Citation Nr: 21032009 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 10-10 237 DATE: May 25, 2021 ORDER Entitlement to an initial compensable rating for right cheek scar, residuals of sebaceous cyst, is denied. Entitlement to service connection for back disability is denied. Entitlement to service connection for psychiatric disability, to include as secondary to service-connected status post total abdominal hysterectomy, is denied. FINDINGS OF FACT 1. From the February 29, 2008 effective date of service connection through the date of her death, the Veteran's right cheek scar did not manifest as painful, unstable, or involving underlying soft tissue damage, only measured 1.25 square cm, was not associated with any characteristics of disfigurement, and did not result in any functional limitation. 2. The preponderance of the evidence is against finding that the Veteran's back disability had manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability was not otherwise etiologically related to an in-service injury, event, or disease. 3. The Veteran's psychiatric disability was not evident during service, or until many years thereafter, was not otherwise related to her military service, and was not caused or aggravated by any service-connected disability. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for right cheek scar, residuals of sebaceous cyst, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.118, Diagnostic Codes (DCs) 7800-7805 (in effect prior to August 13, 2018). 2. The criteria for service connection for back disability have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for psychiatric disability are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1971 to February 1973 and from June 1987 to December 1987, with periods of service in the Reserves between April 1986 and September 1989. These matters initially came before the Board of Veterans' Appeals (Board) from a December 2008 rating decision. The Veteran testified at a Board hearing in August 2014 before a Veterans Law Judge (VLJ). A transcript of that proceeding is associated with the claims file. The VLJ who conducted the hearing has since retired from the Board and is unable to participate in any further adjudication. Following the hearing, these matters were remanded in May 2015 for additional evidentiary development, to include obtaining relevant outstanding Social Security Administration (SSA) records and medical records and scheduling new examinations to assess the severity of the Veteran's service-connected cheek scar and to obtain an opinion as to whether her claimed psychiatric disability was related to service or was caused or aggravated by service-connected disability. Having fully reviewed the claims file, the Board finds that the agency of original jurisdiction (AOJ) substantially complied with the prior remand directives to the extent possible. Stegall v. West, 11 Vet. App. 268, 271 (1998). Thereafter, in November 2016, VA was notified that the Veteran passed away earlier that month. The appellant is the Veteran's surviving spouse and he was substituted as the claimant in August 2019. As noted above, as the VLJ who conducted the August 2014 hearing is no longer with the Board, and as pursuant to Quinn v. Wilkie, 31 Vet. App. 284 (2019), an appellant may have a second hearing following a Board remand, the appellant was offered an opportunity for a new hearing. He was notified that a Board hearing had been scheduled for a date in November 2020 by way of an October 2020 letter. This letter was sent to his address of record and was not returned as undeliverable. The appellant failed to appear for the scheduled Board hearing. To the Board's knowledge, he has not requested that the requested hearing be rescheduled. Therefore, the Board may proceed to consider the appellant's appeal. The appellant has not raised any issues with the duty to notify or duty to assist in obtaining documentary evidence. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Thus, the Board need not discuss any potential issues in this regard. Higher Initial Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to active service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA should interpret reports of examination in light of the whole recorded history, reconciling the reports into a consistent picture so that the current rating may accurately reflect the elements of disability. See 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. See 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. See 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. see 38 C.F.R. § § 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. See 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). The Board has reviewed all the evidence of record. Although the Board has an obligation to provide adequate reasons and bases supporting its decisions, there is no requirement that the Board discuss every piece of evidence in the record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board will summarize the relevant evidence, as deemed appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to each claim. Right Cheek Scar The Veteran's right cheek scar, residuals of sebaceous cyst, was rated noncompensable under the schedule of ratings for the skin. See 38 C.F.R. § 4.118, DC 7800. Changes to the rating schedule for skin disabilities became effective August 13, 2018. The amended rating criteria, if favorable to the appellant's claim, can be applied only for periods from the effective date of the regulatory change. However, the old regulations will be considered for the periods both before and after the change was made. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). As is the case here, as the Veteran passed away prior to the amended criteria, the scar will be considered based on the rating schedule prior to the changes in August 2018. In every instance where the schedule does not provide a 0 percent rating for a diagnostic code, a 0 percent rating shall be assigned when the requirements for a compensable rating are not met. See 38 C.F.R. § 4.31. The diagnostic criteria instruct that scars (including linear scars) and other effects of scars are rated as burn scar(s) of the head, face, or neck (DC 7800); scar(s) not of the head, face, or neck, that are deep and nonlinear (DC 7801); scar(s) not of the head, face, or neck, that are superficial and nonlinear (DC 7802); or, unstable or painful scars (DC 7804), depending upon the predominant disability. Alternatively, disabling effects not considered under ratings for scars are to be evaluated under an appropriate diagnostic code. See 38 C.F.R. § 4.118, DC 7805. Under the applicable criteria for evaluating scars, compensable (10 percent) ratings are assigned for scars of the head, face or neck or other disfigurement of the head, face or neck with one characteristic of disfigurement. See 38 C.F.R. § 4.118, DC 7800. The eight characteristics of disfigurement include: a scar with 5 or more inches (13 or more cm.) in length; a scar at least one-quarter inch (0.6 cm.) wide at widest part; surface contour of the scar is elevated or depressed on palpation; the scar is adherent to underlying tissue; the skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); the skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); the underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm.); or the skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.). See Id., Note 1. Higher ratings may be assigned where the scar is manifested by visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features or three characteristics of disfigurement (of the head, face or neck), deep and covers an area of at least 12 sq. inches but less than 72 sq. inches or unstable or painful (three or four scars). At an October 2008 VA examination, the examiner noted the Veteran had a 3.5 cm right facial scar in the middle of the cheek area. The scar was flat and not undulated. There was no elevation and no keloid formation. There was no inflammation or tissue loss. There was no pain on deep palpation. The color was similar to surrounding skin. The examiner noted that it was very difficult to visualize without close examination, and found the Veteran had a "minimal residual scar" from removal of a cyst on the right cheek. Following the 2015 Board remand, the Veteran underwent another examination in July 2016. She reported that over the years she required no further medical evaluation and/or treatment for the scar on the right cheek and reported no pain, burning, or numbness of the scar, but did note that it itched on occasion. She stated that she did not apply any topical ointments/lotions, and that she did not use makeup to cover the scar as it was barely visible. On examination, the examiner marked that the right cheek scar was barely visible, and noted that as pointed out by the Veteran, she was also not wearing any makeup to cover the scar. The examiner stated that "at close range in direct lighting, there is a pinkish tint to scar that is well-disguised by bilateral cheeks with symmetrically appearing superficial telangiectasias and normal age-related wrinkling that disguise the right cheek scar." The examiner further noted that the scar was smooth and flat, without scaling or irregularity of skin surface on the scar that blended into surrounding tissue without a clearly defined border, and there was no depression, elevation, or dimpling of the scar. It was further noted that the scar was not painful, unstable, did not have frequent loss of covering of skin over the scar, and was not due to a burn. The length and width of the scar was 2.5 x 0.5 cm (1.25 sq. cm.) with no elevation, depression, adherence to underlying tissue, or missing underlying soft tissue. The Veteran's VA treatment records indicate that she did not report any pain or instability to her right cheek scar during physical assessments. As such, prior to her death, the Veteran's facial scar manifested with no more than a well-healed, linear scar of approximately 1.25 sq. cm. surface area, and warranted no more than a noncompensable rating. A higher rating is not warranted because the Veteran's facial scar disability was not painful or unstable and did not demonstrate any characteristic of disfigurement. Given these facts, the Board finds that a noncompensable rating adequately reflected the Veteran's facial scar and a compensable rating is not warranted at any time from the February 29, 2008 effective date of service connection through the date of the Veteran's death. As a final point, in conjunction with the appeal for a higher initial rating for right cheek scar, residuals of sebaceous cyst, neither the appellant nor his representative have raised any other related issues, nor have any other such issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to prevail on the issue of service connection there must be competent evidence of current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Elements of service connection may also be established by showing continuity of symptomatology under 38 C.F.R. § 3.303 (b). Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson v. Shinseki, 581 F.3d 1316 ; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309 (a), such as arthritis. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted if injury or disease was incurred or aggravated during a period of active duty for training (ACDUTRA), 38 U.S.C. § 101(24)(B); 38 C.F.R. § 3.6(a), and for only injury incurred or aggravated during a period of inactive duty training (INACDUTRA) (injuries include acute myocardial infarction, cardiac arrest, or cerebrovascular accident). See 38 U.S.C. § 101(24)(C); 38 C.F.R. § 3.6(a). In addition, service connection may be warranted for disability that is proximately due to, the result of, or aggravated by service-connected disability. See 38 C.F.R. § 3.310. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. Gilbert, at 53. 1. Back disability The appellant contends that the Veteran should be service connected for a back disability because her back was injured in service, and she had continuous back pain following service. The question for the Board is whether, prior to her death, the Veteran had a chronic back disability that manifested during service or to a compensable degree within the applicable presumptive period, whether continuity of symptomatology was shown after service, or whether it was otherwise related to her service. The Board has considered all of the evidence but finds that the preponderance of the probative evidence demonstrates there was no nexus between the Veteran's claimed back disability and her military service. First, the Board concludes that, while the Veteran had a current back disability at the time of her death, best characterized as grade 1 spondylolisthesis of L4-5 with moderate central canal stenosis and DDD of L5-S1 with small annular tear, as endorsed by an October 2008 examiner, which is a chronic disease under 38 C.F.R. § 3.309(a), there is no persuasive evidence showing the condition became chronic during service or manifested to a compensable degree within a presumptive period, and continuity of symptomatology is not established. Specifically, while the Veteran was competent to report having experienced symptoms of back pain and related symptoms in service and since service, she did not have the requisite medical knowledge or expertise to be deemed competent to provide a diagnosis in this case or determine that these in-service symptoms were manifestations of the later diagnosed back disorder. The issue is medically complex, as it requires knowledge of interpretation of complicated diagnostic medical testing. Jandreau, 492 F.3d 1372, 1377. Although the Veteran reported that she had been going to Dr. G.C since service, the records submitted only showed care beginning in 1998. Further, the first indication Dr. G.C. gave of any back problems was not until 2001 and the Veteran specifically denied any back pain in March 2000. In addition, when the Veteran established care with VA in April 1999, she did not report any back issues, but again, rather first reported back pain in 2001. Therefore, there is no indication the Veteran's back disability had manifested to a compensable degree within one year of separation. The Board notes that the Veteran's service treatment records (STRs) indicate that the Veteran sought treatment for back pain in service one time when she was treated for an acute lumbosacral strain in 1971. It was noted that she had fallen down a flight of stairs and complained of pain over the entire body. Following evaluation, the impression was acute lumbosacral strain and she was provided pain medication and placed on light duty for two days. There was no additional treatment or complaints associated with this injury shown through the remainder of her military service. On her separation examination in January 1973, there were no physical abnormalities of her spine and her re-affiliation examination in May 1986 was negative for any abnormalities of her spine and she was found to be physically fit for duty. The Board notes that the STRs included medical treatment and complaints of other complaints and injuries, which weighs heavily against any assertion she had injured her back and had chronic back pain as well, because it is reasonable to assume that since she was taking the time to receive medical care and to complete the medical history forms and affirmatively indicate the medical problems she had, she would have also reported any ongoing back pain. Rather, as summarized above, her medical records showed that any back pain had resolved. This evidence affirmatively shows that although she had some back pain due to strain during service, it had resolved by the time of her separation, with no further complaints during her remaining military service (which extended more than 15 years after that complaint of back pain in 1971). The Veteran herself stated her back pain resolved after the service injury and did not return until the 1990s (see below). Therefore, there is no persuasive evidence of continuity of symptoms. That notwithstanding, the Board must also consider whether service connection for the back disability may still be granted on a non-presumptive direct-incurrence basis; however, the preponderance of the evidence is against finding that a medical nexus existed between the Veteran's claimed back disability and an in-service injury, event or disease. See 38 U.S.C. §§ 1110, 1131; Holton, 557 at 1366; 38 C.F.R. § 3.303(a), (d). Evidence against the claim includes the 2008 VA examination. The examiner noted the diagnosis of grade 1 spondylolisthesis of L4-5 with moderate central canal stenosis and DDD of L5-S1 with small annular tear. The examiner also noted the CT scan dated in June 2008 which showed mild disc space narrowing at L4-5 and that she had grade 1 spondylolisthesis of L4 and L5 with moderate central canal stenosis and mild impression of the right L4 nerve root with some disc material. The Veteran also reported to the examiner that she fell in 1971 and that she had an X-ray done showing pathology of L4-5 and being off duty for 5-10 days on bed rest. The examiner noted the service record of L-S strain without any imaging and that the Veteran herself then reported she had no further problems after that injury and that the back issue had resolved, and she had no issues with her back until 1991 when working as a bartender, where she lifted a lot of beer kegs and buckets of ice. She stated that in 1998 she had daily back pain and quit bartending. The examiner considered the Veteran's contentions and the report of her fall in 1971, but also noted that the Veteran herself stated it had "completely resolved and she was able to function with no back pain until 1991." The examiner discussed the case with an orthopedic surgeon who also concluded "that the severe pathology that is revealed on CT and MRI scan presently is difficulty to attribute to a fall so long ago that did not become symptomatic for 20 years." As such, the examiner and surgeon opined that the back condition was not the result of or caused by the fall in service. The examiner again noted the Veteran fell down some stairs while in service and acknowledged the private opinion that the current back issues were due to this fall, but noted that there was no mention of any back problems at separation. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In this case, the Board finds that the VA opinion is probative. Specifically, the Board finds that the examiner was aware of the Veteran's medical history, provided a fully articulated opinion, referred to a neurosurgeon to support her rationale, considered the opposing opinions and records in the file, and furnished a reasoned analysis for her conclusions. The examiner also accepted the circumstances of the in-service back pain as described by the Veteran and shown in her service records, but still found such back pain was not related to the current condition. The Board therefore attaches significant probative value to this opinion. In favor of the claim, the Veteran provided testimony at the 2014 Board hearing, where she testified as to her injury in service when she fell down the stairs and she was off duty for three weeks (this contradicts the STRs indicating it was for only TWO days). She also stated she had reported back pain and received treatment in service, but as noted above, the STRs contradict this statement. She stated she had seen Dr. G.C since service due to back pain in service (but as noted above, the earliest record from Dr. G.C. is from 1998, and there are no mentions of any back pain, problems, or treatment until 2001). She also provided a statement from Dr. G.C. in October 2007. Dr. G.C. stated that the Veteran had several back injuries while in the military, specifically that she fell down the stairs and had a lumbosacral strain and he "thinks this has precipitated her chronic back problems [and] was most likely caused by the fall." In a January 2009 second letter from Dr. G.C., he stated that the Veteran told him about her fall down the stairs in service and after reviewing her service records, that he feels this is the start of her chronic low back problems. However, although Dr. G.C had been treating the Veteran for years, his opinion is not afforded any probative weight. First, he did not provide an adequate rationale, but rather, appeared to rely on the Veteran's reported history. He did not discuss the normal findings at separation in 1973, the negative findings for any back issues upon re-enlistment in 1986, nor any of the post-service diagnostic test results that the VA examiner discussed. Further, and more importantly, he contradicts his own medical records. For example, again, the medical records do not show that prior to 2001 there was ever any reports of any kind of back pain until the Veteran hurt her back in November 2001. Specifically, although she reported to the 2008 examiner that she quit bartending in 1998 due to back pain, she reported to Dr. G.C. that she was stressed over financial issues and her employers would not give her a raise so she would likely quit. In March 2000, she denied any back issues and had a normal back during examination. Further, he stated the Veteran had "several back injuries while in the military" but this is simply not true, which negates his statements that he reviewed the service records as there was only one incident, which the Veteran herself reported had resolved. As such, the report is not supported by any contemporaneous clinical evidence or recorded history and is purely speculative. A bare conclusion, even one written by a medical professional, without a factual predicate in the record does not constitute persuasive evidence sufficient to establish a nexus between the Veteran's back condition which was clearly first shown in 2001 and any incident related to her active military service. The Board also reviewed the medical evidence submitted by the Veteran including her VA and private medical records; however, the Veteran's statements do not correlate with the medical records. For example, as noted it was not until 2001 that any back condition was reported. Specifically, in March 2002 she was admitted to Wheeling Hospital for hemilaminectomy L4-5 after developing tingling in her back after moving a piano in November 2001. She stated she then woke in January 2002 with severe low back pain and used a cane since. Her VA medical records also show the first report of low back pain being November 2001. In January 2002, she reported a three-week history of left L5 radiculopathy which started suddenly when she woke up one morning which correlates with the private medical records. Then, in November 2007, she reported that in 2005, she fell down her basement stairs and injured her back and that in 2007 she slipped on her iced porch and fell which caused her back pain to worsen. An MRI dated in December 2007 revealed moderate to severe spinal and foraminal stenosis at the L4-5 level. A March 2008 letter from her neurosurgeon indicated that the Veteran stated she lifted heavy kegs of beer while working as a bartender which "she feels may have contributed to her symptoms." The records show that the Veteran worked as a bartender between her active duty service periods, as well as after separation until she quit in 1998. There was no indication in any of the medical records that the Veteran's back condition was related to the in-service event or to her military experience, nor did she relate her military injury as a potential cause of her back condition to her medical providers until contemporaneous in time to her 2008 claim with VA. In fact, when she filed a claim for nonservice-connected pension benefits with VA in 2002, she listed that her back condition began in 1998. As such, the Board concludes that the totality of the evidence, especially the negative VA nexus opinion, the STRs indicating the back strain was resolved, and the medical evidence clearly indicating intercurrent causes led to back pain, all weigh against the claim, and are more persuasive than any evidence in favor of the claim. Therefore, the Board finds that the VA examiner's opinion is more probative in this matter and outweighs the Veteran's lay opinions and the statement from her private physician. There is no other evidence of a relationship between the Veteran's claimed back disability and service, and neither the appellant nor his representative have alluded to the existence of any such evidence. Thus, the preponderance of the evidence is against a finding that the Veteran's claimed back disability had its onset in service, manifested to a compensable degree within one year after any period of active service, or was otherwise related to service. Accordingly, as the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and service connection for back disability is not warranted. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49. 2. Psychiatric Disability As for the Veteran's psychiatric disability, prior to her death, she asserted that she had depression that should be service connected as it was allegedly caused by and began in service, or, in the alternative, was caused by her service-connected hysterectomy. The question for the Board is whether the Veteran had a mental health disorder that began during service or was at least as likely as not related to an in-service injury, event, or disease. Here, the Veteran contended, in part, that she had an acquired psychiatric disorder, to include anxiety and depression, caused by her military service. However, for service connection to be warranted, a psychiatric disorder must be found to relate back to such incidents, or other incidents of active service. First, the Veteran's STRs reveal no diagnosis of or treatment for symptoms of depression. In January 1973, the medical examination marked "normal" findings under psychiatric conditions; and she marked "no" to depression or excessive worry or nervous trouble of any sort. The May 1986 clinical evaluation was marked as normal for her psychiatric condition. In the report of medical history she marked "no" to depression or excessive worry or nervous trouble of any sort. She indicated her 1985 total hysterectomy, but it was marked there had been no problems since and it was not currently disabling. She further marked "no" to having ever been treated for a mental condition. After service, there is no record of treatment for psychiatric issues and no confirmed manifestation of a mental illness to a degree of 10 percent or more within one year of separation. Rather, it was not until April 1999 10 years after Reserves and 12 years since active duty in an initial visit with VA that she reported she had been diagnosed with depression four months prior and had been taking Premarin for about six years for her status post hysterectomy, but denied any other complaints. Her SSA medical records correlate with this timeline, as the earliest record of December 1998 indicated she had some anxiety due to her job and finances. In her SSA disability psych assessment, it was noted that from January 1999 to June 2004, the Veteran had an affective disorder, depression, and anxiety that were not severe. The degree of limitation was marked as mild or none. The examiner noted that she was on medication and that she was asymptomatic and stable. There was no indication in the medical records that her depression was associated with any in service event or experience. In the October 2008 VA examination, the Veteran stated that the military put her on birth control and when she went off them, it caused her to hemorrhage and started her depression. She also stated she was depressed because of marriage issues, and she also reported financial anxiety and sadness over her father and brother dying. She stated she used to be social and do activities with her husband but now that he was gone, she had a restricted social life. The examiner diagnosed her with dysthymic disorder unrelated to the military and noted finances, occupation, and marital discord were main factors. The examiner opined that the Veteran did not have symptoms of an anxiety disorder but rather for a dysthymic disorder and that "her dependent personality features may exacerbate her reaction to life stressors and worsen symptoms of her dysthymic disorder at times." The examiner also noted that the Veteran's first reports of her symptoms becoming problematic were in 1999 after her daughter married and moved out of the house, and that "this was very hard for her to handle." As noted above, the Veteran first established care in April 1999 with VA, where she reported first being diagnosed with depression four months prior. There was no indication in the medical record that her depression was associated with any in service event or experience. Then, in June 2004, it was noted she had a history of depression and current issues were related to family stresses. Then, in May 2005, she described distress associated with marital difficulties as the result of the death of her mother-in-law because her husband was traveling significantly to care for his father. The records were negative for any true mental health care or evaluations until July 2008 when she had a psychological consultation where she reported a number of significant life stressors, both ongoing and acute, to include the death of her brother and mother. She also reported that she was separated from her husband. Following evaluation, the diagnosis was major depression versus dysthymia. There was no indication in the medical evidence that she was suffering from any chronic psychiatric condition associated with her military service. The Veteran also submitted a June 2002 letter from Dr. G.C. who stated that he had been treating the Veteran and she had anxiety and depression since 1999. She also submitted a second October 2007 letter from Dr. G.C., who stated that the Veteran had a history of anxiety and depression that "is most likely caused by...her dysfunction uterine bleeding [and] the stress she was under while in the military and some chronic problems with her back." However, the Board finds that this report is not supported by any contemporaneous clinical evidence or recorded history in this record but rather is purely speculative. A bare conclusion, even one written by a medical professional, without a factual predicate in the record does not constitute evidence sufficient to establish a nexus between any present psychiatric condition and any incident related to the Veteran's active military service or any service connected disability. As such, this opinion is not afforded probative value. At the August 2014 Board hearing, the Veteran testified she had received treatment for depression beginning in 1972 while in the military (no records showing such and she herself denied receiving any mental health treatment in her STRs). She also stated she reported that she had nervous trouble at discharge; but again this contradicts what she actually put on the report of medical history. She also stated she received treatment from Dr. G.C. for depression beginning in 1973, but the earliest record from Dr. G.C. is from December 1998. Further, she specifically denied in her Reserves STRs that she had any mental health disorders upon enlistment and at separation as noted above. All of this evidence weighs heavily against her testimony of having mental health issues during service, which the Board finds not credible. That notwithstanding, as the Veteran was granted service connection for the 1985 hysterectomy and she alleged her depression was caused/aggravated by this, following the 2015 Board remand, the Veteran was afforded another VA examination in July 2016. The examiner confirmed a diagnosis of moderate recurrent depressive disorder. The examiner discussed the Veteran's military service, which the Veteran stated she got along "excellent" with other Marines and her command. She moved up in ranks quickly with no evidence of social impairment and no loss of rank or any disciplinary problems. Post-service, the examiner noted that in 2007, the Veteran's husband left, although they did not divorce; that she was close to her daughter and two grandchildren and has a close friend. She was diagnosed with cancer and has other medical conditions such as a broken tibia, fibromyalgia, and chronic fatigue. She reported she felt depressed in 1970, had second thoughts about joining the Marines, and that she felt depressed again after the uterine bleeding occurred, she underwent several D&Cs, and had the hysterectomy in 1986. She stated her fertility issues caused her to feel depressed, too. The examiner reviewed the private and VA medical records, and noted that the records show the Veteran experienced exacerbations of depression coinciding with stressful life events. The Veteran also stated that her mood was poor lately due to reportedly being told in February that she only had months to live. The examiner, in summarizing the examination report, stated that the Veteran reported being depressed for many years and remembers feeling depressed just before entering the Marines, during her service, and following her service. However, the examiner noted that despite the Veteran's statements, the STR's are silent for any mention of depression, and noted the first time the Veteran presented for mental health treatment was 1999, 14 years after her hysterectomy. As such, the examiner stated that "there is no evidence on record, besides the Veteran's report, to suggest that her depression is due to her military service or her hysterectomy. Having a hysterectomy can be an emotional experience, but there is no medical evidence to support the claim that depression is a direct pathophysiological result of hysterectomy." Further, the examiner noted that the Veteran's medical records show she had "exacerbations of depression periodically, for example in 2008 due to marital issues, and more recently as she is experiencing significant health problems. Recurrent Major Depressive Disorder is, by definition, episodic, with stressful life events often prompting another depressive episode. The Veteran therefore has demonstrated a rather typical pattern of recurrent depressive episodes. There is no evidence on record, besides the Veteran's report, to suggest that her depression is due to her military service or to her hysterectomy." Therefore, the examiner opined it was less likely than not the Veteran's depression is proximately due to or the result of the service-connected disability, as "there is no medical evidence to support the claim that depression is a direct pathophysiological result of hysterectomy. Additionally, there is no evidence of treatment for depression until 14 years later." Further, the examiner stated that "there is also no evidence to support the claim that her depression was aggravated beyond its natural course by her service connected total hysterectomy since (as noted above) depression would be expected to recur, particularly around times of stress in a person's life." As such, the depressive disorder is less likely than not incurred in or was caused by service, or proximately due to or the result of a service-connected disability. Finally, while the Board recognizes the Veteran's assertions prior to her death that her depressive disorder was related to service and she was competent to testify as to events that occurred in military service, the Veteran was not competent to conclude that any condition was connected to her service. Although lay persons are competent to provide opinions on some medical issues, the specific disabilities in this case, psychiatric disorders, fall outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau, 492 F.3d 1372. Further, as discussed in more detail above, a review of the Veteran's VA medical records showed that although she was prescribed medication for depression and anxiety, she did not relay prior to her claim that these symptoms were caused by her service. In addition, as noted, the Veteran's depression was consistently referenced in relation to marital and family and health issues, not the military. Therefore, the Board finds that the Veteran's statements of record cannot be accepted as competent evidence sufficient to establish service connection for her psychiatric conditions. Moreover, there is no persuasive medical opinion that relates the depressive disorder to military service. The only note of record from Dr. G.C. was deemed to be speculative and not probative (see above) and was inconsistent with the rest of the evidence. Further, as noted above, at separation from active duty and enlisting in the Reserves, it was noted she did not have any mental health disorders, which weighs heavily against any statements during the claims process that her depressive disorder began during service. (CONTINUED ON NEXT PAGE) There is no other evidence of a relationship between the Veteran's psychiatric disability and service or service-connected disability, and neither the appellant nor her representative have alluded to the existence of any such evidence. Thus, the preponderance of the evidence is against a finding that the Veteran's claimed psychiatric disability had its onset in service, was otherwise related to service, or was caused or aggravated by service-connected disability. In light of these findings, the Board concludes that service connection for psychiatric disability is not warranted. In reaching this conclusion, the Board considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.§ 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Brian J. Elwood Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G.Hoy, 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.