Citation Nr: 0622460 Decision Date: 07/28/06 Archive Date: 08/10/06 DOCKET NO. 99-00 341 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a right kidney disorder. 2. Entitlement to service connection for low blood pressure. 3. Entitlement to service connection for vasomotor rhinitis. 4. Entitlement to service connection for ulcers. 5. Entitlement to service connection for lupus. 6. Entitlement to service connection for edema of both legs. 7. Entitlement to service connection for arthritis. 8. Entitlement to service connection for cervical spine pain. 9. Entitlement to service connection for traumatic synovitis of the right knee. 10. Entitlement to service connection for post-traumatic stress disorder (PTSD). 11. Entitlement to dental treatment REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. M. Ames, Associate Counsel INTRODUCTION The veteran had active service from July 1970 to August 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 1997, January 1999, November 1999, June 2000, July 2000, and April 2003 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The veteran claims service connection for functional bowel syndrome. She is already service-connected for irritable bowel syndrome. As noted by a VA physician during her July 2005 stomach, duodenum and peritoneal adhesions examination, functional bowel syndrome is synonymous with irritable bowel syndrome. In addition, the VA evaluates the conditions identically. Therefore, this issue is not before the Board, as the veteran is already service-connected for this disorder. FINDINGS OF FACT 1. There is no competent evidence showing that the veteran has current diagnoses of, or disabilities from, a right kidney disorder, low blood pressure, vasomotor rhinitis, ulcers, or lupus. 2. The veteran's bilateral edema of the legs, arthritis, cervical spine pain, and traumatic synovitis of the right knee were not caused by her active military service from July 1970 to August 1983. 3. The veteran has been diagnosed with PTSD, but there is no credible corroboration or verification of the alleged non- combat stressors in service. 4. The veteran is currently entitled to an 100 percent rating by reason of individual unemployability (TDIU) and is therefore eligible for Class IV outpatient dental treatment. CONCLUSIONS OF LAW 1. Service connection for a right kidney disorder is not established. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2005). 2. Service connection for low blood pressure is not established. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2005). 3. Service connection for vasomotor rhinitis is not established. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2005). 4. Service connection for ulcers is not established. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2005). 5. Service connection for lupus is not established. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2005). 6. Service connection for edema of both legs is not established. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2005). 7. Service connection for arthritis is not established. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2005). 8. Service connection for cervical spine pain is not established. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2005). 9. Service connection for traumatic synovitis of the right knee is not established. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2005). 10. Service connection for PTSD is not established. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2005). 11. Entitlement to dental treatment is established. 38 C.F.R. § 17.161(h) (2005). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease that was incurred or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2005). Service connection may be demonstrated either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Direct service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). A disorder may be service connected if the evidence of record reveals that the veteran currently has a disorder that was chronic in service or, if not chronic, that was seen in service with continuity of symptomatology demonstrated subsequent to service. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-97 (1997). Evidence that relates the current disorder to service must be medical unless it relates to a disorder that may be competently demonstrated by lay observation. Savage, 10 Vet. App. at 495-97. For the showing of chronic disease in service, there is a required 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." 38 C.F.R. § 3.303(b). Disorders diagnosed after discharge may still be service connected if all the evidence, including relevant service records, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical evidence do not constitute competent medical evidence. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is resolved in favor of the veteran. 38 U.S.C.A. § 5107(b). The first requirement for any service connection claim is competent evidence of existence of a current disability. Boyer, 210 F.3d at 1353; Brammer v. Derwinski, 2 Vet. App. 492, 494 (1992). The veteran seeks service connection for a right kidney disorder, low blood pressure, vasomotor rhinitis, ulcers, and lupus. The Board, however, finds no competent medical evidence of current diagnoses for these disorders. Specifically, a July 2005 VA arteries, veins, and miscellaneous examination indicated that the veteran's blood urea nitrogen (BUN) and creatinine levels were normal, indicating normal kidney function. Furthermore, VA treatment records do not show any evidence of a diagnosis of or treatment for a right kidney disorder. Her service medical records (SMRs) indicate that in June 1982, the veteran reported a history of kidney problems, but examination revealed normal kidneys with good bilateral kidney function and normal calices, uterus, and bladder. A cross section CT scan of the kidney failed to reveal any mass displacing of the kidney. She was diagnosed with "past history of kidney problems," not currently symptomatic. An October 2003 VA treatment record shows that the veteran had low blood pressure. The physician stated that the veteran was on at least 20 medications for her service- connected and non-service-connected disabilities, including the following: Ranitidine, Cyclobenaprine, Lasix, Isosorbide, Sertraline, and a high dose of Rabeprazole. The physician stated that her cardiovascular examination was unremarkable and that the etiology of her low blood pressure was "she is on lots of medications." The veteran's treatment was to have her medications changed in a manner that would allow her blood pressure to return to normal. After the changes were made to her medication regimen, her blood pressure became normal. She received no further treatment for low blood pressure and does not have a current diagnosis of this disorder. The evidence of record does not show a chronic condition of vasomotor rhinitis. VA outpatient treatment records show one reference to a history of vasomotor rhinitis and that the veteran was prescribed a nasal spray. There is no evidence of a current diagnosis of chronic vasomotor rhinitis. The veteran does not have a current diagnosis of ulcers. She underwent a VA July 2005 VA stomach, duodenum, and peritoneal adhesions examination at which she was diagnosed with gastroesophageal reflux disease and irritable bowel syndrome. She was not diagnosed with ulcers. There is no evidence of record to show that the veteran currently has ulcers. Lastly, the veteran does not have a current diagnosis of lupus. While her outpatient treatment records refer to a "history of lupus," such a diagnosis has been specifically denied. At a July 2005 VA examination, the veteran reported diffuse abdominal and joint pains and arthralgias with no definite joint swelling. She reported episodes of chest pressure and shortness of breath. The examiner reviewed the veteran's claims file, including her SMRs. He concluded that she did not describe a rash that would be consistent with lupus. Additionally, there were no specific photosensitivity reactions or oral ulcerations, and no history of seizures or episodes of psychosis. She had a negative cardiac evaluation and an unremarkable EKG. There were no changes on the EKG that were consistent with pericarditis. Her antinuclear antibody (ANA) was less than 1:40, which was normal. Her rheumatoid factor was 44, which was normal. Other lab results were normal. The examiner diagnosed her with fibromyalgia and stated that she did not meet the criteria for systemic lupus erythematosus. The examiner concluded that based on review of her claims folder, her verbal history, review of her rheumatologist's records, and her examination, "she meets only 2 or possibly 3 of the criteria for systemic lupus erythematosus which does not meet the criteria for diagnosing her with this illness." Other evidence of record shows that she had a positive ANA in December 1997, at 1:160. Her rheumatoid factor was negative and the sedimentation rate was 7. In August 1998, she had an ANA of 1:320. The anti-DNA was 35. She had a rheumatology consult in October 1998 due to the positive ANA and diffuse arthralgias. The 1998 consult report stated that there was no evidence of systemic lupus erythematosus. A VA rheumatologist diagnosed her with fibromyalgia in August 1999. In December 2000 and March 2005, a VA rheumatologist specifically stated that there was no lupus. She has had negative ANAs in October 1998, August 1999 and July 2000. In May 2003 her ANA was positive again, but her anti-DNA was normal. Accordingly, the Board finds that the preponderance of the evidence is against service connection for a right kidney disorder, low blood pressure, vasomotor rhinitis, ulcers, and lupus. 38 U.S.C.A. § 5107(b). Absent current diagnoses of the disorders claimed, service connection may not be established. The Board finds that service connection for a right kidney disorder, low blood pressure, vasomotor rhinitis, and lupus must be denied. The Board finds that the veteran's contentions regarding these claims only provide negative evidence against the veteran's overall case before the VA, as will be discussed below. The Board finds that the veteran has current diagnoses of edema, arthritis, cervical spine pain, and a right knee disability. The veteran was diagnosed with edema of both legs at a July 2005 VA veins and arteries examination. She has been diagnosed with arthritis of several joints. In July 2005, she was diagnosed with neck pain due to fibromyalgia and mild degenerative joint disease of the right knee. However, there is no competent medical evidence of record that provides a link between the veteran's disabilities and her period of active military service. At her July 2005 VA veins and arteries examination, the physician diagnosed her with mild bilateral lower extremity edema with unclear etiology. No cause of the edema was seen during the exam, nor could it be elicited from the veteran's reported history. This examination and the veteran's VA treatment records fail to establish a link between her bilateral lower extremity edema and her period of active service. Arthritis is considered a part of the veteran's evaluation for her service-connected low back condition. Arthritis of the right knee will be discussed with the veteran's claim for a right knee disability. The veteran is service-connected for degenerative changes of the left knee. The veteran was notified in June 2005 and February 2005 to provide specific evidence with regards to her service connection claim for arthritis. She did not specify the location of the arthritis or provide any additional information with regards to joints for which she was not already service-connected. The veteran has a diagnosis of cervical spine pain. In July 2005, the veteran underwent a VA spine examination and was diagnosed with neck pain due to fibromyalgia. The examiner reviewed her SMRs and noted that she suffered a neck injury in 1977 for which she was treated with a cervical collar. However, her cervical myelogram was normal in April 2000 and she had an unremarkable computed tomography scan of her cervical spine in February 2003. The examiner stated that her April 2000 and February 2003 normal test results suggested that there was no evidence of degenerative joint disease or degenerative disc disease at the time. The examiner concluded that her pain was most likely related to soft tissue pain due to her non-service-connected fibromyalgia. The examiner also stated that her neck pain was not related to her service-connected lumbar spine disability. Medical evidence of record does not provide a link between the veteran's active military service and her right knee disability. In July 2005, a VA physician diagnosed her with mild degenerative joint disease. The examiner noted that she suffered a traumatic right knee injury in service in 1971 when she fell on a concrete surface, but that her SMRs were otherwise negative for right knee complaints. The physician concluded that it was "unlikely" that her complaints were related to her in-service symptoms of traumatic synovitis. He further concluded that her right knee disability did not have any relationship to her service-connected low back disability. There is no evidence of record linking any of the above disabilities to the period of active service. With regard to the veteran's own opinion that these disabilities are related to injuries sustained in service, the veteran does not have the medical expertise to find that her current disorder is related to service. See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). The Board finds the facts and examinations cited above are entitled to great probative weight and that they provide evidence against the claims. Accordingly, the Board finds that the preponderance of the evidence is against service connection for edema, arthritis, cervical spine pain, and a right knee disability. 38 U.S.C.A. § 5107(b). The appeals are denied. With regards to the veteran's PTSD claim, service connection for PTSD requires medical evidence diagnosing the condition in accordance with VA regulations; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). See 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304 (regarding combat veterans); Cohen v. Brown, 10 Vet. App. 128 (1997). The veteran did not engage in combat with the enemy during her period of active military service. The diagnostic criteria, including those related to stressors, set forth in The American Psychiatric Association: Diagnostic And Statistical Manual Of Mental Disorders, (4th ed. 1994) (DSM- IV) for mental disorders have been adopted by the VA. 38 C.F.R. § 4.125. According to these criteria, a diagnosis of PTSD requires that a veteran be exposed to a traumatic event, and that she experience a number of specified current symptoms. The traumatic event, or stressor, involves experienced, witnessed, or being confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. In addition, the response must involve intense feelings of fear, helplessness, or horror. If the veteran did not engage in combat with the enemy, or the veteran did engage in combat but the alleged in-service stressor is not combat related, the veteran's lay testimony, by itself, is not sufficient to establish the occurrence of the alleged in-service stressor. Instead, the record must contain credible supporting evidence which corroborates the veteran's testimony or statements. Cohen, 10 Vet. App. at 147; Moreau v. Brown, 9 Vet. App. 389, 395 (1996). The veteran was diagnosed with PTSD by VA physicians in April 2005, March 2005, February 2003, October 2002, and November 2001. She alleges that she has PTSD as a result of stressors experienced while serving in the military. Specifically, she asserts that she was raped in July 1973 and February 1980. In Patton v. West, 12 Vet. App. 272 (1999), the Court held that special consideration must be given to claims for PTSD based on assault. In particular, the Court held that the provisions in M21-1, Part III, 5.14(c), which addressed PTSD claims based on personal assault are substantive rules which are the equivalent of VA regulations and must be considered. See also YR v. West, 11 Vet. App. 393, 398-99 (1998). In December 2005, M21-1, Part III was rescinded and replaced with a new manual, M21-1MR, which contains the same PTSD- related information as M21-1, Part III. The corresponding new citation for M21-1, Part III, 5.14(c) is M21-1MR IV.ii.1.D.14 and 15. The pertinent regulation provides that, in cases of personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a PTSD claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304(f)(3); see also M21-1MR IV.ii.1.D.14 and 15. As recently stated by the Court in Bradford v. Nicholson, No 03-1204 (U.S. Vet. App. July 20, 2006), § 3.304(f)(3) provides "unequivocally" that "VA will not deny a post-traumatic stress disorder claim that is based on in-service personal assault" without first providing the requisite notice. The Court also stated that § 3.304(f)(3) requires VA to advise personal assault claimants that credible supporting evidence of a stressor may include (1) "evidence from sources other than the veterans service records" or (2) "evidence of behavior changes." The Board must provide "a written statement of [its] findings and conclusions, and the reasons or bases for those findings and conclusions, on all material issues of fact and law presented on the record." 38 U.S.C. § 7104. The Board notes that in a letter dated in June 2005, the RO advised the veteran of the VCAA and its effect on her claim. The letter specifically advised her to identify any possible sources of information and evidence such as police reports or medical treatment records for assault or rape. The veteran did not provide any such information and in an April 2004 letter, the veteran stated that she did not tell anyone she was raped. The veteran asserts that she was treated for depression in service in 1980. However, her SMRs are negative for psychiatric treatment with the exception that she reported having had depression or excessive worry at her separation examination. She was subsequently service- connected for depression, attributed to her many severe service-connected and non-service-connected disabilities. The veteran has multiple diagnoses of PTSD. However, the Board is not required to grant service connection for PTSD because a physician accepted the veteran's description of her active service experiences as credible. See Wilson v. Derwinski, 2 Vet. App. 614 (1992). The Board is not required to accept the veteran's uncorroborated account of her active service experiences. See Wood v. Derwinski, 1 Vet. App. 190 (1991). The VA medical providers have generally restated the veteran's account of the in-service stressor and accepted it as credible. However, such statements are undermined by two factors: (1) the medical opinions are based upon the veteran's uncorroborated recitation of the alleged stressor; and (2) none of the medical opinions included an objective review of the in-service evidence or any other contemporaneous indicia that might bolster the veteran's reported stressor. As noted above, a medical provider cannot provide supporting evidence that the claimed in-service stressor actually occurred based upon post-service medical examination. In this respect, although an examiner can render a current diagnosis based on an examination of the veteran, the examiner's opinion regarding the etiology of the underlying condition can be no better than the facts alleged by the veteran. See generally, Guimond v. Brown, 6 Vet. App. 69 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Black v. Brown, 5 Vet. App. 177 (1993). Furthermore, an examination that relies on a questionable history of events is inadequate, and any psychiatric evaluation that forms the basis for an adjudicative decision must be based on an accurate description of events during the veteran's service. See West v. Brown, 7 Vet. App. 70 (1994). The Board is not required to accept a physician's diagnosis just because the physician accepted the veteran's description of her experiences as credible and diagnosed her with PTSD. See West, 7 Vet. App. at 77 (quoting Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992)). Likewise, medical statements that accept a veteran's reports as credible and relate her PTSD to events experienced in service do not constitute the requisite credible evidence of the occurrence of a stressor. Moreau, supra. The fact that the veteran is filing claims with the VA regarding conditions that she does not have only undermines her overall credibility. In sum, the preponderance of the credible evidence does not show corroboration of an alleged in-service stressor, which in turn could serve as the basis for the veteran's diagnosis of PTSD. Any current PTSD is not shown to be related to her active service. The Board finds that the preponderance of the evidence is against granting service connection for PTSD. 38 U.S.C.A. § 5107(b). With regards to the veteran's dental claim, she is currently entitled to TDIU. Legal authority describes various categories of eligibility for VA outpatient dental treatment, to include veterans whose service-connected disabilities are rated at 100 percent by schedular evaluation or who are entitled to the 100 percent rating by reason of TDIU (Class IV eligibility). 38 U.S.C.A. § 1712; 38 C.F.R. § 17.161. Under Class IV, those whose service-connected disabilities are rated at 100 percent by schedular evaluation, or those who are entitled to the 100 percent rate by reason of TDIU, may be authorized any needed dental treatment. 38 C.F.R. § 17.161(h). Therefore, dental outpatient treatment is authorized. The appeal is granted. The Duty to Notify and the Duty to Assist Review of the claims folder reveals compliance with the Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5100 et seq. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). That is, by letters dated in June 2005, February 2005, July 2003, June 2003, and April 2003, as well as information provided in the January 2006 and April 2003 supplemental statements of the case (SSOC), the RO advised the veteran of the evidence needed to substantiate her claims and explained what evidence VA was obligated to obtain or to assist the veteran in obtaining and what information or evidence the veteran was responsible for providing. In addition, the January 2006 and April 2003 SSOCs include the text of the regulation that implements the notice and assistance provisions from the statute. Thus, the Board finds that the RO has provided all notice required by the VCAA. 38 U.S.C.A. § 5103(a). See Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Board notes that the RO did not provide VCAA notice prior to all of the adverse decisions on appeal, some of which were issued prior to the enactment of the VCAA. Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). However, as the Board has already determined that the veteran has received all required VCAA notice, any defect in timing of the VCAA notice results in no prejudice to the veteran and therefore constitutes harmless error. Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004) (holding that the Court must take due account of the rule of prejudicial error when considering compliance with VCAA notice requirements); 38 C.F.R. § 20.1102 (2005) (an error or defect in a Board decision that does not affect the merits of the issue or substantive rights of the appellant will be considered harmless). The February and June 2005 VCAA letters specifically ask the veteran to provide any evidence in her possession that pertains to the claim. Pelegrini, 18 Vet. App. at 120-21. The Board is aware of the recent decision in Dingess v. Nicholson, 19 Vet. App. 473 (2006), regarding notice requirements. Based on a review of this decision, the Board finds no basis to remand this case to the RO for additional development. Simply stated, based on the notice already provided to the veteran cited above, a further amended notice to the veteran would not provide a basis to grant the veteran's claims. With regards to the grant of eligibility for dental treatment, the RO will be responsible for addressing any notice defect with respect to the effective date element when effectuating the award. The Board finds that any deficiency in the notice to the veteran or the timing of these notices is harmless error. With respect to the duty to assist, the RO has secured the veteran's service medical records, VA medical records, and VA examinations. As there is no other indication or allegation that relevant evidence remains outstanding, the Board finds that the duty to assist has been met. 38 U.S.C.A. § 5103A. The Board also notes that the veteran currently has been granted a 100 percent evaluation based on TDIU effective in March 1996. The Board notes that an etiological opinion has not been obtained for low blood pressure, vasomotor rhinitis, arthritis, or ulcers. However, the Board finds that the evidence, discussed above, which indicates that the veteran did not receive treatment for the claimed disorders during service or that there is any competent medical evidence showing or indicating a nexus between service and the disorders at issue, warrants the conclusion that a remand for an examination and/or opinion is not necessary to decide the claim. See 38 C.F.R. § 3.159 (c)(4) (2005). As service and post-service medical records provide no basis to grant this claims, and provide evidence against the claims, the Board finds no basis for a VA examination to be obtained. The duty to assist is not unlimited in scope. See Smith v. Derwinski, 2 Vet. App. 429, 431, 432 (1992). In Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992) (citations omitted), the Court stated, in pertinent part: [T]he "duty to assist" is not a license for a "fishing expedition" to determine if there might be some unspecified information which could possibly support a claim. In connection with the search for documents, the duty is limited to specifically identified documents that by their description would be facially relevant and material to the claim. In this case, the RO has made all reasonable efforts to assist the veteran in the development of his claim. While additional attempts to obtain information can always be undertaken, in light of the record, the Board finds that such an additional attempt, in light of the extensive efforts already performed in this case, can not be justified. Therefore, the Board is satisfied that the duty to assist has been met. 38 U.S.C.A. § 5103A. Further efforts would not provide the veteran any additional benefits. The Board is also satisfied as to compliance with its instructions from the January 2005 and June 2000 remands. See Stegall v. West, 11 Vet. App. 268 (1998). ORDER Service connection for a right kidney disorder is denied. Service connection for low blood pressure is denied. Service connection for vasomotor rhinitis is denied. Service connection for ulcers is denied. Service connection for lupus is denied. Service connection for edema of both legs is denied. Service connection for arthritis is denied. Service connection for cervical spine pain is denied. Service connection for traumatic synovitis of the right knee is denied. Service connection for PTSD is denied. Entitlement to outpatient dental treatment is granted ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs