Citation Nr: 0531520 Decision Date: 11/21/05 Archive Date: 11/30/05 DOCKET NO. 98-19 978 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for coronary artery disease status post myocardial infarction with associated renal disorder, to include consideration as being secondary to a service-connected disability. 2. Whether new and material evidence has been presented to reopen a claim for service connection for hypertension. 3. Entitlement to compensation under 38 U.S.C.A. § 1151 for a coronary disability with renal dysfunction claimed as due to VA medical treatment, surgery and hospitalization in July and August 1989. 4. Entitlement to special monthly compensation based on the need for aid and attendance or on being housebound. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD Michael Martin, Counsel INTRODUCTION The veteran had active service from February 1954 to February 1956. This matter came before the Board of Veterans' Appeals (Board) on appeal from decisions of March 1998 and later by the Department of Veterans Affairs (VA) St. Petersburg, Florida, Regional Office (RO). The Board remanded the case in March 2004 and again in March 2005. A hearing was held at the RO in June 2005 before the undersigned Veterans Law Judge. The issue of entitlement to special monthly compensation based on the need for aid and attendance is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. All evidence necessary for review of the issues on appeal (other than the claim for special monthly compensation) has been obtained, and the VA has satisfied the duty to notify the appellant of the law and regulations applicable to the claims, the evidence necessary to substantiate the claims, and what evidence was to be provided by the appellant and what evidence the VA would attempt to obtain on his behalf. 2. Coronary artery disease and a renal disorder were not present until many years after separation from service, are not related to any incident during service, and were not caused or aggravated by the veteran's service-connected back disorder, service-connected left knee disorder or service- connected scar of the right hip. 3. The RO denied service connection for hypertension in August 1977 on the basis that the disorder had not been incurred in or aggravated by service, and no etiological relationship had been shown between hypertension and a service-connected disability. The veteran was notified in writing of the decision later that month, but he did file a notice of disagreement within one year of notification. 4. The evidence received subsequent to the August 1977 rating decision is cumulative and redundant, does not bear directly and substantially upon the specific matter under consideration, and is not so significant that it must be considered in order to fairly decide the merits of the claim for service connection for hypertension. 5. The preponderance of the evidence shows that the veteran does not have additional coronary or renal disability due to hospitalization or medical or surgical treatment provided by VA in July and August 1989. 6. The preponderance of the competent medical evidence shows that the proximate cause of the veteran's current coronary and renal disability was not carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the hospitalization or medical or surgical treatment, nor was the proximate cause of any such disability an event which was not reasonably foreseeable. CONCLUSIONS OF LAW 1. Coronary artery disease status post myocardial infarction with associated renal disorder was not incurred in or aggravated by service, may not be presumed to have been incurred in service, and was not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2005). 2. The August 1977 rating decision that denied entitlement to service connection for hypertension is final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. § 20.1103 (2005). 3. No new and material evidence has been presented to warrant reopening the claim of entitlement to service connection for hypertension. 38 U.S.C.A. § 5108 (West 2002). 4. The criteria for entitlement to compensation under 38 U.S.C.A. § 1151 for coronary and renal disability, claimed to be caused by hospitalization, or medical or surgical treatment provided by the VA in July and August 1989, are not met. 38 U.S.C.A. § 1151 (West 2002 & Supp. 2005). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matter: Duty to Assist On November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000). The law provides that the VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claimant's claim for a benefit under a law administered by VA. See 38 U.S.C.A. § 5103A. The Act is applicable to all claims filed on or after the date of enactment, or filed before the date of enactment and not yet final as of that date. VCAA, § 7, subpart (a), 114 Stat. 2096, 2099 (2000). The law eliminates the concept of a well-grounded claim, and redefines the obligations of VA with respect to the duty to assist claimants in the development of their claims. First, the VA has a duty to notify the appellant and his representative, if represented, of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102 and 5103. Second, the VA has a duty to assist the appellant in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A. The VA has promulgated revised regulations to implement these changes in the law. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (codified as amended at 38 C.F.R §§ 3.102, 3.156(a), 3.159 and 3.326(a)). In Mayfield v. Nicholson, 19 Vet. App. 103 (2005), the United States Court of Appeals for Veterans Claims (Court) held, in part, that a VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request or tell the claimant to provide any evidence in the claimant's possession that supports to the claim. See also Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). This "fourth element" of the notice requirement comes from the language of 38 C.F.R. § 3.159(b)(1). In this case, the VA's duties have been fulfilled. The Board finds that the veteran was provided adequate notice as to the evidence needed to substantiate his claims. The Board concludes the discussions in the rating decisions, the statement of the case (SOC) supplemental statements of the case (SSOCs) and letters sent to the veteran informed him of the information and evidence needed to substantiate the claims, and complied with the VA's notification requirements. Letters from the RO dated in September 2001 and March 2004 specifically discussed the evidence the veteran would need to submit to support his claims, as well as an explanation of what evidence was to be provided by him and what evidence the VA would attempt to obtain on his behalf. See generally Quartuccio v. Principi, 16 Vet. App. 183 (2002). The more recent letter specifically advised him to let the RO know if there was any other evidence or information that he thought would support his claim, and that he should send in any medical reports he may have. Therefore, the Board finds that the letter as a whole complied with the fourth element. Thus, the Board finds that each of the four content requirements of a VCAA notice has been fully satisfied. The VA has no outstanding duty to inform the appellant that any additional information or evidence is needed. In Mayfield, the Court further noted, citing Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II), that a VCAA notice must be provided to a claimant before the initial unfavorable [agency of original jurisdiction (AOJ)] decision on a service-connection claim. A VCAA notice was not provided to the appellant before the RO decisions regarding his claim for benefits. However, in Mayfield the Court noted that an error in the timing of the notice is not per se prejudicial and that to prove prejudice, the appellant had to claim prejudice with specificity. In the present case, the Board finds that there was no prejudice to the appellant. The Court in Mayfield noted that there could be no prejudice with an error in the timing of the VCAA notice if its purpose of affording the claimant a meaningful opportunity to participate effectively in the processing of his claim, was satisfied. In other words, the claimant should be provided VCAA notice and an appropriate amount of time to respond and proper subsequent VA process. That is what was done in the present case. The appellant was given the VCAA notice letters and was given an ample opportunity to respond. The veteran has not claimed any prejudice as a result of the timing of the VCAA letter. Therefore, to decide the appeal would not be prejudicial error. The Board also finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issues has been obtained. All relevant evidence identified by the veteran was obtained and considered. The veteran has had a personal hearing. His service medical records and post-service treatment records have been obtained, and he has been afforded VA examinations. The Board is unaware of any additional relevant evidence that is available. The veteran has not identified any unobtained evidence that might aid his claims or that might be pertinent to the bases of the denial of his claims. The Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to evaluate the veteran's claims. Therefore, no further assistance to the veteran with the development of evidence is required. In the circumstances of this case, a remand to have the RO attempt to further implement the VCAA with respect to these issues would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the veteran are to be avoided). VA has satisfied its obligation to notify and assist the veteran in this case. Further development and further expending of the VA's resources is not warranted. Taking these factors into consideration, there is no prejudice to the veteran in proceeding to consider the claims on the merits. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). I. Entitlement To Service Connection For Coronary Artery Disease Status Post Myocardial Infarction With Associated Renal Disorder, To Include Consideration As Being Secondary To A Service-Connected Disability. Service connection may be granted for disability due to disease or injury incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110, 1131. If a chronic disorder such as cardiovascular-renal disease is manifest to a compensable degree within one year after separation from service, the disorder may be presumed to have been incurred in service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection connotes many factors but basically it means that the facts, shown by evidence, 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. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. Each disabling condition shown by a veteran's service records, or for which he seeks a service connection must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence. Determinations as to service connection will be based on review of the entire evidence of record, with due consideration to the policy of the VA to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 C.F.R. § 3.303(a). With chronic disease shown as such in service (or within the presumptive period under Sec. 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word ``Chronic.'' When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). 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. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). Service connection may also be granted for disability shown to be proximately due to or the result of a service-connected disorder. See 38 C.F.R. § 3.310(a). This regulation has been interpreted by the Court to allow service connection for a disorder which is caused by a service-connected disorder, or for the degree of additional disability resulting from aggravation of a nonservice-connected disorder by a service- connected disorder. See Allen v. Brown, 7 Vet. App. 439 (1995). The veteran has previously established service connection for dorsolumbar paravertebral myositis, status post surgery with dysfunction due to fracture L1 vertebra with spinal stenosis, rated as 60 percent disabling; residuals of trauma and surgery, left knee, rated as 40 percent disabling; and a donor site scar, right hip, rated as noncompensably disabling. During the hearing held in June 2005, the veteran testified, in essence, that he had had cardiovascular disease ever since service. He described the problem as initially consisting of hypertension and later heart disease. The veteran's service medical records do not contain any references to cardiovascular or renal disease. The report of a medical examination conducted in February 1956 for the purpose of his discharge shows that clinical evaluation of the heart and vascular system was normal. His blood pressure at that time was only 112/70, and no cardiovascular disorder was diagnosed. A chest X-ray was negative for abnormality. His genitourinary system was also normal on clinical evaluation. Urinalysis was negative. There is also no evidence of cardiovascular-renal disease within a year after separation from service. The veteran filed a claim for disability compensation in July 1956; however, the only disability which he mentioned pertained to the left knee. The report of a VA disability evaluation examination conducted in May 1957 is also negative for any references to cardiovascular or renal disorders. Examination of the cardiovascular system shows that the heart size, rate, rhythm and tones were all normal. His blood pressure was only 120/80. A chest X-ray taken in connection with the VA examination was interpreted as showing that the heart shadow was normal in size and shape. A post-service hospitalization record dated in April 1958, over two years after service, reflects that the veteran was seen for umbilical pain and was diagnosed with cystitis. The disorder greatly improved and he was discharged. Neither a cardiovascular disorder nor a renal disorder was specifically diagnosed. Even assuming that this hospitalization pertained to a renal disorder, the record does not contain any indication that the disorder was related to service. On the contrary, the record reflects that the symptoms were of onset of only one week earlier. Thus, this record does not provide any support for the claim. The earliest evidence of the presence of a chronic cardiovascular or renal disorder is from many years after separation from service, and contains no indication that it is related to service or to his service connected disorders. A VA disability evaluation examination conducted in July 1974 reflects that the diagnoses included mild hypertension. However, even at that time, his heart was still described as being not enlarged, with regular sinus rhythm and no murmurs. Significantly more recent treatment records show that the veteran has developed severe coronary artery disease with associated renal disease. For example, a private medical record from the Florida Hospital dated in September 1997 reflects a diagnosis of acute inferoposterior myocardial infarction status post TPA with resolution of chest pain and ECG changes. However, the treatment records do not contain any medical opinion linking such a disorder to service. A VA examination report dated in October 2004 contains medical opinions which weigh against the claim. The examiner reviewed the veteran's medical history and stated that: This observer feels that no case has been made to open up the case of hypertension as there is no evidence that he was hypertensive during service and with that in mind, the coronary artery disease, hypertensive changes in the heart are also not related to service. These further are not related to the service-connected low back pain. With respect to any contention that the veteran developed coronary artery disease with renal dysfunction secondary to a service-connected disability, the Board finds that there is no credible evidence that such a relationship exists. In reaching this conclusion, the Board has considered a note dated in July 1974 from Dr. G. L. Antunez which reflects diagnoses of (a) post-traumatic left knee meniscus operation; (b) discogenic disease L4-L5-S1; (c) secondary weakness of left lower extremity (progressive and intractable); (d) secondary nervous disorder; (e) secondary hypertension; (f) old post-traumatic eyes abnormalities and visual impairment; and (g) secondary chronic arthritis. However, he did not provide an explanation for that conclusion that the service connected left knee and back disorders caused secondary disabilities. A bare conclusory opinion without an explanation of the basis for the opinion is not adequate to support the claim. See Miller v. West, 11 Vet. App. 345, 348 (1998). The Board notes that there is no clinical data or other rationale to support his opinion; nor is there anything otherwise in the record that would give it substance. Therefore, the opinion is essentially unsupported. See Bloom v. West, 12 Vet. App. 185 (1999). With respect to his testimony in which the veteran relates his coronary and renal problems to service or to his service- connected disabiities, the Board notes that the Court has held that lay persons, such as the veteran, are not qualified to offer an opinion that requires medical knowledge, such as a diagnosis or an opinion as to the cause of a disability. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-5 (1992). In summary, coronary artery disease with renal disease was not present until many years after separation from service, and is not related to any incident during service. In addition, the disorder was not caused or aggravated by the service-connected disabiities. Accordingly, the Board concludes that coronary artery disease with renal disease was not incurred in or aggravated by service, may not be presumed to have been incurred in service, and was not proximately due to or the result of a service-connected disability. II. Whether New And Material Evidence Has Been Presented To Reopen A Claim for Service Connection For Hypertension. In an August 1977 rating decision, the RO denied service connection for hypertension. In the decision and notification letter, the RO noted that service connection was not warranted because hypertension was not incurred in or aggravated by service, and no etiological relationship had been established between a service-connected disability and the veteran's hypertension. The veteran was informed of this decision but did not respond within one year. The rating decision is therefore final. 38 U.S.C.A. § 7105(c). The evidence which was of record at the time of the original decision included the service medical records which are summarized above and are negative for the claimed condition. The evidence also included post service VA examination reports and medical treatment records which were negative for any references to hypertension until many years after service. The only medical opinion of record suggesting a possible relationship between the hypertension and a service- connected disability was the report of July 1974 from Dr. G. L. Antunez which, as was noted above, described the hypertension as being a secondary disorder, but did not give any explanation for such a conclusion. The veteran has requested that his claim for service connection for hypertension be reopened. Generally, a final rating or Board decision may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C.A. §§ 7104, 7105(c). However, under 38 U.S.C.A. § 5108, "[i]f new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim." Under 38 C.F.R. § 3.156(a), "new and material evidence" means evidence not previously submitted to agency decisionmakers which bears "directly and substantially" upon the specific matter under consideration. Such evidence must be neither cumulative nor redundant, and, by itself or in connection with evidence previously assembled, such evidence must be "so significant that it must be considered in order to fairly decide the merits of the claim." See Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998). An amended version of 38 C.F.R. § 3.156(a) is effective only for claims filed on or after August 29, 2001. Therefore, this new version does not apply in this case. 66 Fed. Reg. 45620-45630 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. § 3.156(a)). The additional evidence which has been presented includes numerous additional medical treatment records and examination reports which reflect diagnoses of hypertension. The Board notes that such items of evidence essentially duplicate the previously considered evidence. Such items are not considered to be new. It was already established that the veteran had been diagnosed with that disorder after service. Therefore, the additional post service medical records add no additional relevant information. The veteran has not presented any new medical opinion which reflects that his hypertension is related to service or to a service-connected disability. The only pertinent medical opinion is contained in a VA examination report of October 2004 in which the examiner stated that he agreed that there was no evidence other than the veteran's hearsay that he had hypertension in the military. The examiner noted that the first reference to hypertension in the veteran's chart was between 1971 and 1973. He noted that this was clearly after service and did not appear to be service-related. He stated that no case had been made to open up the claim for hypertension. He further stated that it was not related to the service-connected low back pain. Overall, this document weighs against the claim, rather than supports it. Therefore, it cannot be said to be material evidence which would warrant reopening the claim. The Court has held that evidence unfavorable to the veteran's case may not "trigger a reopening" of the claim. Villalobos v. Principi, 3 Vet. App. 450, 452 (1992). Finally, the additional evidence includes testimony given by the veteran and his wife at a VA hearing. However, the testimony essentially duplicates his previously considered contentions, and in any event, does not amount to competent evidence to supply the missing nexus. In summary, the evidence added to the record since the prior rating decision is cumulative and redundant, and does not bear directly and substantially on the question of whether the veteran incurred hypertension as a result of service or as a result of his service-connected disabilities. It is not so significant that it must be considered to fairly decide the claim. What is still lacking is a competent medical opinion relating the current hypertension to service or to a service-connected disability. As such, this evidence is not "new" and "material," as defined in 38 C.F.R. § 3.156(a), and the veteran's claim for service connection is not reopened. III. Entitlement To Compensation Under 38 U.S.C.A. § 1151 For A Coronary Disability With Renal Dysfunction Claimed As Due To VA Medical Treatment, Surgery And Hospitalization In July and August 1989. The veteran contends that the RO made a mistake by denying his claim for compensation because his current coronary and renal problems are due to surgery performed at the VA Medical Center in July and August 1989. The appellant's claim for compensation is premised on 38 U.S.C.A. § 1151. Title 38, U.S.CA. § 1151 provides that, where a veteran suffers an injury or an aggravation of an injury resulting in additional disability by reason of VA hospitalization, or medical or surgical treatment, compensation shall be awarded in the same manner as if such disability were service connected. Subsequent amendments to 38 U.S.C.A. § 1151 made by Public Law 104-204 require a showing not only that the VA treatment in question resulted in additional disability but also that the proximate cause of the disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical or surgical treatment, or that the proximate cause of additional disability was an event which was not reasonably foreseeable. Those amendments apply to claims for compensation under 38 U.S.C.A. § 1151 which were filed on or after October 1, 1997. VAOPGCPREC 40-97. Because the veteran's claim was filed in December 1997, the version of § 1151 that is applicable to this case is the amended version that is applicable only to claims filed on or after October 1, 1997. See Pub. L. No. 104-204, § 422(b)(1), (c), 110 Stat. 2926-27 (1996). The controlling regulation in the case is 38 C.F.R. § 3.358 (Compensation for disability or death from hospitalization, medical or surgical treatment, examinations or vocational rehabilitation training (§ 3.800)) which provides, in pertinent part, as follows: (a) General. Where it is determined that there is additional disability resulting from a disease or injury or an aggravation of an existing disease or injury suffered as a result of training, hospitalization, medical or surgical treatment, or examination, compensation will be payable for such additional disability. (Authority: 38 U.S.C. 1151) (b) Additional disability. In determining that additional disability exists, the following considerations will govern: (1) The veteran's physical condition immediately prior to the disease or injury on which the claim for compensation is based will be compared with the subsequent physical condition resulting from the disease or injury, each body part involved being considered separately. (i) As applied to examinations, the physical condition prior to the disease or injury will be the condition at time of beginning the physical examination as a result of which the disease or injury was sustained. (ii) As applied to medical or surgical treatment, the physical condition prior to the disease or injury will be the condition which the specific medical or surgical treatment was designed to relieve. (2) Compensation will not be payable under 38 U.S.C. 1151 for the continuance or natural progress of disease or injuries for which the training, or hospitalization, etc., was authorized. (c) Cause. In determining whether such additional disability resulted from a disease or an injury or an aggravation of an existing disease or injury suffered as a result of training, hospitalization, medical or surgical treatment, or examination, the following considerations will govern: (1) It will be necessary to show that the additional disability is actually the result of such disease or injury or an aggravation of an existing disease or injury and not merely coincidental therewith. (2) The mere fact that aggravation occurred will not suffice to make the additional disability compensable in the absence of proof that it resulted from disease or injury or an aggravation of an existing disease or injury suffered as the result of training, hospitalization, medical or surgical treatment, or examination. (3) Compensation is not payable for the necessary consequences of medical or surgical treatment or examination properly administered with the express or implied consent of the veteran, or, in appropriate cases, the veteran's representative. "Necessary consequences" are those which are certain to result from, or were intended to result from, the examination or medical or surgical treatment administered. Consequences otherwise certain or intended to result from a treatment will not be considered uncertain or unintended solely because it had not been determined at the time consent was given whether that treatment would in fact be administered. (4) When the proximate cause of the injury suffered was the veteran's willful misconduct or failure to follow instructions, it will bar him (or her) from receipt of compensation hereunder except in the case of incompetent veterans. Based on review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence weighs against the claim for compensation under 38 U.S.C.A. § 1151 for disability alleged to be caused by hospitalization or medical or surgical treatment provided by VA in July and August 1989. The veteran testified in support of his claim during a hearing held in June 2005. He said that he had surgery on his back at a VA facility in 1989, and that this caused kidney problems and caused his hypertension to increase in severity. He further expressed his belief that the elevated severity of the hypertension resulted in a myocardial infarction several years later. The VA hospital summary dated in August 1989 reflects that prior to admission the veteran fell backwards and developed intense back pain. He was found to have a burst fracture at lumbar vertebra #1. He underwent a posterior spinal fusion with bone graft. The discharge diagnoses also included high blood pressure, neuropsychiatric condition, proteinuria, left knee disease and consolidated lobar pneumonia. It was noted that he had a history of high blood pressure since before the admission. The discharge summary contains no indication that the high blood pressure increased in severity as a result of the VA treatment, or that any of the other disorders were caused or aggravated by the VA treatment. Follow-up VA treatment records dated later in 1989 and in 1990 are likewise negative for any information which supports the claim for benefits under § 1151 for coronary or renal disorders. Although a record dated in October 1989 indicates that the veteran started Procardia during the hospitalization for treatment of his blood pressure, the Board notes that records from prior to the hospital admission (such as a VA psychiatric examination report of July 1977) show that the veteran had previously been on anti-hypertensive medications. Therefore, the fact that he was given such medications during the VA hospitalization does not demonstrate the onset or an increase in severity of a cardiovascular disorder. The veteran has not presented any medical opinion to support his claim that the VA treatment resulted in his current coronary and renal disorders. Although the VA aid and attendance examination report dated in October 2004 contains a notation that the veteran's coronary disease began in 1989, this was apparently simply the examiner repeating the history given by the veteran, and does not amount to a medical opinion linking the heart disease to VA treatment in July and August 1989. The fact that the veteran's own account of the etiology of his disability was recorded in his medical records is not sufficient to support the claim. In LeShore v. Brown, 8 Vet. App. 406, 409 (1995), the Court held that: Evidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by that examiner, does not constitute "competent medical evidence"...[and] a bare transcription of a lay history is not transformed into "competent medical evidence" merely because the transcriber happens to be a medical professional. Moreover, the veteran has not presented any medical opinion that the VA treatment was negligent or otherwise defective. Although the veteran has offered his own opinion that his current disabilities are associated with surgery and that the surgery was not done properly, the Court has held that lay persons, such as the veteran, are not qualified to offer an opinion that requires medical knowledge, such as a diagnosis or an opinion as to the cause of a disability. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-5 (1992). In summary, the preponderance of the evidence further shows that the veteran does not have additional disability due to hospitalization or medical or surgical treatment provided by VA. His hypertension was present prior to the surgery and was not aggravated thereby. There is no indication that the surgery caused or aggravated his coronary disease or renal dysfunction. The medical evidence also fails to show that the proximate cause of the current coronary disorder with renal dysfunction was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the hospitalization or medical or surgical treatment, or that the proximate cause of any such disability an event which was not reasonably foreseeable. Accordingly, the Board concludes that the criteria for entitlement to compensation under 38 U.S.C.A. § 1151 for a coronary disability with renal dysfunction, claimed to be caused by hospitalization, or medical or surgical treatment provided by the VA in July and August 1989, are not met. ORDER 1. Service connection for coronary artery disease status post myocardial infarction with associated renal disorder, to include consideration as being secondary to a service- connected disability, is denied. 2. New and material evidence has not been presented to reopen a claim for service connection for hypertension. The request to reopen the claim is denied. 3. The claim for compensation under 38 U.S.C.A. § 1151, for a coronary disorder with renal dysfunction claimed to be caused by hospitalization or medical or surgical treatment provided by the VA in July and August 1989 is denied. REMAND The veteran contends that he is entitled to special monthly compensation based on the need for aid and attendance, or on account of being housebound. Increased compensation is payable to a claimant who has a need for regular aid and attendance. See 38 C.F.R. § 3.350(h). The following factors will be accorded consideration in determining the need for regular aid and attendance: inability of claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. "Bedridden" will be a proper basis for the determination. For the purpose of this paragraph "bedridden" will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. It is not required that all of the disabling conditions enumerated in this paragraph be found to exist before a favorable rating may be made. The particular personal functions which the veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that the veteran is so helpless as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant's condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. See 38 C.F.R. § 3.352. Special monthly compensation is also warranted where the veteran has a single service-connected disability rated as 100 percent, and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service- connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. The latter requirement is met when the veteran is substantially confined as a direct result of service- connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities will continue throughout his or her lifetime. See 38 C.F.R. § 3.350(i). The evidence includes the report of an examination conducted by the VA in October 2004; however, the report contains an opinion which is based not only on impairment from the service-connected disabilities, but also on the nonservice- connected disabilities such as his heart disease. Therefore, further assistance to the veteran with the development of evidence is required. Accordingly, to ensure that the VA has met its duty to assist the appellant in developing the facts pertinent to the claim, the case is REMANDED to the RO for the following development: 1. The veteran should be afforded a VA aid and attendance examination to determine the current severity of the veteran's service-connected disabilities with respect to the criteria for aid and attendance/house bound benefits. The claims folder should be made available to the examiner for review before the examination. The examiner must express an opinion as to whether the veteran's service-connected disabilities (dorsolumbar paravertebral myositis, status post surgery with dysfunction due to fracture L1 vertebra with spinal stenosis, rated as 60 percent disabling; residuals of trauma and surgery, left knee, rated as 40 percent disabling; and a donor site scar, right hip, rated as noncompensably disabling) render him housebound, or in need of aid and attendance. The opinion should be based only on impairment due to the service- connected disorders. The use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation is to be avoided. See 38 C.F.R. § 4.14. 2. After the development requested above has been completed to the extent possible, the RO should again review the record. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the appellant and representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans Benefits Act of 2003, Pub. L. No. 108-183, § 707(a), (b), 117 Stat. 2651 (2003) (to be codified at 38 U.S.C. §§ 5109B, 7112). ______________________________________________ J. E. DAY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs