of Vietnam. Subsequently, the Veteran also served in the Army National Guard from June 1986 to June 2003, ultimately retiring from the Army National Guard. In October 2018, the Board denied the above claims. The Board also remanded the claim of service connection for respiratory problems. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (CAVC). In October 2019, CAVC granted a Joint Motion for Partial Remand (JMPR) vacating the Board’s October 2018 decision to the extent that it denied the aforementioned claims and remanded them for further adjudication consistent with the JMPR. In April 2020, the Board remanded the appeal for appropriate action in accordance with the JMPR. The appeal has now been returned to the Board. Additionally, the requested development for the remanded claim of service connection for respiratory problems has been completed and will be addressed herein. New and Material Evidence Claim Generally, if a claim for service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108. “New” evidence is defined as existing evidence not previously submitted to agency decisionmakers. “Material” evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative, nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Despite the determination reached by the RO, the Board must find new and material evidence in order to establish its jurisdiction to review the merits of a previously denied claim. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). 1. Whether new and material evidence has been submitted to reopen the claim for service connection for a prostate disorder The Veteran seeks service connection for a prostate disorder based on Agent Orange exposure. VA regulations provide that, if a Veteran was exposed to an herbicide agent during active service, presumptive service connection is warranted for prostate cancer. 38 C.F.R. § 3.309(e). Veterans who served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 are presumed to have been exposed to Agent Orange. 38U.S.C.§1116(f). The claim was originally denied in an unappealed May 2009 rating decision because there was no evidence of a prostate condition in service, nor was there any evidence that such disorder was caused or aggravated by service, or evidence of a qualifying disability. In an April 2012 rating decision, the RO declined to reopen the claim as new and material evidence had not been submitted. The Veteran was notified of the rating decision, but did not appeal the decision. As such, the April 2012 rating decision became final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. A final decision cannot be reopened unless new and material evidence is presented. 38 U.S.C. § 5108. The evidence of record at the time of the April 2012 rating decision established that the Veteran served in Vietnam during the required period and he is presumed to have been exposed to Agent Orange during active duty. At that time the record contained the Veteran’s service treatment records showing no evidence of a prostate disorder during service and VA medical records showing a current diagnosis of benign prostatic hypertrophy (BPH). There was no evidence of a diagnosis of prostate cancer and no evidence linking the BPH to active duty or to Agent Orange exposure. The evidence received since the April 2012 rating decision includes a July 2017 statement from the Veteran indicating that he had prostate-specific antigen (PSA) tests that had exceeded the normal limits, and that an October 2009 biopsy that was positive for malignancy. These lay statements are simply a reiteration of previously considered general assertions of service connection. Even assuming their credibility for new and material evidence analysis, the statements are cumulative and cannot be considered new and material evidence. He is simply repeating the prior claim. More importantly, as detailed below, while private treatment records in connection with his application to reopen the claim do show elevated PSA readings, these do not document “prostate cancer”, and in fact, the competent medical evidence received since the previous denial specifically addresses his contentions and contradicts the Veteran’s assertions. Private treatment records added to the claims file since the claim was denied in April 2012, document elevated PSA levels, including a PSA level of 5.09 in September 2009, 4.52 in May 2010, and 7.280 in January 2012. VA treatment records recorded the Veteran’s reports of a prior diagnosis of prostate cancer by a private physician in 2009, but the records fail to show a diagnosis of prostate cancer, and do not link BPH to service. Specific to the Veteran’s assertions of having been diagnosed with prostate cancer, a VA clinician in 2019 clarified that an October 2009 biopsy performed by his private physician showed prostate hyperplasia and acute prostatitis, but not prostate cancer. Subsequent treatment records confirm no diagnosis of prostate cancer. This evidence while new, is not material to that claim and provides evidence against the claim. The evidence established that the Veteran had BPH, a fact previously known. None of the evidence received after the April 2012 rating decision links the Veteran’s current prostate condition and/or BPH to service and there is no evidence of a diagnosis of prostate cancer. In any event, it is important for the Veteran to understand that event if the Board found new and material evidence, that new evidence (as cited above), would provide a basis to deny the claim once again. As the Veteran has not fulfilled the threshold burden of submitting new and material evidence to reopen the finally disallowed claim, the benefit-of-the-doubt doctrine is not applicable. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). Accordingly, the Veteran’s petition to reopen the claim for service connection for a prostate disability is denied. 2. Whether new and material evidence has been submitted to reopen the claim for service connection for hypertension In an April 2012 rating decision, the RO denied the claim for entitlement to service connection for hypertension because there was no evidence that the condition was caused or aggravated by service, nor did the evidence show that it manifested within one year of discharge from active duty service. The Veteran filed a notice of disagreement but did not timely perfect an appeal after a statement of the case was issued in June 2013. Therefore, the April 2012 decision is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The evidence of record at the time of the April 2012 rating decision established that the Veteran had a diagnosis of hypertension. At that time the record also contained the Veteran’s service treatment records which failed to show a diagnosis of hypertension during service; VA medical records showing a current diagnosis of hypertension and an April 2012 VA examination report. The VA examiner reviewed the evidence of record, including the Veteran’s service treatment records and indicated that the Veteran did not have hypertension during service, that he was first diagnosed with hypertension almost 18 years after separation from active duty, and that the Veteran’s hypertension was unrelated to service. The evidence received since the April 2012 rating decision includes additional VA treatment records which show that the Veteran’s hypertension is controlled with medical treatment. Such evidence is new as it was not previously of record. Moreover, such evidence must be presumed credible for the purposes of new and material evidence analysis. However, none of the evidence suggests that his hypertension, which was initially shown more than two decades after discharge from active duty service, had onset in service or was aggravated during service, is otherwise related to any aspect of the Veteran’s service, or manifested within one year of discharge from service. In statements the Veteran and his representative asserted that after serving in Vietnam he experienced headaches and exhibited blood elevated pressure readings. However, these readings were already reviewed by the examiner in the April 2012 and found to not be evidence of hypertension in service. In a July 2017 statement the Veteran reiterated that after he returned from Vietnam he started suffering from very heavy headaches, which he appears to suggest were a manifestation of high blood pressure. There is no competent evidence that supports the Veteran’s suggestion that any headaches experienced after he served in Vietnam were a manifestation of hypertension. The lay statements are simply a reiteration of his previously considered general assertions of service connection (it is not a new contention). Even assuming their credibility for new and material evidence analysis, the statements are cumulative and cannot be considered new and material evidence. Simply stated, once again the Veteran is repeating his prior claim. As the Veteran has not fulfilled his threshold burden of submitting new and material evidence to reopen the finally disallowed claim for service connection for hypertension, the benefit-of-the-doubt doctrine is not applicable. Annoni, 5 Vet. App. at 467. 3. Whether new and material evidence has been submitted to reopen the claim for service connection for hearing loss In an April 2012 rating decision, the RO denied the claim for entitlement to service connection for hearing loss because there was no evidence that the condition was caused or aggravated by service, nor did the evidence show that it manifested within one year of discharge from service. The Veteran was notified of the rating decision, but did not appeal the decision. As such, the April 2012 rating decision became final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The evidence of record at the time of the April 2012 rating decision established that the Veteran had a current diagnosis of mixed hearing loss in the right ear and sensorineural hearing loss in the left ear. A VA examination dated April 2012 showed bilateral hearing loss for VA purposes as defined by 38 C.F.R. § 3.385. At that time the record also contained the Veteran’s service treatment records that showed normal hearing on separation examination from active duty, VA medical records and an April 2012 VA examination report. The VA examiner reviewed the evidence of record, including the Veteran’s service treatment records and indicated that the Veteran did have a documented instance of acoustic trauma with a subsequent hearing test showing some hearing loss in the left ear; however, separation examination testing revealed that hearing improved and his hearing was normal in both ears on separation from active duty. The examiner indicated that the current hearing loss was not related to the Veteran’s active duty service including the acoustic trauma noted therein. The Veteran’s National Guard service treatment records show that he had some level of hearing loss already present on his enlistment to the National Guard in 1986. The evidence received since the April 2012 rating decision includes additional VA treatment records which do not provide any link between the Veteran’s current hearing loss and his active duty. The additionally received medical evidence is new, in that it was not previously before agency decision makers. However, none of this evidence is material for purposes of reopening the claim. Simply stated, the additional medical evidence in no way abrogates the deficiency noted in the prior April 2012 rating decision, namely, that there was no evidence that the Veteran’s hearing loss disability was related to service. The Veteran’s treatment records likewise document no such medical opinion, comment or suggestion. Also added to the file is a December 2020 private audiological evaluation report that recorded the Veteran’s reported history of hearing loss due to military acoustic trauma. Notably, the fact that the Veteran’s own reported history of hearing loss and acoustic trauma in service is documented in the December 2020 private audiological evaluation report does not, without more, constitute competent evidence of the required nexus. In other words, a bare transcription of a lay history is not transformed into ‘competent medical evidence’ merely because the transcriber happens to be a medical professional. See Kirwin v. Brown, 8 Vet. App. 148, 152-153 (1995); see also LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (implicitly holding that incompetent medical evidence cannot enjoy the presumption of truthfulness accorded by Justus, supra, as to determining new and material evidence for purposes of reopening a claim). Accordingly, the Board finds that while the evidence is new, it is not material because it does not raise a reasonable possibility of substantiating the Veteran’s service connection claim for hearing loss. The Veteran is simply raising the same claim. As the Veteran has not fulfilled his threshold burden of submitting new and material evidence to reopen the finally disallowed claim for service connection for hearing loss, the benefit-of-the-doubt doctrine is not applicable. Annoni, 5 Vet. App. at 467. Service Connection Service connection may be established 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. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may 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). To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or “nexus” between the present disability and the disease or injury incurred or aggravated during service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be “competent.” However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination “medical in nature” and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain chronic diseases may be presumed to have been incurred in service by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Such a chronic disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. §§ 3.307(a). When a chronic disease is shown in service, sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). To be “shown in service,” the disease identity must be established, and the diagnosis must not be subject to legitimate question. Walker v. Shinseki, 708 F.3d 1331, 1335 (Fed. Cir. 2013); see also 38 C.F.R. § 3.303(b). There is no “nexus” requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease. Walker, 708 F.3d at 1336. A veteran, who, during active military service, served in Vietnam during the period beginning in January 1962 and ending in May 1975, is presumed to have been exposed to herbicide agents. 38 C.F.R. §§ 3.307, 3.309. Because the Veteran in this case served in Vietnam, exposure to herbicide agents has been conceded. If a veteran was exposed to an herbicide agent (to include Agent Orange) during active service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: AL amyloidosis, chloracne or other acneform diseases consistent with chloracne, type II diabetes, Hodgkin’s disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina), all chronic B-cell leukemias, multiple myeloma, non-Hodgkin’s lymphoma, Parkinson’s disease, early-onset peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea) and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma). The term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. 38 C.F.R. § 3.309(e). Notwithstanding the presumption, service connection for a disability claimed as due to exposure to Agent Orange may be established by showing that a disorder resulting in disability was in fact causally linked to such exposure. See Brock v. Brown, 10 Vet. App. 155, 162-64 5(1997); Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994), citing 38 U.S.C. § 1113(b) and 1116 and 38 C.F.R. § 3.303. Service connection may also be granted on a secondary basis for a condition that is not directly caused by the Veteran’s service. 38 C.F.R. § 3.310. In order to prevail under a theory of secondary service connection, the evidence must demonstrate an etiological relationship between (1) a service-connected disability or disabilities and (2) the condition said to be proximately due to the service-connected disability or disabilities. Buckley v. West, 12 Vet. App. 76, 84 (1998); see also Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, secondary service connection may also be found in certain instances when a service-connected disability aggravates another condition. See Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310 (b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 3. Entitlement to service connection for the residuals of a right knee injury The Veteran seeks service connection for a right knee disability. In a statement in October 2020, the Veteran asserted that he injured his right knee during his first period of active duty while loading ice blocks onto a truck. Reportedly, he did not seek treatment for his knee pain and did not report his injury. His right knee remained progressively painful since that injury. The competent evidence of record confirms that the Veteran has been treated for right knee pain and he has been diagnosed with osteoarthritis. The service treatment records failed to disclose any complaints related to his right knee. There is no evidence of a right knee injury during active duty. On separation from service in April 1970 the Veteran’s lower extremities were clinically evaluated as normal and on the accompanying report of medical history, he denied a history of “trick” or locked knee. At this point, it is important for the Veteran to understand that at this point it is the Veteran himself that provides evidence against his own claim. National Guard service treatment records showed that the Veteran reported having right knee injuries in 1986 and 1989, while not in duty status, providing more evidence against this claim. A June 1989 National Guard treatment record specifically noted a history of a right knee injury with ligament rupture which he re-injured the prior May. The diagnostic impression was that the Veteran had trauma to the right knee which existed prior to his National Guard service. Other National Guard service treatment records note that the Veteran had knee surgery in 1990. Thus, the Veteran was not shown to have arthritis of the right knee in active duty service or within one year following discharge therefrom, as such, service connection cannot be established for arthritis on a presumptive basis. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Here, following service discharge, there is no evidence of treatment for the right knee until more than a decade after discharge from service in 1970. The Court has indicated that the normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many, many, years after service is probative evidence against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board where it found that Veteran failed to account for the lengthy time period after service for which there was no clinical documentation of low back condition); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (A prolonged period without medical complaint can be considered, along with other factors concerning a claimant’s health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability.). To the extent the Veteran is asserting continuity of symptomatology from service, the Board finds such statements inconsistent with the overall record. While the Veteran now claims onset of knee problems in service, he has not credibly shown that his present right knee disability was incurred in service and continued since service as this is inconsistent with the service treatment records and post-service medical evidence and, at some points, his own prior statements. Even assuming, without conceding, for discussion purposes that the credibility of the Veteran’s account of an in-service injury, the record is insufficient to link his current right knee disorder to the alleged injury, or to any other aspect of his service. Simply stated, the fact that he may have incurred a knee injury in service many many years ago does not necessarily lead to the conclusion that his current problem decades later are related to that injury. On the question of a nexus between the claimed right knee disability and service, there is evidence both for and against the claim. In November 2016 a VA examination of the Veteran was conducted. The diagnosis was right knee osteoarthritis. The Veteran reported that he had a fall injury to his right knee during active duty. The examiner opined that the Veteran’s right knee osteoarthritis was less likely than not related to service, but was the result of the natural aging process. In a medical statement in December 2020, a private clinician noted the Veteran’s report of onset of a right knee disability following a knee injury incurred in 1970 during service. The Veteran described falling from a platform and hitting his right knee with a truck adjacent to him. The blanket opinion provided no rationale. Furthermore, the facts upon which the opinion is based are inconsistent with the contemporaneous records, and fail to account for National Guard service treatment records showed that the Veteran initially reported having right knee injuries in 1986 and 1989, while not in duty status. Accordingly, the opinion is afforded little probative value. The Board finds the opinions of the VA examiner in 2016 to be highly persuasive and probative in finding that the evidence does not support a conclusion that the Veteran incurred the current right knee disability in service. The examiner’s findings were based on a review of the evidence, including the service treatment records and examination, which did not substantiate a finding that the Veteran sustained a chronic right knee disability in service. The examiner considered the complete record and the Veteran’s contentions and provided an explanation as to why the evidence does not support a finding that his right knee disorder was due to service, to include injuries incurred therein. Finally, the VA examiner’s opinion was internally consistent and consistent with other evidence of record and are of significant probative value. Consequently, the Board finds the 2016 VA medical opinion reports more probative and outweigh the findings of the private clinician in December 2020. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). In this regard, the Board must find that the service and post-service treatment records provide particular negative evidence against this claim. The Board has considered the statements from the Veteran wherein he associated his right knee disability to injuries incurred in service. The Veteran is certainly competent to report as to the observable symptoms he experiences and their history, but he cannot self-diagnose because of the medically complex nature of such a diagnosis. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); See Jandreau v. Nicholson, 492 F.3d at 1376-77. The ultimate questions in this case are related to an internal medical process which extends beyond an immediately observable cause and effect relationship. Id. Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to his current knee disability is a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) (“Although the Veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with.”). Simply stated, both the best medical evidence in this case, and the facts of this case, provide highly probative evidence against the claim. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for service connection for a right knee disability. As such, that doctrine is not applicable in the instant appeal, and the claim must be denied. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, 1 Vet. App. at 55-56. 4. Entitlement to service connection for a gastrointestinal disorder The Veteran claims service connection for GERD and esophageal reflux. In statements in support of the claim, he associated his gastrointestinal symptoms with drinking contaminated water during active duty in Vietnam. However, he reported recent onset of symptoms and denied reflux or other related condition during active duty. The service treatment records contain no complaints, treatment for, or diagnosis of a gastrointestinal disorder, including reflux or GERD, during active duty or any other period of service. On separation from active duty in April 1970, the Veteran’s gastrointestinal system was clinically evaluated as normal and he denied a history of frequent indigestion or stomach trouble. It is again important to note that at that point above it is the Veteran himself who provides evidence against the claim. In a January 2008 VA assessment report, the Veteran denied any gastrointestinal complaints. VA outpatient nutritional assessment notes dated in October and December 2010 indicate that the Veteran reported “altered GI function probably related to big foods portions and high fat intake as evidenced by 24 hrs diet recall and symptoms of esophageal reflux by which a low irritants diet was advised.” An assessment of reflux esophagitis was reported. Subsequent treatment records also show that an endoscopy in December 2018 showed a hiatal hernia and GERD. Thus, the evidence does not reflect GERD in service or within one year following discharge from service, or until more than four decades after discharge from service. In so noting, the Board recognizes that the mere absence of medical records is not dispositive as to the question of continuity; the lay evidence must be considered as well. See Buchanan, 451 F.3d at 1335. If, however, it is determined based on reliable evidence, that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson, 230 F.3d at 1333. To the extent the Veteran is asserting continuity of symptomatology from service, the Board finds such statements inconsistent with the overall record, to include the service treatment records. Thus, the Veteran has not adequately shown that GERD had onset in service and continued since service. Here, there is no competent and credible evidence of a nexus between the Veteran’s GERD and service, to include ingestion of contaminated water in Vietnam. The only evidence of record in support of such a nexus is the Veteran’s lay opinion. To the extent the Veteran believes that his claimed disability is related to service, as a lay person, the Veteran does not have the specialized training sufficient to render such an opinion. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). The diagnosis and/or etiology of gastrointestinal disability requires medical testing and expertise to determine. Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to his current claimed disorder, is a matter that requires medical expertise to determine. See Clyburn, 12 Vet. App. at 301. Thus, the Veteran’s assertions regarding the etiology of GERD, diagnosed many years after service, and service, are of little probative value. In this regard, it is important for the Veteran to understand that the post-service treatment records provide particularly negative evidence against this case. A VA examination or medical opinion regarding the etiology of his GERD is not indicated as there is no suggestion that the Veteran’s claimed disorder may be associated with service or water consumption in Vietnam. Moreover, there is no competent and probative evidence to show that the Veteran had GERD during or contemporaneous with service and no competent and probative evidence that his claimed disorder is related to his service. Given the foregoing, the Board finds that the preponderance of the evidence is against the claim for service connection for GERD, and that the claim must be denied. See 38 U.S.C. § 5107 (b); Gilbert, supra. 5. Entitlement to service connection for urinary incontinence 6. Entitlement to service connection for erectile dysfunction The Veteran has asserted a vague claim for service connection for urinary incontinence and erectile dysfunction. The Veteran denied onset of symptoms in service, rather he claims the conditions are related to Agent Orange exposure in Vietnam. Concerning presumptive service connection due to Agent Orange exposure, urinary incontinence and erectile dysfunction are not among the disorders entitled to presumptive service connection. 39 C.F.R. § 3.309(e), Note 3. Notwithstanding the foregoing, even when presumptive service connection is not appropriate, a Veteran is not precluded from establishing service connection with proof of actual direct causation. See Combee, supra. The service treatment records for both the period of active duty service and National Guard Service do not show any complaints related to urinary incontinence or erectile dysfunction. VA medical treatment records show the Veteran reported being treated with Detrol LA, by a non-VA physician. This medication was used to treat overactive bladder symptoms. Recent VA medical records after 2008, indicate a diagnosis of BPH without obstructive urinary symptoms. the BPH was being treated medically with Dutasteride. The Board notes that side effects of this medication can be impotence and decrease in libido. In October 2018 and May 2020, he reported urinary incontinence having onset 15 years earlier. An assessment of urinary incontinence, BPH, was noted. However, on evaluation in February 2019 and September 2020 a VA clinician noted no incontinence present. VA records in 2020 show that the Veteran reported erectile dysfunction. Here, there is no competent medical opinion of record linking the current urinary incontinence and/or erectile dysfunction to active duty service, to include exposure to Agent Orange. As such, there are no grounds for service connection on a direct or presumptive basis. The only evidence of record in support of such a nexus is the lay opinion of the Veteran who contends that his urinary incontinence and erectile dysfunction were due to service, as indicated, his assertions are based on the contention of herbicide agent exposure. To the extent the statements from the Veteran are being offered to establish a nexus, such evidence fails because this determination is a complex medical matter beyond the realm of common knowledge of a layperson. In this regard, as above, while the Veteran could competently report observable symptoms, the claimed disorders can have many causes. Jandreau, 492 F.3d at 1377 (Fed. Cir. 2007). Whether a disease is caused by exposure to chemicals is a complex question well known to be the type of question subject to extensive research by medical professionals. The Veteran has not been shown to possess specialized training sufficient to render such an opinion. Accordingly, his assertions as to a relationship between urinary incontinence and/or erectile dysfunction, initially reported many decades after service, and service, are of little probative value. To the extent that the Veteran is somehow asserting that he has urinary incontinence and/or erectile dysfunction as a result of his prostate disorder, BPH, service connection for that disability has been denied, and his petition to reopen that claim is denied above. As such, there is no factual or legal basis upon which to award service connection for a disability that is claimed as secondary to a disability that is not service connected. See 38 C.F.R. § 3.310. A VA examination or medical opinion regarding the etiology of his currently diagnosed urinary incontinence and/or erectile dysfunction was not indicated as there is no suggestion that the Veteran’s claimed disabilities may be associated with service. As the preponderance of the evidence is against the claims, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); See Gilbert, 1 Vet. App. at 54. 7. Entitlement to service connection for a respiratory disorder The Veteran seeks service connection for a respiratory disorder. He asserts that a pulmonary nodule identified in 2016 is cancerous and thus subject to presumptive service connection due to Agent Orange exposure. The service treatment records fail to document a chronic respiratory disorder. On separation from active duty in April 1970, the Veteran’s lungs and chest were clinically evaluated as normal and he denied a history of shortness of breath, chronic cough or chest pain or pressure. The service treatment records for the National Guard Service do not show any complaints consistent with a chronic respiratory disorder. On VA pulmonary consultation in June 2016, the Veteran reported a chronic productive cough, whitish sputum, and some chest tightness ongoing for a year. The Veteran endorsed a history of occupational exposure to fumes working in a petrochemistry and a pharmaceutic for 20 years. An October 2016 VA treatment record revealed that the Veteran was shown to have a small lung nodule on CT examination. Based on the evidence noted above, the Board finds that a chronic respiratory disability was not shown in service, and respiratory cancer was not shown in service or within one year following discharge from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Accordingly, competent evidence linking the current disability to service is needed to substantiate the claim. On the question of medical causation, the weight of the evidence is against the claim. The Veteran underwent a VA respiratory examination in October 2019. The examiner noted a history of pulmonary nodule diagnosed in 2017. A CT scan in March 2019 indicated that the lesion remained stable. Pulmonary function testing revealed no abnormalities. Following a review of the claims file and an examination of the Veteran, the examiner opined that the claimed respiratory disorder was less likely than not incurred in or caused by the claimed in-service injury, event or illness. Notably, the examiner concluded that the evidence failed to show that the pulmonary nodule was cancerous. Accordingly, there was no evidence of a diagnosis of respiratory cancer. In an addendum opinion report in December 2020, the examiner reiterated that that the Veteran’s pulmonary nodule was less likely as not caused by or a result of active military service as there was no evidence treatment in service. The examiner also explained that the Veteran’s pulmonary nodule was not a malignant and he was only being followed under observation by his primary care physician. The pulmonary nodule was not causing any functional loss. Therefore, respiratory cancer was not present. On VA examination in February 2021, a VA examiner reviewed the claims file and determined that there was no evidence to support a diagnosis of lung cancer. Significantly, there is no competent medical opinion of record linking the current respiratory disability to service, to include his presumed exposure to Agent Orange. Although the Veteran has expressed his belief in a connection between his time in service and his claimed respiratory disorder, including his presumed exposure to Agent Orange, he lacks the knowledge and training required to diagnose a disability as complex as respiratory cancer, or to render a nexus opinion on a cause and effect relationship unobservable to a lay person. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Further, he has simply asserted his opinion, without a clear rationale or support; no probative value is given his statements beyond their worth as physical observations. Accordingly, the Board assigns more weight to the competent medical evidence which establishes the Veteran’s respiratory disorder is not cancer, nor is it a respiratory disability that is due to service, to include as due to exposure to Agent Orange. The VA examiners, who thoroughly reviewed the Veteran’s medical records and performed a physical examination of the Veteran, determined that it was less likely than not that the Veteran’s reported respiratory abnormality was related to his military service, noting that the evidence showed that the Veteran’s pulmonary nodule, initially noted more than four decades after service, was benign, and was not in any way associated with the Veteran’s service, including exposure to Agent Orange. The VA examiners provided adequate rationale in support of the opinions rendered and the opinions were internally consistent and consistent with other evidence of record, including the service treatment records and clinical findings reported by the Veteran’s treatment providers after service. Accordingly, the preponderance of the evidence is against the Veteran’s claim for service connection for a respiratory disorder, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); See Gilbert, 1 Vet. App. at 54. 8. Entitlement to service connection for the residuals of a head injury The Veteran claims entitlement to service connection for the residuals of a head injury. The service treatment records document a single report that the Veteran hit his head on a rusty nail in March 1970, more than one-half a century ago. Therefore, the Board has to now consider whether the Veteran currently suffers from any residuals of the head injury. It is important for the Veteran to understand (as noted above) that it is not enough merely to show relevant injury in service since there equally has to be chronic (meaning permanent) disability owing to that injury. For example: A back “injury” does not always lead to a chronic back “disability”. Under VA law, the cornerstone of a valid claim for service connection is that there must be competent and credible evidence of the present existence of the disability being claimed. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), citing Francisco v. Brown, 7 Vet. App. 55, 58 (1994) (“Compensation for service-connected injury is limited to those claims which show a present disability.”); Hicks v. West, 12 Vet. App. 86, 89 (1998); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). See also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (“Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability.:). See, too, Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998). A current disability means a disability shown by competent and credible evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997); Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328 (1997) (indicating VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability); but see also McClain v. Nicholson, 21 Vet. App. 319 (2007) (further clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA’s adjudication of the claim). See also Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (considering the application of McClain on a recent diagnosis even predating the filing of a claim). As noted, the service treatment records show that the Veteran was treated at a field hospital when he reportedly hit his head on a rusty nail in March 1970. No residual symptoms were reported or documented. On separation examination in April 1970, the Veteran’s head and neurologic systems were clinically evaluated as normal and the Veteran denied a history of head injury, headaches, dizziness or fainting spells. Subsequently, the Veteran failed to report any residual symptoms form this head injury on National Guard medical records. National Guard and VA medical treatment records dated after active duty indicate normal findings with respect to the Veteran’s head. In a January 2008 VA assessment report, the Veteran denied any head injury complaints. The evidence of record dose not reveal any current residuals of the active duty head injury. Simply stated, the best evidence in this case provides evidence against the existence of a disability at any time during the period on appeal. The Board has considered the Veteran’s assertions regarding the existence of a disability associated with the in-service head injury. The Veteran is certainly competent to report as to the observable symptoms he experiences and their history. Layno, 6 Vet. App. at 469. In this case, however, his statements do not rise to a level of competency to offer an opinion as to the existence of a current diagnosis or etiology. See Kahana, 24 Vet. App. at 438. Determining the etiology of the Veteran’s claimed residuals of a head injury requires medical inquiry into biological processes, pathology, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have training, expertise, or skills needed to make such a determination. As a result, the probative value of his lay assertions is low. In summary, the Board finds that the weight of the evidence establishes that the Veteran does not have any residuals of the in-service head injury and has not at any time during the claims period. Significantly, the Veteran has not clearly identified any symptoms attributable to the March 1970 head injury. The Board notes that the Veteran was not afforded VA examination for his claimed residuals of a head injury. As there is no evidence of a diagnosis of a disability, much less one associated with service, the claim does not meet the requirements for obtaining a VA medical examination. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). (Continued on the next page)   Regarding all the Veteran’s claims, as a whole, the Board has reviewed the Veteran’s statements in great detail over many years. While it is clear that the Veteran currently has several medical issues, the Board must also find that the Veteran is not always an accurate historian of his disabilities over time, particularly regarding events that occurred many years ago. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for service connection for residuals of a head injury. As such, that doctrine is not applicable in the instant appeal, and the claim must be denied. See 38 U.S.C. § 5107 (b); See Gilbert, 1 Vet. App. at 54. John J. Crowley Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Azizi, T. 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.