Citation Nr: 22018353 Decision Date: 03/29/22 Archive Date: 03/29/22 DOCKET NO. 16-32 475 DATE: March 29, 2022 ORDER 1. Entitlement to service connection for a sleep disorder, to include obstructive sleep apnea (OSA), and as secondary to service-connected disabilities, is denied. 2. Entitlement to service connection for a lumbar spine (low back) disability, to include degenerative arthritis, and as secondary to the service-connected Dercum's disease, is denied. 3. Entitlement to service connection for a pelvic disability, claimed as pelvic pain, to include as secondary to the service-connected Dercum's disease, is denied. FINDINGS OF FACT 1. The Veteran's OSA did not have its onset during active duty service, is not otherwise related to active duty service, and was not caused or aggravated by a service-connected disability or disabilities, to include obesity as an "intermediate step." 2. The Veteran's lumbar spine disability did not have its onset during active duty, arthritis was not manifested within one year following service discharge, and the lumbar spine disability is not otherwise related to active duty, and was not caused or aggravated by a service-connected disability or disabilities. 3. The evidence persuasively weighs against a finding that the Veteran has a current pelvic/hip disability during the appeal period or proximate thereto, to include symptoms that caused functional impairment that affects earning capacity. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a sleep disorder, to include OSA, to include as secondary to service-connected disability or disabilities, have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 2. The criteria for entitlement to service connection for a lumbar spine disability, to include degenerative arthritis, and as secondary to service-connected disability or disabilities, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 3. The criteria for entitlement to service connection for a pelvic/hip disability, to include as secondary to service-connected disability or disabilities, have not been met. 38 U.S.C. §§ 1101, 1110, 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 May 1995 to May 1999. In January 2021, the Veteran provided testimony at a virtual Board hearing before the undersigned Veterans Law Judge (VLJ). In May 2021, the Board remanded the claims for further development. There was substantial compliance with the Board's remand directives to decide the claims on appeal. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection may also be established under 38 C.F.R. § 3.303(b) if a chronic disease is shown in service, and subsequent manifestations of the same chronic disease at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. Arthritis is a chronic condition listed under 38 C.F.R. § 3.309(a); and thus, 38 C.F.R. § 3.303(b) is applicable. Service connection may also be established based upon a legal presumption by showing that a disorder manifested itself within one year from the date of separation from service. 38 U.S.C. § 1101; 38 C.F.R. §§ 3.307, 3.309(a). Service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310(a). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. 1. Entitlement to service connection for a sleep disorder. The Veteran contends that he is entitled to service connection for a sleep disorder, to include obstructive sleep apnea (OSA), because it was incurred in service or otherwise related to service, to include as secondary to the service-connected Dercum's disease and/or psychiatric disorder. During the January 2021 Board hearing, the Veteran testified that while on active duty his ex-wife would tell him that he was snoring and would stop breathing during sleep. The Board has carefully reviewed the evidence of record and finds that service connection for a sleep disorder is not warranted because the weight of the evidence is against a finding that the Veteran's sleep disorder is related to service, to include as secondary to service-connected disabilities, which is explained below. The Veteran has a current diagnosis of a sleep disorder, which is OSA. The Veteran was afforded a VA examination in May 2016 and a diagnosis of OSA was confirmed by the VA examiner. The Veteran had a sleep study performed in February 2016, which revealed OSA. The Board finds there is evidence of a current disability and the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, during the January 2021 Board hearing, the Veteran reported that the sleep disturbances were happening during service. He testified that he would wake his ex-wife up with his snoring and she would wake him up to tell him that he stopped breathing. The Veteran explained that he did not complain and did not go to sick call because of fear that he would be put on light duty and ousted from the platoon or the higher ups. He reported that he was tired and falling asleep at his computer daily at work and was told by a work partner that he was snoring, then was told by fellow veteran's to get a sleep study. The Veteran's service treatment records are silent for a disease or injury involving a sleep disorder. In the December 1998 Report of Medical Examination for purposes of separation, clinical evaluations for the mouth and throat and lungs and chest were normal. In the accompanying December 1998 Report of Medical History, the Veteran reported, "I am in good health," when asked about his present health at the time. He specifically denied that he had "been a sleepwalker;" and "frequent trouble sleeping." The Veteran signed this document, wherein he attested that the information he provided in this form was "true and complete to the best of my knowledge." The Board accords high probative value and credibility to this document, as the Veteran completed it contemporaneously with service. The Veteran and his representative asserted that the Veteran did not go to sick call because he would be called a "sick bay commando," and fear of being put on light duty and ousted from the platoon or higher ups. However, the December 1998 Report of Medical History was completed at service separation, and the Veteran would not have the risk of being put on light duty or ousted at the time and he still did not report symptoms of sleep disturbance. Moreover, the Veteran had reported to sick call for multiple unrelated complaints during service, including knee infection, mouth ulcers, ankle sprain, chest congestion, kidney stones, face rash, poison ivy allergy, etc. There was no disease or injury indicative of OSA or complaints of sleep disturbance noted in service treatment records or in the December 1998 Report of Medical Examination at service separation, and the Veteran indicated that he first sought treatment at VA a few years prior to the January 2021 Board hearing. Thus, the Board finds that the persuasive weight of the evidence is against a finding that there was a disease or injury in service indicative of OSA. The Board has reviewed the record, including service treatment records and post-service medical records and also finds that the weight of the evidence is persuasively against a nexus between the post-service diagnosis of OSA and service and is not secondary to service-connected disabilities. The August 2021 examiner provided an opinion that sleep apnea is less likely as not incurred in or caused by the claimed in-service injury, event, or illness. She provided the rationale that a review of the service treatment records shows no evidence of the diagnosis or treatment for sleep apnea or diagnostic polysomnography (PSG) while on active duty. She added, snoring unrestful sleep, "gasping," "trouble sleeping," insomnia are not pathognomonic for sleep apnea. The examiner explained that sleep apnea is diagnosed by PSG and that apnea/hypoxia index (AHI) is the diagnostic standard for OSA. She indicated that a PSG was not performed until 2016 and lay statements of chronicity are not supported by evidence. The examiner stated there were no symptoms of OSA documented until 2015, despite numerous clinic visits prior and concluded no nexus to active duty exists. She also explained the lack of a relationship between the Veteran's weight gain and service-connected disabilities, which is discussed in further detail below. In May 2016, the Veteran was afforded a VA medical examination and the examiner opined that the Veteran's sleep disturbance, to include OSA, was less likely than not proximately due to or the result of the Veteran's service-connected Dercum's disease. He stated that the most important risk factors for OSA are advancing age, male gender, obesity, and craniofacial or upper airway soft tissue abnormalities. The examiner noted that the Veteran was overweight with a body mass index (BMI) over 30.78, which he explained is considered moderately obese, and a neck circumference of 1712 inches or more for men, which is associated with a higher risk of sleep apnea. He concluded, as per medical literature, enough study was not done yet to show a cause and effect relationship between Dercum's disease / lipomatosis and OSA. In response to the May 2016 examiner's opinion, in an October 2019 appellant's brief, the Veteran's representative asserted that obesity, while not a disability for compensation purposes, can be a steppingstone to secondary disabilities resulting from the obesity. It was noted that the November 2018 psychiatric examination report included chronic sleep impairment as a manifestation of the Veteran's service-connected psychiatric disability. The Veteran asserts that the service-connected obsessive-compulsive disorder and secondary depressive disorder (psychiatric disorder) has caused his obesity, and the obesity, in turn, has resulted in sleep apnea and further impacted his low back disability. The Board emphasizes that obesity cannot qualify as an in-service disease or injury to warrant service connection for another disability because it occurs over time. Although service connection is not allowed for obesity on its own, obesity could act as an "intermediate step" to establish service connection for another disability as secondary to an already service-connected disability under certain circumstances. See VAOPGCPREC 01-17 (January 6, 2017). Given the above, the Board remanded the Veteran's claim in May 2021 for an addendum medical opinion to address any secondary causation between the Veteran's service-connected disabilities and his claimed OSA. An addendum opinion (DBQ) was provided in August 2021. The medical professional opined that the Veteran's OSA was less likely than not proximately due to or the result of the Veteran's service-connected psychiatric disorder. She provided the rationale that the two conditions are not medically related, and OSA is a separate entity entirely from the service-connected mental health condition and unrelated to it. She stated that a thorough review of medical literature failed to demonstrate a causal relationship and thus a nexus has not been established. She explained that there is no medical condition which causes OSA, which she noted has a clear and specific etiology. She added it is a common disorder characterized by narrowing or collapse of the pharyngeal airway during sleep and it is caused by anatomical variations in the craniofacial features and/or neck. There is no evidence to suggest that it is due to PTSD or any other mental condition. The August 2021 examiner opined the Veteran's claimed OSA is also not at least as likely as not aggravated beyond its natural progression by the service-connected psychiatric disorder. She explained that the conditions are unrelated, and no aggravation is plausible. The medical professional provided the opinion that Veteran's OSA was less likely than not proximately due to or the result of the Veteran's service-connected Dercum's disease. She explained that the conditions of OSA and Dercum's disease are not medically related. OSA is a separate entity from Dercum's disease and unrelated to it, and a thorough review of medical literature failed to demonstrate a causal relationship. She explained, Dercum's disease is a skin condition, also known as Adiposis Dolorosa, Anders' syndrome, and Dercum-Vitaut syndrome, a rare condition that is characterized by multiple painful fatty lipomas (benign, fatty tumors). The lipomas mainly occur on the trunk, the upper arms, and upper legs, and are found just below the skin (subcutaneously) but can also be found deeper in the body coupled to muscle, tendons, ligaments, or bone by connective tissue. She indicated nothing in the medical literature shows Dercum's disease causes closure of the airways during sleep and a nexus has not been established. She clarified that the service-connected diagnosis of Dercum's disease with iron deficiency anemia (IDA) and chronic fatigue is not correct, as there is no diagnosis of IDA or chronic fatigue syndrome documented in the treatment record and the service-connected condition should be Dercum's disease. The examiner opined that the Veteran's claimed OSA is not at least as likely as not aggravated beyond its natural progression by the service-connected Dercum's disease. She explained that the conditions are unrelated, and no aggravation is plausible. The Veteran's contention that his obesity was caused by the service-connected disabilities and in turn resulted in his OSA was directly addressed by the examiner. She indicated that the conditions of weight gain and the service-connected conditions are not medically related as the weight gain is a separate entity from the service-connected conditions and unrelated to it. She explained that obesity is primarily due to consuming more calories than the body burns off, which is a choice and an orthopedic condition or service-connected Dercum's disease do not preclude all forms of exercise as there are paraplegics who are not obese. The examiner stated from the weigh-in treatment notes, the Veteran is clearly able to lose weight despite the service-connected disabilities, which indicates a choice. She added that no nexus for cause or aggravation is plausible and obesity would have occurred regardless of the service-connected disabilities as the obesity was due to a choice to consume more calories than the body needs. The Board has considered the evidence of record, including lay statements, and the Board finds that the most probative evidence of record are the VA medical opinions discussed above. The Veteran testified during the January 2021 Board hearing that Dr. Herbst, a private doctor that provided a formal diagnosis for Dercum's disease, told him directly that sleep disturbances were related to the Dercum's disease, however, there is no opinion of record from Dr. Herbst providing a causal nexus between the Veteran's OSA and his Dercum's disease. A July 2016 VA medical record reflects a physician's report that it appeared a major component of the Veteran's visit at the time was because he desired for a physician to document that several of his symptoms are a result of his Dercum's disease, including sleep apnea. The physician indicated that she discussed with the Veteran that she was not familiar with the Veteran's Dercum's disease diagnosis and did not feel comfortable attributing his symptoms to that at the time. She discussed with the Veteran that many people who have served in the military have musculoskeletal issues and do not have the Dercum's disease diagnosis. There are numerous post-service medical records reflecting complaints and treatment for OSA; however, these records do not provide a positive nexus regarding the onset, etiology, or relationship of OSA to military service, to include as secondary to service-connected disabilities. The Veteran has not offered probative and competent evidence in support of a nexus between OSA and service. Lay evidence may be competent to establish medical etiology or nexus. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to." See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Veteran testified that his ex-wife reported that he snored in service, and the Board notes that she is competent to report the Veteran's snoring. However, the Veteran and his ex-wife are not medically trained and are therefore not qualified to competently opine about medical etiology of a pulmonary disorder, OSA, in relation to his in-service snoring or sleep complaints. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Such diagnoses and opinions as to relationship involve unseen systems processes and disease processes that are largely unobservable by the five senses of a lay person, involve an understanding of the pulmonary system, and involve making findings based on medical knowledge and clinical testing results. Consequently, the Veteran's assertion of relationship between OSA and service, to include as secondary to service-connected disabilities, is of no probative value. Here, the May 2016 and August 2021 examiners found that the Veteran's service-connected Dercum's disease and psychiatric disorder are unrelated to the claimed OSA and that there is no causal relationship to the claimed OSA nor is aggravation plausible. To the extent that the Veteran had symptoms in service, the examiners also addressed why the diagnosis of obstructive sleep apnea more than a decade after service was not related to service. Notably, the August 2021 examiner indicated that Veteran's reported symptoms, including snoring, unrestful sleep, "gasping," "trouble sleeping," and insomnia are not pathognomonic for sleep apnea. Therefore, given the reasons above, the Board finds that opinions from May 2016 and August 2021 (DBQ) examiners provide competent and probative evidence that weighs against the Veteran's claim because the examiners reviewed the claims file and collectively provided medical opinions, including direct and secondary addressing both causation and aggravation, supported by well-reasoned rationales, which were based on the application of medical principles and the facts of the case. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012). Absent competent, credible, and probative evidence of a nexus between the Veteran's service and his OSA, the Board finds that his current OSA was not incurred in-service and it is not otherwise related to active service. The Board also finds that his OSA is not caused by or aggravated by the Veteran's service-connected psychiatric disorder or Dercum's disease, as the Veteran has not offered competent and probative medical evidence in support of his claim. See 38 U.S.C. § 5107(a). Accordingly, service connection for OSA is not warranted. The evidence persuasively weighs against the claim of service connection for obstructive sleep apnea (OSA), to include as secondary to a service-connected disability or disabilities. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application, and the claim is denied. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). 2. Entitlement to service connection for a lumbar spine (low back) disability. The Veteran contends that service connection is warranted for a lumbar spine disability because it was incurred in service or otherwise a result of service, to include as secondary to the service-connected Dercum's disease. During the January 2021 Board hearing, the Veteran testified that he had back pains in service, which he contributed to carrying packs and marching and now had degenerative disc disease in his back. He reported hundreds of lipomas in his back area, which Dr. Herbst told him were attaching to his nerves. See also September 2015 DRO hearing transcript. After a careful review of the evidence of record, the Board finds that the evidence persuasively weighs against a finding that service connection for a lumbar spine disability is warranted. The reasons follow. The Veteran has a current lumbar spine disability. In a May 2016 VA examination report, the examiner entered a diagnosis of degenerative arthritis of the spine. Accordingly, the first element of service connection, evidence of a current disability, is met. As to evidence of an in-service disease or injury, the Veteran reported that he had back pains in service, however, he has not provided evidence of a specific disease or injury. Service treatment records do not document complaints, symptoms, diagnosis, or treatment related to the lumbar spine, specifically the Veteran's December 1998 Report of Medical Examination for purposes of separation reflects a normal clinical evaluation of the Veteran's "spine, other musculoskeletal." In the accompanying December 1998 Report of Medical History, the Veteran reported a positive history of "broken bones" but denied "wear[ing] a brace or back support;" "swollen or painful joints;" "arthritis, rheumatism, or bursitis;" "bone, joint, or other deformity;" "paralysis;" and "recurrent back pain or any back injury." The Veteran indicated that "broken bones" related to a motor vehicle accident as an adolescent. The Veteran signed this document, wherein he attested that the information he provided in this form was "true and complete to the best of my knowledge." The Board accords high probative value and credibility to this document, as the Veteran completed it contemporaneously with service. The Veteran and his representative asserted that the Veteran did not go to sick call because he would be called a "sick bay commando," and fear of being put on light duty and ousted from the platoon or higher ups. However, the December 1998 Report of Medical History was completed at service separation, the Veteran would not have the risk of being put on light duty or ousted at the time and he still did not report symptoms related to the lumbar spine. Moreover, the Veteran had reported to sick call for multiple unrelated complaints during service, including knee infection, mouth ulcers, ankle sprain, chest congestion, kidney stones, face rash, poison ivy allergy, etc. There was no diagnosis of a lumbar spine disability or complaints of pain noted in service treatment records or in the December 1998 Report of Medical Examination at service separation, where the Veteran specifically denied a history of recurrent back pain or any back injury. The Board finds no reason to question the accuracy of what the Veteran documented within the Report of Medical History. This is affirmative evidence against an in-service lumbar spine disease or injury. Thus, to the extent that the Veteran alleged an in-service lumbar spine disease or injury, the Board finds such allegation is not credible. The weight of the evidence is persuasively against a finding of a disease or injury involving the lumbar spine during service, and the in-service disease or injury element is not met. Additionally, there is no competent evidence that arthritis manifested within one year from his May 1999 separation from service. A January 2011 VA medical record indicates that he was a new patient and presented to establish care. Back pain is noted in the past medical history. A September 2013 VA record reflects the Veteran's complaint of left thorac rib area pain with some stretches and arm movements and a recent fall and land on his left back, where the wind was knocked out of him with residual pain since. A September 2013 x-ray report of the lumbar spine documents "DJD" as the reason for study and shows an impression of minimal mild thoracic scoliosis and minimal to mild degenerative changes. In a May 2016 VA back (thoracolumbar spine) examination report, degenerative arthritis of the spine, as degenerative lumbar disc disease was noted with a date of diagnosis of 2014. The examiner noted that the Veteran reported lumbar back pain and both hip joints since 2014 and that it had been getting worse. During the January 2021 Board hearing, the Veteran indicated that he first sought treatment at for the lumbar spine in 2004 or 2005. Arthritis is diagnosed primarily on clinical findings, such as x-rays or specialized testing, such as MRI, which the Veteran is not competent to conduct or interpret. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (degenerative arthritis established by x-ray findings); Diagnostic Code 5010 (traumatic arthritis established by x-ray findings); Diagnostic Code 5002 (rheumatoid arthritis must be "objectively confirmed by findings" that show limitation of motion). Cf. 38 C.F.R. § 4.66 (indicating the usual way to diagnose arthritis is by x-ray, which is also required to see arthritic changes). Arthritis of the lumbar spine was not confirmed until x-rays were performed in September 2013, as discussed above. The persuasive weight of the evidence is against a finding that arthritis manifested within one year from the Veteran's May 1999 separation from service. Even assuming a 2004 or 2005 diagnosis of arthritis when the Veteran reported that he first sought treatment at a private provider, it would still be at least 5 years after service. Thus, a presumption of service connection based on the chronicity of arthritis is not warranted. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.307, 3.309(a). As to evidence of a nexus between the current disability and service, the Board finds the evidence persuasively weighs against a finding to establish the required nexus between the disability and the Veteran's military service, to include as secondary to service-connected disability or disabilities. The Veteran was afforded a VA examination for his claimed lumbar spine disability in May 2016. The examiner found that the Veteran's claimed lumbar spine disability was less likely than not proximately due to or the result of the service-connected Dercum's disease. He provided the rationale that physical examination of the Veteran's back was normal, and his lumbar spine x-ray revealed degenerative lumbar disc disease, which is more likely a part of generalized degeneration due to age. The examiner documented that he reviewed peer reviewed medical literature and found that there was not enough study done yet to show a cause-and-effect relationship between Dercum's disease/lipomatosis and degenerative disc disease. Addendum opinions were provided in August 2021. The examiner opined that the claimed lumbar spine disability was less likely than not incurred in or caused by the claimed in-service injury, event or illness. She indicated that on active duty there were no suspicions or concerns for a low back condition and there were no radiologic evidence of disruption to the articular surface of the joint at the time of active duty, therefore, the DJD is most likely as natural aging process. She provided the opinion that Veteran's lumbar spine disability was less likely than not proximately due to or the result of the service-connected Dercum's disease. She provided the rationale that the conditions of lumbar spine and Dercum's disease are not medically related. The lumbar spine is a separate entity from Dercum's disease and unrelated to it, and a thorough review of medical literature failed to demonstrate a causal relationship. She explained, Dercum's is a skin condition, also known as Adiposis Dolorosa, Anders' syndrome, and Dercum-Vitaut syndrome, a rare condition that is characterized by multiple painful fatty lipomas (benign, fatty tumors). The lipomas mainly occur on the trunk, the upper arms, and upper legs, and are found just below the skin (subcutaneously) but can also be found deeper in the body coupled to muscle, tendons, ligaments, or bone by connective tissue. She indicated nothing in the medical literature shows Dercum's disease has caused an orthopedic condition and a nexus has not been established. She noted x-rays show no lipomal infiltration of the lumbar spine and a 2013 x-ray showed mild DJD most likely age-related changes. The examiner also found that the Veteran's claimed lumbar spine disability is not at least as likely as not aggravated beyond its natural progression by the service-connected Dercum's disease. She explained that the conditions are unrelated, and no aggravation is plausible. The examiner also provided an opinion that the lumbar spine disability is less likely than not proximately due to or the result of the Veteran's pelvic/hip disability, however, as the Veteran is not in receipt of service-connection for a pelvic/hip disability and the claim for such is denied herein, the Veteran cannot be awarded service connection for a lumbar spine disability on a secondary basis to a pelvic/hip disability. The opinion is not applicable to the Veteran's claim and the Board need not discuss it in detail. The Veteran is competent to report his symptoms; however, to the extent he is alleging a nexus through his own lay assertions that his lumbar spine disability is caused by or related to his military service or is secondary to the service-connected Dercum's disease, he not competent to offer his opinions, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. The Board finds of most probative value the VA medical opinions. The examination report and opinions provide competent and probative evidence that weighs against the Veteran's claim because the examiners collectively reviewed the claims file, interviewed the Veteran, performed a physical examination, and provided medical opinions supported by well-reasoned rationale, which was based upon the facts of the case and medical principles. Monzingo v. Shinseki, 26 Vet. App. 97, 105-106 (2012). The examiners' opinions are consistent with the lay and medical evidence of record. There is no noted past medical history of such until a January 2011 VA medical record that indicates that he was a new patient and presented to establish care. Subsequently, a September 2013 VA record reflects the Veteran's complaint of left thorac rib area pain with some stretches and arm movements and a recent fall and land on his left back where the wind was knocked out of him with residual pain since and x-rays the same month showed minimal to mild degenerative changes. The Board may take into consideration the passage of a lengthy period of time in which the Veteran did not complain of the disability at issue. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). To the extent that the Veteran is claiming that the lumbar spine disability is caused by the lipomas from the service-connected Dercum's disease attaching in his back area, specifically the nerves, as he was told by Dr. Herbst, the August 2021 examiner directly addressed this. The examiner stated that nothing in medical literature shows Dercum's disease has caused an orthopedic condition and that the Veteran's x-rays show no lipomal infiltration of the lumbar spine but rather showed mild DJD most likely age-related changes. The Board notes the Veteran is already in receipt of service connection and compensated accordingly for peripheral neuropathy of the bilateral upper and lower extremities, which, as the Veteran purported Dr. Herbst suggested, was caused by the lipoma attachment to the nerves. Absent competent, credible, and probative evidence of a nexus between the Veteran's service and the lumbar spine disability; the Board finds that his lumbar spine disability was not incurred in service and it is not otherwise related to active service. There are numerous post-service medical records reflecting complaints and treatment for a lumbar spine disability; however, these records do not provide a positive nexus regarding the onset, etiology, or relationship of lumbar spine disability to military service, to include as secondary to service-connected disabilities. The most probative evidence on medical etiology is against his claim. The Board also finds that the evidence is persuasively against a finding that the Veteran's lumbar spine disability is caused or aggravated by the service-connected Dercum's disease. Accordingly, service connection for a lumbar spine disability is not warranted. For all the reasons laid out above, the Board finds the evidence persuasively weighs against the claim of service connection for a lumbar spine disability, to include degenerative arthritis, and as secondary to a service-connected disability or disabilities, the benefit-of-the-doubt doctrine is not for application, and the claim is denied. Lynch, 21 F.4th 776; 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for a pelvic disability. The Veteran asserts that service connection for a pelvic/hip disability is warranted because it was incurred in or otherwise a result of service, to include as secondary to the service-connected Dercum's disease. During the January 2021 Board hearing, the Veteran testified that he had "ghost pains" in his pelvis in service, that continued and has progressively gotten worse. He reported hundreds of lipomas in his back area, which Dr. Herbst told him were attaching to his nerves. The Board has carefully reviewed the evidence of record and finds that the weight of the evidence is persuasively against a finding that the Veteran has a current pelvic/hip disability during the appeal period. Therefore, service connection is not warranted for the claimed disability. The Veteran was provided a VA examination for his claimed pelvic/hip disability in May 2016. The examiner found that the Veteran did not have a current hip disability. The examiner considered the Veteran's report during the examination that he had lumbar back pain and both hip joint pain, including since 2014 that had been getting worse. The May 2015 examiner indicated that the Veteran reported flare-ups of the hip or thigh "almost on a daily basis" but no response was provided as to whether the Veteran reported having any functional loss or functional impairment of the joint regardless of repetitive use. Objective findings revealed a normal range of motion, bilaterally; ability to perform repetitive use testing with at least three repetitions without additional loss of function or range of motion, bilaterally; and normal muscle strength and no ankylosis of either hip. The examiner noted that imaging studies of the hip or thigh were preformed and the results were available but no degenerative or traumatic arthritis was documented nor any other significant diagnostic test findings or results. The examiner found that regardless of the Veteran's current employment status, there was no functional impact on his ability to perform any type of occupational task, such as standing, walking, lifting, etc. The examiner made specific remarks that no pathology had been detected to render the diagnosis of both hip condition on examination and both hip x-rays were normal. The examiner also provided the opinion that the claimed pelvic condition was less likely than not proximately due to or the result of the Veteran's service-connected condition. The examiner reiterated his remarks in his examination report that there was no pathology to render a diagnosis on examination and x-rays of both hips were normal. Further, he stated that the Veteran has no documented diagnosis of both hip conditions in his problem lists. He stated that he also reviewed the peer reviewed medical literature and enough study was not done yet as to the cause and effect relationship between Dercum's disease/lipomatosis and hip conditions. The findings within the May 2016 are consistent with the August 2021 opinions. The August 2021 examiner opined that the claimed pelvic disability was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner provided the following rationale: No chronic diagnosis made for hip/pelvic condition. Although the Veteran is competent to report symptoms, these reports associated with the C&P process are no way supported by treatment notes. As of 1/12/2021 problem list, there is no chronic hip diagnosis and no documented chronic orthopedic hip complaints. Surely if complaints were as troubling as noted in the DBQ, the Veteran would have reported them, yet there are none. A nexus has not been established. She also provided the opinion that Veteran's hip/pelvis disability was less likely than not proximately due to or the result of the Veteran's service-connected Dercum's disease. She provided the rationale that the conditions of hip/pelvis and Dercum's disease are not medically related. The hip/pelvis is a separate entity from Dercum's disease and unrelated to it, and a thorough review of medical literature failed to demonstrate a causal relationship. She explained, Dercum's is a skin condition, also known as Adiposis Dolorosa, Anders' syndrome, and Dercum-Vitaut syndrome, a rare condition that is characterized by multiple painful fatty lipomas (benign, fatty tumors). The examiner wrote that the lipomas mainly occur on the trunk, the upper arms, and upper legs, and are found just below the skin (subcutaneously) but can also be found deeper in the body coupled to muscle, tendons, ligaments, or bone by connective tissue. She indicated nothing in the medical literature shows Dercum's disease has caused an orthopedic hip condition and a nexus has not been established. She noted x-rays show no lipomal infiltration of the lumbar spine and as of the January 2021 problem list, there is no chronic hip diagnosis and no documented chronic orthopedic hip complaints in the treatment record. The examiner also concluded that the Veteran's claimed hip/pelvis disability is not at least as likely as not aggravated beyond its natural progression by the service-connected Dercum's disease. She explained the conditions are medically unrelated and no chronic diagnosis is made for a hip/pelvis condition. The Board is aware of the holding in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), in which the U.S. Court of Appeals for the Federal Circuit explained that where pain alone results in functional impairment that affects earning capacity, even if there is no identified underlying diagnosis, it can constitute a disability. The Veteran does not contend that that he has experienced functional impairment affecting his earning capacity related to the pelvis/hip, and the evidence of record does not show that the Veteran has had such functional impairment. The May 2016 VA examiner found no functional impact on the Veteran's ability to perform any type of occupational task. The persuasive weight of the evidence is against a finding of a current pelvic/hip disability, to include symptoms that cause functional impairment of earning capacity. To the extent that the Veteran is claiming that the pelvic/hip disability is caused by the lipomas from the service-connected Dercum's disease attaching in his back area, specifically the nerves, as he was told by Dr. Herbst, the August 2021 examiner directly addressed this. The examiner stated that nothing in medical literature shows Dercum's disease has caused an orthopedic hip condition the Veteran's x-rays show no lipomal infiltration of the hip. The Veteran is already in receipt of service connection for peripheral neuropathy of the bilateral upper and lower extremities, which as the Veteran purported Dr. Herbst suggested was caused by the lipoma attachment to the nerves. In the absence of a showing of functional impairment of earning capacity involving the pelvic/hip or a current pelvic/hip disability, service connection is not warranted. As the evidence persuasively weighs against the claim of service connection for a pelvic disability, to include as secondary to service-connected disability or disabilities, the benefit-of-the-doubt doctrine is not for application, and the claim is denied. Lynch, 21 F.4th 776; 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Cheng, 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.