Citation Nr: 21028516 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 16-20 123 DATE: May 11, 2021 ORDER Service connection for a gynecological disorder, claimed as cervical dysplasia, is denied. Service connection for an upper respiratory disorder, claimed as chronic obstructive pulmonary disease (COPD), is denied. Service connection for a liver disorder, claimed as hepatitis C, is denied. Service connection for an acquired psychiatric disorder, to include depressive disorder, is denied. FINDINGS OF FACT 1. Cervical dysplasia is not shown to be causally or etiologically related to any disease, injury, or incident during service. 2. COPD is not shown to be causally or etiologically related to any disease, injury, or incident during service. 3. Hepatitis C is not shown to be causally or etiologically related to any disease, injury, or incident during service. 4. An acquired psychiatric disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, and a psychosis did not manifest to a compensable degree within one year of separation from service. CONCLUSIONS OF LAW 1. The criteria for service connection for cervical dysplasia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for COPD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for hepatitis C have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.384. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1973 to January 1977. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in December 2013 by a Department of Veterans Affairs (VA) Regional Office. In September 2018, the Board denied service connection for cervical dysplasia, COPD, hepatitis C, and depressive disorder. The Veteran appealed the Board's denial to the United States Court of Appeals for Veterans Claims (Court). In August 2019, the Court granted a Joint Motion for Remand (JMR) that vacated the Board's September 2018 decision and remanded it for further consideration. In October 2019 and October 2020, the Board remanded the issues on appeal for additional development and now they return for further appellate review. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as psychoses, to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In this regard, psychosis is defined as brief psychotic disorder, delusional disorder, psychotic disorder due to another medical condition, other specified schizophrenia spectrum and other psychotic disorder, schizoaffective disorder, schizophrenia, schizophreniform disorder, and substance/medication-induced psychotic disorder. 38 C.F.R. § 3.384. When a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for a gynecological disorder, claimed as cervical dysplasia. The Veteran contends that her cervical dysplasia is a result of her military service. As an initial matter, the Board notes that the record reflects various diagnoses of menstrual cramping; menometrorrhagia (heavy periods) secondary to intrauterine device (IUD); pelvic inflammatory disease possibly (PID) secondary to IUD; moderate dysplasia, human papillomavirus (HPV) associated change; and condyloma. The Veteran's service treatment records (STRs) indicate that she was treated for gynecological problems. In June 1974, the Veteran had an IUD implanted. In July 1974, the Veteran reported stomach cramps related to her menstrual cycle. The Veteran was referred to the Obstetrics and Gynecology Clinic for symptoms related to, and possible removal of, her IUD. In September 1974, she was diagnosed with menstrual cramping. The examiner noted the onset of the Veteran's normal menstrual cycle with severe abdominal cramping. Her IUD use was also noted. In November 1974, the Veteran was diagnosed with menometrorrhagia (heavy periods) secondary to IUD. She endorsed abdominal cramping/pain, increased menstrual bleeding for 6 days, and increased dysmenorrhea. Upon examination, her cervix was "clean" and the IUD was in place. A December 1974 STR indicates that the Veteran had menstrual cramping for the preceding 5 days. A January 1975 hematology note reflects that the Veteran had "chronic bleeding on IUD". In February 1976, the Veteran reported left side and stomach pain. Examination revealed general tenderness in the lower abdomen. The Veteran was referred to the Obstetrics and Gynecological Clinic for a complete blood count (CBC) and urine culture. The following day, the Veteran was diagnosed with PID, secondary to IUD. An undated STR reveals that the Veteran continued to report severe left side pain with no apparent cause for onset. An additional undated STR notes the Veteran's fluid menometrorrhagia (heavy periods) since IUD placement. There was no significant radiographic abnormality involving the Veteran's abdomen. The Veteran underwent a separation examination in December 1976, which did not include a cervical dysplasia diagnosis or any gynecological disorder. Following separation, an August 2008 cervical biopsy showed moderate dysplasia, HPV associated change, and condyloma. The Veteran underwent a loop electrical excision procedure (LEEP). She also underwent a subsequent cervical biopsy in August 2011, which revealed mild dysplasia with HPV effect and papillary growth (cervical condyloma). A July 2012 cytopathology report showed epithelial cell abnormality of mild dysplasia along with HPV cytopathic effect. In October 2013, the Veteran was afforded a VA examination and her 2010 cervical dysplasia diagnosis was noted. At such time, she reported having an abortion in 1974 while stationed in Germany and having abnormal pap smears since the abortion. The examiner opined that it was less likely than not that Veteran's cervical dysplasia was incurred in or caused by the claimed in-service injury, event, or illness. After noting the pertinent STRs and post-service treatment records, the examiner reported that the Veteran was diagnosed with abnormal bleeding/menstrual cramps and PID secondary to IUD insertion during military service. The examiner further reported that, after discharge from military service, the Veteran was diagnosed with abnormal pap smear, dysplasia, and condyloma. Here, the examiner explained that evidence-based literature did not support a correlation between abnormal pap smears, dysplasia, or condylomas as secondary to status-post or current use of an IUD. Therefore, the examiner concluded that she was unable to establish a nexus between the Veteran's current abnormal pap smears, dysplasias and condylomas, abnormal bleeding/menstrual cramps, and PID secondary to IUD insertion during service. Thereafter, in September 2018, the Board determined that the October 2013 opinion was adequate to decide the Veteran's claim and, based on the opinion rendered therein, found that service connection for cervical dysplasia was not warranted. The Veteran appealed the Board's September 2018 decision to the Court which, in an August 2019 JMR, vacated the denial and remanded the matter to the Board for further consideration. Specifically, the parties found that the Board erred by: (1) failing to ensure that VA satisfied its duty to assist by making adequate efforts to obtain various private and federal records (from DCH Regional Medical Center/Northport Medical, Whatley Health Services, Greene County Hospital and Mental Health Center of West Alabama, Walter Reed Army Medical Center, Fort Benning, and Fort Bragg); and (2) relying on the October 2013 VA medical opinion in determining that the Veteran's cervical dysplasia was not related to service. In this regard, the parties observed that the October 2013 examiner did not provide an opinion as to whether the Veteran's 1974 abortion caused her cervical dysplasia; that she did not address whether the Veteran's in-service PID, severe pelvic pain, and bleeding were related to her current cervical dysplasia; and that the examination reported contained contradictory or inaccurate facts. Accordingly, in October 2019, the Board remanded the Veteran's claim in order to attempt to obtain the aforementioned records and obtain an addendum opinion that addressed the foregoing matters related to her cervical dysplasia. In this regard, the Agency of Original Jurisdiction (AOJ) undertook all necessary actions to obtain such records and: (1) treatment records from DCH Regional Medical Center, Whatley Health Services, and Northport Medical Center were received; (2) military personnel records were received; and (3) it was determined that records from Greene County Hospital and Mental Health Center of West Alabama, and Walter Reed Army Medical Center were unavailable and the Veteran was notified of such fact in February, April, and July 2020 letters. Additionally, addendum opinions were obtained in May 2020; however, in October 2020, the Board determined that such were not wholly sufficient to decide the Veteran's claim at that time. Accordingly, the Veteran underwent an additional VA examination in February 2021 and an addendum opinion was rendered by a different VA examiner. At such time, the examiner opined that the Veteran's cervical dysplasia was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support thereof, the examiner reported that the Veteran's cervical dysplasia did not have its onset during active duty. Here, she explained that, per the medical record, the Veteran's first abnormal pap smear occurred in 2008 (along with an HPV diagnosis, which could lead to cervical dysplasia). The examiner further explained that such abnormal pap smear and HPV infection occurred over 30 years following military separation. The examiner concluded that it was at least as likely as not that the Veteran's cervical dysplasia was caused by her HPV infection, which was sexually transmitted, and was not caused by her PID that she had over 30 years prior to her HPV diagnosis. The Board acknowledges the Veteran's April 2021 complaint that the examiner did not perform a pelvic examination during the February 2021 VA examination. While the Board's October 2020 remand requested that the Veteran be scheduled for a VA examination in regard to her claim, such was remanded to obtain findings as to whether her cervical dysplasia was related to her military service. Here, the Board directed that all indicated and necessary tests should be conducted. In this regard, following an in-person interview with the Veteran and a review of her claims file, the examiner completed a gynecological conditions Disability Benefits Questionnaire and noted a diagnosis of cervical dysplasia since 2008. Additionally, the Veteran's claims file, to include her STRs, military personnel records, VA and private treatment records, and lay statements, was deemed sufficient by the examiner upon which to base her opinion, and she addressed the questions asked by the October 2020 remand. Nowhere in the examination report did the examiner remark that she needed to perform a pelvic examination of the Veteran in order to provide an adequate nexus opinion. Thus, the Board defers to the judgment of the examiner's assessment that a pelvic examination was not necessary. Therefore, the Board finds that there was substantial compliance with the October 2020 remand directives and a further remand is not warranted. See D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008); Stegall v. West, 11 Vet. App. 268 (1998). The Board has carefully reconsidered the facts of this matter, including the concerns raised in the August 2019 JMR, however, finds that the appeal must again be denied because the preponderance of the evidence is against the Veteran's claim. Here, the Board places great probative weight on the VA examiner's February 2021 opinion that the Veteran's cervical dysplasia was not related to her military service as such considered all of the pertinent evidence of record, 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"). Further, the examiner identified an alternative etiology for the Veteran's current cervical dysplasia specific to her individual case. Notably, there is no contrary, competent medical opinion of record. The Board has also considered the Veteran's lay statements that her cervical dysplasia is related to her military service. However, the Board finds that the question regarding the potential relationship between her diagnosed gynecological disorder and any instance of her service to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In this regard, while the Veteran is competent to describe her in-service experiences and current symptomatology, the Board accords her statements regarding the causation of such disorder little probative value as she is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In the instant case, the question of causation of her gynecological disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, as she does not have the appropriate expertise to offer an opinion as to the etiology of her gynecological disorder, her lay assertions in such regard are afforded no probative weight. Consequently, the Board finds that service connection for cervical dysplasia is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. The preponderance of the evidence is against the Veteran's claim of entitlement to service connection for cervical dysplasia. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 2. Entitlement to service connection for an upper respiratory disorder, claimed as COPD. The Veteran contends that she currently has COPD as a result of her military service. The Veteran's STRs indicate that she was treated for respiratory disorders during service. In this regard, an August 1974 STR reflects that the Veteran was diagnosed with sinusitis and an upper respiratory infection. She reported a chest cold and difficulty breathing at night. The Veteran was prescribed Robitussin DM, Actifed, and Afrin. In November 1974, the Veteran was diagnosed with a viral syndrome. She reported vomiting for the preceding 3 days and left flank pain. In January 1975, the Veteran reported sinus congestion. In April, June, and October 1975, she was again diagnosed with a viral syndrome. The December 1976 separation examination did not reveal COPD or any respiratory disorder. Her chest X-ray was normal, and on the corresponding Report of Medical History, she denied asthma, shortness of breath, chronic cough, and chronic or frequent colds. Post-service treatment records reflect that the Veteran had normal chest X-rays in 2005, 2008, and 2013. An October 2004 private treatment record reflects the Veteran's history of cough and chills. Such record further reflects no history of shortness of breath, productive cough, or wheezing. An October 2008 VA treatment record notes her history of severe COPD. A May 2011 private treatment record indicates the Veteran's complaint of coughing. A June 2011 private treatment record indicates that the Veteran was diagnosed with COPD. In February 2012, she reported wheezing and coughing. In December 2012, the Veteran was diagnosed with pleurisy and endorsed cold-like symptoms and dry coughing. Private treatment records dated in October 2017 and November 2018 reveal assessments of COPD with no exacerbations. The Veteran reported a non-productive cough, which occurred persistently. A September 2019 private treatment record reflects that the Veteran was prescribed medication for wheezing and shortness of breath. The Veteran was afforded a VA examination in October 2013. At such time, the examiner noted a diagnosis of COPD. The Veteran reported that she had shortness of breath with exertion while on active duty. She endorsed increased shortness of breath and coughing when she smoked and was also prescribed an inhaler to help alleviate her breathing problems. Ultimately, the examiner opined that it was less likely than not that the Veteran's COPD was incurred in or caused by the claimed in-service injury, event or illness. In support thereof, the examiner indicated that because of the Veteran's history of heavy tobacco use, her current respiratory disorder was most likely secondary to her tobacco use during service. The examiner further indicated that the Veteran's in-service respiratory disorder occurred more than 35 years ago and could be considered resolved in the absence of flare-ups over time. The examiner expounded on the fact that in 2008, the Veteran complained of congestion with a productive cough of thick sputum and revealed that she smoked one pack of cigarettes a day. Here, the examiner noted that the Veteran's October 2013 chest X-ray showed COPD or asthma. The examiner concluded that she could not establish a nexus between the Veteran's active duty respiratory disorders (viral infections) and her current COPD. Thereafter, in September 2018, the Board determined that the October 2013 opinion was adequate to decide the Veteran's claim and, based on the opinion rendered therein, found that service connection for COPD was not warranted. The Veteran appealed the Board's September 2018 decision to the Court which, in an August 2019 JMR, vacated the denial and remanded the matter to the Board for further consideration. Specifically, the parties found that, as relevant, the Board erred by failing to ensure that VA satisfied its duty to assist by making adequate efforts to obtain various private and federal records (from DCH Regional Medical Center/Northport Medical, Whatley Health Services, Greene County Hospital and Mental Health Center of West Alabama, Walter Reed Army Medical Center, Fort Benning, and Fort Bragg). As noted previously, pursuant to the October 2019 Board remand, the AOJ undertook all necessary actions to obtain such records and: (1) treatment records from DCH Regional Medical Center, Whatley Health Services, and Northport Medical Center were received; (2) military personnel records were received; and (3) it was determined that records from Greene County Hospital and Mental Health Center of West Alabama, and Walter Reed Army Medical Center were unavailable and the Veteran was notified of such fact in February, April, and July 2020 letters. The Board has carefully reconsidered the facts of this matter, including the concerns raised in the August 2019 JMR, however, finds that the appeal must again be denied because the preponderance of the evidence is against the Veteran's claim. Here, the Board places great probative weight on the VA examiner's October 2013 opinion that the Veteran's COPD was not related to her military service as such considered all of the pertinent evidence of record, to include the Veteran's STRs and post-service treatment records and lay statements, and provided a complete rationale, relying on and citing to the records reviewed. Furthermore, 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 contrary medical opinion of record. Moreover, the law mandates that, for claims received by VA after June 9, 1998, a disability will not be considered service-connected on the basis that it resulted from injury or disease attributable to a veteran's use of tobacco products during service. See 38 U.S.C. § 1103; 38 C.F.R. § 3.300(a). Therefore, service connection for COPD due to the use of tobacco products is precluded. The Board has also considered the Veteran's lay statements that her COPD is related to her military service. However, the Board finds that the question regarding the potential relationship between her diagnosed upper respiratory disorder and any instance of her service to be complex in nature. See Woehlaert, supra. In this regard, while the Veteran is competent to describe her in-service experiences and current symptomatology, the Board accords her statements regarding the causation of such disorder little probative value as she is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones, supra. In the instant case, the question of causation of her upper respiratory disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, as she does not have the appropriate expertise to offer an opinion as to the etiology of her upper respiratory disorder, her lay assertions in such regard are afforded no probative weight. Consequently, the Board finds that service connection for COPD is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. The preponderance of the evidence is against the Veteran's claim of entitlement to service connection for COPD. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 3. Entitlement to service connection for a liver disorder, claimed as hepatitis C. The Veteran contends that she currently has hepatitis C as a result of her military service. In regard to service connection claims pertaining to hepatitis C, there are recognized risk factors for contracting hepatitis C that should be taken into consideration when developing and adjudicating a claim of service connection. The medically recognized risk factors are: transfusion of blood or blood products before 1992; organ transplant before 1992; hemodialysis; tattoos; body piercing; intravenous drug use (due to shared instruments); high-risk sexual activity (risk is relatively low); intranasal cocaine use (due to shared instruments); accidental exposure to blood products in health care workers or combat medic or corpsman by percutaneous (through the skin) exposure or on mucous membrane; and other direct percutaneous exposure to blood such as by acupuncture with non-sterile needles or by the sharing of toothbrushes or shaving razors. The Veteran's STRs reveal no abnormalities that were attributed to hepatitis. The December 1976 separation examination reflects that the Veteran's liver was normal, and on the corresponding Report of Medical History, she denied stomach, liver, and intestinal trouble. Post-service treatment records indicate that, in October 2004, the Veteran was being followed with a diagnosis of hepatitis suspect ETOH. Such private treatment record further indicates that the Veteran drank a good bit. An October 2004 ultrasound reveals an impression of increased cortical echogenicity of the right kidney; otherwise, no abnormality was seen in the right upper quadrant. A history of acute hepatitis was noted. In April 2010, the Veteran was diagnosed with hepatitis C. She received in-patient treatment from May 2, 2011, to May 5, 2011, and was diagnosed with acute pyelonephritis with renal insufficiency. Her history of hypertension and hepatitis were noted. Private treatment records dated in October 2017; February, June, and November 2018; and January 2020 reflect assessments of chronic viral hepatitis C; and that hepatic ultrasounds were normal in July 2017 and July 2018. The November 2018 private treatment record further reflects that the Veteran no longer had to go to UAB for monitoring. In September 2018, the Board determined that service connection for hepatitis C was not warranted. The Veteran appealed the Board's September 2018 decision to the Court which, in an August 2019 JMR, vacated the denial and remanded the matter to the Board for further consideration. Specifically, the parties found that, as relevant, the Board erred by failing to ensure that VA satisfied its duty to assist by making adequate efforts to obtain various private and federal records (from DCH Regional Medical Center/Northport Medical, Whatley Health Services, Greene County Hospital and Mental Health Center of West Alabama, Walter Reed Army Medical Center, Fort Benning, and Fort Bragg). As noted previously, pursuant to the October 2019 Board remand, the AOJ undertook all necessary actions to obtain such records and: (1) treatment records from DCH Regional Medical Center, Whatley Health Services, and Northport Medical Center were received; (2) military personnel records were received; and (3) it was determined that records from Greene County Hospital and Mental Health Center of West Alabama, and Walter Reed Army Medical Center were unavailable and the Veteran was notified of such fact in February, April, and July 2020 letters. The Board has carefully reconsidered the facts of this matter, including the concerns raised in the August 2019 JMR; however, finds that the appeal must again be denied because the preponderance of the evidence is against the Veteran's claim. Here, the Board has considered the Veteran's lay statements that her hepatitis C is related to her military service. However, the Board finds that the question regarding the potential relationship between her diagnosed liver disorder and any instance of her service to be complex in nature. See Woehlaert, supra. In this regard, while the Veteran is competent to describe her in-service experiences and current symptomatology, the Board accords her statements regarding the causation of such disorder little probative value as she is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones, supra. In the instant case, the question of causation of her liver disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, as she does not have the appropriate expertise to offer an opinion as to the etiology of her upper respiratory disorder, her lay assertions in such regard are afforded no probative weight. Furthermore, the Board finds that VA's duty to provide a medical examination and/or opinion regarding such claim is not triggered in the instant case. Specifically, there is no indication that the Veteran's hepatitis C is related to her military service. Here, as previously discussed, the Veteran's STRs revealed no relevant complaint of, treatment for, or diagnosis of hepatitis or a liver-related disorder during service; the December 1976 separation examination was negative for a diagnosis of hepatitis; on the corresponding Report of Medical History, she denied stomach, liver, or intestinal trouble; and post-service treatment records are negative for any indication of hepatitis C until 2004. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Court has held that VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Additionally, a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (201). Therefore, the Board finds that a VA examination and/or opinion is not necessary to decide the instant claim. Consequently, the Board finds that service connection for hepatitis C is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. The preponderance of the evidence is against the Veteran's claim of entitlement to service connection for hepatitis C. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 4. Entitlement to service connection for an acquired psychiatric disorder, to include depressive disorder. The Veteran contends that her depressive disorder is a result of her military service. The Veteran's STRs reveal no abnormalities that were attributed to an acquired psychiatric disorder, to include depressive disorder. The December 1976 separation examination reflects that the Veteran was psychiatrically normal; and on the corresponding Report of Medical History, she denied depression or excessive worry, and nervous trouble of any sort. Post-service treatment records reflect that, in June 2009, the Veteran reported feeling depressed and that her son was killed in a motor vehicle accident in March 2005. An additional June 2009 VA treatment record reveals that the Veteran underwent a mental status examination. At such time, the Veteran indicated that her depression began in March 2005 when her son was killed in a car accident, and her symptoms worsened when her mother became ill in 2007. A psychiatric diagnosis was not provided. An August 2009 VA treatment record notes a diagnosis of major depression, recurrent, moderate. In October 2009, the Veteran attributed much of her psychological problems to her lack of income. In September 2011, the Veteran was diagnosed with depression and prescribed Zoloft 50mg. Private treatment records dated in October 2017 and November 2018 note an assessment of major depressive disorder. The Veteran was afforded a VA examination in October 2013. At such time, the examiner noted a diagnosis of depressive disorder, not otherwise specified. The Veteran reported that her substance abuse began during service; and the examiner noted that there was no mental health treatment or diagnosis in service. Ultimately, the examiner opined that it was less likely than not that the Veteran's depressive disorder was incurred in or caused by the claimed in-service injury, event, or illness. In support thereof, the examiner indicated that there was no medical evidence that indicated a nexus between the Veteran's service and her diagnosed depression. The examined further indicated that the Veteran's STRs were negative for complaints of, treatment, or diagnosis of a mental disorder. The examiner emphasized that the Veteran denied having depression and stated that she was in good health on her December 1976 Report of Medical History. Thus, the examiner assessed that the Veteran's depressive disorder was not attributable to her military service. Thereafter, in September 2018, the Board determined that the October 2013 opinion was adequate to decide the Veteran's claim and, based on the opinion rendered therein, found that service connection for depressive disorder was not warranted. The Veteran appealed the Board's September 2018 decision to the Court which, in an August 2019 JMR, vacated the denial and remanded the matter to the Board for further consideration. Specifically, the parties found that, as relevant, the Board erred by failing to ensure that VA satisfied its duty to assist by making adequate efforts to obtain various private and federal records (from DCH Regional Medical Center/Northport Medical, Whatley Health Services, Greene County Hospital and Mental Health Center of West Alabama, Walter Reed Army Medical Center, Fort Benning, and Fort Bragg). As noted previously, pursuant to the October 2019 Board remand, the AOJ undertook all necessary actions to obtain such records and: (1) treatment records from DCH Regional Medical Center, Whatley Health Services, and Northport Medical Center were received; (2) military personnel records were received; and (3) it was determined that records from Greene County Hospital and Mental Health Center of West Alabama, and Walter Reed Army Medical Center were unavailable and the Veteran was notified of such fact in February, April, and July 2020 letters. The Board has carefully reconsidered the facts of this matter, including the concerns raised in the August 2019 JMR; however, finds that the appeal must again be denied because the preponderance of the evidence is against the Veteran's claim. Here, the Board places great probative weight on the VA examiner's October 2013 opinion that the Veteran's depressive disorder was not related to her military service as such considered all of the pertinent evidence of record, to include the Veteran's STRs and post-service treatment records and lay statements, and provided a complete rationale, relying on and citing to the records reviewed. Furthermore, 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 contrary medical opinion of record. Further, the evidence does not show a diagnosis of a psychosis that had its onset in service or was evidenced by continuity of symptomatology thereafter. Rather, the first reports of symptoms that could be related to an acquired psychiatric disorder appear in VA treatment records dated in 2009, approximately 32 years after the Veteran's separation from service. Even accepting the Veteran's lay statements regarding the onset of her symptoms, the record shows she reported first experiencing depressive symptoms in March 2005 following the death of her son in March 2005, approximately 28 years after service discharge. In this regard, the Board has further considered the Veteran's lay statements that her depressive disorder is related to her military service. However, the Board finds that the question regarding the potential relationship between her diagnosed acquired psychiatric disorder and any instance of her service to be complex in nature. See Woehlaert, supra. In this regard, while the Veteran is competent to describe her in-service experiences and current symptomatology, the Board accords her statements regarding the causation of such disorder little probative value as she is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones, supra. In the instant case, the question of causation of her acquired psychiatric disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, as she does not have the appropriate expertise to offer an opinion as to the etiology of her acquired psychiatric disorder, her lay assertions in such regard are afforded no probative weight. Moreover, the Board notes her initial reports of depressive symptoms were specifically linked to post-service events, to include the death of her son and her mother's illness. Consequently, the Board finds that service connection for depressive disorder is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. The preponderance of the evidence is against the Veteran's claim of entitlement to service connection for depressive disorder. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. M. M. Celli Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Koria B. Stanton, Associate 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.