Citation Nr: 21027505 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 19-09 412 DATE: May 5, 2021 ORDER Restoration of service connection for posttraumatic stress disorder (PTSD) is granted. Service connection for obstructive sleep apnea (OSA) is denied. Service connection for a right thumb disorder, status post ganglion cyst removal, is denied. Service connection for a right thumb sarcoma is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, other than PTSD, is remanded. FINDINGS OF FACT 1. The grant of service connection for PTSD in a January 2014 rating decision is not shown to have been clearly and unmistakably erroneous. 2. OSA is not shown to be causally or etiologically related to any disease, injury, or incident during service, to include as due to exposure to herbicide agents. 3. A right thumb disorder status post ganglion cyst removal is not shown to be causally or etiologically related to any disease, injury, or incident during service, to include as due to exposure to herbicide agents. 4. At no time during the pendency of the claim does the Veteran have a current diagnosis of a right thumb soft-tissue sarcoma, and the record does not contain a recent diagnosis of disability prior to the filing of a claim. CONCLUSIONS OF LAW 1. The criteria for restoration of service connection for PTSD are met. 38 U.S.C. §§ 1110, 5109A (2020); 38 C.F.R. §§ 3.12, 3.103, 3.105, 3.303, 3.304, 4.125 (2020). 2. The criteria for service connection for OSA are not met. 38 U.S.C. §§ 1101, 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for a right thumb disorder status post ganglion cyst removal are not met. 38 U.S.C. §§ 1101, 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for a right thumb sarcoma are not met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1968 to October 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 2015 (OSA), June 2017 (right thumb), and May 2018 (psychiatric disorders) rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, the Board remanded the issues of service connection for a right thumb disorder and OSA for additional development and they now return for further appellate review. The December 2018 remand included the issue of entitlement to service connection for a right thumb sarcoma in the remand instructions, noting that such was previously denied in an October 2007 rating decision, and the RO had not adjudicated whether reopening was warranted. Thus, the Board directed the RO to provide proper notice as to the requirements of the requirement to reopen a previously denied claim based on new and material evidence, and adjudicate the petition to reopen. The RO provided the proper notice, but did not adjudicate the petition to reopen. However, the Board notes that the October 2007 rating decision denied service connection for a soft-tissue carcinoma, and the Veteran at that time had only been treated for removal of a soft tissue mass lesion removal from the right occipital region of his head, and the Veteran identified such region in correspondences associated with his claim. Therefore, while the Veteran contends that his right thumb soft-tissue sarcoma could have had the same etiology as the previously denied right occipital sarcoma, it is a different claim for a separate body part, and thus does not require reopening. See Velez v. Shinseki, 23 Vet. App. 199, 20305 (2009). As the RO considered the Veteran's claim on the merits in the June 2017 decision, there is no prejudice to the Veteran, and the Board will review the claim de novo. In October 2019, the Board remanded the issue of entitlement to service connection for an acquired psychiatric disorder other than PTSD for further development, and denied restoration of service connection for PTSD. Thereafter, the Veteran appealed such decision to the United States Court of Appeals for Veterans Claims (Court). In December 2020, the Court granted the Veteran's and the Secretary of VA's (the parties) Joint Motion for Partial Remand (JMPR), which vacated and remanded the Board's October 2019 decision for action consistent with the JMPR. Severance of Service Connection 1. Propriety of the May 2018 severance of service connection for PTSD. The Veteran contends that the May 2018 severance of service connection was improper. In this regard, the Veteran contends that he had a valid diagnosis of PTSD, and consequently restoration of service connection is warranted. After a review of the record, the Board finds that reasonable minds could differ on the presence of a diagnosis of PTSD and its relationship to service. Therefore, the award of service connection in January 2014 was not clearly and unmistakably erroneous, and severance of service connection was not proper. Service connection will be severed only where evidence establishes that it is clearly and unmistakably erroneous (CUE) (the burden of proof being on the Government). 38 C.F.R. § 3.105(d). VA must assure both that due process has been observed in the process of severance and that CUE exists in the award of service connection. 1. Due Process When severance of service connection is considered warranted, a rating proposing severance will be prepared setting forth all material facts and reasons. The claimant will be notified at his or her latest address of record of the contemplated action and furnished detailed reasons therefor and will be given 60 days for the presentation of additional evidence to show that service connection should be maintained. Unless otherwise provided in paragraph (i) of this section, if additional evidence is not received within that period, final rating action will be taken, and the award will be reduced or discontinued, if in order, effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires. 38 C.F.R. § 3.105(d). The initial question for the Board is whether the RO followed the due process requirements of 38 C.F.R. § 3.105(d) for severing service connection. The RO originally granted service connection for PTSD in a January 2014 rating decision effective March 29, 2013. In a March 2017 rating decision, the RO proposed to sever service connection for this disability. The RO stated that the decision to grant service connection for PTSD was clearly and unmistakably erroneous because review of the VA examination reports shows that the Veteran had not been diagnosed with PTSD. In reaching this determination, the RO referred to and quoted from the June 2013 and February 2017 reports of VA examination (showing that PTSD was not diagnosed). In the May 2018 rating decision, the RO severed service connection for PTSD. The RO reiterated the March 2017 rating decision that had proposed to sever service connection for PTSD and noted that the additional VA treatment records did not show a diagnosis of PTSD. Thus, the RO concluded that severance was proper. The RO followed the proper due process steps for severing service connection. The RO issued the proposed rating in March 2017, and the Veteran was notified at his latest address of record of this contemplated action and furnished detailed reasons therefor and was given 60 days for the presentation of additional evidence to show that service connection should be maintained in a March 2017 notice letter. The RO issued the May 2018 rating decision, which severed service connection prospectively effective August 1, 2018. The resulting period for which the Veteran was in receipt of service connection began on March 29, 2013, and ended August 1, 2018, a period of less than ten years. 38 C.F.R. § 3.957. Notice of this rating decision, plus his appeal rights, was sent to the Veteran in May 2018. The August 1, 2018, date was greater than the last day of the month in which a 60-day period from the date of the May 2018 notice expired. Thus, all due process requirements were met in the severance of service connection for PTSD. 38 C.F.R. § 3.105(d). 2. Existence of CUE in the Award of Service Connection Having met the due process requirements, the remaining question before the Board in this case is whether the grant of service connection for PTSD was clearly and unmistakably erroneous. The Board concludes that the severance of service connection was improper because the evidence conflicts as to the diagnosis of PTSD as a current psychiatric condition, and thus service connection based on a difference of opinion was not clearly and unmistakably erroneous. To establish that a grant of service connection was the product of CUE, VA must show that (1) either the correct facts as they were known at the time were not before the adjudicator, the adjudicator made an erroneous factual finding, or the statutory or regulatory provisions were incorrectly applied; (2) the alleged error was undebatable, not merely a disagreement as to how the facts were weighed or evaluated; and (3) the error manifestly changed the outcome of the prior decision. See Allen v. Nicholson, 21 Vet. App. 54, 58-59 (2007) (internal citations omitted). A clear and unmistakable error is one about which reasonable minds could not differ. See 38 C.F.R. § 3.105(a)(1)(i). In most respects, the CUE standard for severing service connection under 38 C.F.R. § 3.105(d) is equivalent to the CUE standard for reversing or revising a prior final decision under 38 C.F.R. § 3.105(a). See Baughman v. Derwinski, 1 Vet. App. 563, 566 (1991). However, the determination is not limited to the law and the record that existed at the time of the original decision. VA may consider medical evidence and diagnoses that postdate the original award of service connection to demonstrate that the diagnosis on which service connection was predicated is clearly erroneous. Stallworth v. Nicholson, 20 Vet. App. 482, 488 (2006). Pertinent to the appeal, service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a nexus between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304. However, if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. Id. Turning to the evidence of record, a May 2013 statement from the Veteran's treating psychotherapist consultant reported that the Veteran had been thoroughly assessed and diagnosed with PTSD. The psychotherapist consultant documented the Veteran's PTSD symptoms including palpable fears, helplessness and anxiety, intrusive/distressing daydreams and nightmares of traumatizing events from his period of service, recurring/distressing dreams, intense psychological distress from exposure to external cues and physiological reactivity to exposure to certain external cues that resemble events experienced during service, avoidant behavior, inability to recall important aspects of the traumatic events, diminished interest in normal activities, restricted range of affect, sense of foreshortened future, sleep difficulties, irritability and outbursts of anger, concentration difficulties, hypervigilance and exaggerated startle responses. The psychotherapist consultant stated that the Veteran had been struggling with these symptoms since his period of service and concluded that the Veteran would require continuous therapy to help reduce his PTSD symptoms. However, a June 2013 report of VA psychiatric and PTSD examination documents that the Veteran did not have a diagnosis of PTSD that conforms to the DSM-IV criteria. The psychologist explained that though the Veteran did experience some stressful events during his service in Vietnam (some which appeared to meet criterion A for PTSD), he did not endorse sufficient symptomatology to meet full criteria for a diagnosis of PTSD. Rather, the Veteran met the DSM-IV criteria for diagnoses of parasomnia not otherwise specified (NOS) and generalized anxiety disorder. In October 2013, a private pulmonary consultant noted that the Veteran reported experiencing dreams of violence and he hit his partner in his sleep once. He also reported serving in Vietnam and having bad dreams for many years. At that time, the Veteran reported having sleep issues since returning from service. In February 2017, the Veteran underwent another VA examination for his PTSD. The examining psychologist concluded that the Veteran met the DSM-5 criteria for diagnoses of generalized anxiety disorder, recurrent/mild major depressive disorder (MDD) and REM sleep behavior disorder. The psychologist reiterated that the Veteran did not meet the DSM-5 diagnostic criteria for PTSD and had not previously been diagnosed with PTSD at the VA or during the prior VA examination. The examiner also noted that the previous examination did not support a link between the Veteran's service and his mental health symptoms, while noting his reported stressor of seeing dead bodies and being fired upon while driving between bases, as well as the stressor of being told rockets were incoming on landing in Vietnam, were supported and confirmed by a January 2014 VA memorandum. The examiner then merely noted that the previous opinion did not link the mental health symptoms to service, and did not provide any opinion. While the Veteran's appeal of this issue was pending before the Court, the Veteran underwent another VA psychiatric examination in August 2020. At that time, the examiner diagnosed the Veteran with PTSD and MDD. The examiner reviewed the previous VA examination reports and opinions, and that the Veteran reported he had seen mental health services after he returned from Vietnam for anxiety, stress, and irritability, but stopped taking the prescribed medications due to side effects. The examiner noted the Veteran's confirmed stressor of frequent exposure to wounded and dead bodies while driving, and noted that such was related to his fear of hostile military or terrorist attack. The examiner then provided a concurrent August 2020 opinion, wherein she concluded that PTSD was at least as likely as not related to the Veteran's active service, and his reported stressors. In this regard, she noted he meets the criteria for PTSD, he experienced life threatening situations during deployment to Vietnam, and has had numerous social function and marital relationship problems. She also noted he deliberately worked a position without much interpersonal contact and still had some issues. She concluded that the Veteran had an onset of problems after his return from Vietnam, and has had persistent symptoms over the years, and given the time of onset of symptoms was following deployment and meeting criteria for PTSD; she opined it is at least as likely as not that Veteran has PTSD as a result of events during deployment. Based on the foregoing, the Board finds that the diagnosis of PTSD by the private provider, and in particular the diagnosis of PTSD with a positive nexus opinion in August 2020 at a VA examination, renders the Board unable to state that the rating decision that granted of service connection was clearly and unmistakably erroneous. See Stallworth, supra. While the Veteran has not always been found to exhibit all the criteria for PTSD in all his VA examinations, the Board cannot state that the January 2014 grant of service connection was the kind of error that, when called to the attention of reviewers, compels the conclusion, to which reasonable minds could not differ, that the results would be manifestly different but for the error. See Fugo v. Brown, 6 Vet. App. 40, 43 (1993). In this regard, although there are two VA examinations which found the Veteran did not meet the criteria for PTSD, including a negative nexus opinion for his mental health symptoms in general, the August 2020 diagnosis and opinion refutes such evidence. The Veteran's stressor of seeing bodies and being fired upon while driving between bases was acknowledged by VA, and was noted as being related to the fear of hostile military activity by a VA psychiatrist, and is thus sufficient for an in-service stressor. See 38 C.F.R. § 3.304(f)(3). Further, as noted above, the August 2020 examiner reviewed the previous examination reports and opinions of record, and included such evidence in her rationale; thus, the Board finds the August 2020 opinion more probative as it considered the conflicting evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (upholding Board determination that VA examination reports were more probative because they were more thorough and detailed, they discussed the conflicting opinions, and examiners had access to the claims file). Accordingly, the conflicting opinions of record show that the error is in fact debated, and therefore could not be clear and unmistakable. In this regard, it is important to note that the issue before the Board is not whether the Veteran has PTSD but is whether the RO's decision to grant PTSD was clearly and unmistakably wrong. This is a very different standard. Consequently, while as noted above, the record is conflicts over the validity of the Veteran's PTSD diagnosis, the Board finds that the grant of service connection for PTSD was not "clearly erroneous", and thus severance of service connection for this disability, effective August 1, 2018, was improper. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Thus, pertinent to a claim for service connection, such a determination requires an initial finding of a current disability. Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; see also Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability"). The requirement of the existence of a current disability is satisfied when a claimant 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. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). When the record contains a recent diagnosis of disability prior to a claimant 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. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Additionally, veterans who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, or in or near the Korean DMZ between September 1, 1967, and August 31, 1971, are presumed to have been exposed to herbicide agents. See 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6). For those veterans who have been exposed to herbicide agents, certain diseases are acknowledged to be presumptively related to such exposure. 38 U.S.C. § 1116(a)(2); 38 C.F.R. § 3.309(e). 2. Entitlement to service connection for OSA. The Veteran contends that his current OSA had its onset in or is otherwise related to his active service, to include as due to exposure to herbicide agents from service in the Republic of Vietnam. However, after a review of the record, the Board concludes that service connection for OSA is not warranted. Initially, the Veteran has a current diagnosis of OSA from an October 2013 sleep study, and confirmed in a July 2019 VA examination. Thus, the first element of service connection is met. Turning to an in-service incurrence or event, the Veteran's service treatment records are silent for any complaint, treatment, or diagnosis referable to a sleeping disorder or problem. Specifically, the Veteran reported on his February 1968 entrance examination that he had frequent trouble sleeping; yet, his records during service were silent for such and his October 1969 separation examination was silent for such and he did not report any sleep issues at the time. Nonetheless, the Veteran has acknowledged exposure to herbicide agents, and contends that OSA is related to such exposure. While OSA is not one of the diseases listed under the regulation for presumptive service connection, a veteran is not precluded from establishing service connection with proof of direct causation. 38 C.F.R. § 3.309(e); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). In this regard, the Veteran contends that he first experienced snoring and apneic episodes when he returned from his active service. He reported his parents were concerned about he talked in his sleep and stopped breathing at times, and he submitted letters in August 2016 from his sisters which recorded that they noticed he had sleeping problems such as snoring, labored breathing, and episodes of stopping breathing since he returned from service. On the day of his October 2013 sleep study, the Veteran detailed additional sleeping complaints including nightmares, bad dreams, and violent behaviour while sleeping. Notably, without referring to any specific problem, he indicated on a questionnaire that his sleeping problems had been an issue for about three years. In July 2019, the Veteran was afforded a VA examination for OSA. The examiner noted the diagnosis of OSA from 2013, but opined that such was less likely than not due to his service. The examiner noted that she had reviewed the veteran's arguments and the lay statements of record; however, he found there was no evidence in the STRs or private medical records that the Veteran had sleep apnea symptoms until 2013. The examiner noted that a lay statement detailing snoring and stopping breathing events that occurred fifty years earlier is not diagnostic. Similarly, the examiner continued that snoring can take place in the absence of sleep apnea, and observed apnea is not diagnostic, noting that a few episodes of apnea per hour is considered normal. The examiner also relied on the Veteran's affirmative denial of sleeping problems on separation from service, noting his body mass index (BMI) was 23.9 on separation from service, and it was 32.6 when he was diagnosed with OSA. The examiner then pointed out that he had known risk factors of OSA in being male, having advancing age, and weight gain. The examiner supported such opinions by including a reference to current literature which showed a much higher prevalence of OSA in individuals with higher BMI. Based on the foregoing, the Board finds that the Veteran's OSA did not have its onset in, or was otherwise due to, the Veteran's active service, to include his exposure to herbicide agents therein. In reaching its decision, the Board finds the July 2019 VA opinion highly probative as it considered all of the pertinent evidence of record, to include the lay statements of record, the Veteran's contentions, and medical records, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion...must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Notably, there is no medical opinion to the contrary, and a review of the record does not reveal any inaccurate factual premises on which the examiner's opinions rely. The Board has also considered the Veteran's assertions that his OSA is related to service, and his herbicide agent exposure; however, such determinations are complex medical matters requiring training and experience that he does not possess. In this regard, the Veteran is not shown to have any medical training that would qualify him to provide an opinion on the etiology of OSA, or the effect that exposure to herbicide agents would have on body systems. The Veteran has not offered any medical principles within lay common knowledge relating the two disorders to one another. He has also not presented evidence of lay observable symptoms which might lead the reasonable lay person to believe the disorders are in any way related. Simply put, the question regarding the etiology of such involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue of the etiology of OSA, such falls outside the realm of common knowledge of a lay person. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, the Veteran's opinion as to the etiology of his OSA is not competent evidence and, therefore, is afforded no probative weight. The Veteran's representative also argued that while the examiner found the Veteran's obesity was a likelier cause of his OSA, the cause of his obesity has not been established. August 2020 Correspondence. Although obesity cannot be service connected as a disability, obesity may serve as an intermediate step between a service-connected disability and a condition claimed on a secondary basis. VAOPGCPREC 1-2017; Walsh v. Wilkie, 32 Vet. App. 300, 305-07 (2020). However, neither the Veteran nor his representative identified any in-service event, injury, disease, or service-connected disability of which the obesity may be the result, let alone offered any actual evidence that a service-connected disability was the cause of or aggravated his obesity. In the absence of any actual evidence supporting this theory of a relationship to service, the Board finds the Veteran's obesity was not an intermediate step between his OSA and some incident of service. Thus, service connection for OSA with obesity as an intermediate step is not warranted. Consequently, the Board finds that the Veteran's OSA is not causally or etiologically related to any event, injury, or disease in service, to include exposure to herbicide agents. Therefore, service connection for such is not warranted. In reaching its determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim for service connection. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for a right thumb disorder status post ganglion cyst removal. 4. Entitlement to service connection for a right thumb sarcoma. The Veteran also contends that he has a right thumb ganglion cyst disorder that is related to his active service. Specifically, he reported that he had three surgeries to remove two ganglion cysts in 2000 and 2001, and he has continuing pain and limitation of motion in the thumb. He also contends that the ganglion cysts were soft-tissue sarcomas, and should be presumptively service-connected due to his exposure to herbicide agents. After a review of the record however, the Board finds that the Veteran does not have a diagnosis of a soft tissue sarcoma of the thumb, and his ganglion cysts are not related to his active service, and thus service connection is not warranted for a right thumb disorder. In this regard, the Board found the Veteran had a recent diagnosis of a right thumb ganglion cyst from 2001 in the December 2018 remand. Further, he showed continuing pain and limitation of motion in the thumb at a recent July 2019 VA examination. Thus, he has a current diagnosis for the right thumb. However, the record is wholly silent as to a right thumb sarcoma. Specifically, the Veteran's STRs are silent for any complaint, treatment, injury, or diagnosis referable to the right thumb. Following service, the Veteran had a ganglion removed from his right thumb in August 2000, which the Veteran's physicians noted showed no evidence of malignancy. Then, after recurrence, the Veteran had another ganglion cyst removed from his right thumb in September 2001. The pre-operative diagnosis from the latter surgery noted that the mass could "possibly could be a giant cell tumor of the finger or recurrence of his ganglion." However, following the excision, the post-operative diagnosis was a ganglion cyst. The Veteran's representative argues that the ganglion cyst removed from the right thumb was a giant cell tumor, which could be a giant cell carcinoma, which could be a soft tissue sarcoma, and thus should be presumptively service connected. June 2019 Correspondence. However, the record that the representative refers to support such opinion was the speculative pre-operative diagnosis which was corrected by the post-operative diagnosis. The record reflects that the right thumb mass was a ganglion cyst, and not a sarcoma. Moreover, in the Veteran's correspondences of record, he continually refers to the sarcoma as previously occurring behind his right ear. This is the location where the Veteran did in fact, have a sarcoma removed previously. During the instant claim, the Veteran has insisted that the location of the disability for which he seeks service connection is the right thumb. There is no evidence of record which supports the presence of a sarcoma affecting the right thumb, even historically. Consequently, again while the Veteran is competent to report experiencing such symptoms, as a lay person, he has not shown that he has medical expertise or knowledge sufficient to diagnose a disability based on his reported symptomatology, and thus he is not competent to provide such diagnosis of a cancerous growth. See Jandreau, supra. Moreover, he does not consistently report that such even exists. Therefore, the Board finds that the Veteran does not have a current diagnosis of a right thumb sarcoma. Turning to the established diagnosis of a right thumb ganglion cyst, status post removal, as noted previously, the Veteran's STRs are silent referable to any thumb disorder. Further, the operations noted above are the first medical evidence of record concerning a right thumb disorder. Nonetheless, the veteran again argued that such cysts were caused by his exposure to herbicide agents. As above, ganglion cysts are not one of the diseases listed under the regulation for presumptive service connection, but he is not precluded from establishing service connection with proof of direct causation. 38 C.F.R. § 3.309(e); Combee, supra. The record reflects later treatment for a right thumb injury first in February 2018, at which time the Veteran reported pain in his right thumb after he jumped out of bed while sleeping and hit the thumb. The Veteran was assessed with a painful right thumb status post trauma. Thereafter, the Veteran continued to report pain in his right thumb, including in an August 2018 treatment record which noted there was soft tissue swelling but no fracture or arthritic change. The Veteran was then afforded a VA examination for his thumb in July 2019. The examiner noted the ganglion cyst diagnosis from 2000 and 2001, as well as their removal, subsequent recurrence, and subsequent removal. However, the examiner noted there had not been any further recurrence, but he had pain and limitation of motion in the right thumb regardless. The examiner then opined that the ganglion cysts of the right thumb was less likely as not due to his service. The examiner noted that there is no evidence that the Veteran had a ganglion cyst, or any hand injury, while in the service, and he affirmatively denied any "tumor, growth, cyst, cancer" on separation. He continued that the first evidence of a ganglion cyst in the medical records is from 2000, and it was highly unlikely that symptoms of an event in service would remain silent for over thirty years before becoming apparent. The examiner concluded by noting there is no consensus of evidence in the peer reviewed medical literature linking herbicide agent exposure to the development of a ganglion cyst. Based on the foregoing, the Board finds that the Veteran's ganglion cysts did not have their onset in, or were otherwise due to, the Veteran's active service, to include his exposure to herbicide agents therein. In reaching its decision, the Board finds the July 2019 VA opinion highly probative as it considered all of the pertinent evidence of record, to include the lay statements of record, the Veteran's contentions, and medical records, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Notably, there is no medical opinion to the contrary, and a review of the record does not reveal any inaccurate factual premises on which the examiner's opinions rely. The Board has also considered the Veteran's assertions that his ganglion cysts are related to service, and his herbicide agent exposure; however, such determinations are complex medical matters requiring training and experience that he does not possess. In this regard, the Veteran is not shown to have any medical training that would qualify him to provide an opinion on the etiology of a ganglion cyst, or the effect that exposure to herbicide agents would have on body systems. The Veteran has not offered any medical principles within lay common knowledge relating the two disorders to one another. He has also not presented evidence of lay observable symptoms which might lead the reasonable lay person to believe the disorders are in any way related. Simply put, the question regarding the etiology of such involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect. Although lay persons are competent to provide opinions on some medical issues, see Kahana, supra, as to the specific issue of the etiology of a ganglion cyst, such falls outside the realm of common knowledge of a lay person. See Woehlaert, supra; see also Jandreau, supra. Accordingly, the Veteran's opinion as to the etiology of his ganglion cysts is not competent evidence and, therefore, is afforded no probative weight. The Veteran's representative also argued that the Veteran reported getting into altercations in service in his psychiatric records, and thus may have injured his hand which may have led to the development of the ganglion cysts. However, while the Veteran did report getting into altercations in his 20s, including a couple in-service, he never reported any hand injury therein or thereafter, and his medical records are silent for any hand injury. Thus, this argument is overly speculative and not supported by the record. Further, the Veteran's representative argued that the July 2019 examiner used too high a standard in finding that no consensus of evidence in the peer reviewed medical literature linking agent orange exposure to the development of a ganglion cyst. However, the examiner used such language in the rationale supporting the opinion that the ganglion cysts were less likely than not related to service, to include exposure to herbicide agents. Notably, the examiner included the requested opinion just prior to the proffered opinion, which included the herbicide agent exposure. Thus, while the examiner used the general term of "related to service' in the actual opinion, the examination report as a whole and the rationale show that the opinion applied to the exposure to herbicide agents. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (noting a medical report must be read as a whole). Thus, the examiner used the correct standard in offering an etiological opinion. Consequently, the Board finds that the Veteran's ganglion cysts were not causally or etiologically related to any event, injury, or disease in service, to include exposure to herbicide agents. Therefore, service connection for such is not warranted. In reaching its determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim for service connection. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder other than PTSD. The Veteran also contends that he has current diagnoses of an acquired psychiatric disorder other than PTSD, which are also due to his active service. Notably, the other psychiatric diagnoses were bifurcated from the PTSD appeal during the severance process. After a review of the record, the Board finds a remand is necessary in order to obtain an etiological opinion regarding such diagnoses. In this regard, the Veteran was diagnosed with parasomnia NOS and generalized anxiety disorder in the June 2013 VA examination; a generalized anxiety disorder, recurrent/mild MDD and REM sleep behavior disorder at the February 2017 VA examination; and MDD at the August 2020 VA examination. The VA examinations of record do not include adequate nexus opinions. The June 2013 examination included a negative nexus opinion, finding that the mental health symptoms were less likely than not related to the Veteran's active service, yet that examination did not include the diagnosis of PTSD for which service connection has been restored, and such examination did not include the new diagnosis of MDD. Thus, the opinion did not consider all the Veteran's diagnoses and whether such were part of or related to the PTSD diagnosis. Further, the February 2017 opinion did not include any etiological opinion. Finally, the August 2020 opinion referred specifically and only to PTSD, without referring to the separate diagnosis of MDD. Further, in general with the restoration of service connection for PTSD, an opinion is necessary in order to determine whether the Veteran has disabilities of a generalized anxiety disorder, parasomnia NOS, REM sleep behavior disorder, and MDD that are separate and distinct from the now service-connected PTSD. The matters are REMANDED for the following action: 1. Forward the record to an appropriate VA clinician to provide an opinion concerning the nature and etiology of a generalized anxiety disorder, parasomnia NOS, REM sleep behavior disorder, and MDD. The record and a copy of this Remand must be made available to the examiner. Following a review of the record, the examiner should opine whether the Veteran has a generalized anxiety disorder, parasomnia NOS, REM sleep behavior disorder, or MDD, that is separate and distinct from his service-connected PTSD, or if they are part of the same disability picture. If any disorder is found to be separate and distinct from PTSD, the examiner should opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder is related to the Veteran's service, to include his reported in-service stressors. A rationale should accompany any opinion offered. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jonathan M. Estes 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.