Citation Nr: 0809718	
Decision Date: 03/24/08    Archive Date: 04/09/08

DOCKET NO.  06-06 826	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Waco, Texas


THE ISSUE

Entitlement to service connection for Raynaud's Syndrome, 
claimed as secondary to service connected diabetes mellitus 
or complications thereof, such as coronary artery disease, 
peripheral neuropathy or diabetic nephropathy.    


REPRESENTATION

Appellant represented by: Texas Veterans Commission


ATTORNEY FOR THE BOARD

B. Morton, Associate Counsel


INTRODUCTION

The veteran served on active duty from July 1964 to June 
1968.

This matter is before the Board of Veterans' Appeals (Board) 
from a March 2005 decision by the Department of Veterans 
Affairs (VA) Regional Office (RO) in Waco, Texas, which 
denied service connection for Raynaud's Syndrome.  The RO 
issued a notice of the decision in March 2005, and the 
veteran timely filed a Notice of Disagreement (NOD) in July 
2005.  Subsequently, in August 2005 the RO provided a 
Statement of the Case (SOC) and a Supplemental Statement of 
the Case (SSOC) in November 2005, and thereafter, in February 
2006, the veteran timely filed a substantive appeal.  The RO 
provided additional SSOCs in May 2006, May 2007 and September 
2007.  

The Board notes that the veteran's claim for service 
connection for Raynaud's Syndrome, which was received by the 
RO in November 2004, specified secondary service connection.  
While the RO decision that was subsequently appealed denied 
service connection on direct and secondary bases, the veteran 
indicated in his NOD that he was only appealing the RO's 
denial of secondary service connection. 

The veteran did not request a hearing on this matter.


FINDINGS OF FACT

1.	VA has made all reasonable efforts to assist the veteran 
in the development of his claim and has notified him of 
the information and evidence necessary to substantiate the 
claim addressed in this decision; of the information VA 
failed to provide or failed to provide in a timely 
fashion, any resulting prejudice has been rebutted.

2.	The veteran currently has Raynaud's Syndrome, but the 
competent medical evidence of record does not establish 
that the veteran's service connected diabetes mellitus, or 
complications thereof, to include coronary artery disease, 
peripheral neuropathy or diabetic nephropathy, caused or 
aggravated his Raynaud's Syndrome. 

CONCLUSION OF LAW

Service connection for Raynaud's Syndrome, claimed as 
secondary to service connected diabetes mellitus or 
complications thereof, such as coronary artery disease, 
peripheral neuropathy or diabetic nephropathy, is not 
warranted.  38 U.S.C.A. §§ 5103, 5103A, 5107(b) (West 2002 & 
Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2007).   


REASONS AND BASES FOR FINDINGS AND CONCLUSION

I. Veterans Claims Assistance Act of 2000 (VCAA)

The enactment of the VCAA, codified at 38 U.S.C.A. §§ 5102, 
5103, 5103A, 5107 (West 2002), significantly changed the law 
prior to the pendency of this claim.  VA has issued final 
regulations to implement these statutory changes.  See 38 
C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2005).  The VCAA 
provisions include an enhanced duty to notify a claimant as 
to the information and evidence necessary to substantiate a 
claim for VA benefits, and they redefine the obligations of 
VA with respect to the duty to assist the veteran with the 
claim.  

a. Duty to Notify
VA has a duty to notify the veteran of any information and 
evidence needed to substantiate and complete a claim.  38 
U.S.C.A. §§ 5102, 5103.  The Board concludes that the January 
2005 letter sent to the veteran by the RO adequately apprised 
him of most of the information and evidence needed to 
substantiate the claim, and of the information it failed to 
provide, any presumed prejudice has been rebutted.

In order to meet the requirements of 38 U.S.C. § 5103(a) and 
38 C.F.R. § 3.159(b), VCAA notice must: (1) inform the 
claimant about the information and evidence 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 that the 
claimant provide any evidence in his possession that pertains 
to the claim.  Sanders v. Nicholson, 487 F.3d 881, 886 (Fed. 
Cir. 2007) (outlining VCAA notice requirements); Beverly v. 
Nicholson, 19 Vet. App. 394, 403 (2005) (same).  

Additionally, during the pendency of this appeal, on March 3, 
2006, the Court of Appeals for Veterans' Claims (Court) 
issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 
484, 486 (2006), which held that the VCAA notice requirements 
of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to 
all five elements of a service connection claim.  Those five 
elements include:  (1) veteran status; (2) existence of a 
disability; (3) a connection between the veteran's service 
and the disability; (4) degree of disability; and (5) 
effective date of the disability.  The Court held that upon 
receipt of an application for a service-connection claim, 
38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to 
review the information and the evidence presented with the 
claim and to provide the claimant with notice of what 
information and evidence not previously provided, if any, 
will assist in substantiating or is necessary to substantiate 
the elements of the claim as reasonably contemplated by the 
application.  Id., at 486.  This notice must also inform the 
veteran that a disability rating and an effective date for 
the award of benefits will be assigned if service connection 
is granted.  Id.  

The January 2005 letter from the RO satisfies most of these 
mandates.  It informed the veteran about the type of evidence 
needed to support a direct service connection claim, namely, 
proof of: (a) an injury in military service or disease that 
began in or was made worse during military service, or an 
event in service causing injury or disease; (b) a current 
physical or mental disability; and (c) a relationship between 
the current disability and an injury, disease or event in 
service.  This correspondence clearly disclosed VA's duty to 
obtain certain evidence for the veteran, such as medical 
records, employment records and records held by any Federal 
agency, provided the veteran gave consent and supplied enough 
information to enable their attainment.  It made clear that 
although VA could assist the veteran in obtaining these 
records, he carried the ultimate burden of ensuring that VA 
received all such records.  This letter additionally apprised 
the veteran that VA would schedule a medical examination or 
obtain a medical opinion for him if the RO determined such to 
be necessary to make a decision on the claim.  It also 
specifically asked the veteran to provide VA with any other 
supporting evidence or information in his possession.  The 
Board thus finds that the veteran was effectively informed to 
submit all relevant evidence in his possession, and that he 
received notice of the evidence needed to substantiate his 
claim, the avenues by which he might obtain such evidence, 
and the allocation of responsibilities between himself and VA 
in obtaining such evidence.  See Beverly, 19 Vet. App. at 
403; see also Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 
(2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 
2006).

With respect to the Dingess requirements, the veteran was 
provided with notice of what type of information and evidence 
was needed to substantiate the claim, but he was not provided 
with notice of the type of evidence necessary to establish a 
rating or effective date for the rating in the January 2005 
letter.  In addition, the January 2005 correspondence did not 
apprise the veteran of the type of evidence required to 
substantiate a secondary service connection claim, namely, 
the existence of: (a) a current disorder (Raynaud's 
Syndrome); (b) a service connected disability; and (c) 
competent medical opinion indicating that the service 
connected disability or disabilities either caused or 
aggravated the current, non-service connected disorder 
(Raynaud's Syndrome).  Where such an error occurred, the 
Board must presume that the error was prejudicial, and VA 
bears the burden of rebutting said presumption.  Sanders, 487 
F.3d at 886, 889 (recognizing that "VCAA notice errors are 
reviewed under a prejudicial error rule" and holding that 
"all VCAA notice errors are presumed prejudicial and . . . 
VA has the burden of rebutting this presumption"); see also 
Mayfield v. Nicholson, 19 Vet. App. 103, 111-16 (2005), rev'd 
on other grounds, 444 F.3d 1328 (Fed. Cir. 2006).  

In Sanders, the Federal Circuit held that any error by VA in 
providing the notice required by 38 U.S.C.A. § 5103(a) and 
38 C.F.R. § 3.159(b)(1) is presumed prejudicial and that once 
an error is identified by the Veterans Court (Court of 
Appeals for Veterans Claims), the burden shifts to VA to 
demonstrate that the error was not prejudicial.  The Federal 
Circuit reversed the Court of Appeals for Veterans Claims' 
holding that an appellant before the Court has the initial 
burden of demonstrating prejudice due to VA error involving: 
(1) providing notice of the parties' respective obligations 
to obtain the information and evidence necessary to 
substantiate the claim: (2) requesting that the claimant 
provide any pertinent evidence in the claimant's possession; 
and (3) failing to provide notice before a decision on the 
claim by the agency of original jurisdiction.  

An error "whether procedural or substantive, is prejudicial 
when [it] affects a substantial right so as to injure an 
interest that the statutory or regulatory provision involved 
was designed to protect such that the error affects 'the 
essential fairness of the [adjudication].'"  Mayfield, 
supra, at 116; accord Sanders, supra, at 891 ("this opinion 
does not . . . change the rule that reversal requires the 
essential fairness of the adjudication to have been 
affected").  That is, "the key to determining whether an 
error is prejudicial is the effect of the error on the 
essential fairness of the adjudication."  Mayfield, supra; 
accord Sanders, supra.  "[A]n error is not prejudicial when 
[it] did not affect 'the essential fairness of the 
[adjudication],'" see Mayfield, supra, at 121, and non-
prejudicial error may be proven by a showing that "the 
purpose of [VCAA] notice was not frustrated, e.g., by 
demonstrating: (1) that any defect was cured by actual 
knowledge on the part of the claimant, (2) that a reasonable 
person could be expected to understand from the [defective] 
notice what was needed, or (3) that a benefit could not have 
been awarded as a matter of law."  Sanders, supra, at 889; 
accord Dalton v. Nicholson, 21 Vet. App. 23, 30 (2007) 
(determining that no prejudicial error to veteran resulted in 
defective VCAA notice when the veteran, through his counsel, 
displayed actual knowledge of the information and evidence 
necessary to substantiate his claim).  Accordingly, "there 
could be no prejudice if the purpose behind the notice has 
been satisfied . . . that is, affording a claimant a 
meaningful opportunity to participate effectively in the 
processing of [the] claim. . . ."  Mayfield, supra, at 128.    
          
The Board determines that any presumed prejudice to the 
veteran as a result of the defective January 2005 VCAA letter 
has been rebutted.  With respect to the lack of notice in the 
January 2005 letter relating to the Dingess elements 
regarding the assignment of effective dates and calculation 
of disability ratings, because the Board has rendered an 
unfavorable opinion in the instant case, denying service 
connection, any defect in such Dingess notice is moot.  
Christman v. American Cyanamid Co., 578 F. Supp. 63, 67 
(D.W.Va. 1983) (noting that "mootness means that no actual 
controversy exists which is subject to judicial 
resolution").     

Turning to the deficient VCAA notice relating to the elements 
of a secondary service connection claim, the Board finds that 
any presumed prejudice has been rebutted.  In particular, the 
veteran, in correspondences received in January 2005 and 
January 2008, has demonstrated actual knowledge of the type 
of evidence needed to substantiate a secondary service 
connection claim.  Dalton, 21 Vet. App. at 30; Veteran's 
January 2008 Letter ("I am indicating that . . . the DM2 
aggravates the Raynaud[']s condition"); Veteran's January 
2005 Letter ("I contend that [Raynaud's Syndrome] is very 
likely secondary to or aggravated by DM type 2, which has 
adverse effects on the vascular and neurological systems").  
As such, any presumed prejudice has been rebutted.  

The Board also recognizes that, according to Pelegrini v. 
Principi, 18 Vet. App. 112, 119-20 (2004), proper VCAA notice 
must "precede an initial unfavorable [agency of original 
jurisdiction (AOJ)] decision on a service-connection claim."  
VA did provide such notice to the veteran prior to the March 
2005 RO decision that is the subject of this appeal in its 
January 2005 letter.  Accordingly, the RO provided proper 
VCAA notice at the required time.

b. Duty to Assist
VA also has a duty to assist the veteran in obtaining 
evidence necessary to substantiate the claim.  38 U.S.C.A. § 
5103A(a) ("The Secretary shall make reasonable efforts to 
assist a claimant in obtaining evidence necessary to 
substantiate the . . . claim").  This duty includes 
assisting the veteran in obtaining records and providing 
medical examinations or obtaining medical opinions when such 
are necessary to make a decision on the claim.  38 U.S.C.A. § 
5103A(b), (c), (d) (setting forth Secretary's various duties 
to claimant).  

VA informed the veteran of its duty to assist in obtaining 
records and supportive evidence, and the veteran in fact did 
receive March 2005 and April 2006 VA medical opinions, which 
were thorough in nature and adequate for the purposes of 
deciding this claim.  While the Board acknowledges that the 
veteran, in the letters received in April 2006 and January 
2008, requested a new medical opinion because of his 
impression that the VA examiner (who had offered both medical 
opinions) "would not consider any of the numerous pages of 
information and specifically indicated to me that she had 
made up her mind and nothing I said or showed her would 
change her mind," the Board finds that the evidence and 
medical opinions of record, complete with adequate rationale, 
are sufficient to resolve this appeal.  Therefore, VA has no 
further duty to provide an examination or opinion.  
38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4).  

Based on the foregoing, the Board finds that the VA fulfilled 
its VCAA duties to notify and to assist the veteran, and 
thus, no additional assistance or notification was required.  
The veteran has suffered no prejudice that would warrant a 
remand, and his procedural rights have not been abridged.  
See Bernard, 4 Vet. App. at 392-94.


II. Law & Regulations 

a.  Secondary Service Connection
Pursuant to 38 C.F.R. § 3.310(a), a "disability which is 
proximately due to or the result of a service-connected 
disease or injury shall be service connected."  See Evans v. 
West, 12 Vet. App. 22, 29 (1998) (noting requirements for 
establishing service connection on a secondary basis).  Thus, 
in order to establish a secondary service connection claim, 
the veteran must show: (1) the existence of a current 
(secondary) disability; (2) the existence of a service-
connected disability; and (3) evidence that the service-
connected disability proximately caused the secondary 
disability.  38 C.F.R. § 3.310(a).  A veteran may also 
establish secondary service connection by demonstrating that 
his current (secondary) disability became aggravated or 
worsened by the already service-connected disease.  Allen v. 
Brown, 7 Vet. App. 439, 448 (1995) (holding that "when 
aggravation of a veteran's non-service-connected [secondary] 
condition is proximately due to or the result of a service-
connected condition, such veteran shall be compensated for 
the degree of disability (but only that degree) over and 
above the degree of disability existing prior to the 
aggravation"); see Libertine v. Brown 9 Vet. App. 521, 522 
(1996) ("Additional disability resulting from the 
aggravation of a non-service-connected [secondary] condition 
by a service-connected condition is also compensable under 
38 C.F.R. § 3.310(a)").  If a veteran succeeds in 
establishing service connection for a secondary condition, 
"the secondary condition shall be considered a part of the 
original condition."  38 C.F.R. § 3.310(a).  

The Board acknowledges that VA recently amended 38 C.F.R. 
§ 3.310, effective October 10, 2006.  This amendment added 
the following provision to this regulation:  "(b) 
Aggravation of nonservice-connected disabilities.  Any 
increase in severity of a nonservice-connected disease or 
injury that is proximately due to or the result of a service-
connected disease or injury, and not due to the natural 
progress of the nonservice-connected disease, will be service 
connected.  However, VA will not concede that a nonservice-
connected disease or injury was aggravated by a service-
connected disease or injury unless the baseline level of 
severity of the nonservice-connected disease or injury is 
established by medical evidence created before the onset of 
aggravation or by the earliest medical evidence created at 
any time between the onset of aggravation and the receipt of 
medical evidence establishing the current level of severity 
of the nonservice-connected disease or injury.  The rating 
activity will determine the baseline and current levels of 
severity under the Schedule for Rating Disabilities (38 CFR 
part 4) and determine the extent of aggravation by deducting 
the baseline level of severity, as well as any increase in 
severity due to the natural progress of the disease, from the 
current level."  38 C.F.R. § 3.310 (2006).  VA amended § 
3.310 "because of a court decision [Allen v. Brown, 7 Vet. 
App. 439 (1995)] that clarified the circumstances under which 
a veteran may be compensated for an increase in the severity 
of an otherwise nonservice-connected [disability,] which is 
caused by aggravation from a service-connected 
[disability]."  71 Fed. Reg. 52744 (Sept. 7, 2006).  Thus, 
"[t]he intended effect of this amendment is to conform VA 
regulations to the [Allen] court's decision."  71 Fed. Reg. 
52744 (Sept. 7, 2006).  Because this amendment is in the 
nature of a clarifying revision, rather than a substantive 
change, and because VA clearly expressed its intent to 
conform this regulation to already-existing case law, the 
Board will employ the same analysis as it has since Allen and 
consistent with the principles contained therein, as outlined 
above.       



b. Standard of Proof
38 U.S.C.A. § 5107 sets forth the standard of proof applied 
in decisions on claims for veterans' benefits.  A veteran 
will receive the benefit of the doubt when an approximate 
balance of positive and negative evidence exists.  38 
U.S.C.A. § 5107; 38 C.F.R. § 3.102.  Thus, when a veteran 
seeks benefits and the evidence is in relative equipoise, the 
veteran prevails.  Wells v. Principi, 18 Vet. App. 33, 36 
(2004); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990).  A 
claim will be denied only if a preponderance of the evidence 
is against the claim.  See Alemany v. Brown, 9 Vet. App. 518, 
519-20 (1996).  


III. Analysis

a. Factual Background
The veteran has been diagnosed with Raynaud's Syndrome, and 
he is currently service connected for diabetes mellitus, type 
II; coronary artery disease; diabetic peripheral neuropathy 
of the bilateral upper and lower extremities; and diabetic 
nephropathy.  

In various statements, spanning January 2005 to January 2008, 
the veteran has alleged that his Raynaud's Syndrome was 
caused or aggravated by his service connected diabetes 
mellitus, or its complications for which he is also service 
connected.  He has also submitted various medical articles 
from Internet sources, which discuss Raynaud's Syndrome as 
well as the effects of diabetes mellitus on the vascular 
system and body generally.  In one article, dated October 
2005, the author suggests that "people with certain . . . 
conditions such as diabetes . . . may be more at risk" for 
developing Raynaud's Syndrome.  In another piece, dated April 
2006, the commentator indicated that "[p]ersons who have 
preexisting narrowing of blood vessels due to cholesterol 
(arteriosclerosis) or persons with other conditions blocking 
the circulation . . . may get symptoms of Raynaud's 
phenomenon after only mild exposure to cool temperatures."  
A January 2008 article associates poor circulation and 
narrowing of the arteries with diabetes mellitus and further 
discusses the nature of Raynaud's Syndrome as involving an 
interference with circulation.      

In a March 2005 VA examination report, where the examiner had 
reviewed the claims file, the clinician opined that the 
veteran's "Raynaud's Disease is less likely as not (less 
than 50/50 probability) caused by, a result of, or aggravated 
by his Type 2 diabetes mellitus."  She offered the following 
rationale for this conclusion: "clinical experience and 
reference text (lack of reference/research material showing 
correlation)."  

In a subsequent April 2006 VA examination report, the same 
clinician concluded that the veteran's Raynaud's Syndrome 
"is less likely as not (less than 50/50 probability) 
secondary to or aggravated by s/c CAD [coronary artery 
disease], Diabetic Peripheral Neuropathy or Diabetic 
Nephropathy."  As a basis for this conclusion, the examiner 
cited to "clinical experience and consultation with 
neurologist at this facility."     

c. Discussion
The Board finds that the evidence preponderates against the 
veteran's service connection claim.  In particular, while the 
veteran currently has a diagnosis of Raynaud's Syndrome and 
is service connected for diabetes mellitus and complications 
thereof, to include coronary artery disease, peripheral 
neuropathy and diabetic nephropathy, the only competent 
medical opinion of record relating to whether a causal nexus 
exists between the Raynaud's Syndrome and any of the service 
connected disabilities weighs against the claim.  That is, 
the VA examiner, both in her March 2005 and April 2006 
medical reports, concluded, based on her experience as a 
medical professional, consultation with neurologists, and the 
lack of medical literature supporting a causal nexus, that 
the veteran's service connected diabetes mellitus and 
complications thereof, such as coronary artery disease, 
peripheral neuropathy and diabetic nephropathy, neither 
caused nor aggravated his Raynaud's disease.  As such, the 
Board must deny this claim.  

The Board acknowledges that the veteran has submitted 
numerous articles from Internet sources, which suggest 
generally that some correlation between diabetes mellitus or 
complications thereof and Raynaud's Syndrome may exist.  This 
evidence alone, however, does not establish the causal 
medical nexus needed to prove his service connection claim.  
The Court of Appeals for Veterans' Claims has held that a 
medical article or treatise "can provide important support 
when combined with an opinion of a medical professional" if 
the medical article or treatise evidence discussed generic 
relationships with a degree of certainty such that, under the 
facts of a specific case, there is at least "plausible 
causality" based upon objective facts rather than on an 
unsubstantiated lay medical opinion.  Sacks v. West, 11 Vet. 
App. 314 (1998) (emphasis added); see also Wallin v. West, 11 
Vet. App. 509, 513-14 (1998) (medical treatise evidence 
discussed generic relationships with a degree of certainty to 
establish a plausible causality of nexus); Mattern v. West, 
12 Vet. App. 222, 228 (1999).  In this case, however, the 
text evidence submitted by the veteran is not accompanied by 
any supportive medical opinion from a medical professional.  
Additionally, as it is generic in nature, it fails to 
demonstrate the relationship between this veteran's Raynaud's 
Syndrome and his service connected diabetes mellitus or 
complications thereof.  For these reasons, the Board must 
find that the text evidence submitted by the veteran does not 
contain the specificity to constitute competent evidence of 
the claimed medical nexus.  Sacks, 11 Vet. App. at 317 
(citing Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996)); 
see also Libertine v. Brown, 9 Vet. App. 521, 523 (1996).

The Board also acknowledges the veteran's contention about 
the etiology of his Raynaud's Syndrome and how his service 
connected disabilities have aggravated said disorder.  As a 
layperson, however, he is not competent to provide a medical 
opinion about causation or aggravation.  Epps v. Brown, 9 
Vet. App. 341, 344 (1996); Espititu v. Derwinski, 2 Vet. App. 
492, 494-95 (1992).  While the veteran is certainly competent 
to describe symptoms, without an indication in the record 
that he has had the relevant medical training, he is not 
competent to provide an opinion on whether any etiological 
relationship exists between his Raynaud's Syndrome and his 
service connected disabilities.  As a result, his own 
assertions are not probative to the critical issue in this 
case of whether the veteran's diabetes mellitus or any 
complications thereof have caused or aggravated his Raynaud's 
Syndrome.         
   

IV. Conclusion 
For the reasons stated above, the Board finds that service 
connection is not warranted.  As the preponderance of the 
evidence is against the claim, the benefit of the doubt 
doctrine does not apply to the instant case.  38 U.S.C.A. 
§ 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. 
Cir. 2001) (holding that "the benefit of the doubt rule is 
inapplicable when the preponderance of the evidence is found 
to be against the claimant"); Gilbert, 1 Vet. App. at 56.  


ORDER

Service connection for Raynaud's Syndrome, claimed as 
secondary to service connected diabetes mellitus or 
complications thereof, such as coronary artery disease, 
peripheral neuropathy or diabetic nephropathy, is denied.



____________________________________________
R. F. WILLIAMS
Veterans Law Judge, Board of Veterans' Appeals




 Department of Veterans Affairs