Citation Nr: 21025351 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 15-25 245 DATE: April 27, 2021 ORDER 1. Entitlement to service connection for bilateral hearing loss disability is denied. 2. Entitlement to service connection for a sleep disorder, to include insomnia disorder, and to include as secondary to service-connected disability or disabilities, is denied. 3. Entitlement to service connection for acid reflux, including gastroesophageal reflux disease (GERD), is denied. 4. Entitlement to an initial disability rating in excess of 80 percent for chronic kidney disease, stage III status-post renal cell carcinoma and radical right nephrectomy with fatigue (chronic kidney disease), is denied. 5. Entitlement to an initial compensable disability rating for a surgical scar status-post right radical nephrectomy (surgical scar) prior to October 23, 2018, in excess of 10 percent from October 23, 2018, to June 27, 2019, and in excess of a noncompensable disability rating since June 28, 2019, is denied. 6. Entitlement to an effective date prior to March 14, 2017, for the grant of service connection for chronic kidney disease is denied. 7. Entitlement to an effective date prior to March 14, 2017, for the grant of service connection for a surgical scar is denied. FINDINGS OF FACT 1. The Veteran’s current bilateral hearing loss disability did not onset in service, manifested to a compensable degree within one year of separation from service, and it is not otherwise related to service. 2. The Veteran’s current insomnia disorder is not caused by or otherwise related to active duty, and it is not caused or aggravated by a service-connected disability or disabilities. 3. The Veteran’s current acid reflux disorder, to include GERD, is not caused by or otherwise related to active duty, and it is not caused or aggravated by a service-connected disability. 4. The Veteran’s chronic kidney disease has not required regular dialysis, or precluded more than sedentary activity from persistent edema and albuminuria, or blood urea nitrogen (BUN) more than 80 milligram percent (mg%), or creatinine more than 8 mg%, or markedly decreased function of kidney or other organ systems, especially cardiovascular. 5. Prior to October 23, 2018, and since June 28, 2019, the Veteran’s one surgical scar of the abdomen was not unstable or painful, and did not cover an area of 144 square inches or greater. Although the Veteran’s surgical scar was painful from October 23, 2018, to June 27, 2019, the Veteran did not have three or more scars that were unstable or painful at any time during the appeal. 6. The effective date of the law allowing for presumptive service connection for renal cell carcinoma based on exposure to contaminated water at Camp LeJeune is March 14, 2017. 7. As the Veteran’s surgical scar is secondary to his service-connected chronic kidney disease, which was granted service connection effective March 14, 2017, an earlier effective date for the secondary disability cannot be assigned prior to the primary disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385. 2. The criteria for entitlement to service connection for a sleep disorder, to include insomnia disorder, and to include as secondary to service-connected disability or disabilities, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 3. The criteria for entitlement to service connection for acid reflux, to include GERD, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 4. The criteria for an initial disability rating in excess of 80 percent for chronic kidney disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.115a, 4.115b, Diagnostic Code (DC) 7528. 5. The criteria for entitlement to an initial compensable disability rating for a surgical scar prior to October 23, 2018, in excess of 10 percent from October 23, 2018, to June 27, 2019, and in excess of a noncompensable disability rating since June 28, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.118, DCs 7804, 7805. 6. The criteria for an effective date prior to March 14, 2017, for the grant of service connection for chronic kidney disease have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 7. The criteria for an effective date prior to March 14, 2017, for the grant of service connection for a surgical scar have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from June 1974 to June 1976, including service at Camp Lejeune from October 1974 to June 1976. This case has a complicated procedural history. Specifically, the record shows that in August 2016, the Board remanded the service-connection claims for bilateral hearing loss disability, a sleep disorder, and acid reflux for additional development. Following the development, in a February 2019 decision and remand, the Board, in pertinent part, denied the service-connection claims for bilateral hearing loss disability and a sleep disorder and remanded the claim for service connection for acid reflux. The Veteran appealed the Board’s denial of the service connection claims for bilateral hearing loss disability and a sleep disorder to the United States Court of Appeals for Veterans Claims (Court). Per a January 2020 Joint Motion for Remand (Joint Motion), the Court issued an order vacating the Board’s February 2019 denials of service connection for bilateral hearing loss and a sleep disorder, and remanding the matters to the Board. The Board remanded these matters to the Agency of Original Jurisdiction (AOJ) for additional development in July 2020, to include associating with the claims file outstanding treatment records and obtaining VA examinations and/or VA addendum medical opinions for bilateral hearing loss disability and a sleep disorder. Furthermore, the Board remanded the claims of entitlement to service connection for acid reflux, as well as an earlier effective date and an increased rating for the surgical scar, in December 2020 to: obtain outstanding treatment records; issue a statement of the case (SOC); obtain an addendum VA medical opinion for the acid reflux claim; and, issue a supplemental statement of the case (SSOC) if any benefit was denied by the AOJ. The record shows that outstanding treatment records were associated with the claims file; the Veteran underwent VA examinations and/or addendum VA medical opinions for the bilateral hearing loss disability, a sleep disorder, and acid reflux in December 2020 and January 2021; an SOC was issued in December 2020; and an SSOC was issued in January 2021. There was substantial compliance with the Board’s July 2020 and December 2020 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection, Generally The Veteran contends that his current bilateral hearing loss disability is caused by his active duty. Furthermore, he asserts that his current sleep disorder, to include insomnia, and his acid reflux are caused by his active duty, to include as due to contaminated water at Camp Lejeune, and/or are caused or aggravated by his service-connected disabilities. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). “To establish a right to compensation for a present disability, a Veteran must 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.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Additionally, pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran has a diagnosis of sensorineural hearing loss, which is an organic disease of the nervous system; thus, these provisions apply to this disability. Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. Id. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Effective March 14, 2017, 38 C.F.R. §§ 3.307 and 3.309 were amended to add eight diseases establishing presumptive service connection for exposure to contaminants in the water supply at Camp Lejeune. The amendments apply to claims received by VA on or after January 13, 2017, and claims pending before VA on that date. 82 Fed. Reg. 4173 (Jan. 13, 2017). The listed diseases are adult leukemia, aplastic anemia and other myelodysplastic syndromes, bladder cancer, kidney cancer, liver cancer, multiple myeloma, non-Hodgkin’s lymphoma, and Parkinson’s disease. Additionally, under the Camp Lejeune Act of 2012, VA will provide cost-free health care for 15 additional listed conditions. See 38 C.F.R. § 17.400. In order to establish presumptive service connection for a disease associated with exposure to contaminated water at Camp Lejeune, a veteran, former reservist, or member of the National Guard must show the following: (1) service at Camp Lejeune for no less than 30 days (either consecutive or nonconsecutive) from August 1, 1953 to December 31, 1987; (2) that he or she currently suffers from a disease associated with exposure to contaminants in the water supply at Camp Lejeune enumerated under 38 C.F.R. § 3.309(f); and (3) that the current disease process manifested to a degree of 10 percent or more at any time after service. 38 C.F.R. §§ 3.307(a)(7), 3.309(f). VA is also required to consider service connection on a direct basis for any other disease not listed in 38 C.F.R. § 3.309(f) that is alleged to have been caused by the contaminant in the water supply at Camp Lejeune if there is (1) evidence of a current disease or disability, (2) evidence of exposure to the contaminated water at Camp Lejeune while on active duty, and (3) a medical nexus between the two, supported by a sufficient scientific explanation. The Veteran’s service personnel records show that he served at Camp Lejeune from October 1974 to June 1976. Accordingly, he is presumed to have been exposed to contaminated drinking water during service. In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). In determining whether service connection is warranted for a disorder, 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; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Bilateral Hearing Loss Disability The Veteran contends that this current bilateral hearing loss disability is caused by in-service noise exposure. Sensorineural hearing loss may be presumed to have been incurred in service if manifested to a compensable degree within one year after discharge from service. 38 U.S.C. §§ 1101, 1110, 1131; 38 C.F.R. §§ 3.307, 3.309; Fountain v. McDonald, 27 Vet. App. 258 (2015). A disorder may be service-connected if the evidence of record shows that the Veteran currently has a disorder that was chronic in service, or if not chronic, that was seen in service with continuity of symptomatology demonstrated thereafter. 38 C.F.R. § 3.303(b). The Court has held that the threshold for normal hearing is from 0 to 20 decibels, and that higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The Court further held that 38 C.F.R. § 3.385 then operates to establish when a hearing loss disability can be service connected. Id. at 159. For the purposes of applying the laws administered by VA, impaired hearing only will be considered to be an actual ratable disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Initially, the Board determines that the Veteran has a current bilateral hearing loss disability for VA purposes. Specifically, the Veteran underwent a VA audiological examination in April 2017, during which his audiogram showed that the pure tone thresholds, in dB, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 20 30 40 50 35 LEFT 20 25 40 45 33 Furthermore, the Board notes that noise exposure is consistent with the duties and circumstances described in the Veteran’s personnel records based on his military occupational specialty (MOS) as a mortar man. Thus, in-service noise exposure is substantiated. Accordingly, the only question to be answered is whether the Veteran’s current bilateral hearing loss disability is caused by service, manifested to a compensable degree within one year of separation from service, or is otherwise related to service. In that regard the Board notes that that the Veteran’s service treatment records do not show complaints of or treatment for hearing loss during service. For example, his June 1974 service entrance examination showed the following pure tone thresholds, in dB: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 5 X 5 LEFT 5 5 5 X 5 Likewise, during the June 1976 separation examination, the Veteran’s pure tone thresholds were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 0 5 0 LEFT 10 5 0 0 0 The Veteran’s post-service records are silent for complaints of or treatment for hearing loss until he filed the present claim for service connection in July 2015, or approximately 39 years after service separation. Notably, a February 2004 general VA examination completed in connection with a prior claim for nonservice-connected pension does not show any complaints of or mention of hearing loss. The Veteran was afforded a VA audiological evaluation in August 2015. The examiner noted that frequencies could not be tested because the results were inconsistent and the Veteran was not cooperative during testing. The Veteran was afforded another VA audiological evaluation in April 2017. The Veteran reported that following military service, he did electrical work for approximately 15 to 20 years with some noise exposure. The examiner opined that the Veteran’s bilateral hearing loss disability was less likely than not related to service. The examiner reasoned that the Veteran’s service records reveal hearing thresholds were within normal limits at the time of entrance and separation with no significant threshold shift. Although the Board determined in the February 2019 decision that the April 2017 VA examiner’s opinions were adequate and highly probative on the causal connection between the Veteran’s current bilateral hearing loss disability and his active duty, the parties agreed in the January 2020 Joint Motion that this examiner failed to explain the significance of threshold shifts. Furthermore, the Joint Motion noted that the April 2017 VA examiner did not explain why the Veteran’s normal hearing thresholds at service separation supported an opinion that his current hearing loss disability was less likely than not related to his military service. In order to comply with the Joint Motion’s directives, the Board remanded the Veteran’s claim in July 2020 to obtain an addendum VA medical opinion. In a January 2021 VA addendum opinion, an examiner also determined that it was less likely than not (less than 50 percent probability) that the Veteran’s current bilateral hearing loss disability was incurred in or caused by an in-service injury, event, or illness. The examiner explained that a review of the Veteran’s claims file and service medical records revealed that the Veteran had normal hearing sensitivity at both the service entrance and separation examinations with no significant threshold shifts. The examiner explained that the audiogram is the objective standard for noise injury, and because the Veteran’s hearing was normal at service separation with no significant threshold shifts having occurred during active duty, there is no evidence the that the Veteran’s military noise exposure caused a permanent noise injury affecting hearing sensitivity. Based on this objective evidence, along with the Institute of Medicine (IOM) study, which the examiner cited to, and which indicated that delayed-onset hearing loss due to noise exposure was unlikely, the examiner concluded that the Veteran’s current hearing loss disability is deemed less likely as not (less than 50/50 probability) caused by or a result of military noise exposure or military service. The examiner cited to the 2006 IOM study for the proposition that “there is not sufficient evidence from longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one’s lifetime, long after the cessation of that noise exposure...[however] based on the anatomical and physiological data available on the recovery process following noise exposure, it is unlikely that such delayed effects occur.” Given this evidence, the Board finds that the Veteran’s current bilateral hearing loss disability did not onset in service, manifested to a compensable degree within one year of separation from service, and it is not otherwise related to service. As previously noted, sensorineural hearing loss may be presumed to have been incurred in service if manifested to a compensable degree within one year after discharge from service. 38 U.S.C. §§ 1101, 1110, 1131; 38 C.F.R. §§ 3.307, 3.309; Fountain, 27 Vet. App. at 258. In addition, a disorder may be service-connected if the evidence of record shows that the Veteran currently has a disorder that was chronic in service, or if not chronic, that was seen in service with continuity of symptomatology demonstrated thereafter. 38 C.F.R. § 3.303(b). Here, however, the evidence does not show, and the Veteran does not assert, that his bilateral hearing loss disability manifested within one year of separation from service. In fact, the record shows that the Veteran complained of hearing loss for the first time in 2015. The absence of post-service complaints, findings, diagnosis, or treatment for approximately 39 years after service is one factor that tends to weigh against a finding of continuous symptoms for this disorder since separation from service. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Therefore, presumptive service connection is not warranted. The Board finds the January 2021 VA examiner’s findings and opinions to be highly probative evidence regarding the causal relationship between the Veteran’s current bilateral hearing loss disability and his active duty. This examiner possessed the necessary education, training, and expertise to provide the requested opinion. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In addition, the examiner provided a detailed rationale for the opinions, which was based on thorough review of the service treatment records, post-service treatment records, lay statements of the Veteran, and supporting medical treatise evidence. The January 2021 VA examiner’s opinions considered an accurate history, were definitive, and supported by a detailed rationale that considered the lay and medical evidence. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Significantly, the Veteran has not presented or identified any contrary medical opinion that supports the claim for service connection for hearing loss disability. VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). The Board has considered the Veteran’s assertions that his current hearing loss disability is related to noise exposure in service. The Board acknowledges that it is within the realm of common medical knowledge that exposure to loud noises may cause hearing loss. However, determining the precise cause of the Veteran’s hearing loss disability is not a simple question, as there are conceivably multiple potential causes of the Veteran’s current sensorineural hearing loss. Ascertaining the cause of hearing loss involves considering multiple factors and knowledge of how those factors interact with the mechanics of human hearing. In this case, the facts are complex enough that the Veteran’s intuition about the cause of his hearing loss is not sufficient to place the nexus question in equipoise. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (Lance, J., concurring) (“The question of whether a particular medical issue is beyond the competence of a layperson – including both claimants and Board members – must be determined on a case-by-case basis.”). In support of the Veteran’s claim, his attorney referred to a medical article titled “Acceleration of Age-Related Hearing Loss by Early Noise Exposure.” See December 2018 Correspondence. Medical treatise evidence can, in some circumstances, constitute competent medical evidence. Wallin v. West, 11 Vet. App. 509, 514 (1998); 38 C.F.R. § 3.159(a)(1). However, while the article submitted by the Veteran’s attorney addresses hearing loss, it does not contain information or analysis specific to the Veteran’s case. Furthermore, the Board notes that the January 2021 VA examiner specifically considered and addressed this article in determining that the Veteran’s current bilateral hearing loss disability was less likely than not caused or otherwise related to his active duty. The examiner explained that this article reported that mice with cochlear damage measured by Otoacoustic Emissions at early ages was accelerated with age, and that this was only found in the animal model and has not been duplicated with human beings. The examiner explained that the Veteran clearly had normal hearing at separation, and therefore, this model does not apply to the Veteran as no cochlear damage was evident at separation. As such, the evidence is of limited probative value and is outweighed by the January 2021 VA opinion that considered the specific facts in the Veteran’s case. Therefore, as the preponderance of the evidence is against entitlement to service connection for bilateral hearing loss disability, the benefit of the doubt doctrine does not apply, and the Veteran’s claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. 2. Sleep Disorder The Veteran contends that he has a current sleep disorder, diagnosed as insomnia, that is caused by his active duty and/or caused or aggravated by a service-connected disability or disabilities. Initially, the Board notes that the Veteran has a current diagnosis of an insomnia disorder. For example, in addition to multiple a treatment records throughout the appeal that show diagnoses and treatment for chronic insomnia and fatigue, the December 2020 VA examination for his psychiatric symptoms showed a diagnosis of insomnia disorder, and that he had difficulty initiating and maintaining sleep. Thus, the first element of service connection is met. Nonetheless, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s current sleep disorder is caused by or otherwise related to his active duty or his service-connected disabilities. Notably, VA treatment records indicate that he has consistently reported sleep problems associated with his nonservice-connected acquired psychiatric disorder. For example, during an April 2018 VA psychological examination, the examiner noted that sleep impairment is not marked as a clinically significant symptom because the Veteran practiced poor sleep hygiene, which likely interfered with his rest. Additionally, the Veteran reported problems sleeping secondary to racing thoughts related to an incident of being slighted and feeling the need for revenge, which he learned in his gang indoctrination. The Veteran reported sleep problems “on and off.” He reported sleep latency. He indicated that before bed he listened to music and may read. He reported that he thought about things and his mind would not shut down. He reported a bedtime of 8:00pm but reported that he may not fall asleep until 3:00am or 4:00am. He showed no history of sleep apnea or other sleep disorder. He reported taking medication for sleep, which sometimes worked and sometimes did not work. After a thorough review of the Veteran’s claims file, to include citations to the evidence in the record, the December 2020 VA examiner opined that it was less likely than not that the Veteran’s current insomnia disorder is caused or aggravated by his service-connected disabilities. The examiner explained that in addition to the insomnia disorder, the Veteran was also diagnosed with an unspecified depressive disorder with anxious distress and polysubstance abuse and disorder, which was in sustained remission. The Veteran told the examiner he has “always” had difficulty with sleep. The examiner determined that the Veteran’s behavioral problems clearly pre-date his military service, even according to the Veteran’s self-reporting. To be specific, the Veteran stated that his mother went to court with him after he got in trouble for selling drugs prior to his enlisting into service. The Veteran told the examiner that he joined the military in order to avoid going to jail. The examiner explained that review of the medical records indicated that the Veteran had also been jailed “a few times for making phony paper money and selling drugs.” The examiner explained that this suggested personality factors (e.g., Cluster B characteristics), which predated the Veteran’s military service, and which suggested a higher than average arousal and stimulation-seeking behaviors and involved engagement in activities that have a high probability of painful consequences, such as substance use, involvement with women, etcetera. The examiner noted that Cluster B characteristics, such as Antisocial Personality, have a genetic etiology. The examiner cited to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in noting that an “[a]ntisocial personality disorder is more common among the first degree biological relatives of those with the disorder than in the general population....Within a family that has a member with antisocial personality disorder, males more often have antisocial personality disorder and substance use disorders...” The examiner noted that the Veteran described his father and grandfather as “bootleggers” and expressed pride in their long history of this activity in Kentucky. Moreover, the examiner noted that no particular stressors, events, or injuries were cited within his active service that were related to the current insomnia disorder. The examiner concluded that the Veteran’s sleep disorder was less likely than not incurred in or caused by his in-service events. Given this evidence, the Board finds that the Veteran’s current insomnia disorder is not caused by or otherwise related to active duty, and it is not caused or aggravated by a service-connected disability or disabilities. While the Veteran is competent to report symptoms that he perceived through his own senses, including his difficulty with initiating and maintaining sleep, he is not competent to offer an opinion as to the cause or aggravation of his current sleep disorder due to the medical complexity of the matter involved. Insomnia disorder requires specialized training for a determination as to diagnosis, causation, and progression, and is therefore not susceptible to lay opinions on causation or aggravation. Thus, the Veteran is not competent to render an opinion or attempt to present lay assertions to establish the causation of his current insomnia disorder. The Board determines the December 2020 VA examiner’s findings and opinions to be highly probative evidence regarding the cause of the insomnia disorder and the causal relationship between this disorder and the Veteran’s active duty and his service-connected disabilities because of the examiner’s expertise, training, education, proper support and explanations, and thorough review of the Veteran’s records and self-reported symptoms. This examiner explained that even by his own statements, the Veteran’s sleep problems have ben been present since prior to his active duty. For example, the Veteran reported that he had “always” had difficulty with sleep. Accordingly, the examiner indicated that because the Veteran’s abnormal sleep symptoms, including symptoms associated with insomnia disorder, have been present since prior to the Veteran’s active duty, they were not caused or aggravated by his service-connected disabilities of chronic kidney disease, partial pancreatectomy, splenectomy, a surgical scar, tinnitus, or headaches, as all of these disabilities have been present since or post-active duty. See 38 C.F.R. § 3.310(a). Therefore, as the preponderance of the evidence is against entitlement to service connection for a sleep disorder, to include insomnia disorder, the benefit of the doubt doctrine does not apply, and the Veteran’s claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. 3. Acid Reflux The Veteran asserts that his current acid reflux disorder is caused by his service, including being exposed to contaminated water at Camp Lejeune, and/or caused or aggravated by his service-connected disabilities. The record shows that the Veteran has been diagnosed with GERD during the appeal. For example, a December 2019 VA medical opinion showed that the Veteran has been diagnosed with acid reflux since a May 2005 barium swallow. Additionally, he is presumed to have been exposed to contaminated drinking water during service as he served at Camp Lejeune from October 1974 to June 1976, and the evidence shows that service-connection has been granted for residuals of renal cancer, including chronic kidney disease, partial pancreatectomy, splenectomy, and a surgical scar, as well as tinnitus and headaches. Thus, the first and second elements of direct and secondary service connection have been met, and the question to be answered is whether the Veteran’s current acid reflux is caused by service or caused or aggravated by his service-connected disabilities. In that regard, a January 2021 VA examination, which included a review of the Veteran’s available records but did not include an in-person examination, showed that the Veteran was diagnosed with GERD since 2005. The examiner noted that the Veteran did not complain of reflux during service and that his service separation examination in June 1976 showed no reflux complaints or diagnosed chronic gastrointestinal disorders. In fact, the examiner noted that there were no reflux or associated complaints in the Veteran’s records from 1976 to 2005, or 29 years since service separation. The examiner noted that in May 2005, the Veteran was noted to have intermittent dysphagia to solids and that he had a history of heavy alcohol use for many years by 2005. Testing showed that he had evidence of acid reflux, but the esophagogastroduodenoscopy (EGD) was normal. He was prescribed Prilosec medication, which completely relieved his symptoms. The Veteran reported to the examiner that he was currently taking this medication and that he did not have any gastrointestinal symptoms. This examiner opined that the Veteran’s current acid reflux is less likely as not caused by or related to his exposure to Camp Lejeune contaminated water. By way of background, the examiner explained that excessive retrograde movement of acid-containing gastric secretions or bile and acid-containing secretions from the duodenum and stomach into the esophagus is the etiologic effector of GERD. From a therapeutic point of view, informing patients that gastric refluxate is made up not only of acid but also of duodenal contents (e.g., bile, pancreatic secretions) is important. A functional (frequent transient LES relaxation) or mechanical (hypotensive LES) problem of the LES is the most common cause of GERD. Transient relaxation of the LES can be caused by foods (coffee, alcohol, chocolate, fatty meals), medications (beta-agonists, nitrates, calcium channel blockers, anticholinergics), hormones (e.g., progesterone), and nicotine. The examiner explained that GERD is a common disease that can cause troublesome symptoms and have a significant impact on quality of life. GERD is a chronic and highly prevalent disorder, and that a recent systematic review showed that the prevalence of GERD was 18.1–27.8 percent in North America. The examiner noted that a search of a medical treatise repository for acid reflux and trichloroethylene, perchloroethylene, benzine and vinyl chloride returned no articles. Acid reflux/GERD was not listed as a suspected health disorder from exposure to the contaminated water at Camp Lejeune in Agency for Toxic Substances and Disease Registry’s (ATSDR’s) papers on Camp Lejeune including “Assessment of the Evidence for the Drinking Water Contaminants at Camp Lejeune and Specific Cancers and Other Diseases” and “Health effects linked with trichloroethylene (TCE), tetrachloroethylene (PCE), benzene, and vinyl chloride exposure.” Following a thorough review and citation to the evidence of record and medical treatise evidence, the examiner indicated that one must look at personal risk factors and external risk factors, such as exposure to contaminated water at Camp Lejeune, for a disorder when assessing causation. At the same time, the examiner noted that one must look at the strength of those factors in causing or contributing to the disease in question. The examiner explained that acid reflux or GERD is a medical disorder involving abnormal function of the lower esophageal sphincter allowing stomach contents to flow into the esophagus. This is a common disorder that has been well studied and found to be due to abnormal function of this sphincter. While it has been found that certain chemicals—alcohol and caffeine being common ones—may enhance reflux by relaxing the sphincter, no association with the contaminants at Camp Lejeune are mentioned in the literature as being associated with this disorder. The examiner noted that nothing was found on review of the evidence of record to elaborate on potential causes in this case. The examiner explained that GERD or reflux was repeatedly mentioned as a past and known disorder for the Veteran, who had more significant medical problems to occupy his physicians attention. Nonetheless, given the lack of evidence of any association between the Camp Lejeune contaminants and this disease, as well as the fact that ATSDR did not mention it as an accepted disorder that might be due to exposure there, it is not possible to consider it due to Camp Lejeune when it is such a common disorder in the general population. Therefore, the examiner concluded that the Veteran’s acid reflux is less likely as not caused by or related to his exposure to Camp Lejeune contaminated water. Moreover, a December 2020 VA examiner opined that the Veteran’s acid reflux is less likely than not caused or aggravated by his service-connected disabilities, including chronic kidney disease, partial pancreatectomy, splenectomy, and a surgical scar. The examiner explained the Veteran’s acid reflux, which was diagnosed by barium swallow in May 2005, began before the Veteran’s renal cell carcinoma, and its residuals of chronic kidney disease, partial pancreatectomy, splenectomy, and a surgical scar. The Board notes that the evidence shows that the Veteran was diagnosed with renal cell carcinoma in 2013, or approximately seven years after the diagnosis of acid reflux. Thus, the examiner concluded that the Veteran’s acid reflux is not related to these service-connected disabilities. This examiner also opined that it is less likely than not that the Veteran’s acid reflux was aggravated beyond its natural progression by the service-connected disabilities as there was no medical link between the Veteran’s acid reflux and the service-connected disabilities. Given this evidence, the Board finds that the Veteran’s acid reflux is not caused by or otherwise related to active duty, to include exposure to contaminated water at Camp Lejeune, and it is not caused or aggravated by the service-connected disabilities. While the Veteran is competent to report symptoms that he perceived through his own senses, including the sensation of heartburn and the taking of medication for this disorder, he is not competent to offer an opinion as to the cause or aggravation of his current acid reflux disorder due to the medical complexity of the matter involved. GERD requires specialized training for a determination as to diagnosis, causation, and progression, and is therefore not susceptible to lay opinions on causation or aggravation. Thus, the Veteran is not competent to render an opinion or attempt to present lay assertions to establish the causation of his current acid reflux disorder. However, the Board determines that the December 2020 and January 2021 VA examiners’ findings and opinions are highly probative evidence regarding the cause of the acid reflux and the causal relationship between this disorder and the Veteran’s active duty and his service-connected disabilities because of the examiners’ expertise, training, education, proper support and explanations, and thorough review of the Veteran’s records and self-reported symptoms. Therefore, as the preponderance of the evidence is against entitlement to service connection for acid reflux, the benefit of the doubt doctrine does not apply, and the Veteran’s claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310; Gilbert, 1 Vet. App. at 55. Increased Ratings, Generally The Veteran contends that the disability ratings for his service-connected chronic kidney disease and a surgical scar should be rated higher than the currently-assigned ratings. VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. The Schedule assigns DCs to individual disabilities. DCs provide rating criteria specific to a particular disability. If two DCs are applicable to the same disability, the DC that allows for the higher disability rating applies. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Schedule recognizes that a single disability may result from more than one distinct injury or disease; however, rating the same disability or its manifestation(s) under different DCs – a practice known as pyramiding – is prohibited. See 38 C.F.R. § 4.14. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as “staged ratings.” The record shows that the Veteran appealed the initially-assigned disability ratings for the chronic kidney disease and a surgical scar; thus, the appeal period for these disabilities stems from March 14, 2017. 4. Chronic Kidney Disease The Veteran’s chronic kidney disease, which is a residual of his renal cell carcinoma, is rated pursuant to 38 C.F.R. § 4.115b, DC 7528, as 80 percent disabling since March 14, 2017. Pursuant to DC 7528, malignant neoplasms of the genitourinary system are to be rated 100 percent disabling. A note following DC 7528 provides that, following the cessation of surgical, x-ray, antineoplastic chemotherapy or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. If there has been no local reoccurrence or metastasis, rate on residuals as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115b, DC 7528. The record shows that the Veteran’s renal cell carcinoma has not had a local reoccurrence or metastasis since to prior to the date that service connection has been granted. Furthermore, the record shows that this chronic kidney disease has predominantly manifested as renal dysfunction symptoms. Renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular, warrants a 100 percent rating. Renal dysfunction manifested by persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion is assigned an 80 percent rating. See 38 C.F.R. § 4.115a. Initially, the Board finds that the Veteran’s chronic kidney disease has not manifested as renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. A May 2017 VA examination showed that the Veteran was diagnosed with renal cell carcinoma of the right kidney, which required a right radical nephrectomy surgery in February 2013. Although the Veteran had symptoms of renal dysfunction, his chronic kidney disease did not require regular dialysis. His neoplasm was malignant but in remission. The examiner noted that the Veteran’s treatment was completed and that he was currently in watchful waiting status. Laboratory studies from April 2017 showed that the Veteran’s BUN was 20mg%, his creatinine was 1.7mg%, and his estimated glomerular filtration rate (EGFR) was 50. The Veteran reported that he had subjective fatigue, which was not measurable, and that he had subjective complaints of abdominal cramps and spasms. The examiner noted that the examination did not reveal any abdominal cramping, pain, or spasm. The examiner noted that the functional impact of this disability was that the Veteran was unable to maintain employment as a result of protracted recovery periods after his surgery. The Veteran reported that profound fatigue continued and that he was unable to work a full eight-hour day. Very similar symptoms were noted in a May 2018 VA examination, which showed that the Veteran denied bowel or bladder incontinence, injections or other prescribed treatment, routine dialysis, or the use of assistive devices. He also denied the need for help with activities of daily living. He reported that he occasionally drove himself. The Veteran was noted to be underweight, and the examiner noted that the January 2018 renal function tests showed BUN of 17mg%, creatinine of 2.0mg%, and EGFR of 41. In an October 2018 VA examination report, the Veteran state that the onset of the renal cell carcinoma began as stomach pain off and on, as well as fatigue, for years. His current symptoms included taking Tylenol as needed, as well as medication for depression. The examiner checked off a box indicating that the Veteran did not have renal dysfunction. Laboratory tests showed creatinine of 1.8mg% from August 2018. In addition to these VA examination reports, the VA treatment records show renal function tests throughout the appeal period. For example, such tests from January 2017 showed BUN of 17mg%, creatinine of 1.8mg%, and EGFR of 47. Similarly, the December 2017 tests showed BUN of 25mg%, creatinine of 2.1mg%, and EGFR of 39. June 2018 tests showed BUN of 17mg%, and creatinine of 1.7mg%, while the January 2019 renal function tests showed BUN of 20mg%, and creatinine of 1.7mg%. March 2019 tests showed BUN of 23mg%, and creatinine of 1.6mg%, while the May 2019 renal function tests showed BUN of 21mg%, and creatinine of 1.92mg%. Likewise, BUN was 16mg%, 16mg%, and 17mg% in April 2020, June 2020, and July 2020, respectively, while creatinine levels were 1.76mg%, 1.72mg%, and 1.80mg% during those same dates. Additionally, a January 2019 VA nephrology note showed that the Veteran had some fatigue but no other uremic symptoms. He also did not have a dialysis catheter installed. Given this evidence, the Board finds that a rating in excess of 80 percent for chronic kidney disease is not warranted at any time during the appeal. The weight of the evidence does not show that the Veteran had any renal dysfunction symptoms that manifested as requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. The evidence, including the VA examination reports from May 2017, May 2018, and October 2018, as well as the laboratory and renal function findings throughout the appeal, do not show that the Veteran’s BUN was more than 80mg% or that his creatinine was more than 8mg%. Furthermore, although the Veteran has reported persistent fatigue due to his kidney disability, the record does not show that his symptoms require dialysis treatment, or that he is precluded from more than sedentary activity. In fact, the Veteran denied the need for assistance with activities of daily living during the May 2018 VA examination. Thus, the criteria for the next higher rating of 100 percent under renal dysfunction have not been met. See 38 C.F.R. § 4.115a. For these reasons, the Board finds that the weight of the competent evidence is against the claim for a rating in excess of 80 percent for chronic kidney disease. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the Veteran’s claim must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 4.3. 5. Surgical Scar The Veteran asserts that his surgical scar on the abdomen, which is a residual of the right kidney removal, should be rated higher than the current ratings. The record shows that this scar has been rated as noncompensable from March 14, 2017, until October 22, 2018, as 10 percent disabling from October 23, 2018, until June 27, 2019, and as noncompensable since June 28, 2019, under 38 C.F.R. § 4.118, DCs 7804 or 7805. DC 7804 rates unstable or painful scars, and sets forth the following disability ratings: 30 percent for five or more scars that are unstable or painful; 20 percent for three to four scars that are unstable or painful; or, 10 percent for one or two scars that are unstable or painful. 38 C.F.R. § 4.118. According to Note (1), an “unstable” scar is a scar “where, for any reason, there is frequent loss of covering of skin over the scar.” DC 7805 provides that scars (including linear scars) may be rated on disabling effects not considered in DCs 7800 to 7804. In this regard, DC 7802 assigns a 10 percent rating for a burn scar or a scar due to other causes, not of the head, face, or neck, that is superficial and nonlinear and covers an area or areas of 144 square inches (929 centimeters (cm)) or greater. 38 C.F.R. § 4.118, DC 7802. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, DCs 7804 and 7805 were not changed by the August 13, 2018, amendments. A May 2017 VA examination for scars showed that the Veteran had one scar that was from a right nephrectomy surgery. The scar was linear and measured 33.5 cm. The scar was not painful or unstable with frequent loss of covering over the scar. The examination report for the chronic kidney disease symptoms from the same day showed identical symptoms and characteristics of the scar. A May 2018 VA examination report for the chronic kidney disease symptoms also showed that the Veteran had one residual scar in the abdomen, which measured 33 cm. by 0.3 cm. or a total area of 9.9 cm squared. The scar was not painful or unstable. The examiner described the scar as a well-healed surgical scar, roughly upside down “V” shaped, with mild hyperpigmentation, non-keloidal, and without tenderness to palpation, fluctuance, erythema, or exudate. An October 23, 2018, VA examination for scars showed that the Veteran was diagnosed with one scar of the abdomen, which was status-post laparotomy for right kidney removal for carcinoma, partial pancreas resection, and removal of the spleen. The examiner noted that this one scar was well-healed, with no keloid, but was mildly tender. Although the Veteran had this one scar with abdominal wall tenderness, the scar was not unstable. Most recently, a VA examination for scars, which was conducted on June 28, 2019, showed that the Veteran had one scar at the anterior trunk under the ribs. The scar was 34.0 cm by 0.2 cm in size and was not unstable or painful, including tender to palpation. The examiner noted that the total area of the scar was approximately 6.8 cm squared. Given this evidence, the Board finds that higher evaluations for the Veteran’s surgical scar are not warranted. Specifically, prior to the October 23, 2018, VA examination, and since the June 28, 2019, VA examination, the record shows that the Veteran’s one surgical scar of the abdomen was not unstable or painful, and did not cover an area of 144 square inches or greater. While the October 23, 2018, examination showed that this surgical scar was tender around the abdominal wall, but not unstable, there is no indication in the record that the Veteran had more than one painful or tender scar during the appeal. Thus, an initial compensable disability rating prior to October 23, 2018, in excess of 10 percent from October 23, 2018, to June 27, 2019, and in excess of a noncompensable disability rating since June 28, 2019, is not warranted. 38 C.F.R. § 4.118, DCs 7804, 7805. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the Veteran’s claim must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 4.3. Earlier Effective Dates, Generally The Veteran and his attorney assert that an effective date prior to March 14, 2017, for the grant of service connection for chronic kidney disease and the surgical scar are warranted. Specifically, they assert that an effective date of June 20, 2013, should be assigned because that is when the Veteran filed the claim for service connection for kidney cancer, and the surgical scar is a secondary disability stemming from the surgery that removed the kidney cancer. Because the evidence pertaining to these disabilities is located in the same or similar records, the Board shall analyze these claims together below. The effective date of an evaluation and grant of compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. An earlier effective date may be granted prior to the date of the filing of the claim for a rating increase if it is ascertainable that an increase in disability occurred within one year prior to the filing of the claim. See 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). The effective date for a grant of service connection is the day following the date of separation from active service or the date entitlement arose, if the claim is received within one year after separation from active service. 38 U.S.C. § 5110 (b)(1). The effective date of an award for presumptive service connection is the date of receipt of claim, or date entitlement arose, whichever is later. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2)(ii). A “claim” is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. See 38 C.F.R. § 3.1(p). “Date of receipt” of a claim, information, or evidence means the date on which a claim, information, or evidence was received by VA. See 38 C.F.R. § 3.1(r). Any documented communication from, or action by, a veteran indicating intent to apply for a benefit under laws administered by VA may be considered an informal claim. See 38 C.F.R. § 3.155(b). To determine when a claim was received, the Board must review all communications in the claims file that may be construed as an application or claim. See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992). Additionally, retroactive effective dates are allowed, to a certain extent, in cases where an award or increase of compensation is granted pursuant to a liberalizing law. 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114(a). Under these provisions, the claimant must have met all eligibility criteria for the liberalized benefit on the effective date of the liberalizing law or VA issue, and have been continuously eligible from that date to the date of claim or administrative determination of entitlement. These provisions apply to original and reopened claims, as well as claims for increase. Id.; see McCay v. Brown, 9 Vet. App. 183, 188 (1996), aff’d, 106 F.3d 1577, 1581 (Fed. Cir. 1997). In such cases, the effective date of the award or increase shall be fixed in accordance with the facts found, but shall not be earlier than the effective date of the liberalizing law or VA issue. 38 C.F.R. § 3.114(a). If a claim is reviewed at the claimant’s request more than one year after the effective date of the law, the effective date of the award may be one year prior to the date of receipt of such request if the veteran met all the criteria of the liberalizing law or issue as of the effective date of the liberalizing law. 38 C.F.R. § 3.114(a)(3). 6. -7. Earlier Effective Date for Chronic Kidney Disease and a Surgical Scar As noted above, the Veteran and his attorney contend that an effective date of June 20, 2013, should be assigned for the grant of service connection for chronic kidney disease, as that is when the Veteran initially filed a claim for service connection for kidney cancer. For example, in a September 2018 statement, the Veteran’s attorney contended that this date, rather than the date that the liberalizing law went into effect, be assigned because the Veteran’s claim for service-connection for kidney cancer was pending before VA on the date that the law became effective, i.e., on March 14, 2017. A review of the record shows that VA received the Veteran’s claim for service connection for kidney cancer on June 20, 2013. In a July 2014 rating decision, and confirmed in a February 2015 rating decision, the Veteran’s claim for kidney cancer was denied, which the Veteran appealed by filing a March 2015 Notice of Disagreement (NOD) and perfected to the Board by filing a July 2015 Substantive Appeal to the Board (VA Form 9). As noted above, during the appeal period, 38 C.F.R. § 3.309(f) was amended to provide a presumption of service connection for kidney cancer for veterans stationed at Camp Lejeune between August 1, 1953 and December 31, 1987. The regulation was made effective March 14, 2017. Based on this liberalizing law, the AOJ granted service connection for kidney cancer on a presumptive basis, with a complication of chronic kidney disease, stage III and assigned an effective date of March 14, 2017 in a July 2018 rating decision. Specifically, this rating decision noted that although VA received the Veteran’s claim prior to March 14, 2017, the AOJ was unable to grant service connection from any date prior to the date of the law change because the evidence is insufficient to warrant service connection on a direct basis. The rating decision noted that medical opinions from July 2014 and April 2018 VA examiners did not show a direct link between renal cancer and chronic kidney disease and exposure to the chemicals from contaminated water at Camp Lejeune during the Veteran’s service. In November 2018, the Veteran’s attorney again asserted that an earlier effective date of June 20, 2013, was warranted for the award of service connection for kidney cancer and associated complications, including chronic kidney disease, because the Veteran filed the claim then, and entitlement to service connection for chronic kidney disease should be established under a theory of direct service connection. In that regard, the Veteran and his attorney submitted a March 2016 letter from the Veteran’s private doctor, Dr. Stephan Sweitzer, who noted that he was being asked to provide an opinion about the cause of the Veteran’s renal cancer by the Veteran’s attorney. The doctor noted that according to the request from the attorney, the Veteran was exposed to some type of water contamination at Camp Lejeune containing TCE and PCE. The doctor noted that he did not have any direct knowledge of the Veteran’s previous exposure to these chemicals, but that the chemicals were considered carcinogens and have the potential to cause various types of cancers, including kidney cancer. The doctor noted that the Veteran did not have any obvious metastatic disease nor did he have any disability related to the removal of his kidney cancer. The doctor noted that the Veteran was able to function normally on a daily basis. The doctor also stated that it “is certainly possible that exposure to the drinking water at Camp Lejeune, which was possibly contaminated with these organic compounds, could be related to the development of his kidney cancer,” but that the doctor could not give any further information based on that. The Board notes that the probative value of the medical opinions from the July 2014 and April 2018 VA examiners outweigh the opinions noted in the March 2016 private doctor’s letter, as the private doctor’s opinion is greatly diminished by the fact that he determined it was possible that exposure to drinking water at Camp Lejeune could be related to the development of the Veteran’s kidney cancer. Such a speculative opinion is not probative, but is rather is inconclusive. See Warren v. Brown, 6 Vet. App. 4, 6 (1993) (stating that a physician’s statement framed in terms such as “may,” “could,” or “possible” is not probative); see also Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (statement that outcome “may or may not” have been different is speculative). The Board acknowledges the Veteran’s argument that he is entitled to an earlier effective date of June 20, 2013, for the grant of service connection for chronic kidney disease, which is due to kidney cancer or renal cell carcinoma. However, an effective date prior to March 14, 2017, is legally precluded under any view of the regulations governing effective dates. The effective date for a grant of service connection is the date of receipt of the claim or the date entitlement arose, whichever is later under 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i). Here, March 14, 2017, the date entitlement arose, is the later of the two dates, as the evidence does not show that service connection on a direct basis is warranted for renal cell carcinoma. Additionally, the law provides that, where compensation is awarded pursuant to any Act or administrative issue, the effective date shall not be earlier than the effective date of such Act or administrative issue. 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114. Here, the effective date of the law allowing for presumptive service connection for kidney cancer based on exposure to contaminated water at Camp Lejeune is March 14, 2017. Thus, an effective date prior to that date is prohibited by law. Likewise, the Veteran’s surgical scar status-post right radical nephrectomy is secondary to his service-connected chronic kidney disease, as due to the renal cell carcinoma. When service connection is granted for a secondary disability, it is considered part of the original disability, meaning the effective date for a secondary disability cannot predate the effective date for the primary disability from which the secondary disability was derived. See 38 C.F.R. § 3.310(a). As March 14, 2017, is the effective date of the grant of service connection for the chronic kidney disease, there can be no earlier effective date for the secondary disability. Accordingly, entitlement to an effective date prior to March 14, 2017, for the grant of service connection for chronic kidney disease and a surgical scar is denied. 38 U.S.C. § 5107(b). A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Hodzic, 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.