Citation Nr: 21029994 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 14-32 295 DATE: May 17, 2021 ORDER Service connection for obstructive sleep apnea, to include as due to herbicide agent exposure, is denied. Service connection for peripheral neuropathy, left lower extremity, to include as due to herbicide agent exposure, is denied. Service connection for peripheral neuropathy, right lower extremity, to include as due to herbicide agent exposure, is denied. Service connection for a disability manifested by memory loss/confusion, to include as due to herbicide agent exposure and/or secondary to service-connected disability, is denied. REMANDED Service connection for a disability manifested by dizziness, to include as due to herbicide agent exposure and/or secondary to service-connected disability, is remanded. Service connection for supraventricular tachycardia, to include as secondary to service-connected disability, is remanded. Service connection for hypertension, to include as due to herbicide agent exposure and/or secondary to service-connected disability, is remanded. Service connection for headaches, to include as due to herbicide agent exposure and/or secondary to service-connected disability, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran's obstructive sleep apnea began during active service, or is otherwise related to an in-service injury or disease, to include exposure to herbicides. 2. The preponderance of the evidence is against finding that the Veteran's left lower extremity peripheral neuropathy was manifest in service or to a degree of 10 percent within 1 year of separation or is related to service. 3. The preponderance of the evidence is against finding that the Veteran's right lower extremity peripheral neuropathy was manifest in service or to a degree of 10 percent within 1 year of separation or is related to service. 4. The preponderance of the evidence of record is against finding that the Veteran has had a disability manifested by memory loss/confusion at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for service connection for obstructive sleep apnea, to include as due to herbicide agent exposure, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for service connection for peripheral neuropathy, left lower extremity, to include as due to herbicide agent exposure, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. The criteria for service connection for peripheral neuropathy, right lower extremity, to include as due to herbicide agent exposure, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 4. The criteria for service connection for a disability manifested by memory loss/confusion, to include as due to herbicide agent exposure and/or secondary to service-connected disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1967 to May 1969. The Board of Veterans' Appeals (Board) thanks him for his service to our country. These matters come before the Board on appeal from a March 2013 rating decision issued by the Department of Veterans Affairs (VA). In correspondence dated December 29, 2020, the Veteran's representative requested an extension of 90 days to submit additional evidence. However, as the Veteran's representative has not requested an additional extension of time, and as the requested extension has elapsed, the Board may proceed with appellate review. This case was previously before the Board in June 2018 and March 2020, when the Board remanded the issues on appeal for additional development. There has been substantial compliance with the remand in connection with the obstructive sleep apnea, right and left lower extremity peripheral neuropathy and memory loss/confusion claims and the Board will proceed with their adjudication. Stegall v. West, 11 Vet. App. 268 (1998). Unfortunately, as discussed in the Remand section below, there has not been substantial compliance with the remand in connection with the supraventricular tachycardia and hypertension claims and they require additional development. Id. The claims for a disability manifested by dizziness and headaches also require additional development. SERVICE CONNECTION With respect to each claim decided in this decision, service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. Establishing direct service connection generally requires competent evidence of three elements: (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 U.S.C. § 1110; 38 C.F.R. § 3.303. The Veteran served in Korea and exposure to Agent Orange has been conceded. See March 2013 VA Administrative Decision. If a veteran was exposed to an herbicide agent during active service, certain diseases will be service connected. See 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). In this regard effective September 6, 2013, VA amended its adjudication regulations concerning presumptive service connection for disabilities associated with exposure to certain herbicide agents. See 78 Fed. Reg. 54,763, Disease Associated with Exposure to Certain Herbicide Agents: Peripheral Neuropathy. Specifically, VA amended §§ 3.307(a)(6)(ii) and 3.309(e) by replacing the term "acute and subacute peripheral neuropathy" with the term "early-onset peripheral neuropathy." VA also removed Note 2 to § 3.309(e), which had stated that, in order for the presumption to apply, the neuropathy be transient and appear within weeks or months of exposure to an herbicide agent and resolve within two years of the date of onset. Under the amendments, early-onset peripheral neuropathy still needs to become manifest to a degree of 10 percent or more within one year after the date of last exposure to herbicides in order to qualify for the presumption of service connection, but it no longer needs to be transient. These amendments apply to claims received by VA on or after September 6, 2013 and to claims pending before VA on that date. The remaining disorders on appeal decided herein are not disorders entitled to presumptive service connection based on exposure to herbicide agents under 38 C.F.R. §§ 3.307 and 3.309. The Secretary of Veterans Affairs (Secretary) has determined that there is no positive association between exposure to herbicides and any other condition for which he has not specifically determined a presumption of service connection is warranted. See Diseases Not Associated with Exposure to Certain Herbicide Agents, 75 Fed. Reg. 81,332 (Dec. 27, 2010). Certain chronic diseases, including peripheral neuropathy, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a one-year presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Even if a disorder is not entitled to a regulatory presumption, service connection may be established with evidence of direct causation under 38 U.S.C. § 1110; 38 C.F.R. § 3.303, as set forth above. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). Service connection is also warranted for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (a). To establish secondary service connection there must be evidence: (1) of a current disability (for which secondary service connection is sought); (2) of an already service-connected disability; and (3) that the current disability for which service connection is sought was either (a) caused or (b) aggravated by the service-connected disability. 38 C.F.R. § 3.310 (a); see Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). 1. Service connection for obstructive sleep apnea, to include as due to herbicide agent exposure. The Veteran contends that his current sleep apnea is related to active service, to include Agent Orange exposure. The question for the Board is whether the Veteran has a current disability that began during service, is at least as likely as not related to an in-service injury, event, or disease, or may be presumed to be related to service. The Board concludes that, while the Veteran has a current diagnosis of sleep apnea, the preponderance of the evidence weighs against finding that the Veteran's sleep apnea began during service or is otherwise related to an in-service injury, event, or disease, to include Agent Orange exposure. The Veteran's service treatment records reflect that at separation in March 1969 he denied frequent trouble sleeping and all pertinent clinical evaluations were normal. VA and private treatment records are negative for complaints, symptoms, findings or diagnoses of sleep apnea for many years after the Veteran's separation from active duty. Service incurrence may be rebutted by the absence of medical treatment or diagnosis for the claimed condition for many years after service. Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); see also Horn v. Shinseki, 25 Vet. App. 231, 240 n.7 (2012). Consequently, the Board finds the fact that the first medical evidence of sleep apnea was many years after the Veteran's service tends to disprove the assertion that his sleep apnea was incurred during, or is related to, his active military service. March 28, 2014 letters by Dr. D. Horton of Medical Associates reflect his opinion that the Veteran's obstructive and central sleep apnea "could be" related to Agent Orange exposure, and it is "more likely than not" that the Veteran's symptoms are attributable to Agent Orange exposure. Dr. Horton provided no rationale whatsoever, and did not indicate that he reviewed the Veteran's pertinent clinical records. Rather, the opinion appears based on the Veteran's own self-reported medical history. As a result, the Board finds that his opinion has little probative value. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). The report of an August 2006 VA sleep study provides that the study did not suggest disordered breathing and sleep quality showed no significant abnormality. The Veteran has repeatedly stated that he was not diagnosed in 2006 with sleep apnea because he purposely tried to stay awake during the sleep study and sleep on a side which would not cause apnea, and that he believed a second sleep study should have been done. A November 2017 VA Agent Orange examination report provides no complaints, symptoms, findings or diagnoses relevant to sleep apnea. The report of a June 2019 VA Sleep Apnea examination relates that the Veteran had a diagnosis of obstructive sleep apnea. A June 2019 VA Medical Opinion provides that the examiner interviewed and examined the Veteran and reviewed the VA eFolder, all pertinent records and the entire record. The examiner stated that the Veteran's sleep apnea was less likely than not incurred in or caused by Agent Orange exposure during service. The examiner stated that the Veteran had sleep apnea diagnosed after service and explained sleep apnea was a condition with specific established diagnostic criteria and was not diagnosed by the simple complaint of fatigue, tiredness, sleepiness or other nonspecific complaints. The examiner further explained snoring was not sleep apnea and sleep apnea was caused by the blockage of the upper airway by the tongue and soft palate. The examiner explained risk factors included a genetic predisposition, obesity, short large diameter neck, smoking, alcohol consumption and the use of sedatives and tranquilizers. The examiner explained no exposures of anything have a causative relationship to sleep apnea, including Agent Orange. The examiner stated that, therefore, after reviewing the C-file, VA eFolder, and all pertinent records, it was his opinion that the Veteran had no diagnosis of sleep apnea that was at least as likely as not (50 percent or greater probability) incurred in or caused by the Agent Orange exposure during active duty. The Board finds that the June 2019 medical opinion constitutes probative evidence that the Veteran's sleep apnea is not related to Agent Orange exposure during active duty. The Board also finds that this medical opinion outweighs the March 28, 2014 letters by Dr. D. Horton. The June 2019 medical opinion is based on current mental examination results and a review of the medical record, including in-service treatment records. The June 2019 examiner explained his opinion with references to the Veteran's medical history and his own medical expertise. This fact is particularly important, in the Board's judgment, as the references make for a more convincing rationale that outweighs Dr. Horton's opinion. See Bloom, supra. See also Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.); Elkins v. Brown, 5 Vet. App. 474, 478 (1993) (medical opinions as to a nexus may decline in probative value where the physician fails to discuss relevant medical history). While the Veteran believes that his sleep apnea is related to active duty, to include Agent Orange exposure, as a layperson he is not competent to opine as to this complex medical matter. Specialized medical training and expertise are required. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the competent medical evidence discussed above. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the claim. 38 U.S.C. § 5107. 2. Service connection for peripheral neuropathy, left lower extremity, to include as due to herbicide agent exposure. 3. Service connection for peripheral neuropathy, right lower extremity, to include as due to herbicide agent exposure. The Veteran contends that his current peripheral neuropathy of the bilateral lower extremities is related to athlete's foot shown in his service treatment records at separation, or to Agent Orange exposure during active duty. The question for the Board is whether the Veteran has a current disability that began during service, is at least as likely as not related to an in-service injury, event, or disease, or may be presumed to be related to service. The Board concludes that, while the Veteran has a current diagnosis of peripheral neuropathy of the left lower extremity and right lower extremity, the preponderance of the evidence weighs against finding that the Veteran's disabilities began during service or are otherwise related to an in-service injury, event, or disease, to include Agent Orange exposure. The preponderance of the evidence also indicates the Veteran's peripheral neuropathy of the bilateral lower extremities was not manifest in service or to a degree of 10 percent within one year of separation. VA and private treatment records are negative for complaints, symptoms, findings or diagnoses of peripheral neuropathy for many years after the Veteran's separation from active duty. Service incurrence may be rebutted by the absence of medical treatment or diagnosis for the claimed condition for many years after service. Maxson, supra; see also Horn, supra. Consequently, the Board finds the fact that the first medical evidence of peripheral neuropathy was many years after the Veteran's service tends to disprove the assertion that his peripheral neuropathy was incurred during, or is related to, his active military service. The Veteran contends that he first had symptoms of peripheral neuropathy of the lower extremities while in service but that his foot complaints were simply diagnosed as Athlete's foot. In this regard, his service treatment records reflect that at separation in March 1969 he denied neuritis and paralysis. He reported foot trouble, which was identified as athlete's foot. All pertinent clinical evaluations were normal. An October 2003 private "comprehensive examination" record by Dr. T. J. Pond reflects the Veteran had no ongoing problems other than pernicious anemia for which he got B12 shots and was on "no other regular medications." It further reflects that there was no positive finding with regard to the central nervous system and that the Veteran's neurological system was intact with no evidence of motor weakness, sensory change, or gait or station abnormality. A November 2011 private record from Dr. O. Marchena reflects that the Veteran had a fairly normal neurologic examination with the exception of "very mild peripheral neuropathy." A November 2013 UVA progress note reflects that the Veteran had no numbness or tingling either intermittently or permanently. March 28, 2014 letters by Dr. D. Horton of Medical Associates reflect his opinion that the Veteran's persistent numbness in the extremities "could be" related to Agent Orange exposure, and it is "more likely than not" that the Veteran's numbness is attributable to Agent Orange exposure. Dr. Horton provided no rationale whatsoever, and did not indicate that he reviewed the Veteran's pertinent clinical records. Rather, the opinion appears based on the Veteran's own self-reported medical history. As a result, the Board finds that his opinion has little probative value. See Bloom, supra (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). The report of a May 2014 VA examination for peripheral neuropathy provides the medical opinion that it was less likely as not that the Veteran's peripheral neuropathy was related to the Veteran's athletes foot in service. The examiner noted review of the Veteran's military medical records revealed documentation in the March 1969 separation examination of athlete's foot. The question to this examiner was whether the Veteran's right and left lower peripheral neuropathy was at least as likely as not (50 percent or greater probability) incurred in or caused by his treatment for foot problems/athlete's foot shown in May (sic) 1969? The answer was no, the Veteran's right and left lower peripheral neuropathy [was not] at least as likely as not (50 percent or greater probability) incurred in or caused by his treatment for foot problems/athlete's foot shown in May/March 1969. The examiner explained there was no pathophysiological relationship between athlete's foot (tinea infection) and the development of peripheral neuropathy. The examiner also noted the Veteran's C-file did not reveal evidence of such a relationship, nor was there a relationship between the Veteran's military service and the current post-service diagnosis of lower extremity peripheral neuropathy. The examiner further explained the Veteran's discharge physical was silent for a lower extremity neurological condition as well as within the immediate post-service period. The Board finds that the May 2014 VA medical opinion constitutes probative evidence that the Veteran's current peripheral neuropathy of the bilateral lower extremities is not related to active duty, or the athlete's foot shown at separation. The medical opinion is based on current mental examination results and a review of the medical record, including in-service treatment records and post-service treatment records. The examiner explained his opinions with references to the Veteran's medical history and his own medical expertise. This fact is particularly important, in the Board's judgment, as the references makes for a more convincing rationale that outweighs Dr. Horton's opinion. See Bloom, supra. See also Prejean, supra (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.); Elkins, supra (medical opinions as to a nexus may decline in probative value where the physician fails to discuss relevant medical history). The report of a November 2017 VA Agent Orange examination relates that the Veteran denied peripheral vascular coldness/numbness/tingling, and neurological tremor/paralysis. Neurological examination results were appropriate, intact and normal. Atrophy, weakness and tremors were not found. The report did not provide any assessment concerning peripheral neuropathy. The report of a June 2019 VA Peripheral Neuropathy examination relates that the Veteran had a diagnosis of lower extremity peripheral neuropathy. A June 2019 VA medical opinion provides that the examiner interviewed and examined the Veteran and reviewed the VA eFolder, all pertinent records and the entire record. The examiner stated that the Veteran's peripheral neuropathy of the bilateral lower extremities was less likely than not incurred in or caused by the Agent Orange exposure during service. The examiner stated that the evidence of the record supported there was nothing to suggest any symptoms, signs, complaints or treatment that remotely suggested peripheral neuropathy and explained the only reference to the Veteran's feet was "foot trouble" which on the same separation examination was expanded to mean athletes feet, a fungal skin condition that had nothing to do with peripheral neuropathy. The examiner stated that he was aware that the Veteran now stated he meant that he was having symptoms of neuropathy in 2019 but found this is not the evidence of the record. The examiner also noted the Veteran also stated he noticed the symptoms in the 1990's. The examiner further explained that peripheral neuropathy related to Agent Orange was a presumptive disability when it is early onset peripheral neuropathy, a condition this Veteran did not have. The examiner stated that, therefore, after reviewing the C-file, VA eFolder, and all pertinent records, it was his opinion that the Veteran had no diagnosis of peripheral neuropathy of the bilateral lower extremity that was at least as likely as not (50 percent or greater probability) incurred in or caused by Agent Orange exposure during service. The Board finds that the June 2019 medical opinion constitutes probative evidence that the Veteran's peripheral neuropathy of the bilateral lower extremities is not related to Agent Orange exposure during active duty. The Board also finds that this medical opinion outweighs the March 28, 2014 letters by Dr. D. Horton. The June 2019 medical opinion is based on current mental examination results and a review of the medical record, including in-service treatment records. The examiner explained his opinion with references to the Veteran's medical history and his own medical expertise. This fact is particularly important, in the Board's judgment, as the references makes for a more convincing rationale that outweighs Dr. Horton's opinion. See Bloom, supra. See also Prejean, supra; Elkins, supra (medical opinions as to a nexus may decline in probative value where the physician fails to discuss relevant medical history). While the Veteran believes that his current peripheral neuropathy of the bilateral lower extremities is related to the athlete's foot shown at separation, or Agent Orange exposure during active duty, as a layperson he is not competent to opine as to these complex medical matters. Specialized medical training and expertise are required. See Jandreau, supra; see also Kahana, supra. Consequently, the Board gives more probative weight to the competent medical evidence discussed above. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the claim. 38 U.S.C. § 5107. 4. Service connection for a disability manifested by memory loss/ confusion, to include as due to herbicide agent exposure and/or secondary to service-connected disability. The Veteran contends that he has a disability manifested by memory loss or confusion as a result of exposure to Agent Orange, or secondary to service-connected disability. He asserts that he has symptoms such as confusion and memory loss after sleep apnea episodes. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the preponderance of the evidence shows that the Veteran does not have a current diagnosis of disability manifested by memory loss or confusion and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). A " 1-Minute Med School " article associated with the eFolder reflects that symptoms of sleep apnea include headaches and an inability to concentrate. As service connection for sleep apnea is denied, service connection for a disability secondary to sleep apnea cannot be warranted. 38 C.F.R. § 3.310 (a). March 2012 correspondence from Neurology Associates of Lynchburg (Dr. O. Marchena) reflects that the Veteran reported a long history of intermittent confusional episodes, but that MRI scan and EEG were benign. Dr. Marchena stated that he was "unsure about the etiology of these episodes" but that the Veteran related them to Agent Orange exposure. As the MRI and EEG were benign, the Board finds that this correspondence does not constitute medical evidence of current disability. March 28, 2014 letters by Dr. D. Horton of Medical Associates reflect his opinion that the Veteran's symptoms of poor concentration and memory "could be" related to Agent Orange exposure, and that it is "more likely than not " that the Veteran's symptoms were attributable to exposure to Agent Orange. Dr. Horton provided no rationale whatsoever, and did not indicate that he reviewed the Veteran's pertinent clinical records. Rather, the opinion appears based on the Veteran's own self-reported medical history. Significantly, Dr. Horton did not provide actual underlying diagnoses related to memory loss or confusion, but merely noted that the Veteran had symptoms or poor concentration and memory. As a result, the Board finds that his opinion has little probative value as to whether the Veteran has a current disability. See Bloom, supra (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). A November 2015 UVA Neuropsychology evaluation report by Dr. K. Fuchs reflects that the Veteran reported a long history of cognitive difficulties, to include memory loss and dizziness after sleep apnea. The Veteran repeatedly reported that his deficits only occurred on days when he had headaches and had not gotten enough oxygen while sleeping. Upon testing, it was noted that the Veteran exhibited "very good cognitive skills and did not exhibit significant deficits." It was further noted that given his medical history he "may have some degree of cerebrovascular compromise that could be contributing to reduced efficiency in some areas." As the Veteran showed "very good cognitive skills and did not exhibit significant deficits", the Board finds that this report does not constitute evidence of current disability. A September 2017 VA clinical note reflects that a risk of not using CPAP/Bi-Level therapy includes memory difficulties. As service connection for sleep apnea is denied, service connection for a disability secondary to sleep apnea cannot be warranted. 38 C.F.R. § 3.310 (a). A November 2017 VA Agent Orange examination report provides no complaints, symptoms, findings or diagnoses relevant to memory loss or confusion. The report of a June 2019 VA Mental Disorders reveals that the examiner reviewed relevant evidence cited by the Board's June 2018 remand. See Stegall, supra. The report provides that the Veteran did not now have and had never been diagnosed with a mental disorder. The examiner stated that he was not making any mental health-related diagnosis including memory/confusion and the Veteran did not meet criteria for such a condition. Furthermore, the examiner explained, even if the Veteran did have such a diagnosis, it would not likely be related to Agent Orange as Agent Orange was not known to cause such problems. The examiner also noted Veteran also appeared to feel the past (and occasional present) claimed memory/confusion episodes were due to his sleep apnea. The examiner pointed out that the VA medical provider in that day's compensation examination also gave to the opinion that sleep apnea was not due to Agent Orange either. The examiner also noted a 2015 neuropsychological evaluation from the University of Virginia did not diagnosis any mental health disorder, including cognitive disorder involving memory/confusion and the Veteran performed adequately on testing that day. The Board finds that the June 2019 medical opinion constitutes probative evidence that the Veteran does not have the claimed disability. The Board also finds that this medical opinion outweighs the March 28, 2014 letters by Dr. D. Horton. The June 2019 medical opinion is based on current mental examination results and a review of the medical record, including in-service treatment records and post-service VA and private treatment records. The examiner explained his opinion with references to the Veteran's medical history and his own medical expertise. This fact is particularly important, in the Board's judgment, as the references makes for a more convincing rationale that outweighs Dr. Horton's opinion, which significantly only refers to symptoms but does not provide any actual underlying diagnoses related to memory loss or confusion. See Bloom, supra. See also Prejean, supra (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.); Elkins, supra (medical opinions as to a nexus may decline in probative value where the physician fails to discuss relevant medical history). While the Veteran believes that he has the claimed current diagnosis, as a layperson he is not competent to opine as to this complex medical matter. Specialized medical training and expertise are required. See Jandreau, supra; see also Kahana, supra. Consequently, the Board gives more probative weight to the competent medical evidence discussed above. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the claim. 38 U.S.C. § 5107. REASONS FOR REMAND 1. Service connection for a disability manifested by dizziness, to include as due to herbicide agent exposure and/or secondary to service-connected disability, is remanded. 2. Service connection for headaches, to include as due to herbicide agent exposure and/or secondary to service-connected disability, is remanded. The claims for service connection for dizziness and headaches are remanded to obtain an adequate medical opinion. Specifically, the June 2020 VA medical opinion is inadequate because the examiner used the wrong standard for aggravation by service-connected disability; that is, "beyond normal progression." See Ward v. Wilkie, 31 Vet. App. 233 (2019). Accordingly, the claims are remanded for new opinions that use the appropriate standard for aggravation by service-connected disability. 3. Service connection for supraventricular tachycardia, to include as secondary to service-connected disability, is remanded. 4. Service connection for hypertension, to include as due to herbicide agent exposure and/or secondary to service-connected disability, is remanded. The claims for service connection for supraventricular tachycardia and hypertension are remanded for compliance with the March 2020 remand. See Stegall, supra. VA CAPRI records associated with the Veteran's eFolder in March 2020 and November 2020 reflect that private medical records of heart and kidney treatment were frequently scanned into VistA imaging. For example, a December 2018 VA record noted that scanned documents from the Cardiovascular Group could be viewed through VistA imaging. These scanned documents are not part of the Veteran's VA eFolder. On remand, the Agency of Original Jurisdiction (AOJ) should obtain all scanned/VistA imaging records relevant to the Veteran's supraventricular tachycardia and hypertension claims. Since the Board is remanding these claims, the AOJ should update the eFolder to include all outstanding VA treatment records. The matters are REMANDED for the following actions: 1. Please obtain and associate with the Veteran's eFolder copies of all outstanding VA treatment records. 2. Please obtain and associate with the Veteran's eFolder all scanned/VistA imaging records relevant the Veteran's supraventricular tachycardia and hypertension claims. 3. Please obtain an addendum opinion from an appropriate VA clinician regarding whether it is at least as likely as not that the Veteran's disability manifested by dizziness, and his headaches, were aggravated (defined as any increase in disability), by service-connected disability. The clinician must provide a complete rationale for any opinion expressed. If the clinician cannot provide an opinion without resort to speculation, the clinician should provide an explanation as to why this is so and identify what, if any, additional evidence would permit such an opinion to be made. 4. Please complete any needed additional development deemed necessary as a result of the additional materials received on remand. 5. Thereafter, readjudicate the issues on appeal. If any benefit sought is not granted, furnish the Veteran and his representative with a supplemental statement of the case and afford them an opportunity to respond before the record is returned to the Board for further review. M. ESPINOZA Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Davitian, 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.