Citation Nr: 0810284 Decision Date: 03/28/08 Archive Date: 04/09/08 DOCKET NO. 04-32 102 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to service connection for pulmonary tuberculosis. 2. Whether new and material evidence has been submitted to reopen a claim of service connection for heart disease and, if so, whether service connection should be granted for heart disease. 3. Whether new and material evidence has been submitted to reopen a claim of service connection for beriberi. 4. Whether new and material evidence has been submitted to reopen a claim of service connection for peptic ulcer disease. 5. Whether new and material evidence has been submitted to reopen a claim of service connection for post-traumatic osteoarthritis. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Douglas J. Boorstein, Associate Counsel INTRODUCTION The veteran served on active duty in the Philippine Commonwealth Army from November 1941 to December 1942. The veteran was held as a prisoner of war by the Japanese government from April 1942 to December 1942. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2004 rating decision of the Manila, Philippines, Department of Veterans Affairs (VA) Regional Office (RO). Relevant to this appeal, the RO denied service connection for pulmonary tuberculosis. The RO further determined that new and material evidence sufficient to reopen a claim for service connection for beriberi had not been submitted but that new and material evidence had been submitted to reopen the claim of service connection for ischemic heart disease; service connection was then denied for ischemic heart disease. Irrespective of the agency of original jurisdiction's (AOJ's) determination, the Board must decide whether the veteran has submitted new and material evidence to reopen the claim. Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). In a January 2006 rating decision, the RO denied the veteran's request to reopen claims of service connection for peptic ulcer disease and post-traumatic osteoarthritis. The issues of whether new and material evidence has been presented to reopen claims of service connection for peptic ulcer disease and post-traumatic osteoarthritis are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained. 2. The veteran was a prisoner of war (POW). 3. The AOJ denied the claim of entitlement to service connection for beriberi and for ischemic heart disease in an August 2002 rating decision. Notice was issued to the veteran in August 2002. The veteran did not appeal the decision. 4. Since the August 2002 rating decision, which denied service connection for beriberi, evidence that relates to an unestablished fact necessary to substantiate the claim has not been presented or secured. 5. Since the August 2002 rating decision, which denied service connection for heart disease, evidence that relates to an unestablished fact necessary to substantiate the claim has been presented. 6. The competent evidence of record does not demonstrate that the veteran has a current diagnosis of ischemic heart disease, beriberi heart disease, atherosclerotic heart disease, hypertensive vascular disease (including hypertensive heart disease) and/or their complications (including myocardial infarction, congestive heart failure, arrhythmia). 7. Pulmonary tuberculosis was not manifested in service or within three years following active duty discharge, and is not shown to be related to the veteran's service. CONCLUSIONS OF LAW 1. The August 2002 rating decision that denied service connection for beriberi is final. Evidence received since that decision is not new and material. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. §§ 3.156(a), 20.1103 (2007). 2. The August 2002 rating decision that denied service connection for heart disease is final. Evidence received since that decision is new and material. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. §§ 3.156(a), 20.1103 (2007). 3. Heart disease, to include ischemic heart disease, beriberi heart disease, atherosclerotic heart disease, hypertensive vascular disease (including hypertensive heart disease) and their complications (including myocardial infarction, congestive heart failure, arrhythmia), was not incurred in or aggravated by service and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). 4. Pulmonary tuberculosis was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303; 3.307, 3.309 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify & Assist The Veterans Claims Assistance Act of 2000 (VCAA) imposes obligations on VA in terms of its duty to notify and assist claimants. When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2006); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004), the Court held that VA 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 that the claimant provide any evidence in his possession that pertains to the claim. The Board finds that the VCAA notice requirements have been satisfied based on the RO's October 2003, January 2004, and June and November 2004 letters. VA informed the veteran that in order to substantiate a claim for service connection, the evidence needed to show he has a current disability, a disease or injury in service, and evidence of a nexus between the post service disability and the disease or injury in service, which was usually shown by medical records and medical opinions. The June 2004 letter indicated that the veteran should submit "any evidence" pertaining to his claim. The Board therefore finds that the four Pelegrini elements were satisfied. Although the June and November 2004 letters were sent after the initial adjudication of the veteran's claims, the Board nevertheless finds that the veteran has not been prejudiced, as his claims have been readjudicated in a statement of the case and subsequent supplemental statements of the case. See Prickett v. Nicholson, 20 Vet. App. 370, 376-78 (2006). Kent v. Nicholson, 20 Vet. App. 1 (2006), established new requirements regarding the VCAA notice and reopening claims. The Court held that the VCAA notice must include the bases for the denial in the prior decision and VA must respond with a notice letter that describes what evidence would be necessary to substantiate that element or elements required to establish service connection that were found insufficient in the previous denial. Id. Therefore, the question of what constitutes material evidence to reopen a claim for service connection depends on the basis on which the prior claim was denied. See Evans v. Brown, 9 Vet. App. 273, 283 (1996) (holding evidence is material if it is relevant to and probative of an issue that was a specified basis for the last final disallowance). The VA has adequately advised the veteran of the basis of the previous denial. The January 2004 letter clearly explained what new and material evidence was, and also explained that the veteran would have to submit evidence proving a diagnosis of beriberi and that it was caused by service. The November 2004 letter again explained new and material evidence and that the veteran would have to submit evidence of the existence or diagnosis of beriberi and ischemic heart disease. To whatever extent the decision of the Court in Dingess v. Nicholson, supra, requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date, the Board finds no prejudice to the veteran in proceeding with the present decision. Although no letter compliant with Dingess was sent, since the claims for service connection are being denied, no disability rating or effective date will be assigned, so there can be no possibility of any prejudice to the veteran. As to informing the veteran of which information and evidence he should provide to VA and which information and evidence VA would attempt to obtain on his behalf, VA informed him it had a duty to obtain any records held by any federal agency. It also informed him that on his behalf, VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. VA must also make reasonable efforts to assist the veteran in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA has obtained the veteran's SMRs, private treatment records and VA examination records. Assistance to the veteran shall also include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Regarding the veteran's claimed heart disease, the veteran was provided with a VA examination pertaining to this claim in November 2003. With regard to the veteran's claimed beriberi, VA has not provided the veteran with an examination in connection with his claim; however, the Board finds that VA was not under an obligation to have the veteran examined for his claim. The veteran has not brought forth new and material evidence to reopen the claim. 38 C.F.R. § 3.159(c)(4)(iii) states that paragraph (c)(4) applies to a claim to reopen a finally adjudicated claim only if new and material evidence is presented or secured. For these reasons, the Board finds that VA was not under an obligation to provide an examination in connection with his claim. Regarding the veteran's claimed pulmonary tuberculosis, merely filing a claim for benefits and showing a current illness does not trigger these duties. VA's duty to provide a medical examination is not triggered unless the record contains competent evidence that the claimed disability began during service or within an applicable presumptive period, and evidence of an association between the claimed disability and that event, illness or injury in service. 38 U.S.C.A. § 5103A; McLendon v. Nicholson, 20 Vet. App. 79, 80 (2006). However, the Board also notes that § 5103A only requires a VA examination when the record "does not contain sufficient medical evidence for the Secretary to make a decision on the claim." As the record in this case does contain sufficient medical evidence, the Board finds that a VA examination is not required for the veteran's claimed pulmonary tuberculosis. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim. The evidence of record provides sufficient information to adequately evaluate the claim, and the Board is not aware of the existence of any additional relevant evidence which has not been obtained. Therefore, no further assistance to the veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). New and Material Evidence to Reopen the Claim for Service Connection for Beriberi Historically, in this case, the veteran initially applied for service connection for beriberi in November 2000. The RO denied his claim in August 2002 on the basis that service connection for beriberi was not shown by the evidence of record, in that there was no current diagnosis of beriberi. The veteran did not appeal. 38 C.F.R. §§ 3.303, 3.307, 3.309 (2003). The RO's decision is final. 38 U.S.C.A. § 7105. Section 5108 provides that "[i]f new and material evidence is presented or secured with respect to a claim which has been disallowed, the [Board] shall reopen the claim and review the former disposition of the claim." New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). When determining whether a claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). Additionally, when determining whether the claimant has submitted new and material evidence to reopen a claim, consideration must be given to all the evidence since the last final denial of the claim. Evans v. Brown, 9 Vet. App. 273 (1996). In Evans, the United States Court of Appeals for Veterans Claims (Court) indicated that the newly presented evidence need not be probative of all the elements required to award the claim, but need only tend to prove each element that was a specified basis for the last disallowance. Id. at 284. The Board has carefully considered the evidence of record and finds that the evidence is not new and material. Historically, the veteran applied for service connection for beriberi and was denied service connection in August 2002. At the time of the RO's decision, the evidence of record consisted of various service medical records, private medical records, and a VA examination dated May 2002. Since the August 2002 RO decision, the veteran has submitted numerous new pieces of evidence, including various private medical records, and affidavits prepared by private individuals, none of whom is a physician. The veteran received further VA examinations, although these examinations did not pertain to the veteran's beriberi. Reports from these examinations have been made a part of the record. The evidence is new, in that the RO has not considered it before. However, it is not material, in that it does not relate to an unestablished fact necessary to substantiate the claim. Regarding the private medical reports, although these reports do discuss many other diseases, they do not indicate that the veteran currently has a diagnosis of beriberi, nor do they indicate that the veteran suffers from any residuals of beriberi. Although a letter from a private physician dated July 2004 indicates that the veteran had beriberi in service, it does not indicate that the veteran has a current diagnosis of beriberi or residuals thereof except as mentioned below pertaining to the heart. Although the private individual's affidavits indicate that the veteran had edematous legs during service, they do not attribute the edematous legs to beriberi. Regardless, these lay individuals are not competent to attribute the edematous legs to beriberi. Lay assertions on medical causation do not constitute material evidence to reopen a previously denied claim. See Moray v. Brown, 5 Vet. App. 211 (1993); See also Beausoleil v. Brown, 8 Vet. App. 459, 464 (1996); see Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992); see also Evans v. Brown, 9 Vet. App. 273. Further, these lay affidavits do not constitute evidence of a current disability. With respect to the appellant's contentions, the Board finds that these are essentially cumulative of evidence already of record at the time of the August 2002 RO decision because the veteran had already submitted similar statements regarding the fact that he had beriberi that was caused by service. For the reasons and bases set forth above, the Board finds that new and material evidence has not been submitted to reopen the claim of entitlement to service connection. 38 U.S.C.A. §§ 5108, 7104(b); 38 C.F.R. §§ 3.156(a), 20.1105. Having found that the evidence is not new and material, no further adjudication of this claim is warranted. See Kehoskie v. Derwinski, 2 Vet. App. 31 (1991). The Board addresses the veteran's claim of service connection for beriberi heart disease separately below. New and Material Evidence to Reopen the Claim for Service Connection for Heart Disease Again, the RO denied his claim in August 2002 on the basis that service connection for heart disease was not shown by the evidence of record, in that there was no current diagnosis of heart disease. The veteran did not appeal. 38 C.F.R. §§ 3.303, 3.307, 3.309 (2003). The RO's decision is final. 38 U.S.C.A. § 7105. At the time of the RO's decision, the evidence of record consisted of various service medical records, private medical records, and VA examinations. Since the August 2002 decision, private medical records of August and September 2003 indicate a diagnosis of atherosclerotic cardiovascular disease. As a diagnosis of a presumptive POW-related has now been indicated, the veteran has provided evidence of a key missing element, and that evidence is new and material. The claim is, therefore, reopened. Service Connection - General Principles Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 2002). Service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2007). Cardiovascular-renal disease may also be presumed connected to service if it is manifest to a degree of 10 percent within one year of service discharge. 38 U.S.C.A §§ 1101, 1110; 38 C.F.R. §§ 3.307, 3.309 (2007). To prevail on the issue of service connection, there must be medical evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of an inservice injury or disease and medical evidence of a nexus between the claimed inservice disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection - Prisoner of War Presumptive Provisions In addition to the general rules of service connection discussed above, special presumptions apply to former prisoners of war. The term "former prisoner of war" means a person who, while serving in the active military, naval or air service, was forcibly detained or interned in the line of duty by an enemy or foreign government, the agents of either, or a hostile force. The VA shall accept the findings of the appropriate service department that a person was a POW during a period of war unless a reasonable basis exists for questioning it. 38 U.S.C.A. § 101(32)(West 2002); 38 C.F.R. § 3.1(y)(2007). The regulation governing presumptions applicable to prisoners of war was amended on October 7, 2004. Prior to this amendment, beriberi heart disease was defined as including ischemic heart disease in a former POW who had experienced localized edema during captivity. 38 C.F.R. § 3.309(c), Note (2003). Other heart diseases were not listed. Under the amended version, 38 C.F.R. § 3.309 relating to presumptive diseases concerning POWs provided as follows: Diseases specific as to former prisoners of war. (1) If a veteran is a former prisoner of war, the following diseases shall be service-connected if manifested to a degree of disability of 10 percent or more at any time after discharge or release from active military, naval, or air service even though there is no record of such disease during service, provided the rebuttable presumptions of 3.307 are also satisfied: psychosis; any of the anxiety states; dysthymic disorder (or depressive neurosis); organic residuals of frostbite, if it is determined that the veteran was interned in climatic conditions consistent with the incurrence of frostbite; post-traumatic osteoarthritis; atherosclerotic heart disease or hypertensive vascular disease (including hypertensive heart disease) and their complications (including myocardial infarction, congestive heart failure, arrhythmia); stroke and its complications. (2) If the veteran; (i) Is a former prisoner of war and: (ii) Was interned or detained for not less than 30 days, the following diseases shall be service-connected if manifested to a degree of 10 percent or more at any time after discharge or release from active military, naval, or air service even though there is no record of such disease during service, provided the rebuttable presumption provisions of Sec. 3.307 are also satisfied: avitaminosis; beriberi (including beriberi heart disease); chronic dysentery; helminthiasis; malnutrition (including optic atrophy associated with malnutrition); pellagra; any other nutritional deficiency; irritable bowel syndrome; peptic ulcer disease; peripheral neuropathy except where related directly to infectious causes; cirrhosis of the liver. 69 Fed. Reg. 60083-60090 (October 7, 2004) (codified at 38 C.F.R. § 3.309(c)). Although the veteran filed his claim in September 2003, thus permitting the older version of section 3.309(c) to be applied, the Board will apply the newer version, as it includes assertions of additional heart diseases that could, potentially, be service-connected. The Board will also consider whether the veteran has ischemic heart disease, as set forth in the older version of section 3.309(c). The veteran will not be prejudiced by the application of this revised regulation, as this regulation liberalized the requirements for proving service connection for heart disease in former prisoners of war, in that it expands the number of diseases which can be service connected. Service Connection - Pulmonary Tuberculosis Where a veteran served ninety days or more during a period of war and tuberculosis becomes manifest to a degree of 10 percent within three years from date of termination of such service, tuberculosis shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2007). Legal Analysis - Heart Disease The veteran has claimed service connection for heart disease and, specifically, ischemic heart disease due to beriberi. The veteran contends that he incurred this heart disease while a prisoner of war from May to December 1942. The evidence of record indicates that the veteran was a prisoner of war. The Board will consider both claims. After careful review of the evidence, the Board finds that service connection is not warranted for the heart disease, including for ischemic heart disease based on localized edema during captivity. During service, service medical records from December 1942 indicate that the veteran denied a past history of beriberi, including numbness and edema of the extremities. The veteran's legs were noted to not be edematous. The veteran was X-rayed by VA in May 2002, this X-ray determined that the veteran had an atheromatous aorta. The veteran received a VA examination in June 2002. Based on this examination, and electrocardiogram and echocardiogram performed during it, the examiner determined that the veteran did not have ischemic heart disease, and that the veteran had a normal size left ventricle with good systolic function. The examiner also noted that the veteran had an apical beat palpable at the fifth intercostal space. The veteran's heart had a regular rhythm and there was no murmur. The examiner, when asked to determine whether the veteran had heart disease, determined that the veteran did not have any heart disease. Also of record is a private medical center record indicating treatment and diagnosis from August and September 2003. This indicates that the veteran has a diagnosis of atherosclerotic cardiovascular disease, cerebrovascular insufficiency, and an atheromatous aorta. No basis was specified to support the diagnosis of atherosclerotic cardiovascular disease or a cerebrovascular insufficiency. Further, these same records indicate that an examination of the veteran's heart and an electrocardiogram were within normal limits. Both cholesterol and triglycerides were measured and found to be within normal limits. In November 2003, the veteran was provided with a VA examination, including an echocardiogram and electrocardiogram. Echocardiogram revealed thickened mitral valve leaflets, thickened aortic valve leaflets, and a thickened aortic valve annulus. The veteran was noted to have sinus bradycardia on electrocardiogram, but the examiner also noted on electrocardiogram that the veteran had a normal sized left ventricle with good systolic function. The VA examiner did not note any abnormality in the veteran's heart. Ischemic heart disease was not found. An electrocardiogram (apparently performed privately) dated April 2004 indicates a diagnosis of left atrial enlargement. X-ray reports from a private medical facility dated from May and December 2004 indicate that the veteran's heart size is normal. A letter from a private physician dated December 2004 notes that the veteran does not have edema of the legs, does not have beriberi, and does not have symptoms of heart failure. Other records, including an April 2005 record from a private hospital, indicate that the veteran has an atheromatous aorta, based on an X-ray evaluation. In light of these various records, the Board concludes that the preponderance of the evidence indicates that the veteran does not have ischemic heart disease, atherosclerotic heart disease or hypertensive vascular disease (including hypertensive heart disease) and their complications (including myocardial infarction, congestive heart failure, arrhythmia); stroke and its complications, or beriberi heart disease. The Board acknowledges that some of the records, particularly the treatment record from the private medical facility dated in August and September 2003, provide evidence that conflicts with the VA examination, in that it diagnoses the veteran with atherosclerotic heart disease. Additionally, the April 2004 private electrocardiogram indicates that the veteran has left atrial enlargement. It is noted that it is the Board's responsibility to weigh the credibility and probative value of all of the evidence and, in so doing, the Board may accept one medical opinion and reject others. Schoolman v. West, 12 Vet. App. 307, 310- 11 (1999). It is also the responsibility of the Board to determine the probative weight to be ascribed as among multiple medical opinions in a case, and to state reasons or bases for favoring one opinion over another. The probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). In evaluating the probative value of competent medical evidence, the United States Court of Appeals for Veterans Claims (Court) has stated, in pertinent part: "The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicators; . . ." Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). As stated by the Court, credibility is the province of the Board. It is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons or bases. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). Here, the August and September 2003 record from the private medical facility does not provide any rationale to support the conclusion that the veteran has atherosclerotic heart disease. Rather, this diagnosis is summarily notated as a conclusion. As there is no rationale to support the diagnosis of atherosclerotic heart disease, its probative value is severely limited. The April 2004 electrocardiogram indicating left atrial enlargement also has severely limited probative value as subsequent x-rays showed normal heart size. Regarding the VA examinations, these list tests and indicate specific results. The lack of diagnosis of a heart condition is consistent with the results of these tests, which, as discussed above, did not indicate any abnormalities with the veteran's heart. The Board therefore finds the VA examinations to be more probative. Furthermore, the results of these VA examinations are consistent with some of the private records provided by the veteran, which, as discussed above, indicate that the veteran has a normal sized heart. The Board notes the July 2004 private medical statement that the veteran's beriberi contributed to his ischemic heart disease. However, this is of very little probative value because the veteran denied having beriberi in 1946, at a time more contemporaneous to the events in question, and the private doctor's assumption that the veteran had beriberi as a POW is not credible. August 2004 and February 2005 affidavits from service comrades purport to establish that the veteran had beriberi and edema of the legs. However, the former statement from P.V. said that he saw the veteran being treated for swollen legs, but again this is contradicted by the contemporaneous evidence of record. The same is true of the latter statement from A.C. who also places his recollections as occurring several years after the veteran's recognized service. The overwhelming weight of the evidence is that the veteran does not have heart disease related to beriberi or edematous lower extremities during his POW service. The Board acknowledges that both the VA and private medical records indicate that the veteran has an atheromatous aorta. While an atheromatous aorta involves the vascular system, it does not fall within the parameters of heart, or coronary disease, and is, therefore, not a disease enumerated in 38 C.F.R. § 3.309(c). Similarly, the VA diagnoses of thickened mitral valve leaflets, thickened aortic valve leaflets, and a thickened aortic valve annulus are also not diagnostic of the heart diseases listed in § 3.309(c). As of yet, the heart diseases listed as presumptive diseases for POWs have not been demonstrated. Thus, after a careful review of the evidence, the Board finds that the veteran does not have a diagnosis of ischemic heart disease, beriberi heart disease, or a diagnosis of any of the other diseases relating to the heart listed in 38 C.F.R. § 3.309(c). Without such a diagnosis, the veteran's claim cannot be granted. See Hickson. While the veteran appears sincere in his belief that he currently has heart disease and it is attributable to his service, particularly his time as a prisoner of war, the veteran is not competent to diagnose a heart condition, as that would require a medical opinion. Beausoleil v. Brown, 8 Vet. App. 459, 464 (1996); see Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The Board therefore finds that the preponderance of the competent and credible evidence is against the claim for service connection for ischemic heart disease or any other cardiovascular disability enumerated in § 3.309(c), and there is no doubt to be resolved. See Gilbert, 1 Vet. App. at 55. The claim for service-connected heart disease is denied. Service Connection - Pulmonary Tuberculosis After reviewing the entire evidence of record, the Board finds that service connection for pulmonary tuberculosis is not warranted. The competent, credible evidence of record fails to show that the veteran has pulmonary tuberculosis which can be connected to service, either on a direct or a presumptive basis. In this case, the evidence of record consists of records from a hospital in 1942, shortly after the veteran's release from the prisoner of war camp. These records indicate that on physical examination, the veteran's lungs were clear. A fluoroscopic examination confirmed this finding. When asked on a separate form (apparently dated April 1949) to list all injuries or illnesses from July 1941 through June 1946, the veteran indicated "none." A March 1989 medical certificate also does not list pulmonary tuberculosis as a disease that the veteran was treated for from September 1945 to February 1946. In fact, this certificate notes that the veteran's lungs were "apparently normal" at that time. The earliest record of the veteran's pulmonary tuberculosis is an August 1987 X-ray report. This is over forty years after the veteran separated from service. The veteran has submitted other records which indicate a diagnosis of pulmonary tuberculosis. These include a February 2001 note from a private physician indicating treatment for pulmonary tuberculosis, a note in the treatment records from a private medical provider dated August 2003, as well as May and December 2004 X-Ray reports from a private medical provider indicating bilateral Koch's disease. VA examinations also noted abnormalities in the lungs. Although many of these documents indicate that the veteran has a current diagnosis of pulmonary tuberculosis, none of them relate his current tuberculosis to his service. In this regard, the Board notes that during a POW protocol examination conducted by VA in May 2002, the social worker noted that the veteran's current pulmonary tuberculosis was caused by the hard labor and inadequate food during his period of captivity as a prisoner of war. A July 2004 letter from a private provider indicates that the veteran's pulmonary tuberculosis was caused by malnutrition suffered during World War II. With regard to the social worker's findings during the May 2002 VA POW protocol examination, the social worker is not a physician. There is no evidence of record that she has specialized medical knowledge to be competent to offer medical opinion as to cause or etiology of the claimed disability. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Further, her determination is contradicted by the evidence of record, which indicates that the veteran first had a diagnosis of pulmonary tuberculosis in 1987. With regard to the private provider's July 2004 letter, this letter is also contradicted by the evidence of record. There is no evidence that the veteran had tuberculosis in service or within three years thereafter. The Board therefore assigns this letter no probative weight, as it is not supported by the evidence of record. Although the veteran has contended that he has had pulmonary tuberculosis since service, as discussed above, the earliest medical record pertaining to treatment for it was from 1987. This lengthy period without treatment is evidence that there has not been a continuity of symptomatology, and it weighs against the claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Although it appears that the veteran sincerely believes that his pulmonary tuberculosis is attributable to his time spent in service as a prisoner of war, he is not a trained medical professional and therefore is not competent to offer medical opinions as to the etiology of his disability. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). As the preponderance of the evidence is against this claim, the benefit of the doubt doctrine is not applicable, and the claim must be denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert. ORDER New and material evidence has not been presented to reopen a claim of entitlement to service connection for beriberi, and this claim is denied. New and material evidence has been presented to reopen a claim of entitlement to service connection for ischemic heart disease, and to this extent, the appeal is granted. Entitlement to service connection for heart disease is denied. Entitlement to service connection for pulmonary tuberculosis is denied. REMAND As noted in the Introduction, a January 2006 decision by the RO denied the veteran's request to reopen claims of service connection for peptic ulcer disease and post-traumatic osteoarthritis. In March 2006, after notice of certification was sent to the veteran, the Board received a statement from the veteran indicating that he felt that he should be granted compensation for post-traumatic osteoarthritis and peptic ulcer disease. The Board finds that this statement expresses dissatisfaction with the denial of the veteran's waiver request and can be construed as a notice of disagreement. See 38 C.F.R. § 20.201 (2007). A statement of the case was not issued. The filing of a notice of disagreement initiates the appeal process. Manlincon v. West, 12 Vet. App. 238 (1999). The Board is required to remand, rather than refer, this issue. Id. Accordingly, the case is REMANDED for the following action: 1. Send the veteran a statement of the case on the issues of whether or not new and material evidence has been received to reopen claims of entitlement to service connection for peptic ulcer disease and post-traumatic arthritis. Advise the veteran that a timely substantive appeal will be necessary to perfect the appeal to the Board. 2. Only if the appeal is timely perfected are the issues to be returned to the Board for further appellate consideration, if otherwise in order. 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 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ______________________________________________ HOLLY E. MOEHLMANN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs