Citation Nr: 22017784 Decision Date: 03/26/22 Archive Date: 03/26/22 DOCKET NO. 18-39 992 DATE: March 26, 2022 ORDER Entitlement to service connection for sarcoidosis is granted. Entitlement to service connection for asthma as secondary to sarcoidosis is granted. Entitlement to service connection for skin rashes/lesions (claimed as skin condition), to include as secondary to sarcoidosis and asthma, is denied. Entitlement to service connection for degenerative arthritis of the lumbar spine is denied. FINDINGS OF FACT 1. The evidence persuasively weighs in favor of a finding that the Veteran's sarcoidosis constitutes a diagnosed, but medically unexplained chronic multisymptom illness that is attributable to her service in the Gulf War. 2. The evidence persuasively weighs in favor of a finding that the Veteran's asthma is a complication of her sarcoidosis, caused and aggravated by her sarcoidosis. 3. The evidence of record persuasively weighs against a finding that the Veteran's skin rashes and/or lesions began during active service, is otherwise related to an in-service injury or disease, or was caused or aggravated by a service-connected disability. 4. The evidence of record persuasively weighs against finding that the Veteran's degenerative disc disease, lumbar spine began during active service, or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for sarcoidosis are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.317. 2. The criteria for service connection for asthma as secondary to sarcoidosis are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for skin rashes/lesions are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310, 3.317. 4. The criteria for service connection for degenerative disc disease, lumbar spine are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 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 March 1982 to March 1992. She is a veteran of the Gulf War who served in Southwest Asia in Kuwait and Saudi Arabia. This matter comes to the Board of Veterans' Appeals (Board) from a May 2016 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO), which declined to reopen the Veteran's claims for service connection for sarcoidosis and skin rashes/lesions on the grounds that that the previous denial was final and new and material evidence had not been submitted, and denied the claims for service connection for asthma and degenerative arthritis disease of the lumbar spine. The Veteran testified at a September 2021 Board hearing before the undersigned Veterans Law Judge (VLJ). A copy of the transcript has been included in the record. In October 2021 the Board determined that the Veteran had submitted new and material evidence relevant to her claims for service connection for sarcoidosis and skin rashes/lesions and reopened both claims. The Board remanded the claims, along with claims for service connection for asthma and degenerative arthritis of the lumbar spine, for additional VA examinations. Substantial compliance with the remand requests having been achieved, the Board may proceed to consider the claims. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). The Board notes that the Veteran's service treatment records (STRs) are not complete. As noted by the RO in a rating decision in April 2006, the Veteran's medical service records for the period March 1, 1982 through March 18, 1992 could not be obtained. The Board acknowledges its heightened duty "to consider the applicability of the benefit of the doubt rule, to assist the claimant in developing the claim, and to explain its decision" when service treatment records are lost or missing. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) (citing Russo v. Brown, 9 Vet. App. 46, 51 (1996)). However, no presumption, either in favor of the claimant or against VA arises when there are lost or missing service records. See Cromer, 19 Vet. App. at 217-18 (2005) (Court declined to apply an "adverse presumption" against VA where records had been lost or destroyed while in Government control because bad faith or negligent destruction of the documents). Service Connection The Veteran contends that her sarcoidosis, asthma, skin rashes/lesions, and degenerative disc disease (claimed as arthritis and lower back condition), are directly service connected. She additionally asserts that her sarcoidosis is secondary to her asthma; her asthma is secondary to her sarcoidosis; and her skin rashes/lesions are secondary to her sarcoidosis or asthma. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing direct service connection generally requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a). Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran served in the Southwest Asia Theatre during the Gulf War. Pursuant to 38 U.S.C. § 1117, a Persian Gulf Veteran with a qualifying chronic disability that manifests to a degree of 10 percent or more before December 31, 2021, may be entitled to compensation. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1). Generally, a chronic disability may qualify for presumptive service connection pursuant to 38 C.F.R. § 3.317 if the qualifying chronic disability results from (1) an undiagnosed illness, or (2) a diagnosed, but medically unexplained chronic multi-symptom illness (MUCMI) that is defined by a cluster of signs or symptoms such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders. 38 U.S.C. § 1117(a)(2)(A), (B), (C); 38 C.F.R. § 3.317(a)(2)(i)(B). An "undiagnosed illness" means a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A diagnosed MUCMI is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi-symptom illness. A medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Alternatively, presumptive service connection may be warranted for any diagnosed illness that the Secretary determines in regulations warrants a presumption of service connection as due to service in Southwest Asia during the Gulf War. 38 U.S.C. § 1117. Of particular relevance to this claim, the Board notes that effective August 5, 2021, the VA has recently promulgated an interim final rule regarding presumptive service connection for Gulf War veterans for three chronic respiratory health conditions in association with exposure to fine particulate matter, to include asthma, rhinitis, sinusitis, to include rhinosinusitis, for those Gulf War Veterans who served in Southwest Asia, Afghanistan, Syria, Djibouti, and Uzbekistan. Under the interim final rule, certain diseases (including asthma) shall be service connected even though there is no evidence of such disease during the period of service if it becomes manifest to any degree (including non-compensable) within 10 years from the date of separation from military service that includes active-duty service during the Gulf War in the Southwest Asia, Afghanistan, Syria, Djibouti, and Uzbekistan. 38 C.F.R. § 3.320(a). Under the provision exposure is presumed unless there is affirmative evidence to establish that the veteran was not exposed to fine particulate matter during service. See 38 C.F.R. § 3.320(a). The interim final rule applies to all claims received by the VA on or after August 5, 2021, and that were pending before the VA, the United States Court of Appeals for Veterans' Claims, or the United States Court of Appeals for the Federal Circuit on August 5, 2021. See 86 Fed. Reg. 42724, 42724 (August 5, 2021). Here, the Veteran was on active service in Kuwait and Saudi Arabia from December 1990 to June 1991 Where the evidence does not warrant presumptive service connection, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has determined that a Veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran is entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal," and does not require that the evidence be in exact equipoise. Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021), affirmed en banc, 21 F.4th 776, No. 2020-2067, 2021 U.S. App. LEXIS 37312 (Fed. Cir. Dec. 17, 2021). 1. Service connection for sarcoidosis is granted. The Veteran claims her sarcoidosis is attributable to her in-service toxin exposure while serving in the Persian Gulf. For reasons outlined below, the Board finds presumptive service connection is warranted. Turning to the record of the Veteran's claim for entitlement for service connection for sarcoidosis, her service treatment records (STRs) contain no complaints of respiratory problems while on active service. A chest X-ray in January 1992 was negative for abnormalities. Her separation exam in February 1993 does not indicate any abnormality of the lungs or respiratory system. The Veteran's February 2002 enlistment examination for enlistment in the Reserves does not note any respiratory or beathing problems. She was graded as 1, the highest rating, in all categories of her physical profile. She specifically denied having asthma, shortness of breath, or bronchitis. A medical examination for a position as a corrections officer in March 1993 specifically noted no shortness of breath or asthma. Nine years later she sought medical treatment for a cough that produced blood-streaked sputum in August 2002. She reported experiencing a sore throat, episodic headaches, congestion, night sweats, and difficulty speaking more than in whispers for the previous three days. She was instructed to continue the over-the-counter medications such as Tylenol or Theraflu that she had been taking, given a Z-pack she was given, and encouraged to drink more fluids and rest. Following an examination in March 2008, a private provider concluded that although the Veteran met one criteria for lupus, a positive ANA, she showed no other symptoms, signs, or lab findings to suggest an autoimmune disease. A CT scan in September 2010 showed clear lungs, with mildly enlarged lymph nodes. In January 2011, a biopsy on samples taken of her lymph nodes revealed the presence of sarcoidosis. In February 2011 the Veteran had a VA examination for sarcoidosis. The examiner noted that her STRs were silent for sarcoidosis and that medical records since her separation indicated sarcoidosis had been suspected by a private physician in 2010, 18 years after separation. The examiner found no documented instances of lung involvement and noted that the most recent chest X-ray was normal. He observed that the etiology of sarcoidosis is unknown, and while it is diagnosable, it is currently unexplained. A CT scan the following year in August 2011 revealed extensive intra-abdominal lymphadenopathy which was suspected to be secondary to sarcoidosis. Scans and X-rays throughout 2012, 2013, and 2014 continued to show signs of sarcoidosis, though there were intermittent period in which it seemed to be in remission. She was treated over the period with both methotrexate, azathioprine, and Plaquenil. A VA examination in May 2016 determined that the Veteran had no physiologic or pulmonary involvement attributable to sarcoidosis, nor involving any other organ system. The examiner noted that sarcoidosis is an inflammatory disease that affects multiple organs in the body, mostly the lungs and lymph glands, and is a type of autoimmune disease associated with an abnormal immune system. In view of the fact that the Veteran's STRs did not reflect any complaints that might be associated with sarcoidosis, her February 2002 Reserve enlistment that was negative for a respiratory condition, and her diagnosis 18 years after her separation, the examiner opined that it was less likely than not related to an event in the Veteran's active service, particularly her service in Southwest Asia. An VA examination in November 2021 echoed the prior VA examinations conclusions. The examiner noted the diagnosis of sarcoidosis in 2012 and clear chest X-rays, but observed that the disease is "a rare condition.... [that] typically would not show up" in an X-ray or other common respiratory tests. The examiner opined that the Veteran's sarcoidosis was less likely than not proximately due to or the result of an in-service injury, event, or illness. He explained that there was no documentation of the disease, or even complaints or symptoms, during or shortly after the Veteran's period of active duty. He additionally observed that the medical literature does not support that sarcoidosis can be a complication, symptom, or condition that results from a skin rashes/lesions or asthma. Rather, he pointed out, the risk factors for developing the disease are age (ages 20 to 60), gender (women are slightly more likely to develop it), race people of African or Northern European decent have a higher incidence), and family history. Finally, he opined that her sarcoidosis was not caused by the Veteran's exposure to environmental toxin during the Gulf War, explaining that the condition did not manifest until more than a decade after exposure. He rejected the characterization of sarcoidosis as a medically unexplained chronic multi-symptom illness (MUCMI), explaining that is partially diagnosed with an unknown etiology. The Veteran contends that her sarcoidosis is the result of her service in the Southwest Asia Theatre during the Persian Gulf War, where she was exposed to toxic chemicals and various environmental hazards. Alternatively, she contends that her sarcoidosis is directly related to her active service or is secondary to her asthma or skins rashes/lesions, both of which she argues are service connected as well. The medical evidence does not support that the Veteran's sarcoidosis began in service or is directly attributable to service. The Board has considered whether presumptive service connection is for application in light of her Persian Gulf War service and her contended toxin exposure. In that regard, the medical evidence in this case is ambiguous. The November 2021 VA examiner opined that the Veteran's sarcoidosis is a "partial" diagnosis and, therefore, not quite an "undiagnosed" illness. In any case, as noted above a diagnosed MUCMI refers to a diagnosed illness that is medically unexplained, either because of the etiology or because of the pathophysiology is inconclusive. Any illness that is at least partially understood, however, will not be considered "medically unexplained" and, therefore, not be considered a MUCMI. Stewart v. Wilkie, 30 Vet. App. 383, 389-90 (2018). Resolving reasonable doubt in favor of the Veteran, the Board concludes that the Veteran's sarcoidosis is a MUCMI. That is, the Veteran's sarcoidosis is a diagnosed, but medically unexplained chronic multi-symptom illness. Throughout time, although no examiner has linked the Veteran's condition to service or found the Veteran's in-service toxin exposure likely related to her sarcoidosis, all examiners conclusively agree that sarcoidosis is a rare condition, unlikely to show up on diagnostic tests, of unknown etiology, unexplained pathophysiology, and medically unexplained. The Veteran's sarcoidosis has existed from January 2011. Thus, it is considered chronic under the regulatory definition. Moreover, the sarcoidosis has manifested to a degree of 10 percent or more because its persistent symptoms have required at least chronic low dose or intermittent corticosteroids, as required for a 10 percent rating under 38 C.F.R. § 4.97, Diagnostic Code 6846. Given that the Veteran's sarcoidosis has manifested to a degree of at least 10 percent and the persuasive weight of the evidence deems sarcoidosis a multi-symptom illness of unknown etiology, the Board finds service connection is warranted as a matter of statutory presumption. 2. Entitlement to service connection for asthma is granted. The Veteran contends her asthma was either incurred in service due to toxin exposure in the Persian Gulf or, alternatively, is secondary to her sarcoidosis. For reasons outlined below, the Board finds presumptive service connection is not for application here, but secondary service connection is warranted. Turning to the evidence of record, her STRs are silent for any respiratory complaints or treatments. She denied suffering asthma on a January 1992 examination form and a chest X-ray the following day was negative. Her separation exam in February 1993 does not indicate any abnormalities of the lungs or respiratory system. A medical examination for a position as a corrections officerspecifically noted no shortness of breath or asthma. A chest X-ray in September 1995 disclosed no findings of acute cardiopulmonary disease. The Veteran did not report suffering asthma or respiratory problems at a VA examination the same day. The examiner noted there were clear breath sounds on auscultations. The Veteran's February 2002 Reserve enlistment examination does not note any respiratory or beathing problems, and she specifically denied suffering asthma, bronchitis, shortness of breath. In October 2009, filling out a private provider's heath form for recent symptoms and prior medical problems, she specifically denied having asthma, a chronic cough, bronchitis, or shortness of breath. A CT scan in September 2010 following complaints of severe constipation and acid reflux showed clear lungs with no indications of asthma noted. Scans in December 2012, February 2013, and April 2013 of the Veteran's chest revealed no acute abnormality. In February 2016 she developed a chronic cough severe enough to give her headaches. After two days, she sought treatment at the emergency room. She was assessed as suffering acute bronchitis. Chest X-rays taken as part of a May 2016 VA medical examination indicated only that the Veteran's lungs were mildly hyperaerated but grossly clear. After additional tests and an in-person examination, the examiner determined that asthma and sarcoidosis limited her pulmonary function, but the condition did not impact her ability to work. He concluded that was less likely than not that the Veteran's asthma was related to her military service, particularly her service in the Southwest Theatre of operations, as she denied having asthma in 2002 and was not diagnosed with it until after 2015. In her NOD filed in July 2018, the Veteran claimed that her unit had been in close proximity to burning oil wells during its time in Kuwait. At the Board hearing in January 2021, the Veteran testified that she had been exposed to burn pits while serving in Kuwait and Saudi Arabia and asserted that the exposure to chemical air pollutants induced her asthma. In a letter directed to a VA facility in February 2021, she described her unit being so close to burning oil wells that the soldiers' "entire bodies and uniforms [were] saturated with oil." She added that her duties involved in burning human waste with toxic chemicals, and the area was "infested" with "burning bodies," body parts were "lying around" and rodents were "everywhere." Chest X-rays in November 2021, as part of a VA examination, showed normal results. A VA examiner opined after an in-person examination in November 2021 that sarcoidosis "can cause complications to the lungs which can result in asthma," and implied that it was as least as likely as not that the Veteran's sarcoidosis caused or aggravated her asthma. The May 2016 VA examiner's opinion, which concluded that it was "less likely than not" that the Veteran's asthma was related to an exposure event during her service in Southwest Asia because she was not diagnosed with the disease until 24 years after her last possible exposure event, sets forth the results of his comprehensive review of the claims file and the Veteran's lay reports; the applicable medical literature; and provided a clear and consistent rationale for his opinion. In short, the Veteran did not incur asthma during service and the persuasive weight of the evidence shows she did not have a diagnosis of asthma until, at the earliest, in October 2009, which was over 10 years after her service in Southwest Asia and, therefore, presumptive service connection is inapplicable here. See 38 C.F.R. § 3.320(a) (indicating that for all claims received by the VA on or after August 5, 2021, certain diseases (including asthma) shall be service connected even though there is no evidence of such disease during the period of service if it becomes manifest to any degree (including non-compensable) within 10 years from the date of separation from military service that includes active-duty service during the Gulf War in the Southwest Asia, Afghanistan, Syria, Djibouti, and Uzbekistan). On the other hand, the persuasive weight of the evidence also associates the Veteran's asthma as a complication of her sarcoidosis. As the Board has now service-connected the Veteran's sarcoidosis, service connection for asthma is also warranted as secondary to sarcoidosis. See 38 C.F.R. § 3.310. That is, the medical evidence indicates that the Veteran's asthma was caused or developed as a complication of her now service-connected sarcoidosis and, therefore, her service connection for asthma is warranted. 3. Service connection for skin rashes/lesions condition is denied. With regard to her skin rashes/lesions claim, the Veteran claims her condition is attributed to her in-service toxin exposure. As will be outlined below, the Board finds service connection is not warranted. Turning to the relevant evidence of record, the Veteran's STRs show that the Veteran first reported a skin condition in March 1991, when she complained of a recurrent rash on her hands and face to the 12th Evacuation Hospital while serving in Southwest Asia. She was treated with topical steroids and told to see a dermatologist. Three days later she was seen at the Armed Forces Hospital in Saudi Arabia, where she was treated with lotion and oral medications. At an examination in January 1992, the Veteran did not indicate she had a rash or skin condition. Her separation exam does not note the presence of a rash or any other similar complaints. She complained at a VA facility about an itching rash on her face, neck, and trunk in February 1995. She was diagnosed with neurodermatitis, given medication, and told to return if the condition did not improve in 24 to 48 hours, since she had been responding poorly to the medications. Other medical notes the same day suggest the "appearance of allergies." A week later she was examined again. It was noted she was responding poorly to the medication. The diagnosis was still neurodermitis. The same day she was examined for the Persian Gulf Registry. She reported a recurrent skin rash. The examiner indicated that the diagnosis was neurodermatitis. The Veteran was seen by a dermatologist in July 1995 for a skin condition on her head. She was prescribed Rogaine. She was examined a VA facility in September 1995. The examiner noted hair loss, for which she was being treated by a dermatologist, and a skin rash on her neck, arms and legs, which the Veteran reported had been reoccurring since 1991 when she had been in the Gulf War. The examiner described the rash as "very pruritic." He noted patches on her elbows, back of the neck, and faintly on her thighs. In July 2002, she reported an itchy skin rash on both legs that she noticed several days after suffering flea bites. The attending physician noted small healed dark spots on both legs and prescribed Lotrisone cream. She complained of a rash on her face an abdomen in November 2003 several days after she began taking a prescribed antibiotic. She was instructed to discontinue the antibiotic. She sought medical care in September 2005 for dry, itchy skin on her arms and back that she had for several months and itchy skin on her toe which had started shortly after she had had her nails done. She was diagnosed with mild atopic dermatitis and counseled to use moisturizer and take lukewarm showers on her arms and trunk and irritant dermatitis to antifungal sprays and told to avoid them. She reported breaking out in acne on her face in April 2009, a problem she had developed recently that had left dark spots. She was prescribed Benzamycin gel. Not quite a year later, in January 2010, she informed her doctor during a visit that she had had a rash on her face and left upper trunk, but it had since healed, leaving only discoloration. She informed him that she had been breaking out "off and on" since returning from the Gulf War. She was prescribed Hydroquinone cream. Less than six month later, in June 2010, she saw her doctor for a rash on her left arm and the right side of her neck. The doctor noted annular eczematous patches on those parts of her arms and neck that were left exposed to the sun, assessed the condition as dermatitis, and prescribed Lidex cream. She complained of a rash on her arms and next the following month from exposure to the sun, explaining that she had an allergic reaction to sunscreen. She was given Desonide lotion for her face and Diprolene cream for her arms and neck. She returned in August 2010 complaining of a rash on her hand, arm, and neck, and was given antifungal cream. The cream was changed a month later after the symptoms were not resolved. At VA examination in February 2011, the Veteran informed the examiner that she had problems with rashes that had begun during her active service between 1991 and 1992. She reported being treated for a facial rash in-service, with intermittent outbreaks since. She stated that she suffered breakouts about one to two times a year, with symptoms lasting from two weeks to one month. She described having pruritic, raised lesions that drained clear fluid intermittently. The rash, she recounted, involved different regions at different times over her face, abdomen, back, arms, legs, and chest, and after it resolved it left some residual dark patches. She denied noticing any specific triggers for an outbreak and reported suffering the last one in September 2010. The examiner noted no active lesions. The etiology of the dermatitis, the examiner concluded, was "unclear." At a regular check-up at a VA facility in August 2011, the Veteran complained of a longstanding rash and itching skin and asked for a refill of her medication Temovate, which alleviated the condition. The staff physician assessed non-specific dermatitis and noted treatment with topical steroids. She continued to complain of experiencing break outs and rashes during check-ups at VA facilities in November 2013, January 2014, and April 2014. In January 2015, doctors diagnosed spongiotic dermatitis after a skin biopsy. The Veteran was examined by a VA examiner in November 2021 for her skin condition. The examiner noted a diagnosis of dermatitis in 2021. He observed no visible characteristic lesions at the time of the exam. He stated that since his review of the Veteran's STRs indicated that there is no documentation of a diagnosis of dermatitis while the Veteran was on active military service the assessment up through 1995 had been for neurodermatitis, with dermatitis first diagnosed in 2005 it was less likely than not the claimed skin rashes/lesion were incurred in or caused by an in-service injury, event, or illness. He further opined that the skin rashes/lesions were less likely than not proximately due to or the result of the Veteran's sarcoidosis or asthma. He explained that there is no medical study that supports that a skin rash or lesion is a complication, symptom, or condition that results from either disease. He also rejected the characterization of the Veteran skin condition as either an undiagnosed illness or a diagnosed illness the result of a MUCMI, noting that the condition had been repeatedly diagnosed as dermatitis, which is a known diagnosis with a known pathophysiology. The examiner also concluded that the Veteran's skin condition was less likely than not related to her exposure to toxins around burn pits in Saudi Arabia, as she was not diagnosed with dermatitis while on active service and thus during the time she was exposure to burn pits or shortly thereafter. In short, the evidence of record shows the Veteran had in-service complaints of skin rashes while in the Persian Gulf and the Veteran contends, she had similar rashes periodically since service. As explained by the 2021 VA examiner, however, the Veteran was seen up through 1995 with neurodermatitis, but starting in 2005, the Veteran's various skin treatments were for dermatitis, which is her current ongoing condition albeit with no signs of dermatitis on the most recent examination. The examiner indicated that the two conditions were distinct and unrelated. The examiner further opined that dermatitis was neither an undiagnosed illness nor a MUCMI. As such, the examiner found no skin rash, no skin lesion, no recurrent skin condition that could be linked to the Veteran's military service directly or as a matter of presumption or as attributed to her sarcoidosis. The Board finds the November 2021 VA examiner's opinion persuasive as the rationale is adequate with consideration of the Veteran's lay statements and with consideration of the entirety of the claims file and applicable medical literature. See Nieves-Rodriguez, 22 Vet. App. at 304 (2008). The Board considered the Veteran's lay statements describing her history of skin rashes, but she has not demonstrated competence in distinguishing one skin condition from another or otherwise being able to render a competent opinion on etiology, which requires medical expertise. In that regard, the Board finds the medical evidence more probative. See Jandreau, 492 F.3d at 1376-77 (noting general competence to testify as to symptoms but not to provide medical diagnosis). The Board has considered all reasonably raised theories but finds no basis in which to award service connection considering direct, secondary, and/or any arguably applicable presumptive service-connection provision. For reasons asserted, service connection for skin rashes / lesions is not warranted. 3. Entitlement to service connection for degenerative arthritis of the lumbar spine is denied. The Veteran claims her lumbar spine condition was caused by or incurred during service with symptoms since separation. The Board finds the service connection is not warranted. Turning to the relevant evidence of record, the Veteran's STRs indicate that in January 1992 on an examination form she denied suffering arthritis, rheumatism, or bursitis, though she claimed to have swollen or painful joints. At her separation examination in January 1993, her spine and other musculoskeletal areas were assessed to be normal and recurrent back pain was not noted in the summary of defects or diagnoses. That same month she complained of back pain after urination, and in June 1993 of low back pain associated with abdominal pain, but both conditions cleared without further intervention. Her spine was assessed as normal at her 2002 physical examination for her entrance to the Reserves, and she denied arthritis, rheumatism, or bursitis. She admitted suffering recurrent back pain but explained in a note that she had been in a car accident in August 2001 and suffered back and shoulder injuries. In July 2002 she reported back pain "on and off" for the previous three weeks; she told the nurse that she had encountered problems with her back since being involved in a car accident in August 2001. She related that the diagnosis at the time of the accident was "lumbar strain." Several weeks later she was still complaining of back pain and recounted that she had been having off and on back spasms since her motor vehicle accident in 2001. In March 2008 during a visit to be evaluated for joint pain, she complained of difficulty sleeping the night before due to back pain. The attending physician diagnosed a back spasm in her lower back and noted they had begun in "about 2006." In April 2011, the Veteran had a magnetic resonance imaging (MRI) of her lumbar spine. It revealed a small diffusely bulging disc at the L3-L4 with disc herniation that might compress the L3 nerve root, causing possible radiculopathy. Two months later, in June 2011, she reported suffering "significant back pain," and a week later complained of lower back pain with pain radiating down her leg. She continued to complain of mild and constant lower back pain, with the pain radiating down her leg, at a January 2012 follow-up visit. A spinal injection a month later appeared to improve her condition. A spinal X-ray in July 2013 revealed osteoarthritis. Another X-ray in January 2014 should osteoarthritis as well. She continued to report lower back pain with radiating pain in February 2015 and December 2015. A VA examination in May 2016 noted a diagnosis of degenerative disc disease. The Veteran informed the examiner that she started having back pain while on duty in 1984, when she had back spasms and had to go on bed rest. She recalled being treated at a VA facility in 1994 for muscle spasms. She declared she had flare-ups, but could not identify any specific activity that might cause them. The examiner determined that her range of motion (ROM) was normal and detected no pain during the exam. She was unable to perform repetitive use testing nor repetitive use testing over time. The examiner was unable to assess whether pain, weakness, fatigability or incoordination would significantly limit her functional ability over time. No guarding, muscle strength loss, muscle atrophy, radicular pain, ankylosis, or intervertebral disc syndrome (IVDS) was observed. The examiner concluded that the Veteran suffered degenerative disc disease, which is wear and tear of the disc surface. She noted that the Veteran reported suffering back pain while on active service only once, in January 1992. She had enlisted in the Reserves in February 2002 and the examination at the time revealed a normal spine. The Veteran was not diagnosed with degenerative disc disease until November 2014. The most significant contributing factors for the disease, she observed, are age and weight. The Veteran's age 51 and her body mass index (BMI) 30.73 are consistent with constituting those factors. Therefore, she concluded, it was less likely than not that the Veteran's degenerative disc disease was related to an injury or illness during the Veteran's service in Southwest Asia. The Veteran testified at the January 2021 Board hearing that she had developed back problems well before she served in the Southwest Theatre. She recalled that when she was stationed at Fort Hood, their commanding officer would drop them off at the base perimeter and make them run back to their quarters. Her husband, who served with her during her time in the service, filed a statement that she had developed back problems after road marches. X-rays taken during a VA examination in November 2021 showed mild lumbar spondylosis without acute fracture or subluxation. The examiner noted diagnoses of lumbosacral strain, radiculopathy of the sciatic nerve, and lumbar spondylosis. The Veteran informed the examiner that her lower back pain had started in 1992. She reported mild flare-ups that made it difficult for her to perform prolonged walking, running, or standing. He found that her ROM was limited, and noted pain in each range, and in passive as well as active motion. He observed not additional loss of function upon the repetitive use test, but estimated that there would be significant additional loss due to pain on repetitive use over time as well as during flare-ups. He noted no guarding, muscle spasms, no muscle atrophy, ankylosis, or IVDS. There was mild radiculopathy pain, paresthesias, and numbness. He concluded that due to the symptoms of pain and decreased ROM, the Veteran was unable to perform occupational tasks such as prolonged walking, running, and standing. The examiner opined that it was less likely than not that the Veteran's degenerative disc disease was incurred in or caused by an in-service injury, event, or illness. He pointed out that the Veteran's STRs did not show that she had been diagnosed with degenerative disc disease, was not diagnosed with it withing a year of her separation, and did not evince a continuity and chronicity. He further concluded that the Veteran's lay statements of experience symptoms of back pain during her duties of jumping from trucks for drills and running with full gear were not supported by her STRs, as she had denied suffering back pain of having spine trouble during her 1992 examination. An adequate medical opinion must be based upon a consideration of the Veteran's prior medical history and must describe the Veteran's condition in sufficient detail so as to allow the Board to make a fully informed evaluation. Ardison v. Brown, 6 Vet. App. 405, 407 (1994). In short, an adequate medical opinion should contain sufficient information such that the Board is not required to rely on its own independent medical judgment. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board finds the May 2016 VA examiner's opinion to be complete, adequate, and persuasive. The opinion sets forth the results of her comprehensive reviews of the claims file and the Veteran's lay reports; reviews the applicable medical literature; and provides clear and consistent rationales for her opinion. Hence, the Board finds the opinion highly probative and, taken in conjunction with the lay and medical evidence of record, attaches significant weight to both the opinion and the addendum on the matter of nexus between the Veteran's injuries and his military service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl, 21 Vet. App. at 124. The Board finds the November 2021 VA examiner's opinion deficient in its failure to fully address the issue and provide a medical rationale for whether the Veteran's post-service 2001 motor vehicle accident with contemporaneous complaints of back pain was an intercurrent cause of the Veteran's current degenerative disc disease. See Bloom v. West, 12 Vet. App. at 187 (the Board must consider whether the examining medical provider had a sufficiently clear and well-reasoned rationale when weighing how probative an opinion may be). The examination and opinions are still held to be probative on the issues of direct and secondary service connection for the Veteran degenerative disc disease, however. See Mozingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("even if a medical opinion is inadequate to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight...[I]f the opinion is merely lacking in detail, then it may be given some weight based upon the amount of information and analysis it contains."). In determining whether the record reflects that the Veteran's degenerative disc disease is related to her service, the Board acknowledges the Veteran's belief that there is such a causal connection as well as her own description of in-service incurrence. The Board notes that the Veteran is competent to report the onset and continuity of symptoms such as pain. See Layno v. Brown, 6 Vet. App. 465, 469(1994). The Veteran is certainly competent to describe the circumstances of her military duties, the pain he felt during service, and the pain he felt since service. Competency and credibility, however, are two distinct inquiries. Whereas the former is a threshold legal concept that pertains to whether a particular piece of proffered evidence can even be considered by the factfinder, the latter pertains to the credibility and weight of such evidence as assigned by the trier of fact. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (distinguishing between competence and weight and credibility and explaining that the "former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). If evidence is not competent, it cannot be considered as evidence by the factfinder. Id. However, the mere fact that evidence is deemed competent does not mean that it must be found persuasive of a particular fact. See Id. If evidence is found to be competent, it is for the Board to determine what, if any, probative value to assign to that evidence. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (it is the responsibility of the Board to assess the probative weight of the evidence). Here, although the Veteran is certainly competent to comment on the events in service, the Board finds the Veteran's contentions regarding in-service incurrence and continuity of pain since service not credible. She denied back or spinal problems in a 1992 examination. She her spine was assessed normal at her separation exam. She admitted suffering back pain at her Reserves entrance examination in January 2001 but explained then that she suffered back pain as a result of being involved in a motor vehicle accident in August 2001. On repeated separate occasions in 2002 when seeking medical care for her back pain she informed caregivers that it had started after her 2001car accident. In assessing the credibility of evidence, the Board may consider any number of factors, to include conflicting statements or evidence, and the potential bias of the declarant. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006); Pond v. West, 12 Vet. App. 341, 345 (1999). The lack of contemporaneous evidence is also relevant; however, it may not generally serve as the sole basis for discrediting lay statements or testimony. Buchanan, 451 F.3d at 1337. Here, the Board emphasizes the Veteran's credibility is not being discounted solely because of a lack of contemporaneous evidence. Rather, in reporting back pain upon entry to the reserves, and more importantly, seeking relief from back pain from caregivers, the Veteran pinpointed the origins of the distress not as an early in-service injury she had been suffering for a decade, but as a relatively recent injury unconnected to her military service. Cf. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (a lack of notation where such notation would normally be expected may be relied on as evidence against the existence of the fact or facts that ordinarily would have been noted). Thus, the Board does not find the Veteran's statements of continuity of symptoms credible, as they are in contradiction with other evidence of record. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curium,78 F.3d 604 (Fed. Cir. 1996) (when determining whether lay evidence is satisfactory, the Board may properly consider internal consistency, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and demeanor of witness (if hearing held)). Therefore, the Board finds the VA examinations with subsequent medical opinions to be significantly more credible and persuasive than statements made to VA for purposes of seeking compensation. Veteran's inconsistent and contradictory statements concerning her pain, coupled with a 10-year gap between separation and first documented complaint, lead the Board to conclude there is a preponderance of evidence against finding continuity of symptomology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (the Board can consider bias in lay evidence, the significant time delay between the affiants' observations and the date on which the statements were written, and conflicting statements of the veteran in weighting credibility). Further, the Veteran is not considered competent to medically attribute her current degenerative disc disease to a specific cause, as doing so requires medical knowledge and expertise that the Veteran has not been shown to possess. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau, 492 F. 3d at 1376-77. Therefore, her statements do not constitute competent evidence that may be probative in showing an etiological relationship between the Veteran's in-service activities and the current degenerative dis disease. To determine whether such a relationship exists, the Board turns to the competent medical evidence of record. The United States Court of Appeals for Veterans Claims has stated that the probative value of a medical opinion is based on the expert's personal examination of the patient, the physician's knowledge, and skill in analyzing the data, and the medical conclusion that the physician reaches. Further, the credibility and weight to be attached to these opinions are within the province of the adjudicator. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). With respect to a nexus between the current degenerative disc disease and in-service occurrence, the Board assigns more probative weight to the VA examinations of record, which both opined in the negative after thorough review of the Veteran's file and consideration of the Veteran's lay statements. As such, the Board finds no causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163(Fed. Cir. 2004). The Board has also considered whether the Veteran is entitled to service connection for degenerative disabilities as "chronic diseases." See 38 C.F.R. § 3.303 (b). The Veteran's degenerative disc disease is a form of arthritis which is listed as a "chronic" disease under 38 C.F.R. § 3.309 (a). The Board notes that the Veteran was diagnosed with degenerative disc disease at the earliest 19 years after her separation from active service. Thus, the record does not show that the Veteran's disabilities manifested to a compensable degree within one year of separation. Furthermore, the prolonged period of almost 10 years from separation from service until the Veteran's first complaints of back pain which were diagnosed and treated as back spasms - is evidence for consideration in determining continuity of symptomatology and weighs against the claim here. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). In the absence of credible evidence of degenerative disc disease within one year after separation or credible evidence of continuity of symptomatology, service connection is not warranted on a presumptive basis under the provisions of 38 C.F.R. §§ 3.303(b), 3.307, and 3.309. In light of the above, the preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not for application. The claim therefore must be denied. 38 U.S.C. § 5107 (b). SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Wilkinson, Edward L. 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.