Citation Nr: 21028086 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 15-39 817 DATE: May 10, 2021 ORDER Entitlement to service connection for a sleep disability, including sleep apnea and to include as due to posttraumatic stress disorder (PTSD), is denied. Entitlement to service connection for a skin disability, to include psoriasis, rosacea, and tinea versicolor, to include as due to PTSD, is granted. Entitlement to service connection for hypertension, to include as due to exposure to herbicide agents, is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for a bilateral shoulder disability is denied. Entitlement to service connection for a back disability is denied Entitlement to service connection for a neck disability is denied. REFERAL In an April 2021 Informal Hearing Presentation, the Veteran's representative raised the issue that the Veteran should be service connected for his cardiovascular disease, secondary to his PTSD. However, this matter is not currently on appeal and therefore, it is REFERRED to the Regional Office (RO) for proper adjudication. FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran was not be diagnosed with sleep disability, including sleep apnea, at any time during the pendency of the appeal. 2. The Veteran's June 1967 entry examination diagnosed skin disability (i.e., tinea versicolor) the their no clear and unmistakable evidence that it was not aggravated beyond its natural progression by his time in service. 3. Despite the Veteran's presumptive herbicide exposure, the preponderance of the evidence shows that his hypertension was not present in service or until many years thereafter and it is not related to service or to an incident of service origin. 4. The preponderance of the evidence shows that the Veteran was not be diagnosed with bilateral hearing loss for VA purposes at any time during the pendency of the appeal. 5. The Veteran's bilateral shoulder disability was not present in service or until many years thereafter and it is not related to service or to an incident of service origin. 6. The Veteran's back disability was not present in service or until many years thereafter and it is not related to service or to an incident of service origin. 7. The Veteran's neck disability was not present in service or until many years thereafter and it is not related to service or to an incident of service origin. CONCLUSIONS OF LAW 1. The criteria for the establishment of service connection for a sleep disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for the establishment of service connection for a skin disability diagnosed as tinea versicolor are met. 38 U.S.C. §§ 1110, 1131, 1153, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for the establishment of service connection for hypertension are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for the establishment of service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for the establishment of service connection for a bilateral shoulder disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for the establishment of service connection for a back disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for the establishment of service connection for a neck disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service with the United States Air Force (USAF) from June 1967 to June 1971 with service in the Republic of Vietnam. The Veteran died in November 2019. In July 2020, the RO granted the appellant, the Veteran's surviving spouse, motion for substitution. These matters were previously before the Board and were remanded for further development in May 2019. However, given the Veteran's death, some of the development, such as obtaining VA examinations, could not be completed. The development that could be completed has been accomplished and the matters are again before the Board. The Board notes the Veteran was in receipt of a 100 percent disability rating and SMC from September 2014 and the appellant has been granted service connection for cause of death. The Service Connection Claims Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 C.F.R. § 3.303(d). In addition, service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 C.F.R. § 3.303(d). Other specifically enumerated disorders, including arthritis, hypertension, and sensor neural hearing loss, will be presumed to have been incurred in service if they manifested to a compensable degree within the first year following separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this regard, in order to establish service connection for the claimed disorders, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection for impaired hearing is subject to 38 C.F.R. § 3.385, which provides that impaired hearing will be considered to be a 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 the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. The requirements for service connection for hearing loss as defined in 38 C.F.R. § 3.385 need not be shown by the results of audiometric testing during a claimant's period of active military service in order for service connection to be granted. 38 C.F.R. § 3.385 does not prevent a claimant from establishing service connection on the basis of post-service evidence of hearing loss related to service when there were no audiometric scores reported at separation from service. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The regulation does not necessarily preclude service connection for hearing loss that first met the regulation's requirements after service. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). Thus, a claimant who seeks to establish service connection for a current hearing disability must show, as is required in a claim for service connection for any disability, that a current disability is the result of an injury or disease incurred in service, the determination of which depends on a review of all the evidence of record including that pertinent to service. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303 and 3.304; Hensley, 5 Vet. App. at 159-60. The Court in Hensley also held that "audiometric testing measures threshold hearing levels (in decibels (dB)) over a range of frequencies (in Hertz (Hz)); the threshold for normal hearing is from 0 to 20 dB, and higher threshold levels indicate some degree of hearing loss." Hensley, 5 Vet. App. at 157. As to herbicide exposure, VA laws and regulations provide that a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam war (i.e., January 9, 1962, to May 7, 1975), shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence to the contrary. 38 U.S.C. § 1116(a)(3); 38 C.F.R. § 3.307(a)(6)(iii). The last date on which such a Veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he served in the Republic of Vietnam during the Vietnam war period. 38 C.F.R. § 3.307. For these Vietnam Veterans, diseases associated with exposure to certain herbicide agents will be presumed to have been incurred in service even though there is no evidence of that disease during the period of service at issue. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309. Effective February 24, 2011, VA amended its adjudication regulations to extend a presumption of herbicide exposure to certain Veterans who served in Korea. Specifically, a veteran who, during active military, naval, or air service, served between April 1, 1968, and August 31, 1971, in a unit that, as determined by the Department of Defense (DoD), operated in or near the Korean demilitarized zone (DMZ) in an area in which herbicides are known to have been applied during that period, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iv). As to herbicide exposure due to military service in Thailand, VA has determined that special consideration of herbicide exposure on a factual basis should be extended to veterans whose duties placed them on or near the perimeters of certain Thailand military bases where herbicide may have been sprayed. In this regard, VA in a Memorandum entitled Herbicide Use in Thailand During the Vietnam Era, reported as follows: The DoD list indicates only that limited testing of tactical herbicides was conducted in Thailand from 2 April through 8 September 1964. Specifically, the location identified was the Pranburi Military Reservation associated with the Replacement Training Center of the Royal Thai Army, near Pranburi, Thailand. The Report of these tests noted that 5 civilian and 5 military personnel from Fort Detrick, Maryland conducted the spray operations and subsequent research. This location was not near any U. S. military installation or Royal Thai Air Force Base... Tactical herbicides such as Agent Orange were used and stored in Vietnam, not Thailand... There are records indicating that commercial herbicides were frequently used for vegetation control within the perimeters of air bases during the Vietnam era.... While the Thailand CHECO Report does not report the use of tactical herbicides on allied bases in Thailand, it does indicate sporadic use of non-tactical (commercial) herbicides within fenced perimeters. Therefore, if a veteran's MOS (military occupational specialty) or unit is one that regularly had contact with the base perimeter there was a greater likelihood of exposure to commercial pesticides including herbicides. Security police units were known to have walked the perimeters, especially dog handlers. However, as noted above there are no records to show that the same tactical herbicides used in Vietnam were used in Thailand... If the veteran s claim is based on servicing or working on aircraft that flew bombing missions over Vietnam, please be advised that there is no presumption of 'secondary' exposure based on being near or working on aircraft that flew over Vietnam or handling equipment once used in Vietnam. Aerial spraying of tactical herbicides in Vietnam did not occur everywhere and it is inaccurate to think that herbicides covered every aircraft and piece of equipment associated with Vietnam. Additionally the high altitude jet aircraft stationed in Thailand generally flew far above the low and slow flying UC 123 aircraft that sprayed tactical herbicides over Vietnam during Operation RANCH HAND. Also there are no studies that we are aware of showing harmful health effects for any such secondary or remote herbicide contact that may have occurred... If the veteran's claim is based on general herbicide use within the base, such as small scale brush or weed clearing activity along the flight line or around living quarters, there are no records of such activity involving tactical herbicides only the commercial herbicides... Based on the manual and supporting material it is generally presumed that herbicide was hand sprayed around the perimeter of identified bases in Thailand during certain periods of the Vietnam War era. See 38 C.F.R. § 19.5. VA has not extended the same special consideration to all service members who had contact with a Thai base perimeter. Those with periodic or occasional contact with the perimeter, such as the Veteran, but whose duty stations were not located there, are not entitled to special consideration. Therefore, the evidence must show that the Veteran's duties placed him on or near the base perimeter for a significant period of time. The list of diseases associated with exposure to certain herbicide agents is as follows: parkinsonism, bladder cancer, hypothyroidism, AL amyloidosis, chloracne or other acneform disease consistent with chloracne, type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic Bcell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, nonHodgkin's lymphoma, Parkinson's disease, early-onset peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). For purposes of applying the herbicide presumption, "service in Vietnam" includes service in the waters offshore or service in other locations if the conditions of service involved duty or visitation to Vietnam from January 9, 1962, to May 7, 1975. 38 U.S.C. § 1116(a)(3); 38 C.F.R. §§ 3.307(a)(6)(iii); 3.313(a). The availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a Veteran from establishing service connection with proof of direct causation. Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). If a pre-existing disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder. In that case 38 U.S.C. § 1153 applies and the burden falls on the veteran to establish aggravation. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If the presumption of aggravation under 38 U.S.C. § 1153 arises, the burden shifts to the government to show a lack of aggravation by establishing "that the increase in disability is due to the natural progress of the disease." 38 U.S.C. § 1153; see also 38 C.F.R. § 3.306; Jensen, 19 F.3d at 1417. A pre-existing disease or injury will be found to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a). Evidence of a veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. In this regard, a temporary or intermittent flare-up of a preexisting disease does not constitute aggravation. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991); Green v. Derwinski, 1 Vet. App. 320, 323 (1991). If the disorder becomes worse during service and then improves due to in-service treatment to the point that it was no more disabling than it was at entrance into service, the disorder has not been aggravated by service. Verdon v. Brown, 8 Vet. App. 529 (1996). The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In evaluating the evidence, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Sleep Apnea Claim During his lifetime and the Veteran contended he had a sleep disorder including apnea that was incurred in or due to his time in service or that is proximately due to his service-connected PTSD. Initially, the Board finds that the Veteran, and know the appellant, are both competent and credible to report on the observable symptoms of his claimed sleep disorder. See Davidson, supra. However, the service treatment records do not show the Veteran was treated for sleep problems nor diagnosed with a sleep disability while in service. Post-service, and more important for this case, while the Veteran's treatment records document his periodic complaints and treatment for sleep problems, they are negative for his being diagnosed with a sleep disorder including apnea. Specifically, while the Veteran mentioned sleep problems in conjunction with his PTSD and nightmares (see e.g., April 2011, August 2019 treatment records), the record shows that this sleep problem is a symptom of his PTSD and has been accounted for in determining his rating for his service-connected PTSD (see November 2018 PTSD examination.). Moreover, the Board notes the Veteran was supposed to have an examination for his sleep condition prior to his death, but that this examination never happened. Therefore, the Board must make a decision based on the evidence of record. F! while the Veteran and the appellant are competent to report on the symptoms he observes, the Board finds that they are not competent to diagnose a sleep disorder because diagnosing it requires special medical training that they do not have and therefore they cannot provide the missing diagnosis. See Davidson, supra. Lastly, the Board in reaching the above conclusion has not overlooked the United States Court of Appeals for Veterans Claims holding in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) nor the United States Court of Appeals for the Federal Circuit holding in Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). However, the Board also finds that the facts of this appeal are distinguishable from those cases because the record is negative for the claimed disorder resulting in functional impairment that affects earning capacity. See Owens, supra. Accordingly, the Board finds that the most probative evidence of record shows that the Veteran did not have diagnoses of a sleep disorder including apnea at any time during the pendency of the appeal and this claim is denied on a direct and secondary bass. 38 U.S.C. § 1110, 38 C.F.R. § 3.303, 3.310. Skin Disability Claim The Veteran contended he had a skin disability, to include psoriasis, rosacea, and tinea versicolor, that was incurred in or due to his time in service or that is proximately due to his time in service. The Veteran has been diagnosed with several skin disorder, including tinea versicolor. Moreover, the Veteran's June 1967 entry examination shows his being diagnosed with a skin disorder-tinea versicolor. Therefore, because a skin disorder diagnosed as tinea versicolor was "noted" on his entrance onto active duty, the Board finds that presumption of soundness does not attache to this claim. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Therefore, the next question for the Board to consider is whether there is clear and unmistakable evidence that the skin disorder diagnosed as tinea versicolor was not aggravated by the Veteran's military service. In this regard, service treatment records document the Veteran's treatment for tinea versicolor while in service. However, the April 2014 examiner opined this condition clearly and unmistakably existed prior to the Veteran's entrance to service. This examiner also opined that the condition was not aggravated beyond its natural progression by the Veteran's time in service. The Veteran's claim was remanded in order to afford him an examination to determine whether his pre-existing condition was aggravated beyond its natural progression by his time in service as the April 2014 examiner did not explain what was meant by his condition not being documented to be exacerbated while in service. Clearly, the Veteran's STRs show treatment. Yet, due to his death, the post-Remand VA opinion could not be obtained. In this regard, the Board finds that the April 2014 examiner's explanation could be interpreted to mean that while the Veteran was seen in service for this a skin disorder diagnosed as tinea versicolor, the documentation did not show that this treatment was for a worsening condition. Rather, it was treatment for the normal routine care required for tinea versicolor. See Tirpak v. Derwinski, 2 Vet. App. 609 (1992). However, the Board finds this interpretation does not meet the threshold of VA being able to show by clear and unmistakable evidence that the Veteran's tinea versicolor was not aggravated by service. See Owens, supra. 1. Therefore, with granting the benefit to the appellant, the Board finds that the record does not show clear and unmistakable evidence that the Veteran's skin disorder diagnosed as tinea versicolor was not aggravated by his military service and service connection is granted. See 38 U.S.C. §§ 1110, 1131, 1153, 5107(b); 38 C.F.R. §§ 3.102, 3.303. Hypertension Claim The Veteran contended he has hypertension that was incurred in or due to his time in service. Additionally, the Veteran contended his hypertension was due to his exposure to herbicides while serving in Vietnam. A veteran who suffers from certain diseases, may be entitled to a rebuttable presumption of service connection if the veteran was exposed to an herbicide agent, such as Agent Orange, during active service. 38 C.F.R. § 3.309 (e). For the criteria for presumptive service connection to be met for most of the diseases listed at 38 C.F.R. § 3.309 (e), that disease shall have become manifest to a degree of 10 percent or more any time after service. 38 C.F.R. § 3.307 (a)(6)(ii). This list does not currently include hypertension. The Board concedes the Veteran was exposed to herbicides while in Vietnam. See June 2020 VA memo. Additionally, the Veteran's records indicate he has been diagnosed with hypertension. See e.g., November 2018 hypertension examination. As to service connection for hypertension based on the presumptions found at 38 C.F.R. § 3.309(a), the Veteran does not claim and the record does not show that any of his disability manifest to a degree of 10 percent or more in the first year following his separation from service. Therefore, the Board finds that these presumptions do not apply to the current appeal. As to service connection for hypertension based on the presumptions found at 38 C.F.R. § 3.309(e), the Board notes that it is not a listed disease process. Therefore, the Board finds that these presumptions also do not apply to the current appeal. As to establishing service connection for diabetes mellitus, erectile dysfunction, heart disease, as well as right and left upper and lower extremity peripheral neuropathy based on proof of direct causation under 38 C.F.R. § 3.303 (see Stefl, supra), the Board first notes that as reported above exposure is presumed. However, a review of the Veteran's service treatment records does not show treatment or complaints of high blood pressure or hypertension while in service. Indeed, the Veteran in his separation examination, "denied all other medical and surgical history" or other than occasional hay fever, diptheria as a child, tinea versicolor, braces as a child, and reactions to penicillin. Therefore, the Board finds that the most probative evidence of record shows that the Veteran did not sustain a disease or injury while on active duty that caused his hypertension despite his herbicide exposure. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). More importantly, the record does not show that the Veteran had a continued problem with hypertension in and since service or his post-service hypertension had its onset during service. In this regard, publication of Veterans and Agent Orange: Update 11 (2018), published by the National Academy of Science (NAS), found "sufficient evidence" of an association between hypertension and exposure to herbicide agents such as Agent Orange. This publication upgrades hypertension's previous classification in the category of "limited or suggestive" evidence of an association to the category of "sufficient" evidence of an association. According to NAS, "[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure. While the Board is aware of this study and has considered it, the Board finds that it does not provide competent and credible evidence of a nexus to military service. See Tirpak, supra. Moreover, the Board concludes that hypertension did not have its onset during service and has not been continuous since that time. See Owens, supra. In this regard, the Veteran had an examination for his hypertension in November 2018 in which the examiner noted the Veteran had been diagnosed with hypertension in the 1980s, based on the Veteran's report it was discovered during an examination. Moreover, the Board recognizes that the mere absence of medical records is not dispositive as to the question of continuity; the lay evidence must be considered as well. See Buchanan v. Nicholson, 451 F.3d at1335. If, however, it is determined based on reliable evidence, that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). To the extent the Veteran s asserted continuity of symptomatology from service, the Board finds such statements inconsistent with the overall record, to include the available service treatment records and post-service treatment records, which fail to document any related complaints until many years after discharge from service. See Owens, supra. Therefore, the Board finds that the most probative evidence of record shows that the Veteran did not have a continued problem with hypertension in and since service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(b). Turning to the question of a nexus to service for the post-service hypertension, the Board finds that the record does not include a medical opinion linking the Veteran's post-service hypertension is not due to his military service. See 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303(d). In this regard, the Board notes that the Veteran was not provided a VA examination because he died before he could be provided an examination as to this question while the appeal was in Remand status. The Board also finds that neither the Veteran's statements to the RO before his death nor the appellant's current statements can provide the missing nexus opinion because this is a medical question and neither has the needed medical training. See Davidson, supra. Therefore, the Board finds that the most probative evidence of record shows that the Veteran's post-service hypertension is not due to his military service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Given the foregoing, the Board finds that the preponderance of the evidence is against the claim for service connection for hypertension and that the claim must be denied. See 38 U.S.C. § 5107 (b); Gilbert, 1 Vet. App. at 53-56. Bilateral Hearing Loss Claim The Veteran contended he had bilateral hearing loss that was incurred in or due to his time in service. Initially, the Board finds that the Veteran, and know the appellant, are both competent and credible to report on the observable symptoms of his claimed hearing loss. See Davidson, supra. However, the service treatment records do not show the Veteran was treated for hearing loss nor diagnosed with hearing loss while in service. In fact, a periodic audiogram in June 1968 also showed hearing loss within normal limits. Moreover, he checked "no" to the question whether he had any ear, nose, or throat problems at his separation examination. Post-service, and more important for this case, while the Veteran's treatment records document his periodic complaints and treatment for hearing loss, they are negative for his being diagnosed with hearing loss in either ear despite VA attempting to obtain the diagnosis on a number of occasions. Specifically, the Veteran had an examination for his bilateral hearing loss in October 2014. The examiner reported puretone thresholds and speech discrimination scores could not be tested. The examiner reported the puretone levels received were unreliable and that because of language difficulties, cognitive problems, and inconsistent word recognition scores, speech discrimination scores wouldn't be reported. The examiner, while checking the Veteran had normal hearing, stated he actually didn't know if the Veteran's hearing was normal or not. The Veteran had another examination for his bilateral hearing loss in May 2015. However, the examiner again reported she could not test puretone levels or speech discrimination. The examiner reported the Veteran's right ear puretone average was 45 dB and left ear puretone average was 50 dB while speech reception thresholds were obtained at 25dB for the right ear and 15 dB for the left ear. The examiner stated the large differences between these results suggested poor puretone test reliability. The examiner again reported she was unsure if the Veteran had normal hearing or not. In January 2011, the Veteran had an audio evaluation which showed the Veteran's puretone levels did not show hearing loss for VA purposes and his speech discrimination scores were 100 percent in both ears. Moreover, while hearing loss has been on the Veteran's active problem list for several years (see e.g. April 2012, August 2019 treatment records) but there is no indication in the Veteran's record that puretone levels rise to the level of hearing loss for VA purposes. Furthermore, while the Veteran and the appellant are competent to report on the symptoms he observes, the Board finds that they are not competent to diagnose hearing loss as defined by VA because diagnosing it requires special medical training that they do not have and therefore they cannot provide the missing diagnosis. See Davidson, supra. Lastly, the Board in reaching the above conclusion has not overlooked Saunders, supra; and Martinez-Bodon, supra. However, the Board also finds that the facts of this appeal are distinguishable from those cases because the record is negative for the claimed disorder resulting in functional impairment that affects earning capacity. See Owens, supra. Accordingly, the Board finds that the most probative evidence of record shows that the Veteran did not have diagnoses of bilateral hearing loss at any time during the pendency of the appeal and this claim is denied. 38 U.S.C. § 1110, 38 C.F.R. §§ 3.303, 3.385. Back, Neck, and Bilateral Shoulder Claims The Veteran contends he has back, neck, and bilateral shoulder disabilities that were incurred in or due to his time in service. Specifically, the Veteran has stated he fell out of a bucket truck while in service. See e.g., August 2007 treatment record. The Veteran has been treated for all of his above-claimed conditions and has diagnoses of all claimed conditions. The Veteran has been diagnosed with a neck disability. (See e.g., 2007, September 2008 treatment records.) In 2007, an MRI showed the Veteran had a bulging disc and after a car accident, in September 2008, it was shown the Veteran had a cervical sprain and spondylosis. These records also indicate the Veteran had right upper extremity radiculopathy. Imaging from August 2014 also show degenerative arthritis in the Veteran's back and shoulders. The Board also finds that the Veteran, and know the appellant, are both competent and credible to report on the observable symptoms of his back, neck, and bilateral shoulder disabilities. See Davidson, supra. However, the service treatment records do not show complaints of ongoing back, neck, or shoulder trouble. Indeed, his separation examination did not make mention of any back, neck, or shoulder conditions. An examination performed in June 1968 also did not show any back, neck, or shoulder problems. In his separation examination, the Veteran did report he had worn a brace or back support before in 1965 to 1966, but this was prior to his time in service. Therefore, the Board finds that the most probative evidence of record shows that the Veteran did not sustain a disease or injury while on active duty that caused his back, neck, and bilateral shoulder disabilities. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). As to service connection for h based on the presumptions found at 38 C.F.R. § 3.309(a), the record does not show that arthritis in the back, neck, and/or shoulders manifest to a degree of 10 percent or more in the first year following his separation from service. Therefore, the Board finds that these presumptions do not apply to the current appeal. More importantly, the record does not show that the Veteran had a continued problem with back, neck, and bilateral shoulder disabilities in and since service or his post-service back, neck, and bilateral shoulder disabilities had their onset during service. In this regard, the Board concludes that back, neck, and bilateral shoulder disabilities did not have its onset during service and has not been continuous since that time. See Owens, supra. In this regard, the Veteran had an examination for his hypertension in November 2018 in which the examiner noted the Veteran had right shoulder disabilities, but did not note any left shoulder condition, degenerative arthritis in his back which was diagnosed in 2018, and degenerative disc disease and a disc bulge in his neck, which was diagnosed in 2007, and spondylosis, diagnosed in 2018. Moreover, the Board recognizes that the mere absence of medical records is not dispositive as to the question of continuity; the lay evidence must be considered as well. See Buchanan, supra. If, however, it is determined based on reliable evidence, that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson, supra. To the extent the Veteran s asserted continuity of symptomatology from service, the Board finds such statements inconsistent with the overall record, to include the available service treatment records and post-service treatment records, which fail to document any related complaints until many years after discharge from service. See Owens, supra. Therefore, the Board finds that the most probative evidence of record shows that the Veteran did not have a continued problem with back, neck, and bilateral shoulder disabilities in and since service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(b). Turning to the question of a nexus to service for the post-service back, neck, and bilateral shoulder disabilities, the Board finds that the record does not include a medical opinion linking any of these disabilities to his military service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(d). In this regard, the Board notes that the Veteran was not provided a VA examination because he died before he could be provided an examination as to this question while the appeal was in Remand status. The Board also finds that neither the Veteran's statements to the RO before his death nor the appellant's current statements can provide the missing nexus opinion because this is a medical question and neither has the needed medical training. See Davidson, supra. (Continued on the next page) Therefore, the Board finds that the most probative evidence of record shows that the Veteran's post-service back, neck, and bilateral shoulder disabilities are not due to his military service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Given the foregoing, the Board finds that the preponderance of the evidence is against the claims for service connection for back, neck, and bilateral shoulder disabilities and that the claims must be denied. See 38 U.S.C. § 5107 (b); Gilbert, 1 Vet. App. at 53-56. NEIL T. WERNER Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Snoparsky 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.