Citation Nr: 21032732 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 16-33 236 DATE: May 27, 2021 ORDER Service connection for an acquired psychiatric disorder is denied. Service connection for a back disability is denied. Service connection for a respiratory disability is denied. Service connection for headaches with vomiting is denied. REMANDED Entitlement to service connection for a sleep disorder is remanded. FINDINGS OF FACT 1. The Veteran does not have a current diagnosis for PTSD; his unspecified depressive disorder did not manifest in service or is otherwise attributed to service. 2. The Veteran's back disability was not shown as chronic in service and did not manifest to a compensable degree within one year of service; continuity of symptomatology is not established or is attributable to intercurrent causes; and not otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that the Veteran's chronic obstructive pulmonary disease (COPD) began during active service or is otherwise related to an in-service injury or disease. 4. The Veteran's migraine headaches were not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. 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, 3.307, 3.309. 2. The criteria for service connection for a back disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for a respiratory disability 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 headaches with vomiting have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1989 to August 1990, with additional National Guard service. He also had a period of active duty for training (ACDUTRA) from May 1999 to June 1999. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In November 2018, these matters were remanded by the Board for further development, which has since been completed, except for the claim of sleep disorder that will be discussed in the Remanded section below. Service Connection Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Certain chronic diseases 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 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). In addition to active duty, "active service" includes certain periods of training for National Guard or Reserve service. A veteran's National Guard service may only be considered qualifying service for the specific time periods when he has orders calling him to federal service. Allen v. Nicholson, 21 Vet. App. 54 (2007); see also 10 U.S.C. § 12401. Service connection may only be granted for a disability resulting from disease or injury incurred or aggravated while performing active duty for training (ACDUTRA), or for an injury incurred or aggravated while performing inactive duty training (INACDUTRA or IDT), but not for a disease during inactive duty training, except from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident. 38 U.S.C. §§ 101(24), 106; 38 C.F.R. § 3.6. The chronic disease presumption does not apply to claims based on a period of ACDUTRA. Smith v. Shinseki, 24 Vet. App. 40, 47 (2010). 1. Entitlement to service connection for an acquired psychiatric disorder. The Board recharacterized the Veteran's claim for PTSD in the November 2018 remand. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran asserts he experienced abuse, mistreatment, and discrimination during service, while stationed at Fort Hood. See May 2014 VA Form 21-0781, Statement in Support of Claim for Service Connection for PTSD. Later statements show the Veteran asserts he was locked in a gas chamber for punishment, saw his friend get shot on the range, and/or held his friend to prevent him from doing harm to himself. The Veteran has current psychiatric diagnoses. His service records verified he was stationed at Fort Hood. The question remains as to whether the Veteran's psychiatric disorder is related to his active service or had onset during and continued since separation from service. The Board concludes that, while the Veteran has a current diagnosis of unspecified depressive disorder, the preponderance of the evidence weighs against finding that it is related to his active service or had onset during and continued since separation from service. The preponderance of the evidence is against finding for a current diagnosis of PTSD for VA compensation purposes. On his April 1990 Chapter 13 separation Report of Medical History (RMH) form, he denied depression or excessive worry or nervous trouble of any sort. His April 1990 Chapter 13 separation examination was normal for psychiatric on clinical evaluation. Prior to separation, he underwent a mental status evaluation in May 1990. The clinician noted that the Veteran's behavior was normal, and the service member had the mental capacity to understand and participate in the Chapter 13 proceedings. On his November 1997 enlistment RMH form for the National Guard, he denied nervous trouble of any sort or depression or excessive worry. The physician's summary noted that the Veteran stated there was a lot of abuse during service and that he went to the Judge Advocate General (JAG) and Chaplin, but his November 1997 enlistment physical examination for the National Guard found normal psychiatric on clinical evaluation. During his service in the National Guard, his January 1998, December 1998, and December 1999 annual medical certificate reflected that the Veteran denied having current medical problems or been seen by a physician or other health care provider since his last periodic physical or annual medical screening. He was seen during ACDUTRA in June 1999 for tick on left leg, blister on his feet, and bug bites. There were no other ACDUTRA treatment records. His service records do not reflect combat service, nor has he alleged having been in combat. Private treatment records in 2013 to 2014 show he was seen for a history of PTSD and depressive disorder. At his initial visit in December 2013, Dr. R.L. noted that the Veteran had no history of treatment for emotional problems. On his initial assessment questionnaire form, he noted that he did not believe he was depressed, just that he had seen a lot of things. An October 2014 VA note indicated the Veteran's statement lacked sufficient information to conduct a search at the Military Records Research Center. A subsequent note in January 2015 stated that the research center does not corroborate personal trauma events. On his VA Form 9, C.A.W., his sister, wrote that the Veteran has been emotionally scarred from the mistreatment, abuse, and discrimination encountered during service. When he was released from active service, C.A.W. averred that she thought he was 'crazy and shell shocked.' In February 2018, the Veteran was evaluated by Dr. N.J.S. for Social Security Administration (SSA) disability benefits. Dr. N.J.S. noted that he was a poor historian, frequently becoming fixated on describing his 'TBI, PTSD, back pain, and migraines.' The Veteran reported experiencing trauma in service and reported that 'it was a lot of people playing mind games.' However, he denied experiencing intrusive memories, recurrent nightmares, psychological distress to cues, flashback, hypervigilance, or an exaggerated startle response related to his in-service events. Dr. N.J.S.'s impressions were unspecified anxiety disorder and malingering. In February 2019, D.T. submitted a statement that the Veteran has been in treatment at their facility since November 2018, and that he carried a 'chronic mental illness.' No etiology opinion was provided. The Veteran underwent a VA mental disorders examination in November 2019, pursuant to the Board's remand. The examiner provided a diagnosis of unspecified depression with anxious distress. The Veteran reported that he fell and hit his head on the ground in 1990. He was also in a motor vehicle accident in 2010. The Veteran reported four stressors: 'being locked in the gas chamber' for punishment, his 'best friend got shot on the range,' 'my roommate jumped out the window and I was holding him,' and that he 'dealt with contaminated soil.' The examiner found these stressors did not meet criterion A. The examiner found no documented head injuries in service. After review of the Veteran's claims file and based on the clinical interview, the examiner found that his psychiatric disorder was less likely than not related to service. The examiner explained that the Veteran did not receive mental treatment in service, and he was seen for VA treatment in 2003 and 2005 with negative depression and PTSD screenings. He was not diagnosed with PTSD until 2014, which was several years after separation from service. In August 2020, the Veteran was afforded a VA contract examination for PTSD. The examiner provided a current diagnosis of unspecified depressive disorder with anxious distress, after finding that his symptoms did not meet the diagnostic criteria for PTSD under the DSM-5 criteria. The Veteran reported three stressors: he was verbally abused and threatened by his superiors at Fort Hood, he held his friend during a suicide attempt, and he was locked in the gas chamber for punishment. The examiner found that these stressors did not meet criterion A. The examiner also found that his unspecified depression with anxious distress was less likely than not due to service. There was no evidence that would suggest mental health treatment during service, and the Veteran denied anxiety and PTSD at his 2003 and 2005 VA treatment visits. Given the above, the Board finds that a current diagnosis of PTSD has not been established. The Board has considered the medical evidence provided by the VA examiner, VA contract examiner, and Dr. R.L. in connection with the Veteran's claim. In comparing these medical reports and opinions, greater weight may be placed on one physician's opinion than another's depending on factors such as the reasoning employed by the physicians and whether (and the extent to which) they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). In this case, the Board finds the opinions of the 2019 VA examiner and 2020 VA contract examiner regarding whether the Veteran has a diagnosis of PTSD to be competent and the most persuasive. These examiners reviewed and summarized the relevant medical history, including the Veteran's private mental health treatment. These findings were corroborated by Dr. N.J.S. in his SSA mental health evaluation, who also did not provide a PTSD diagnosis. The findings from Dr. R.L. are not fully explained and simply indicate that the Veteran had a history of PTSD. Therefore, the VA examiner and VA contract examiner's assessments are considered more probative. As for a causal link, the preponderance of the evidence is against finding that the Veteran's unspecified depressive disorder is due to service. The Board finds the VA and VA contract opinions highly probative in determining whether the Veteran's unspecified depressive disorder is related to his period of service, as they are shown to have been based on a review of the Veteran's record and are accompanied by a sufficient explanation. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board has considered the private medical records from Dr. R.L. and D.T., but as neither addressed the nature and etiology of the Veteran's psychiatric disorders, they are of little probative value. Moreover, the Board finds that there has not been continuity of signs or symptoms of a psychiatric condition since separation from service. Namely, the Veteran's annual medical certificates in 1998 and 1999 while in National Guard denied having current medical problems or that he had been seen by a physician or other health care provider since his last periodic physical or annual medical screening. The first indication of mental health treatment was not until 2013, which is many years after service. The Board acknowledges the Veteran's assertions that his unspecified depressive disorder is related to his military service and has considered his and C.A.W.'s assertions. However, as this issue is medically complex, they are not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Since the competent and probative evidence of record fails to indicate that the Veteran's unspecified depressive disorder had onset in, or is otherwise related to service, service connection is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for a back disability. The Veteran indicated he has experienced back problems since service. Specifically, he asserts that he hurt his back during field exercises from April to July of 1990 while lifting, loading, and unloading artillery rounds. See December 2014 correspondence. He also asserts that he suffered a lower back injury in June 1990 loading and unloading artillery rounds in the field, suffering an injury to his left arm and was then seen in Fort Hood. Moreover, he reported aggravating his back trying to hold onto another service member. See July 2016 VA Form 21-4138, Statement in Support of Claim. Service treatment records were negative for complaints of or treatment for a lower back condition. On his April 1990 Chapter 13 separation Report of Medical History (RMH) form, he denied arthritis, rheumatism, or bursitis and bone, joint, or other deformity. He reported recurrent back pain and wrote that he was in perfect health except for back pains on and off. The physician's summary section of the form noted recurrent back pain. On his April 1990 Chapter 13 separation examination, the Veteran's spine, other musculoskeletal was found to be normal on clinical evaluation. Prior to his actual separation from service, a June 1990 emergency care record in the Fort Hood area showed the Veteran was seen for laceration to his left arm after being attacked by a female with a knife at a club. There was no mention of a lower back injury. On his November 1997 enlistment RMH form for the National Guard, he denied arthritis, rheumatism, or bursitis; bone, joint, or other deformity; or recurrent back pain. The November 1997 enlistment physical examination for the National Guard found his spine, other musculoskeletal was normal on clinical evaluation. During his service in the National Guard, his January 1998, December 1998, and December 1999 annual medical certificate reflected that the Veteran denied having current medical problems or been seen by a physician or other health care provider since his last periodic physical or annual medical screening. He was seen during ACDUTRA in June 1999 for tick on left leg, blister on his feet, and bug bites. There were no other ACDUTRA treatment records. At an initial visit with Dr. G. in December 2002, the Veteran reported he was in a motor vehicle accident (MVA) one day prior. He reported that his car was hit from behind and he bumped his head, jerked his neck, and hurt his left shoulder and lower back. Dr. G. noted no history of previous injury to the back. He was diagnosed with lumbar sprain. In April 2005, he was seen at his local VA medical center for complaints of lower back pain upon movement in a certain way for the past year. He reported he was in a car accident a couple of years ago. A March 2006 VA treatment record showed the Veteran was seen for chronic back pain. He reported his low back pain started in the 1990s when he was working for the artillery and had to carry some heavy equipment. Magnetic resonance imaging (MRI) results showed multiple level foraminal stenosis and degenerative disc disease (DDD) with mild bulging. In October 2010, he was seen multiple times at Baton Rouge Orthopaedic for his cervical and lumbar strains from a car accident in late September 2010. The clinician notes reflect that he was involved in a MVA where he was hit from behind. The computed tomography (CT) scan taken the day of the MVA was negative for fractures or dislocations of his back. A late October 2010 MRI report showed the Veteran had disc desiccation with minimal annular bulging and moderate facet arthropathy of his lumbar spine. Private medical records from Genesis Physical Therapy reflects treatment for his lower back after a motorcycle accident in November 2010. A March 2012 private treatment record showed that he was seen for back pain. He reported his back pain was present since the MVA in 2010, where he cracked his spine. Private treatment records from Dr. D. showed that he was seen in September 2013 for complaints of back pain for the past 3 years since his 2010 MVA that resulted in head concussion and spine injury. At a December 2013 mental health visit with Dr. R.L., the Veteran reported that he had 2 accidents in 2010, one of which a truck pulled out in front of him when he was riding a motorcycle. He reported that it 'messed up my back.' A December 2014 private emergency treatment record showed he was in a MVA that resulted in an acute lumbar sprain. On his VA Form 9, C.A.W. reported that the Veteran injured his back in the field putting '109 inch rounds and 8 inch rounds into the howitzer' by himself in August 1990 and was not allowed to leave immediately to see a doctor. More contemporaneous records from Dr. H. showed diagnoses of low back pain, arthritis, spondylosis of lumbar joint, and lumbar radicular pain. In January 2018, the Veteran had a medical evaluation for SSA disability benefits purposes, but it did not address the nature and etiology of his back disorders. Pursuant to the Board's remand, the Veteran had a VA back conditions examination in November 2019. The Veteran repeatedly stated his memory was very poor. He recalled being in a motorcycle accident in 2010 and was in a truck accident in August 2017. The Veteran reported joining the National Guard in 1997 and could not recall whether he reported back pains or not. At the examination, he reported pain in his lumbar spine, middle thoracic area, and neck areas. His back pain was all the time and that it never gets any better. The examiner provided diagnoses of history of intermittent back pain with normal examination currently, low back and thoracic contusions with muscle pain from motor vehicle accident in September 1993, lumbar strain due to motor vehicle accident in June 1999, lumbar sprain due to December 2002 motor vehicle accident, and degeneration of intervertebral lumbar discs. After reviewing the claims file and the Veteran's medical records, the examiner opined that his back condition was less likely than not due to service. The rationale was there was only one orthopedic complaint in service, which was his April 1990 Chapter 13 separation RMH, where he stated he had "perfect health except back pains on and off." His physical examination showed normal spine and other musculoskeletal, and normal neurological. His PULHES were all "1," and a summary of defects on the Chapter 13 physical examination report made no mention of any back problem or defect. The examiner considered the statements by him and C.A.W., but found that while he was seen at the Fort Hood emergency department in June 1990, it was following his being assaulted at a club with his left arm cut there was no suggestion of any recent back injury. The examiner also considered the Veteran's report of holding back his friend during service but noted there was no finding of any healthcare evaluation of this, pointing toward an insignificant occurrence, if it did occur. After detailing the numerous private and VA medical reports addressing his back and multiple MVA reports, the examiner explained that there are clear post-military motor vehicle accident-related back diagnoses. After a review of the evidentiary record, the Board finds the preponderance of the evidence weighs against finding that the Veteran's current degeneration of lumbar discs was shown as chronic in service, manifested to a compensable degree within a presumptive period, or was noted in service with attributable continuity of symptomatology. Dr. G. noted no history of previous injury to the back in 2002. The medical evidence of record shows the earliest report of DDD of the lumbar spine was in 2006, years after separation from service and decades outside of the applicable presumptive period. The Board gives more probative weight to competent medical evidence, which establishes that the Veteran's history of intermittent back pain and lumbar strain are due to intercurrent causes and not due to service. There was no service treatment record reflecting the reported in-service artillery lifting injury or of the Veteran injuring his back after holding his friend back in service. The June 1990 in-service emergency record did not reflect treatment for a low back injury; his private treatment records all reflect back pain reported after MVAs in 2002 and 2010. The November 2019 VA examiner opined that the Veteran's current lumbar disabilities were less likely than not related to an in-service injury, event, or disease, including the April 1990 notation made on the Veteran's RMH regarding recurrent back pain during active service. The examiner explained that the Veteran's April 1990 physical examination showed normal spine and other musculoskeletal, and his PULHES were all "1." The examiner further explained after detailing the numerous VA and private medical reports regarding back treatment that there are clear post-military motor vehicle accident-related back diagnoses. There is no medical opinion to the contrary. While the Veteran is competent to report having experienced symptoms of back pain in service and intermittently since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of his current lumbar disabilities or arthritis as he has not demonstrated the necessary medical expertise. The issue is medically complex, as it requires interpretation of complicated diagnostic medical testing. Jandreau, 492 F.3d at 1377. In conclusion, the criteria for service connection for a back disability have not been met. As the preponderance of the competent evidence weighs against the claim, it is denied. 3. Entitlement to service connection for a respiratory disability. The Veteran indicated he has experienced shortness of breath since service. Specifically, he asserted that during basic or advanced training in February 1990 at Fort Sill, the whole unit contracted a mystery illness after sleeping on the ground that made them have breathing problems and chest pains. He was sent to the 'Post Hospital' and given penicillin. Similarly, he stated that during gas chamber training, he had to take off his gas mask and stayed in rooms until he was told he could leave. Since then, he averred that he has had breathing problems with shortness of breath. See December 2014 correspondence. The Veteran has been diagnosed with chronic obstructive pulmonary disease (COPD). His service records confirm assignment at Fort Sill. Therefore, the question is whether a link has been shown between the two. Based on the evidence of record, the Board finds that service connection is not warranted. Service treatment records show he was treated at the troop medical clinic in Fort Sill in January 1990 for complaints of sore throat and sinus issues. He was advised to take Tylenol and Cepacol lozenges, do warm saltwater gargles, and was released for duty. An undated record showed the Veteran was seen for sore throat symptoms ongoing for the past 4 days. He was diagnosed with upper respiratory infection/pharyngitis and prescribed e-mycin and Tylenol as treatment, with instructions to follow-up as needed. There was no follow-up record. On his April 1990 Chapter 13 separation Report of Medical History (RMH) form, he denied ear, nose, or throat trouble and asthma, but marked 'don't know' for shortness of breath. The physician's summary section noted '11. Chronic sinusitis? no [complaints of] chest pain since stopped smoking.' On his April 1990 Chapter 13 separation examination, the Veteran's nose, sinuses, mouth and throat, and lungs and chest were found to be normal on clinical evaluation. The summary of defects and diagnoses section did not indicate any respiratory conditions. Prior to his actual separation date, a June 1990 service treatment record showed that the Veteran was seen for cold, sore throat, and a productive cough for the past month. He was diagnosed with bronchitis. There was no follow-up visit associated with this record. On his November 1997 enlistment RMH form for the National Guard, he denied ear, nose, or throat trouble; asthma; or shortness of breath. The November 1997 enlistment physical examination for the National Guard found his nose, sinuses, mouth and throat, and lungs and chest were normal on clinical evaluation. During his service in the National Guard, his January 1998, December 1998, and December 1999 annual medical certificate reflected that the Veteran denied having current medical problems or been seen by a physician or other health care provider since his last periodic physical or annual medical screening. He was seen during ACDUTRA in June 1999 for tick on left leg, blister on his feet, and bug bites. There were no other ACDUTRA treatment records. A September 2005 lung study revealed the Veteran had mild obstruction consistent with smoking history. The VA clinician suggested he stopped smoking. In September 2006, the RO made a finding that the Department of Defense found the Veteran's documentation did not show he was exposed to mustard agent, to include mustard gas. Pursuant to the Board's remand, the Veteran was afforded a VA examination for respiratory conditions in November 2019. He was diagnosed with COPD. The Veteran reported he was exposed to dirt and that he was given a bronchodilator at one time, but not now. The examiner opined the COPD was less like than not due to service. The rationale was that review of service treatment records showed treatment for acute bronchitis in June 1990, but no in-service documentation of asthma was found. The examiner noted that an August 2005 VA treatment record showed treatment for an upper respiratory illness associated with wheezing and a September 2005 pulmonary function testing (PFT) study showed mild obstruction; he was advised to stop smoking. The examiner also noted a May 2000 medical record indicated treatment of acute bronchitis. The clinical records do not support chronic bronchitis and/or asthma during service or within one year after service. These findings are consistent with COPD at least as likely as not due to cigarette smoking. An August 2020 VA contract medical opinion also indicated that the Veteran's claimed asthma and shortness of breath was less likely than not due to service. The examiner explained that there are no records of recurrent wheezing or shortness of breath consistent with asthma after reviewing the claims file until September 2005, when a VA clinician noted that he had mild obstruction of the lungs consistent with smoking history. Private treatment records and SSA-related medical records are silent for a respiratory condition. Given the foregoing, service connection is not warranted. The Board finds the November 2019 VA examiner and August 2020 VA contract examiner's opinions probative because they are based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 394. There is no medical opinion to the contrary. The Veteran believes his current respiratory disability is related to an in-service injury, event, or disease. However, he is not competent to provide a nexus opinion regarding whether a remote history of in-service treatment for an upper respiratory infection or bronchitis is etiologically related to his current COPD. Such a determination is medically complex, as it requires knowledge of complicated diagnostic medical testing and understanding of internal physiologically processes involving the respiratory system. Therefore, it is outside the competence of the Veteran because the record does not show he has the medical training, expertise, or credentials to make such a determination. Jandreau, 492 F.3d at 1377. Consequently, the Board gives more probative weight to the competent and persuasive VA and VA contract medical opinions. In sum, service connection for a respiratory disability is not warranted. As the preponderance of the evidence is against the claim, the benefit of doubt doctrine is not for application. 4. Entitlement to service connection for headaches with vomiting. The Veteran asserted that he has experienced headaches with vomiting since service. Specifically, he asserted that basic or advanced training in February 1990 at Fort Sill and training with dust in the field from the tank trails led to his headaches with vomiting condition. See December 2014 correspondence. He has a current diagnosis for migraine headaches, including migraine variants. See November 2019 VA examination. His service records reflect an assignment to Fort Sill. Thus, the question for the Board is whether a link has been shown between service and his current diagnosis. After review, the Board finds that service connection is not warranted for the reasons stated below. Service treatment records show treatment for bronchitis, sinus problems, and an upper respiratory infection. On his April 1990 Chapter 13 separation RMH, the Veteran denied frequent or severe headache. His April 1990 Chapter 13 separation examination indicated his head, face, neck, and scalp were normal on clinical evaluation. On his November 1997 enlistment RMH form for the National Guard, he denied frequent or severe headaches. The November 1997 enlistment physical examination for the National Guard found his head, face, neck, and scalp was normal on clinical evaluation. During his service in the National Guard, his January 1998, December 1998, and December 1999 annual medical certificate reflected that the Veteran denied having current medical problems or being seen by a physician or other health care provider since his last periodic physical or annual medical screening. He was seen during ACDUTRA in June 1999 for tick on left leg, blister on his feet, and bug bites. There were no other ACDUTRA treatment records. Post-service, at an initial visit with Dr. G. in December 2002, the Veteran reported he was in a MVA one day prior. He reported that his car was hit from behind and he bumped his head, jerked his neck, and hurt his left shoulder and lower back. The impression was motor vehicle accident with headaches. A January 2003 note by Dr. G. showed because of the 2002 motor vehicle accident, the Veteran suffered a fair amount of neck pain, left shoulder pain, back pain, headaches, and stress. In September 2006, the RO made a finding that the Department of Defense found the Veteran's documentation did not show he was exposed to mustard agent, to include mustard gas. VA treatment and SSA-related records are silent for complaints of or treatment for headaches. Pursuant to the Board's remand, the Veteran underwent a VA examination for headaches in November 2019. He reported being exposed to a gas during training in service and denied any head injury. The headaches are frontal occipital or unilateral temporal in location and throbbing and burning in nature, with nausea and phono or photophobia. The examiner opined the migraine headaches were less likely than not due to service, as there was no evidence of headaches in service or for years after. A second August 2020 VA contract medical opinion indicated the examiner also found that the Veteran's headaches were less likely than not due to service. The rationale was that there are no records or mention of recurrent headaches suggestive of any type of chronic headaches in service. The examiner found that mention of headaches occurred only after his December 2002 MVA. Based on the evidence of record, the Board finds that service connection is not warranted. The preponderance of the evidence is against finding that a medical nexus exists between the Veteran's migraine headaches and an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. There is no evidence showing a link between the migraine headaches and service at any time during the appeal period. As a result, direct service connection is not warranted. Second, the disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. There were no service, National Guard, or ACDUTRA treatment records showing complaints of headaches. The 2020 VA contract examiner noted the Veteran reported that his headaches began after his 2002 motor vehicle accident. Dr. G. noted in 2003 that the Veteran suffered headaches because of the 2002 MVA. While the Veteran has asserted that the migraine headaches began in service and have continued since, the Board assigns more probative value to the objective medical evidence, which has shown otherwise. Thus, service connection is not warranted on a presumptive basis. The Board recognizes that the Veteran is competent to report pain, such as headaches. However, he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the neurologic system and interactions with the body. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v., 492 F.3d at 1377 n.4. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply. Service connection is not warranted for headaches with vomiting. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for a sleep disorder is remanded. Remand is required as the requested examination by the Board in November 2018 did not take place. Specifically, the prior remand requested the RO schedule the Veteran for a general VA examination for his claimed back, sleep disorder, respiratory, and headache disabilities. On remand, the RO scheduled separate examination for all claimed disorders but the sleep disorder. While the Board acknowledges the RO requested a medical opinion for the Veteran's claimed sleep disorder in August 2020, as cited to in the October 2020 supplemental statement of the case, the Board's review found that that examiner did not provide the requested opinion. Accordingly, remand is required for a VA examination that complies with the November 2018 Board remand. Stegall v. West, 11 Vet. App. 26, 271 (1998). The matter is REMANDED for the following action: Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed sleep disorder. The claims folder, including this remand must be sent to the examiner for review. The examiner is asked to answer: Does the Veteran have a currently diagnosed sleep disorder? If yes, is it as likely as not that this disability was incurred in, or due to the Veteran's active military service? The examiner must discuss the Veteran's reports of difficulties sleeping since service. A fully-explained rationale for the requested opinion should be provided. If the examiner feels that the requested opinions cannot be rendered without resorting to speculation, he or she must explain why this is so. Stephanie M. Owen Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Tang, 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.