Citation Nr: 0937655 Decision Date: 10/02/09 Archive Date: 10/14/09 DOCKET NO. 04-40 205 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to service connection for coronary artery disease, claimed as secondary to service-connected sarcoidosis and service-connected right bundle branch block. 2. Entitlement to service connection for a disability affecting the left elbow, left wrist, left leg, left shoulder, right shoulder and low back, claimed as secondary to service-connected sarcoidosis. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Bush, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from January 1966 to January 1969. This case comes to the Board of Veterans' Appeals (the Board) on appeal from a June 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. The Veteran subsequently moved to New Hampshire; the Manchester RO currently has jurisdiction over the Veteran's claims. Procedural history Service connection for a cardiovascular disorder on a secondary basis was denied by the RO in rating decisions dated in December 1997, June 1998, January 1999, March 2000 and August 2002, which the Veteran did not appeal. The present appeal stems from the above-referenced June 2003 rating decision, which, in part, denied the Veteran's claims for service connection for coronary artery disease and for a disability of the left elbow, left wrist, left leg, left shoulder, right shoulder and low back. The Veteran presented personal testimony before the undersigned Veterans Law Judge at a hearing which was conducted in Washington, D.C. in October 2005. A transcript of the hearing is associated with the Veteran's claims folder. In October 2006, the undersigned requested an opinion from an Independent Medical Expert (IME). See 38 U.S.C.A. § 7109 (West 2002); 38 C.F.R. § 20.901 (2008). Two opinions have been obtained, and the Veteran has been provided opportunity to respond thereto. The Board remanded this case in April 2007 for additional development. The case has been returned to the Board. Issues not on appeal In an October 1993 rating decision, the RO in Washington, D.C. denied the Veteran's claim of entitlement to service connection for chronic cardiovascular disease, claimed as being directly due to service. The Veteran initiated an appeal of the October 1993 rating decision. In an unappealed September 1997 decision, the Board denied the issue of entitlement to service connection for cardiovascular disease on a direct basis. The Board's decision is final. See 38 C.F.R. § 20.1100 (2006). In a December 2007 statement, it appears as though the Veteran is attempting to reopen the previously-denied claim of entitlement to service connection for cardiovascular disease on a direct basis. That issue has not yet been addressed by the RO, and it is referred to the RO for appropriate action. See Godfrey v. Brown, 7 Vet. App. 398 (1995) [the Board does not have jurisdiction of issues not yet adjudicated by the RO]. In June 2007, the Veteran raised the matter of entitlement to service connection for a back disability on a direct basis. That issue has not yet been addressed by the RO, and it is referred to the RO for appropriate action. The Board emphasizes that the current appeal involves the separate and distinct matters of secondary service connection for cardiovascular disease and a back disability. Compare 38 C.F.R. §§ 3.303, 3.310 (2008). FINDINGS OF FACT 1. In an unappealed August 2002 rating decision, the RO denied the Veteran's claim of entitlement to service connection for a cardiovascular disorder on a secondary basis. 2. The evidence associated with the claims folder subsequent to the August 2002 RO rating decision is so significant that it must be considered in order to fairly decide the merits of the Veteran's claim of entitlement to service connection for a cardiovascular disorder on a secondary basis. 3. A preponderance of the competent medical evidence of record does not indicate that a medical nexus exists between the Veteran's service-connected sarcoidosis or right bundle branch block and his currently diagnosed coronary artery disease. 4. A preponderance of the competent medical evidence of record does not indicate that a medical nexus exists between the Veteran's service-connected sarcoidosis and his currently diagnosed disability affecting the left elbow, left wrist, left leg, left shoulder, right shoulder and low back. CONCLUSIONS OF LAW 1. The August 2002 RO decision is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.1103 (2008). 2. Since the August 2002 RO decision, new and material evidence has been received; therefore the claim of entitlement to service connection for a cardiovascular disorder on a secondary basis is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2008). 3. Coronary artery disease is not proximately due to nor is it the result of the Veteran's service-connected sarcoidosis or right bundle branch block. 38 C.F.R. § 3.310 (2008). 4. A disability affecting the left elbow, left wrist, left leg, left shoulder, right shoulder and low back is not proximately due to nor is it the result of the Veteran's service-connected sarcoidosis. 38 C.F.R. § 3.310 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks service connection on a secondary basis for (1) a cardiovascular disorder and (2) a disability affecting the left elbow, left wrist, left leg, left shoulder, right shoulder and low back. As was discussed in the Introduction, the claim for a cardiovascular disorder was denied in the past; implicit is the Veteran's contention that new and material evidence has been received to reopen the previously- denied claim. In the interest of clarity, the Board will first discuss certain preliminary matters. Stegall concerns As was alluded to in the Introduction, the Board remanded this case in April 2007. The Board instructed the agency of original jurisdiction (AOJ) to send the Veteran appropriate notice pursuant to the Veterans Claims Assistance Act of 2000 (VCAA), to include the evidentiary requirements with respect to the submission of new and material evidence as well as secondary service connection claims, as well as the holdings of the United States Court of Appeals for Veterans Claims (the Court) in Kent v. Nicholson, 20 Vet. App. 1 (2006) and Dingess v. Nicholson, 19 Vet. App. 473 (2006). The AOJ was then to readjudicate the claims. Corrective VCAA notice letters were issued in May 2007, December 2007 and February 2009, and the VA Appeals Management Center (AMC) subsequently readjudicated the claims in the June 2009 SSOC. Thus, the Board's remand instructions have been complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance]. The VCAA The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also redefines the obligations of VA with respect to its statutory duty to assist claimants in the development of their claims. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). For claims to reopen, such as the instant case, the VCAA appears to have left intact the requirement that a veteran must first present new and material evidence in order to reopen a previously and finally denied claim under 38 U.S.C.A. § 5108 before the Board may determine whether the duty to assist is fulfilled and proceeding to evaluate the merits of that claim. It is specifically noted that nothing in the VCAA shall be construed to require VA to reopen a claim that has been disallowed except when new and material evidence is presented or secured, as described in 38 U.S.C.A. § 5108. See 38 U.S.C.A. § 5103A(f) (West 2002). Once the claim is reopened, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claimant's claim for benefits under a law administered by the Secretary, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A (West 2002). Therefore, the VCAA duty to notify currently applies to both issues on appeal; the standard of review and duty to assist do not apply to the claim for a cardiovascular disorder unless it is reopened. See Holliday v. Principi, 14 Vet. App. 280 (2000) [the Board must make a determination as to the applicability of the various provisions of the VCAA to a particular claim]. The Board has carefully considered the provisions of the VCAA and the implementing regulations in light of the record on appeal, and for reasons expressed immediately below finds that the development of the issues has proceeded in accordance with the provisions of the law and regulations. Standard of review After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2008). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. This standard does not apply to a claim to reopen until such claim has in fact been reopened. The standard of review as to the issue involving the submission of new and material evidence will be set forth where appropriate below. Notice The VCAA requires VA to notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided to VA that is necessary to substantiate the claims. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103 (West 2002); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002) [a letter from VA to an appellant describing evidence potentially helpful to the appellant but not mentioning who is responsible for obtaining such evidence did not meet the standard erected by the VCAA]. After having carefully reviewed the record, the Board has concluded that the notice requirements of the VCAA have been satisfied with respect to the issues on appeal. The Board observes that the Veteran was informed of the evidentiary requirements for secondary service connection in letters from the AMC dated December 18, 2007 and February 4, 2009, including evidence that "your service-connected disability either caused or aggravated your additional disability." See the December 2007 VCAA letter at page 4; see also the February 4, 2009 letter at page 9. With respect to notice regarding new and material evidence, a letter from the AMC dated May 17, 2007 and the February 2009 letter specifically explained that the Veteran was "previously denied service connection for coronary artery disease . . . The appeal period for that decision ahs expired and the decision is now final." The Veteran was also advised that evidence sufficient to reopen the Veteran's previously denied claim must be "new and material," closely mirroring the regulatory language of 38 C.F.R. § 3.156(a). The Veteran was also specifically advised in the in the February 2009 letter as to the reason this claim was previously denied: "Your claim was previously denied because there is no medical literature to show that sarcoidosis causes coronary artery disease and a VA examiner opined that your coronary artery disease is not secondary to your sarcoid or right bundle branch block." [Emphasis as in original] See Kent v. Nicholson, 20 Vet. App. 1 (2006). The Board acknowledges that the May 2007 and February 2009 VCAA letters incorrectly informed the Veteran of the date of the last final rating decision denying service connection for coronary artery disease. However, in light of the fact the Board is reopening the claim, any VCAA error in connection with that issue is harmless. Crucially, the RO informed the Veteran of VA's duty to assist him in the development of his claims in the above-referenced May 2007, December 2007 and February 2009 VCAA letters. Specifically, the Veteran was advised in the letters that VA would obtain all evidence kept by the VA and any other Federal agency, including VA facilities and service medical records. He was also informed in the letters that VA would, on his behalf, make reasonable efforts to obtain relevant private medical records that the he identified. Included with the letters were copies of VA Form 21- 4142, Authorization and Consent to Release Information, and the letters asked that the Veteran complete this release so that VA could obtain these records on his behalf. The letters also informed the Veteran that for records he wished for VA to obtain on his behalf he must provide enough information about the records so that VA can request them from the person or agency that has them. The Veteran was specifically notified in the May 2007 and February 2009 letters to describe or submit any additional evidence which he thought would support his claim. See the May 17, 2007 letter at page 2; see also the February 4, 2009 letter at page 3. This request complies with the "give us everything you've got" requirement contained in 38 C.F.R. § 3.159 (b) in that the RO informed the Veteran that he could submit or identify evidence other than what was specifically requested by the RO. [The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008. See 73 Fed. Reg. 23353- 56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the Veteran to provide any evidence in the Veteran's possession that pertains to the claim. See 38 C.F.R. § 3.159(b)(1).] In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court observed that a claim of entitlement to service connection consists of five elements: (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. Because a service connection claim is comprised of five elements, the Court further held that the notice requirements of section 5103(a) apply generally to all five elements of that claim. Therefore, upon receipt of an application for a service connection claim, section 5103(a) and section 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. This includes notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, element (1) is not at issue, and the Veteran was provided notice as to elements (2) and (3) as detailed above. The February 2009 VCAA letter provided notice as to elements (4) and (5), degree of disability and effective date. In any event, because the Veteran's claims are being denied, elements (4) and (5) are moot. In short, the record indicates that the Veteran received appropriate notice pursuant to the VCAA. There is no indication that there exists any evidence which could be obtained which would have an effect on the outcome of this case. Therefore, no further VCAA notice is necessary. See Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) [VCAA notice not required where there is no reasonable possibility that additional development will aid the Veteran]. Duty to assist In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate claims for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. The law provides that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claims. An examination is deemed "necessary" if the record does not contain sufficient medical evidence for VA to make a decision on the claims. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2008). The VCAA appears to have left intact the requirement that a Veteran must first present new and material evidence in order to reopen a previously and finally denied claim under 38 U.S.C.A. § 5108 before the Board may determine whether the duty to assist is fulfilled and proceeding to evaluate the merits of that claim. It is specifically noted that nothing in the VCAA shall be construed to require VA to reopen a claim that has been disallowed except when new and material evidence is presented or secured, as described in the provisions of 38 U.S.C.A. § 5108. See 38 U.S.C.A. § 5103A(f) (West 2002). With respect to the claim for a disability affecting the left elbow, left wrist, left leg, left shoulder, right shoulder and low back, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claimant's claim for benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A (West 2002). The Board finds that reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claims, and that there is no reasonable possibility that further assistance would aid in substantiating them. In particular, the RO has obtained reports of private treatment of the Veteran and records from the Social Security Administration. Additionally, the RO obtained a VA examination in June 2002 and a VA medical opinion in December 2002 and the Board obtained IME opinions in October 2006 and November 2006, which will be discussed below. The VA examination and IME reports reflect that the examiners reviewed the Veteran's past medical history, including his private treatment records, documented his current medical conditions, reviewed pertinent medical research, conducted an appropriate physical examination (in June 2002) and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board therefore concludes that the VA examination and IME reports are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2008); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) [holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate]. In short, the Board finds that under the circumstances of this case, VA has satisfied the notification and duty to assist provisions of the law and that no further actions pursuant to the VCAA need be undertaken on the Veteran's behalf. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2008). The Veteran has been accorded the opportunity to present evidence and argument in support of his claims. He is ably represented by his service organization. He provided personal testimony to the undersigned in October 2005. Therefore, the Board will proceed to a decision. 1. Entitlement to service connection for coronary artery disease, claimed as secondary to service-connected sarcoidosis and service-connected right bundle branch block. Relevant law and regulations Secondary service connection Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310(a) (2008); Harder v. Brown, 5 Vet. App. 183, 187 (1993). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Finality/new and material evidence In general, VA rating decisions that are not timely appealed are final. See 38 U.S.C.A. § 7104 (West 2002); 38 C.F.R. § 20.1103 (2008). Pursuant to 38 U.S.C.A. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, related to an unsubstantiated 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. See 38 C.F.R. § 3.156(a) (2008). There must be new and material evidence as to each and every aspect of the claim that was lacking at the time of the last final denial in order for there to be new and material evidence to reopen the claim. See Evans v. Brown, 9 Vet. App. 273 (1996). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Analysis Finality/new and material evidence The request to reopen the previously-denied claim of entitlement to service connection for a cardiovascular disorder was denied in an unappealed August 2002 rating decision. That decision is final. See 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2008). The August 2002 denial of service connection was predicated on the absence of evidence of a medical nexus evidence establishing a connection between the service-connected disability and the current disability [Wallin element 3]. The record contains more recent evidence satisfying Wallin element (3). Specifically, a November 2002 report from C.N.B., M.D., indicates the Veteran's service-connected right bundle branch block contributes to his current cardiovascular disorder. The Veteran's claim of entitlement to secondary service connection for a cardiovascular disorder is accordingly reopened based on this new and material evidence. Procedural concerns The Board has reopened the Veteran's claim for a cardiovascular disorder and is considering moving forward to discuss the claim on its merits. Before doing so, however, the Board must address certain procedural concerns. (i.) Bernard considerations First, there is the case of Bernard v. Brown, 4 Vet. App. 384 (1993). In Bernard, the Court held that before the Board may address a matter that has not been addressed by the RO, it must consider whether the claimant has been given adequate notice of the need to submit evidence or argument, an opportunity to submit such evidence or argument, an opportunity to address the question at a hearing, and whether the claimant has been prejudiced by any denials of those opportunities. In the present case, the Veteran's claim for a cardiovascular disorder has been adjudicated on its merits, without regard to the submission of new and material evidence, in the June 2003 rating decision and September 2004 SOC. Additionally, as detailed in the VCAA discussion above, the Veteran has been amply apprised of what is required to establish his claim of entitlement to service connection for a cardiovascular disorder. Finally, the Veteran has set forth his contentions as to why he believes that service connection should be granted for a cardiovascular disorder on numerous occasions, to include during his personal hearing with the undersigned. The Board therefore finds that the Veteran will not be prejudiced by its consideration of this issue on its merits; return of this case to the RO for additional consideration is not required. (ii.) VA's statutory duty to assist As discussed above, VA's statutory duty to assist the Veteran in the development of his claim attaches at this juncture. The Board has already detailed in the VCAA discussion above that the duty to assist has been satisfied. There is no indication in the record that any evidence which may be pertinent to this issue has not been obtained. Accordingly, the Board finds that under the circumstances of this case, the VA has satisfied the notification and duty to assist provisions of the law and that no further actions pursuant to the VCAA need be undertaken on the Veteran's behalf. (iii.) Standard of review The applicable standard of review has been discussed above in the VCAA portion of the opinion and need not be repeated. Crucially, the Justus presumption of credibility does not attach after a claim has been reopened. In evaluating the evidence and rendering a decision on the merits, the Board is required to assess the credibility, and therefore the probative value, of proffered evidence in the context of the record as a whole. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The Board wishes to make it clear that although there may be of record new and material evidence sufficient to reopen the claim, this does not mean that the claim must be allowed based on such evidence. In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the United States Court of Appeals for the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a veteran's injury or disability, even where it would not be enough to convince the Board to grant a claim. Merits discussion The Veteran attributes his current coronary artery disease to the use of steroids to treat his service-connected sarcoidosis. He alternatively contends that his currently diagnosed coronary artery disease is related to service- connected right bundle branch block. As noted above, in order to establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin, supra. With respect to Wallin element (1), medical evidence of a current disability, there are numerous diagnoses of coronary artery disease of record. With respect to Wallin element (2), a service-connected disability, the Veteran is currently service connected for a right bundle branch block and also for sarcoidosis. Wallin element (2) is accordingly satisfied. [The Board observes in passing that the Veteran is also service-connected for posttraumatic stress disorder, degenerative joint disease and instability of the right knee and residuals of excision of abdominal lipomas; however, his contentions concern only the right bundle branch block and sarcoidosis]. With respect to Wallin element (3), there are conflicting medical opinions as to whether the Veteran's coronary artery disease is related to sarcoidosis or right bundle branch block. By law, the Board is obligated under 38 U.S.C. § 7104(d) to analyze the credibility and probative value of all evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide reasons for its rejection of any material evidence favorable to the veteran. See, e.g., Eddy v. Brown, 9 Vet. App. 52 (1996). The Board has the authority to "discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence." See Madden, supra. However, the Court has held that the Board may not reject medical opinions based on its own medical judgment. See Obert v. Brown, 5 Vet. App. 30 (1993). In evaluating the probative value of competent medical evidence, the 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 adjudicator . . . Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Board has carefully evaluated the medical evidence, and for reasons stated immediately below finds that the evidence against the claim (i.e., medical opinions which found no relationship between the Veteran's coronary artery disease and his service-connected sarcoidosis or right bundle branch block) outweighs the evidence in favor (the medical opinions which found such a relationship). The Board will discuss the opinions relating to sarcoidosis and the right bundle branch block separately. (i.) Sarcoidosis There are three medical opinions which are arguably in the Veteran's favor. D.R.R., M.D., opined in May 1999 that "the cause of this [cardiac] abnormality is uncertain but could be related to his sarcoid." Also of record is the May 2002 letter of I.B., M.D., who states that the Veteran's "heart disease and subsequent condition may certainly stem from his service-connected sarcoid." Finally, Dr. H.E.J. stated in November 2006 that corticosteroids play a role in acceleration of arteriosclerosis and that corticosteroids used to treat the Veteran's service-connected sarcoidosis "may well have been aggravated as a result of the 18 month treatment with prednisone." Initially, the Board notes that the opinions of Drs. D.R.R. and I.B. do not contain any supporting reasoning. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) [the failure of the health care provider to provide a basis for his/her opinion goes to the weight or credibility of the evidence]; see also Bloom v. West, 12 Vet. App. 185, 187 (1999) [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."]. In addition, use of the words "could" and "may" renders all three opinions speculative. The Court has held that medical opinions which are speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). The Board thus places little weight of probative value on the opinions of Drs. I.B., K.K.R. and H.E.J. Evidence against the claim consists of the June 2002 VA examiner's opinion that Veteran's coronary artery disease "is not secondary to his sarcoid. He has cardiac risk factors such as hypertension and hypercholesterolemia which are well-established causes of coronary artery disease and would account for his coronary artery disease." C.N.B., M.D., indicated in November 2002 that he agreed with the findings of the June 2002 examiner that the Veteran's sarcoid did not contribute to the Veteran's coronary artery disease. However, he provided no rationale for his conclusory opinion, and it is of relatively little probative value. See Hernandez-Toyens and Bloom, both supra. The Board sought additional clarification as to this matter in October 2006, specifically whether the Veteran's coronary artery disease was a result of his service-connected sarcoidosis. Dr. E.S.S, a specialist in cardiology, reviewed the Veteran's claims folder and determined that the Veteran's coronary artery disease was not due to sarcoidosis: The sarcoidosis did not impact the development of coronary artery disease . . . While sarcoidosis may affect the heart, it does so as an infiltrative process causing a reduction of cardiac function. The available studies do not demonstrate significant cardiac involvement. The Veteran's cath report and echo report from 9/11/01 showed no reduction in overall LV function. It did not show evidence of arterial aneurysms, dilated chambers, or valvular insufficiency which may attend cardiac sarcoid. The echo did not show the typical "ground-glass appearance," and the thallium stress test of 12/00 did not show diffuse defects that are characteristic of sarcoidosis. In fact even the EKGs from September 10, 11, and 12 did not show a complete bundle branch block. I thus do not believe that cardiac sarcoidosis is responsible for his decrease in exercise tolerance. Dr. E.S.S. further stated that the use of steroids to treat sarcoidosis did not contribute to the Veteran's coronary artery disease, highlighting the fact that "[s]teroids may cause an increase in blood pressure, but this resolves after discontinuing the medication." The Board accordingly finds that a preponderance of the competent medical nexus opinion evidence is against the Veteran's claim. That is, the opinions of the June 2002 VA examiner and Dr. E.S.S. outweigh the conclusory statements of Drs. D.R.R., I.B. and H.E.J. (ii.) Right bundle branch block There are two medical opinions in the Veteran's favor as to this aspect of the claim. Dr. I.B. opined in May 2002 that the Veteran's current heart problems "may" be related to his service-connected right bundle branch block. However, the Board has already detailed above how this speculative opinion cannot support his claim. See Obert and Tirpak, both supra. Also in the Veteran's favor is a November 2002 opinion of Dr. C.N.B., who opined that: It is my opinion that this [Veteran's] right bundle branch block likely does contribute to his cardiovascular mortality/effort tolerance and overall cardiac function. This concept is supported in the literature [cited] above . . . The right bundle is a conduction pathway of the heart and when conduction pathways are blocked the result is usually decreased cardiac function[;] therefore in this [Veteran's] case his new sarcoid induced right bundle branch block in conjunction with his coronary artery disease likely causes a negative synergistic effect on his cardiac function/effort tolerance (i.e. the [Veteran] currently likely has less cardiac function today with his right bundle branch block and his coronary artery disease then [sic] he would have if he only had coronary artery disease). Evidence against the claim consists of the June 2002 VA examiner's opinion that Veteran's coronary artery disease is "not secondary to his right bundle branch block." The VA examiner expanded on his opinion in December 2002, noting that: I have reviewed Dr. [C.N.B.]'s statement and his reference to right bundle branch block in Heart Disease by Braunwald . . . [which] indicates that the coexistence of right bundle branch block with ischemic heart disease suggests more extensive multivessel disease and reduced long-term survival. This would be true if the veteran's right bundle block were a result of coronary artery disease. In the case of [the Veteran], the right bundle branch block has been attributed to sarcoidosis and NOT to his coronary artery disease. All evidence in the c- file shows that he has severe coronary artery disease and this would adequately explain his current symptoms and decreased effort tolerance . . . Therefore, in my opinion, his right bundle branch block secondary to his sarcoid does not contribute to his cardiovascular mortality. [Emphasis as in the original report.] The Board sought additional clarification as to this matter from Dr. E.S.S. in October 2006. After review of the Veteran's claims folder, Dr. E.S.S. determined that the Veteran's coronary artery disease was not due to the right bundle branch block: The right bundle branch block (RBBB) has no impact on this [veteran's] symptoms . . . This [veteran's] RBBB predated the onset of coronary disease . . . By the time of his cath in 2001, the right bundle had resolved. While RBBB that develops as a result of severe coronary artery disease is an ominous finding, RBBB in the absence of severe ischemic disease is a benign condition. The Board has carefully evaluated the conflicting evidence and for reasons stated immediately below places greater weight on the opinion of the June/December 2002 VA examiner and the October 2006 IME opinion than it does on the November 2002 opinion of Dr. C.N.B. The Board initially notes that Dr. C.N.B. is a neuro- radiologist, as opposed to Dr. E.S.S., who was selected to provide the Board with a medical opinion given his expertise cardiology. See Black v. Brown, 10 Vet. App. 297, 284 (1997) [in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data]. Further, both the 2002 VA examiner and Dr. E.S.S. based their opinions as to the lack of a medical nexus relationship on a review of all of the Veteran's medical records, and Dr. E.S.S. emphasized the fact that the Veteran's right bundle block predated his coronary artery disease and had resolved prior to the onset of heart disease. Significantly, Dr. C.N.B. did not account for the fact that the Veteran's right bundle branch block resolved prior to the onset of coronary artery disease in rendering his opinion. The failure of Dr. C.N.B. to explain his positive medical nexus statement in light of this medical evidence weighs heavily against the probative value of his opinion. See Hernandez-Toyens and Bloom, both supra. Unlike the opinion of the Dr. C.N.B., the opinions of the June/December 2002 VA examiner and Dr. E.S.S. are well- reasoned and draw on specific aspects from the Veteran's medical history, which reflects that the Veteran's right bundle branch block resolved prior to the onset of coronary artery disease. As such, the Board finds their opinions to be highly probative. See Bloom, supra. Based on the entire record, the Board gives the opinion of Dr. C.N.B. little weight of probative value. The Board has also considered medical treatise evidence submitted by the Veteran's representative in October 2005. The Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin, 11 Vet. App. at 514 (1998); see also 38 C.F.R. § 3.159(a)(1) [competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses]. While the article submitted by the Veteran's representative discusses a relationship between sarcoidosis and the heart, this article contains no information or analysis specific to the Veteran's case, and does not draw upon a physical examination of the Veteran. The Court has held on several occasions that medical evidence that is speculative, general or inconclusive in nature cannot support a claim. As such, the treatise evidence submitted by the Veteran is of no probative value as to the matter of medical nexus. See generally Obert and Tirpak, both supra. The only other evidence in the claims file alleging that a medical relationship exists between the Veteran's coronary artery disease and his service-connected sarcoidosis or right bundle branch block are the Veteran's statements and those of his representative. It is now well settled, however, that lay persons without medical training, such as the Veteran and his representative, are not qualified to render medical opinions regarding matters such as etiology of disease, which call for specialized medical knowledge. See Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992); see also 38 C.F.R. § 3.159 (2008) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. The Veteran's statements and that of his representative are accordingly lacking in probative value. Accordingly, the competent medical evidence of record does not indicate that a medical nexus exists between the Veteran's service-connected sarcoidosis or right bundle branch block and his currently diagnosed coronary artery disease. Wallin element (3) has not been met, and the Veteran's claim fails on this basis. The benefit sought on appeal is accordingly denied.. 2. Entitlement to service connection for a disability affecting the left elbow, left wrist, left leg, left shoulder, right shoulder and low back, claimed as secondary to service-connected sarcoidosis. The Veteran contends that he incurred a disability affecting his left elbow, left wrist, left leg, left shoulder, right shoulder and low back as a result of his service-connected sarcoidosis, more specifically due to steroid treatment for service-connected sarcoidosis. See the October 2005 hearing transcript, page 19. Analysis With respect to Wallin element (1), the medical evidence of record reflects the Veteran has undergone numerous lumbar laminectomies, bilateral shoulder surgery, left wrist surgery, and excision of bone chips from his left elbow. Numerous treating clinicians have indicated the Veteran evidences a systemic problem in multiple joint sites which has required these surgeries. For instance, K.S.K, M.D., diagnosed "premature arthritic problems requiring multiple surgical procedures" and Dr. I.B. indicated the Veteran "developed premature arthritis problems requiring multiple surgical procedures." With respect to Wallin element (2), a service-connected disability, the Veteran is currently service connected for sarcoidosis. Wallin element (2) is accordingly satisfied. [The Board observes in passing that the Veteran is also service-connected for posttraumatic stress disorder, a right bundle branch block, a right knee disability and residuals of excision of abdominal lipomas; however, his contentions concern only sarcoidosis]. With respect to Wallin element (3), there are conflicting medical opinions as to whether the Veteran's multiple joint problems are related to sarcoidosis. There are of record some medical opinions which are arguably in the Veteran's favor. Dr. I.B. opined in May 2002 that the Veteran's current joint problems "may" stem from his service-connected sarcoid and use of steroids to treat sarcoidosis. Dr. T.V.K. opined in October 1997 that the Veteran's joint problems "could be" secondary to steroid therapy for sarcoidosis. Finally, Dr. K.S.K. stated in July 1995 that the Veteran's premature arthritis problems "may stem from use of steroids or from arthritis associated with his underlying disease process, sarcoid." However, these opinion, couched as they are in terms of possibility are speculative and cannot support his claim. See Obert and Tirpak, both supra. Also in the Veteran's favor is a November 2002 opinion of Dr. C.N.B., who opined that: It is my opinion that this [Veteran's] current arthritis [of the right and left] shoulders and his tendon rupture of his right shoulder were caused by his service related sarcoidosis . . . Sarcoidosis is a well-known cause of joint arthritis, however in this case the mechanism of this [Veteran's] multiple joint problems is certainly the unwanted side effect of his long term prescription from prednisone which was used to treat his sarcoidosis in the 1970s . . . Steroids [are] a known cause of both tendon and joint destruction and this [Veteran] has no other known etiology of his early joint and tendon problems. This is clearly medical opinion evidence in the Veteran's favor. Evidence against the claim consists, first, of a December 2002 VA medical opinion that Veteran's various joint problems were not related to steroid treatment service-connected sarcoidosis, as follows: There is no evidence in the c-file to indicate that the Veteran had any of the[] characteristic manifestations of chronic sarcoid arthropathy. In the C-file there is evidence of previous trauma to the left forearm . . . and left knee . . . indicating some of [the veteran's] joint problems are traumatic in origin. The veteran's shoulder problems were variously described as calcific bursitis of the right and left shoulder and calcific tendinitis of the right shoulder with impingement type syndrome for which he was treated with acromioplasty of the right shoulder on March 23, 1992. This was nearly twenty years after he had received a course of steroids [for sarcoidosis]. Such a long period of time between cessation of his steroid therapy and his shoulder problem, in my opinion, militates against a causal relationship between his steroid therapy and shoulder problems. The C-file does not contain details of onset of shoulder problems to establish a nexus between them and his earlier sarcoidosis. . . The evidence shown above does not support left elbow, left leg, right shoulder, left shoulder, left wrist and lumbar conditions as being secondary to sarcoidosis. The Board sought additional clarification as to this matter in October 2006, specifically whether the Veteran's multiple joint problems were a result of steroid use to treat service- connected sarcoidosis. The IME, Dr. H.E.J., who as noted above is a specialist in rheumatology, reviewed the Veteran's claims folder in November 2006 and determined that the Veteran's multiple joint problems were not due to steroid use for service-connected sarcoidosis: Corticosteroids are not usually recognized as a factor for aggravation of osteoarthritis. The only exception would be secondary osteoarthritis following avascular necrosis of the joint which is well known to be associated with corticosteroid treatment. In this case, there has been no evidence of avascular necrosis. The other possibility where corticosteroids would have been a factor would be the appearance of corticosteroid-associated osteoporosis with subsequent vertebral collapse which this veteran does not appear to have. Rotator cuff tears and calcific tendonitis are not known to be associated with sarcoidosis or corticosteroid treatment. Similarly, the ulnar and median nerve release are not known to be associated with corticosteroid treatment. The Board has carefully evaluated the conflicting evidence and for reasons stated immediately below places greater weight on the opinion of the December 2002 VA examiner and the November 2006 IME opinion than it does on the November 2002 opinion of Dr. C.N.B. The Board initially notes that Dr. C.N.B. is a neuro- radiologist, as opposed to Dr. H.E.J., who was selected to provide the Board with a medical opinion given his expertise in rheumatology. See Black, supra. Further, both the December 2002 VA examiner and Dr. H.E.J. based their opinions as to the lack of a medical nexus relationship on a review of all of the Veteran's medical records, and provided reasoning which included: some of the Veteran's joint problems were traumatic in nature, other joint problems were not associated with sarcoidosis or steroid treatment for the same, and there was a significant gap in time between the Veteran's steroid treatment and development of shoulder problems. Significantly, Dr. C.N.B. did not account for these facts in rendering his opinion. The failure of Dr. C.N.B. to explain his positive medical nexus statement in light of the Veteran's entire medical history weighs against the probative value of his opinion. See Hernandez-Toyens and Bloom, both supra. In addition, Dr. C.N.B. stated that the Veteran "has no other known etiology of his early joint and tendon problems". This appears not to be true. The December 2002 examiner specifically referenced trauma to various joints. Unlike the opinion of the Dr. C.N.B., the opinions of the December 2002 VA examiner and Dr. H.E.J. are well-reasoned and draw on specific aspects from the Veteran's medical history which, as noted above, reflects that some of the Veteran's joint problems were traumatic in nature, other joint problems were not associated with sarcoidosis or steroid treatment for the same, and the significant gap in time between the Veteran's steroid treatment and development of shoulder problems. As such, the Board finds their opinions to be highly probative. In short, the opinion of Dr. C.N.B. is at odds with the remainder of the medical record. Based on the entire record, the Board gives the opinion of Dr. C.N.B. little weight of probative value. The Board has also considered medical treatise evidence submitted by the Veteran's representative in October 2005. The Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin, 11 Vet. App. at 514 (1998); see also 38 C.F.R. § 3.159(a)(1) [competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses]. While the article submitted by the Veteran's representative discusses a relationship between sarcoidosis and the bones and joints, this article contains no information or analysis specific to the Veteran's case, and does not draw upon a physical examination of the Veteran. The Court has held on several occasions that medical evidence that is speculative, general or inconclusive in nature cannot support a claim. As such, the treatise evidence submitted by the Veteran is of no probative value as to the matter of medical nexus. See generally Obert and Tirpak, both supra. The only other evidence in the claims file alleging that a medical relationship exists between the Veteran's multiple joint problems and his service-connected sarcoidosis and steroid treatment for sarcoidosis are the Veteran's statements and those of his representative. It is now well settled, however, that lay persons without medical training, such as the Veteran and his representative, are not qualified to render medical opinions regarding matters such as etiology of disease, which call for specialized medical knowledge. See Espiritu, supra; see also 38 C.F.R. § 3.159 (2008), supra. The Veteran's statements and that of his representative are accordingly lacking in probative value. Accordingly, the competent medical evidence of record does not indicate that a medical nexus exists between the Veteran's service-connected sarcoidosis and his currently diagnosed disability affecting his left elbow, left wrist, left leg, left shoulder, right shoulder and low back. Wallin element (3) has not been met, and the Veteran's claim fails on this basis. Conclusion For reasons and bases expressed above, the Board finds that a preponderance of the evidence is against the claim of entitlement to service connection for coronary artery disease and a disability affecting the left elbow, left wrist, left leg, left shoulder, right shoulder and low back on a secondary basis. Contrary to the assertions of the Veteran's representative, the benefit of the doubt rule is not for application because the evidence is not in relative equipoise. The benefit sought on appeal is denied. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for coronary artery disease, claimed as secondary to service-connected sarcoidosis and right bundle branch block, is denied. Entitlement to service connection for a disability affecting the left elbow, left wrist, left leg, left shoulder, right shoulder and low back, claimed as secondary to service- connected sarcoidosis, is denied. ____________________________________________ Barry F. Bohan Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs