Citation Nr: 21024553 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 04-17 858 DATE: April 23, 2021 ORDER 1. Entitlement to service connection for a bilateral leg disability is denied. 2. Entitlement to service connection for a left ankle disability is denied. 3. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depressive disorder, is denied. 4. Entitlement to service connection for asthma is denied. 5. Entitlement to service connection for ulcers is denied. 6. Entitlement to service connection for a right ankle disability is denied. FINDINGS OF FACT 1. The Veteran has not been diagnosed with a bilateral leg disability during the pendency of his claim. 2. The Veteran has not been diagnosed with a left ankle disability during the pendency of his claim. 3. The most probative medical evidence fails to show the Veteran has a psychiatric disorder had its onset in service, or is otherwise related to service. 4. The Veteran’s asthma clearly and unmistakably pre-existed his active service, and was not aggravated by service. 5. The preponderance of the evidence shows that the Veteran’s ulcer condition did not have its onset in service and is not etiologically related to service. 6. The preponderance of the evidence shows that the Veteran’s right ankle disability did not have its onset in service and is not etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a bilateral leg disability have not been met. 38 U.S.C. §§ 1101, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). 2. The criteria for entitlement to service connection for a left ankle disability have not been met. 38 U.S.C. §§ 1101, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). 3. The criteria for service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2020). 4. The criteria for entitlement to service connection for asthma have not been met. 38 U.S.C. §§ 1110, 1111 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2020). 5. The criteria for entitlement to service connection for ulcers have not been met. 38 U.S.C. §§ 1101, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). 6. The criteria for entitlement to service connection for a right ankle disability have not been met. 38 U.S.C. §§ 1101, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1965 to March 1968. This appeal came before the Department of Veterans Affairs (VA) Board of Veterans Appeals (Board) from an August 2003 rating decision of the VA Regional Office (RO) in Houston, Texas. Jurisdiction has since been transferred to the RO in Jackson, Mississippi. The Board denied the claims in November 2007. The Veteran appealed to the Court of Appeals for Veterans Claims (Court). In a September 2010 Memorandum Decision, the Court vacated all of the determinations except for service connection of emphysema, of which the denial of the Board was reaffirmed. In December 2011, the Board remanded this appeal for further action consistent with the Memorandum Decision, to include scheduling VA examinations for each of the remaining issues. In February 2017, the Veteran was afforded a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. In March 2018, the Veteran elected to proceed in this matter pro se. The Board has expanded and recharacterized the Veteran’s original claim for service connection for a nervous condition as one of entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depressive disorder, in order to accurately reflect all psychiatric disorders of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record). In May 2017, the Board remanded this matter to afford the Veteran another opportunity to attend VA examinations related to the issues on appeal. As a threshold matter, the Board finds that the Veteran, by cancelling his examinations, has failed to report for his scheduled VA examinations in this appeal without good cause. Following the Board’s May 2017 remand, the RO scheduled the Veteran for VA leg, ankle, ulcer, asthma, and psychiatric examinations and etiology opinions; however, the Veteran cancelled the examination requests. See Exam Request (January 2021). He did not report good cause or request alternative examination dates. Under 38 C.F.R. § 3.655 (a), when entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination or reexamination and a claimant, without good cause, fails to report for such examination, or reexamination, action shall be taken in accordance with paragraph (b) or (c) of this section as appropriate. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. For purposes of this section, the terms examination and reexamination include periods of hospital observation when required by VA. 38 C.F.R. § 3.655 (a). Under paragraph (b) for original or supplemental claim, or claim for increase, when a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. When the examination was scheduled in conjunction with any other original claim, a supplemental claim for a benefit which was previously disallowed, or a claim for increase, the claim shall be denied. 38 C.F.R. § 3.655 (b). Given this, the claims will be decided based on the evidence of record. Service Connection Under the relevant laws and regulations, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2018). In general, service connection requires competent evidence showing: (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). Alternatively, service connection may be established under 38 C.F.R. § 3.303 (b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. The provisions of 38 C.F.R. § 3.303 (b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App. 370, 374 (2002). When considering whether lay evidence is competent, the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a headache, varicose veins, or tinnitus. However, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of psychiatric, respiratory, or orthopedic disorders. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for a bilateral leg disability and a left ankle disability is denied. The Veteran contends that he experiences a bilateral leg disability and a left ankle disability that are related to his military service. Indeed, he has attributed these conditions to parachuting while on active duty, specifically following incidents during which he landed in a tree and on a cow. See February 2017 Board Hearing Transcript p. 6-8; March 1998 VA Examination Report. Pertinent to a claim for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); see Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a Veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. Under applicable regulation, the term “disability” means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1. See Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). Likewise, in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), the Federal Circuit held that “pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability” if it “reaches the level of a functional impairment of earning capacity.” Id. at 1367-69. In the instant case, the Board notes that the post-service treatment records do not reflect any complaints, symptoms, or treatment related to the claimed leg or left ankle disabilities. Furthermore, the probative evidence of record fails to demonstrate a current diagnosis related to the legs or left ankle. Although the Board has also considered the Court’s holding in Romanowsky, supra, there is also no probative evidence of a recent diagnosis of these conditions prior to the Veteran’s claim, nor evidence of functional impairment attributed to these complaints. The Board notes that service treatment records documented shin splints of the left leg, as well as a left knee sprain. See Service Treatment Records dated November 9, 1965 and November 27, 1966. The December 1967 separation examination reflects that the Veteran denied any symptoms related to a leg disorder, or cramps in the legs, and his lower extremities were clinically evaluated as normal. He further denied any symptoms pertaining to an ankle disorder, arthritis, joint trouble, or foot trouble, and his feet were clinically evaluated as normal. Following service, a September 2003 VA treatment record indicated possible sciatica, hernia pain, arthritis, or spinal stenosis in relation to the leg complaints, while another VA examiner noted lower leg spasticity. See VA Treatment Record dated September 26, 2003; January 2002 VA Examination Report. However, the remainder of the record is silent regarding a confirmed diagnosis of a bilateral leg disorder or any symptomatology or complaints related to a left ankle disability. As noted above, the RO attempted to schedule VA leg and ankle examinations for the Veteran in January 2021. The Veteran cancelled these examinations with no showing of good cause and did not request to have them rescheduled. As such, opinions addressing a possible nexus with service were provided without an in-person examination of the Veteran. Following a review of the claims file, the February 2021 VA examiner determined that the Veteran did not have a bilateral leg disability or left ankle disability that were related to his military service. In providing this opinion, she noted the September 2003 VA treatment record, January 2002 examination report, in-service complaints, and the Veteran’s lay statements regarding parachuting during active duty. The examiner explained that there was no objective medical evidence to confirm a chronic bilateral leg disorder or left ankle condition. The Board affords great probative weight to the recent February 2021 VA examination report, as it is consistent with the findings contained in the post-service VA treatment records. The Board has considered the Veteran’s general allegations that these conditions are related to service. He is competent to report having pain, or discomfort, but the evidentiary record does not reflect that these symptoms have been attributed to a specific diagnosis, or produced functional impairment to the legs or left ankle. The Board notes that the Veteran is competent to report his own symptoms or matters within his personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In addition, laypersons may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (the Board’s categorical statement that ‘a valid medical opinion’ was required to establish nexus, and that a layperson was ‘not competent’ to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, the matter of a medical diagnosis for disabilities not capable of lay observation, such as those at issue here, is a matter within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). Specifically, these diagnoses involve medical subjects concerning internal physical processes extending beyond an immediately observable cause-and-effect relationship, and requires the administration and interpretation of specialized testing. In the instant case, there is no suggestion that the Veteran has had any medical training. Therefore, as the Veteran does not have the appropriate medical training and expertise to competently self-diagnose a disability involving his legs or left ankle, the lay assertions in this regard have no probative value. Jandreau, supra at 1377 n.4 (“[s]ometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”); see also Woehlaert, supra. There is also no persuasive evidence that he has symptoms that result in any functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (holding that a “disability” under 38 U.S.C. § 1110 refers to functional impairment of earning capacity). The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Thus, where, as here, the probative evidence indicates that the Veteran does not have a current probative diagnosis of a disability of the legs or left ankle for the entire appeal period; there can be no valid claim for service connection. 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 of entitlement to service connection for a bilateral leg disability and a left ankle disability. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 2. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depressive disorder, is denied. Establishment of service connection for PTSD requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f). For the purposes of 38 C.F.R. § 3.309 (a), the term “psychosis” only includes diagnoses of brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder not otherwise specified, schizoaffective disorder, schizophrenia, schizophreniform disorder, shared psychotic disorder, and substance-induced psychotic disorder. 38 C.F.R. § 3.384. As the Veteran’s claim is not related to psychoses, service connection on a presumptive basis as a chronic disease is not warranted. The Board notes that post-service treatment records are inconsistent in determining whether the Veteran has a diagnosis of a psychiatric disorder. The Board acknowledges that several treatment records have suggested diagnoses of PTSD and depressive disorder. See VA Treatment Record dated August 11, 2008 and September 9, 2002. However, in September 2002, a treatment provider ruled out a diagnosis of PTSD. See VA Treatment Record dated September 23, 2002. Furthermore, it is unclear whether these diagnoses were made pursuant to DSM-IV or DSM-V criteria and no rationale was provided in support of these findings. To the extent that any diagnosis of a psychiatric disorder has been rendered in a treatment record, such determinations have not been shown to have been based on a review of the Veteran’s claims file or any other detailed and reliable medical history. Additionally, these treatment records warrant less probative weight than the other medical evidence of record (which indicates that the Veteran does not have PTSD or any other psychiatric diagnosis) as they do not contain an analysis or discussion as to whether or not all of the criteria for these conditions were met. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (recognizing the Board’s “authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence”). As noted above, the RO attempted to schedule a VA psychological examination for the Veteran in January 2021. The Veteran cancelled this examination with no showing of good cause and did not request to have it rescheduled. As such, an in-person examination of the Veteran could not be completed. Following a review of the claims file, a February 2021 VA examiner concluded that without a recent evaluation, he was unable to provide a relevant current diagnosis and etiological opinion without resorting to mere speculation. The examiner acknowledged the January 2002 mental health evaluation, but explained that such a report could not provide any indication of the Veteran’s more recent psychiatric state. The Court has explained that opinions which contain the “mere speculation” language, without more, amount to “nonevidence” neither for nor against the claim because service connection may not be based on speculation or remote possibility. See Bloom v. West, 12 Vet. App. 185 (1999) (holding that a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). Additionally, the Court held in Jones v. Shinseki, 23 Vet. App. 382 (2010), that, when a medical examiner concludes that he or she is unable to provide a nexus opinion without speculation, this alone does not make the medical opinion inadequate; a medical opinion with such language may be adequate if the examiner sufficiently explains the reasons for this inability. Id. at 389-90; see also Obert v. Brown, 5 Vet. App. 30, 33 (1993) (noting that speculative opinion is not legally sufficient to establish service connection). Additionally, before the Board can rely on an examiner’s conclusion that an etiology opinion would be speculative, however, the examiner must explain the basis for such an opinion, or the basis must otherwise be apparent in the Board’s review of the evidence. Cf. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion “must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Furthermore, VA must ensure that any medical opinion, including one that states no conclusion can be reached without resorting to speculation, is “based on sufficient facts or data.” See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2009). Therefore, it must be clear from either the examiner’s statements or the Board’s decision that the examiner has considered “all procurable and assembled data” by obtaining all tests and records that might reasonably illuminate the medical analysis. See Daves v. Nicholson, 21 Vet. App. 46 (2007). Here, the February 2021 examiner explained that the Veteran’s unwillingness to attend a VA examination prevented him from providing an etiological opinion without resorting to mere speculation. Thus, the Board finds that this examiner explained clearly why he was unable to determine the etiology of the Veteran’s claimed acquired psychiatric disability without resorting to mere speculation and this opinion is adequate for VA adjudication purposes. Further, the Board notes that while the examiner determined that he was unable to provide an opinion as to the etiology of the Veteran’s acquired psychiatric disorder, when viewing the opinion as a whole, he also made observations which weigh against the Veteran’s claim. For instance, the examiner noted that the January 2002 psychological evaluation could not provide an accurate picture of the Veteran’s current mental health. The Board finds the opinion of the VA examiner to be probative, as it was based on a thorough review of the claims file, to include the Veteran’s lay statements and medical history. See Bloom v. West, 12 Vet. App. 185, 187 (1999). As such, the February 2021 opinion is afforded greater probative value than the inconsistent diagnoses found in the post-service treatment records. In addition, the December 1967 separation examination report reflects that the Veteran denied any current psychiatric symptoms such as depression or excessive worry, loss of memory, or nervous trouble of any sort, and that he was clinically evaluated as psychiatrically normal upon separation. The Board notes that the Veteran contends that he has a psychiatric disorder as a result of various in-service stressors, to include being ambushed by enemy fire while stationed in the Dominican Republic. See February 2017 Board Hearing Transcript p. 9-10. He has also reported being exposed to violence in the Dominican Republic, as well as observing the death of a fellow servicemember when his parachute failed to open. See VA Treatment Record dated September 9, 2002. In this regard, the Veteran is competent to testify as to his observations. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007. In addition, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, unlike disorders that may be observable as to both their incurrence and their cause, the cause of a psychiatric disability is not readily apparent to lay observation, and the Court has held that psychiatric diagnoses are generally the province of medical professionals. See Clemons, supra (“It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant”). Moreover, even if credible and competent, the general lay assertions are outweighed by the February 2021 VA medical opinion, which is the only probative opinion of record. As explained above, the most persuasive and probative evidence of record does not reflect that the Veteran has an acquired psychiatric disorder, to include PTSD or depressive disorder, that was incurred in service. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993). The lay statements of the Veteran, as well as the post-service treatment records were considered, but are found to be less probative than the VA medical opinion. Thus, given the lack of probative and persuasive value of evidence demonstrating a current disability that was incurred in service, the evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and regulation. See Gilbert, supra; 38 C.F.R. § 3.102. Accordingly, for the reasons and bases discussed above, the Board concludes that the preponderance of the evidence is against finding PTSD, or any other psychiatric disability, was incurred in service. Therefore, service connection for an acquired psychiatric disorder is denied. 3. Entitlement to service connection for asthma is denied. Every veteran is presumed to be in sound condition upon entry except as to any injury or disease noted at the time of enlistment. 38 U.S.C. § 1111; Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). In determining whether a specific condition is “noted” on entry, the Board’s analysis is limited to whether the condition was recorded in the enlistment examination report. 38 C.F.R. § 3.304 (b). Here, the Veteran’s asthma was noted on the May 1965 enlistment Report of Medical History. His sister wrote in 1996, the Veteran had been very sickly as a child, and had experienced pulmonary problems that included several episodes of pneumonia, bronchitis, allergies, and asthma, and that the Veteran was restricted from playing sports in high school. Further, a June 1965 service medical record entry made soon after enlistment that month reflects that the Veteran reported a long history of asthma or asthma-like symptoms since childhood, of treatment for asthma, and that he had upper respiratory infections. Lastly, the February 2021 opinion from a medical review of the record, was that the Veteran had clear and unmistakable evidence of pre-existing asthma. The Board therefore finds that the Veteran’s asthma clearly and unmistakably existed prior to service. Likewise, the evidence is clear and unmistakable that asthma was not aggravated by service. In-service medical attention to asthma was limited to June 1965, and the first week of July 1965. An entry dated July 8, 1965 reflects the lungs were clear. No further complaints are noted over the ensuing 24+ months, and examination at service separation showed no abnormality of the lungs. At the same time, the Veteran denied he ever had asthma or shortness of breath. As noted above, the RO attempted to schedule a VA examination to evaluate the Veteran’s asthma in January 2021. The Veteran cancelled this examination with no showing of good cause and did not request to have it rescheduled. As such, an opinion was provided without an in-person examination of the Veteran. Following a review of the claims file, the February 2021 VA examiner determined that the Veteran’s asthma was clearly and unmistakably not aggravated beyond its natural progression by his military service. In doing so, she acknowledged the reports of pre-existing asthma, in-service respiratory treatment, as well as the lay statements and buddy statements provided in support of the Veteran’s claim. However, the examiner stated there was no evidence of permanent aggravation beyond normal progression identified. Given the forgoing, and viewing the evidence as a whole, the Board concludes asthma clearly and unmistakably pre-existed service and was not aggravated by service. Therefore, service connection for asthma is not warranted. In reaching this decision, the Board has considered the lay statements of the Veteran. However, he does not have medical expertise, and therefore is not competent to give a probative opinion concerning the progression of his asthma. Therefore, any such assertions of a medical link between the asthma and military service are not probative. Jandreau, supra. 4. Entitlement to service connection for ulcers is denied. Post-service treatment records indicate that the Veteran has been diagnosed with gastric ulcers. See VA Treatment Record dated April 25, 2003. The Board finds that service connection is not warranted for ulcers. Initially, the Board finds a preponderance of the evidence shows that this condition was not present during active duty. The Board notes that the Veteran experienced gastritis and stomach cramps during service. See Service Treatment Record July 7, 1966. However, there were no reports of gastrointestinal symptoms or diagnoses at the time of the separation examination. Thus, there is no evidence to suggest that the prior incidents are related to his current ulcer condition. Following service, the Veteran was diagnosed with a gastric ulcer in June 1996. At that time, the treatment provider indicated that the ulcer was related to medication prescribed for treatment of the Veteran’s knees. See VA Treatment Record dated June 21, 1996; March 1998 VA Examination Report. At the February 2017 Board Hearing, the Veteran testified that he experienced stomach cramps and gastritis after eating bad food while stationed in the Dominican Republic. See February 2017 Board Hearing Transcript p. 16. The Board also acknowledges his prior contentions that his gastrointestinal symptoms began while on active duty. See Correspondence dated April 2003. As noted above, the RO attempted to schedule a VA examination to evaluate the Veteran’s asthma in January 2021. The Veteran cancelled this examination with no showing of good cause and did not request to have it rescheduled. As such, an opinion was provided without an in-person examination of the Veteran. Following a review of the claims file, the February 2021 VA examiner determined that the Veteran’s ulcers were less likely than not related to his military service. She noted the in-service treatment, the June 1996 diagnosis of ulcers, as well as the lay statements regarding his gastrointestinal symptoms and their claimed onset. However, the examiner explained that there was no in-service diagnosis of a chronic gastrointestinal condition, nor any objective medical evidence to support a link between the post-service ulcers and active duty. The Board affords the February 2021 VA opinion probative weight. In this regard, the examiner reviewed the Veteran’s file and offered a discussion analyzing the pertinent evidence of record and explaining the basis for the opinion, as supported by the Veteran’s medical history. See Nieves- Rodriguez, supra. There is no medical evidence of record indicating that the Veteran’s ulcers are linked to his military service. The only evidence in support of this link is his own lay assertion. As discussed above, lay persons are competent to provide opinions on some medical issues. See Kahana, supra. In this case, the Veteran is not competent to render an etiology opinion for his ulcer condition. Determining the etiology of the Veteran’s condition requires medical inquiry into gastrointestinal processes and functioning. Such internal 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 medical training or skills. Because the Veteran’s lay opinion is not competent in this case it is therefore not probative. It cannot satisfy the nexus element of a service connection claim. Therefore, service connection may not be established based upon the Veteran’s assertion that his ulcers were caused by his military service. Additionally, because an ulcer did not manifest to a compensable degree within a year of the Veteran’s separation from service, service connection for ulcers as a presumptive disease is not warranted. 38 C.F.R. §§ 3.307, 3.309. As such, the preponderance of the evidence is against service connection for an ulcer condition. Reasonable doubt does not arise, and the benefit-of-the-doubt doctrine does not apply; the Veteran’s claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to service connection for a right ankle disability is denied. Post-service treatment records indicate that the Veteran has been diagnosed with an old ligament injury with some mild laxity of the right ankle. See March 1998 VA Examination Report. He has attributed his ankle condition to parachuting during service, specifically following incidents during which he landed in a tree and on a cow. See February 2017 Board Hearing Transcript p. 6-8; March 1998 VA Examination Report. The Board finds that service connection is not warranted for a right ankle disability. Initially, the Board notes that the Veteran reported that he twisted his right ankle during service. See Service Treatment Record dated December 22, 1967. However, there was no diagnosis of an ankle condition provided at that time, as the treatment provider determined the right ankle was normal. As such, the evidence does not suggest that the in-service report is related to the current diagnosis. As noted above, the RO attempted to schedule a VA examination to evaluate the Veteran’s ankle condition in January 2021. The Veteran cancelled this examination with no showing of good cause and did not request to have it rescheduled. As such, an opinion was provided without an in-person examination of the Veteran. Following a review of the claims file, the February 2021 VA examiner determined that the right ankle disability was less likely than not related to military service. She acknowledged the in-service self-report of a twisted ankle, but noted that the treatment provider characterized the ankle as normal upon examination. The examiner considered the Veteran’s lay statements regarding parachuting during service, but concluded that any in-service injury was acute in nature. She opined that there was no objective medical evidence of a chronic ankle condition related to active duty. The Board affords the February 2021 VA opinion probative weight. In this regard, the examiner reviewed the Veteran’s file and offered a discussion analyzing the pertinent evidence of record and explaining the basis for the opinion, as supported by the Veteran’s medical history. See Nieves- Rodriguez v. Peake, supra. There is no medical evidence of record indicating that the Veteran’s right ankle disability is linked to his military service. The only evidence in support of this link is his own lay assertion. As discussed above, lay persons are competent to provide opinions on some medical issues. See Kahana, supra. In this case, the Veteran is not competent to render an etiology opinion for his right ankle condition. Determining the etiology of the Veteran’s condition requires medical inquiry into musculoskeletal processes and functioning. Such internal 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 medical training or skills. Because the Veteran’s lay opinion is not competent in this case it is therefore not probative. It cannot satisfy the nexus element of a service connection claim. Therefore, service connection may not be established based upon the Veteran’s assertion that his right ankle disability was caused by his military service. (Continued on the next page)   As such, the preponderance of the evidence is against service connection for a right ankle disability. Reasonable doubt does not arise, and the benefit-of-the-doubt doctrine does not apply; the Veteran’s claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. M. KILCOYNE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Trojanowski, 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.