Citation Nr: 1002766 Decision Date: 01/19/10 Archive Date: 02/01/10 DOCKET NO. 09-19 545 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for lymphoma (Waldenstrom's macroglobulinemia), due to ionizing radiation. 2. Entitlement to service connection for chronic renal failure, claimed as kidney damage, secondary to service- connected malaria. 3. Entitlement to an increased (compensable) evaluation for malaria. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran, spouse, and Craig Bash, MD. ATTORNEY FOR THE BOARD Christopher Maynard, Counsel INTRODUCTION The Veteran had active service from December 1943 to March 1946. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2008 decision by the RO which denied the benefits sought on appeal. A hearing before the undersigned member of the Board was held in Washington, DC in September 2009. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. All evidence necessary for adjudication of this claim have been obtained by VA. 2. The Veteran was not exposed to ionizing radiation in service. 3. The probative evidence fails to link the Veteran's lymphoma (Waldenstrom's macroglobulinemia) to radiation exposure, disease, or injury in service. 4. The Veteran does not have a kidney disorder, including chronic renal failure which is shown to be proximately due to or the result of or being aggravated by his service-connected malaria. 5. The Veteran's malaria is inactive with no current residuals. CONCLUSIONS OF LAW 1. Lymphoma, including Waldenstrom's macroglobulinemia was not incurred in or aggravated by service, nor may it be presumed to have been incurred or aggravated therein. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.311 (2009). 2. Service connection for a kidney disorder, including chronic renal failure secondary to service-connected malaria is denied. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.310 (2009). 3. The criteria for a compensable evaluation for malaria have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 4.3, 4.31, 4.88b, Part 4, Diagnostic Code 6304 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.159, 3.326; see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Prior to initial adjudication of the Veteran's claims, a letter dated in November 2007, fully satisfied the duty to notify provisions of VCAA. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). With respect to the duty to assist in this case, the Veteran's service treatment records and all medical records identified by him have been obtained and associated with the claims file. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. VA medical opinions have been obtained regarding the issues concerning malaria and kidney failure. No VA medical opinion is necessary regarding the lymphoma issue because it is predicated on the Veteran's exposure to ionizing radiation, and as will be explained below, he has failed to submit credible evidence of such exposure. Service Connection - In General Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be demonstrated either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Direct service connection requires a finding that there is a current disability that has a definite relationship with an injury or disease or some other manifestation of the disability during service. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992). Service connection for disability that is claimed to be attributable to exposure to ionizing radiation during service can be demonstrated by three different methods. Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 71 (1997). First, there are diseases that are presumptively service connected in radiation-exposed veterans under 38 U.S.C.A. § 1112(c) and 38 C.F.R. § 3.309(d). Second, service connection can be established under 38 C.F.R. § 3.303(d) with the assistance of the procedural advantages prescribed in 38 C.F.R. § 3.311, if the condition at issue is a radiogenic disease. Third, direct service connection can be established under 38 C.F.R. § 3.303(d) by showing that the disease was incurred during or aggravated by service without regard to the statutory presumptions. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). Under Combee, VA must not only determine whether a veteran had a disability recognized by VA as being etiologically related to exposure to ionizing radiation, but must also determine whether the disability was otherwise the result of active service. In other words, the fact that the requirements of a presumptive regulation are not met does not in and of itself preclude a claimant from establishing service connection by way of proof of actual direct causation. A "radiation-exposed veteran" is defined by 38 C.F.R. § 3.309(d)(3) as a veteran who while serving on active duty or on active duty for training or inactive duty training, participated in a radiation-risk activity. "Radiation-risk activity" is defined to mean: onsite participation in a test involving the atmospheric detonation of a nuclear device; the occupation of Hiroshima or Nagasaki, Japan, by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946; internment as a prisoner of war in Japan that resulted in an opportunity for exposure to ionizing radiation comparable to that of veterans who were in the occupation forces of Hiroshima or Nagasaki during the period August 6, 1945, to July 1, 1946; or certain service on the grounds of gaseous diffusion plants located in Paducah, Kentucky, Portsmouth, Ohio, and Oak Ridge, Tennessee; or, in certain circumstances, service on Amchitka Island, Alaska. See 38 C.F.R. § 3.309(d)(ii). Diseases presumptively service connected for radiation- exposed veterans under the provisions of 38 U.S.C.A. § 1112(c) and 38 C.F.R. § 3.309(d)(2) are: Leukemia (other than chronic lymphocytic leukemia), cancer of the thyroid, cancer of the breast, cancer of the pharynx, cancer of the esophagus, cancer of the stomach, cancer of the small intestine, cancer of the pancreas, multiple myeloma, lymphomas (except Hodgkin's disease), cancer of the bile ducts, cancer of the gallbladder, primary liver cancer (except cirrhosis or hepatitis B as indicated), cancer of the salivary glands, cancer of the urinary tract; bronchiolo- alveolar carcinoma; cancer of the bone; cancer of the brain; cancer of the colon; cancer of the lung; and cancer of the ovary. 38 U.S.C.A. § 1112(c)(2); 38 C.F.R. § 3.309(d). If a claimant does not qualify as a "radiation-exposed veteran" under 38 C.F.R. § 3.303(d)(3) and/or does not suffer from one of the presumptive conditions listed in 38 C.F.R. § 3.309(d)(2), the veteran may still benefit from the special development procedures provided in 38 C.F.R. § 3.311 if the veteran suffers from a radiogenic disease and claims exposure to ionizing radiation in service. Under 38 C.F.R. § 3.311, "radiogenic disease" means a disease that may be induced by ionizing radiation and shall include the following: (i) All forms of leukemia except chronic lymphatic (lymphocytic) leukemia; (ii) thyroid cancer; (iii) breast cancer; (iv) lung cancer; (v) bone cancer; (vi) liver cancer; (vii) skin cancer; (viii) esophageal cancer; (ix) stomach cancer; (x) colon cancer; (xi) pancreatic cancer; (xii) kidney cancer; (xiii) urinary bladder cancer; (xiv) salivary gland cancer; (xv) multiple myeloma; (xvi) posterior subcapsular cataracts; (xvii) nonmalignant thyroid nodular disease; (xviii) ovarian cancer; (xix) parathyroid adenoma; (xx) tumors of the brain and central nervous system; (xxi) cancer of the rectum; (xxii) lymphomas other than Hodgkin's disease; (xxiii) prostate cancer; and (xxiv) any other cancer. 38 C.F.R. § 3.311(b)(2). Section 3.311(b)(5) requires that prostate cancer and skin cancer become manifest five years or more after exposure. 38 C.F.R. § 3.311(b)(2). When a claim is based on a disease other than one of those listed in 38 C.F.R. § 3.311(b)(2), VA shall nevertheless consider the claim under the provisions of 38 C.F.R. § 3.311 provided that the claimant has cited or submitted competent scientific or medical evidence that the claimed condition is a radiogenic disease. 38 C.F.R. § 3.311(b)(4). Where a veteran served 90 days or more during a period of war or during peacetime service after December 31, 1946 and calculi of the kidney, bladder, or gallbladder, cardiovascular-renal disease, or a tumor is manifest to a compensable degree within one year from date of termination of such service, such disease shall be presumed to have been incurred in or aggravated by 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. §§ 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2009). A disorder may be service connected if the evidence of record, regardless of its date, shows that the veteran had a chronic disorder in service or during an applicable presumptive period, and that he still has such a disorder. Se 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-95 (1997). Such evidence must be medical unless it relates to a disorder that may be competently demonstrated by lay observation. Id. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). Disorders diagnosed after discharge may still be service connected if all the evidence, including pertinent service records, establishes that the disorder was incurred in service. See 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). Service connection also may be granted for a disability that is proximately due to or the result of a service-connected condition. When service connection is established for a secondary condition, the secondary condition is considered as part of the original condition. 38 C.F.R. § 3.310(a) (2009). When aggravation of a disease or injury for which service connection has not been granted is proximately due to, or the result of, a service-connected condition, the veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service- connected disease or injury, and not due to the natural progress of the disease, will be service-connected. In reaching this determination as to aggravation of a nonservice-connected disability, consideration is required as to what the competent evidence establishes as the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service- connected condition), in comparison to the medical evidence establishing the current level of severity of the nonservice- connected disease or injury. The findings as to baseline and current levels of severity, are to be based upon application of the corresponding criteria under the Schedule for Rating Disabilities (38 C.F.R. part 4) for evaluating that particular nonservice-connected disorder. 38 C.F.R. § 3.310(b) (2009). Medical evidence of a "chronic" disease should set forth the physical findings and symptomatology elicited by examination within the applicable period. See 38 C.F.R. § 3.307(b); Oris v. Derwinski, 2 Vet. App. 95, 96 (1992). A chronic disease need not be diagnosed during the presumptive period but characteristic manifestations thereof to the required degree must be shown by acceptable medical and lay evidence followed without unreasonable time lapse by definite diagnosis. 38 C.F.R. § 3.307(c); Caldwell v. Derwinski, 1 Vet. App. 466, 469 (1991). An important factor in the factual question of reasonableness in lapse of time from manifestation to diagnosis under 38 C.F.R. § 3.307(c) is the difficulty in diagnosing the disability and the strength of the evidence establishing an identity between the disease manifestations and the subsequent diagnosis. A strong evidentiary link tends to ensure the disease is not due to "intercurrent cause" as set forth in 38 C.F.R. § 3.303(b); Cook v. Brown, 4 Vet. App. 231, 238 (1993). The lapse in time from manifestation to diagnosis under 38 C.F.R. § 3.307(c) "is ultimately a question of fact for the Board to address." See Bielby v. Brown, 7 Vet. App. 260, 266 (1994). Lymphoma Initially, it should be noted that the Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, concerning the issues on appeal. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record. That is, every item of evidence does not have the same probative value. 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. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends, in essence, that his lymphoma (Waldenstrom's macroglobulinemia) was caused by exposure to ionizing radiation from the atomic bombs dropped on Hiroshima and Nagasaki on August 6 and August 9, 1945, while he was on the island of Okinawa, where he had arrived in April 1945 and departed in October 1945. The Veteran asserted that although Okinawa was hundreds of miles from Nagasaki and Hiroshima, he was, nonetheless, exposed to radiation fall-out which settled on Okinawa that was brought there by typhoons that struck the island after the detonations. At a hearing in September 2009, the Veteran recalled that he saw dust particles on rocks while on patrol on Okinawa several days after the explosions, which he believed was contaminated with ionizing radiation. He also submitted numerous articles on the subject of nuclear blasts, radiation exposure, weather conditions in the Pacific in 1945, and opinions from three physicians to the effect that his Waldenstrom's macroglobulinemia was caused by radiation exposure during service. The articles concerning nuclear blasts and radiation exposure indicated that fallout, produced from fission products and neutron-induced radionuclides in surrounding materials (i.e. water, soil, structures, nuclear device debris), is dispersed downwind with the fireball and debris cloud. As the cloud travels downwind, the cooling and falling radioactive material settles on the ground, creating a large swath of deposited material. The highest concentrations (creating the most dangerous radiation levels) falls closest to the detonation site. Radioactive fallout spreads in an irregular elliptical pattern in the direction the wind blows, with the most dangerous fallout near the explosion site within minutes of detonation, but could be carried several miles away. Fallout could potentially travel hundreds of miles, but its concentration and radiation dose decreases as it spreads and as time passes. Time, distance, and shielding are the three basic ways of protection from radiation exposure. Doubling the distance from a point source divides the dose level by four. The increased cancer risk is proportional to radiation dose. The survivors of Hiroshima and Nagasaki blasts had about a 10 percent increased risk of developing cancers over normal aged specified rates. Exposure to fallout is the most dangerous in the first few hours after the blast and decays rapidly with time. During the first hour after a nuclear explosion, radioactivity levels drop precipitously. Radioactivity levels are reduced by about 90 percent after seven hours, and by about 99 percent after two days. An example of the rapid decay of fallout from a hypothetical 10 kiloton explosion showed initial exposure rates after three hours was down to 20 percent; after eight hours, down to 10 percent and after 48 hours, was down to 1 percent. The information concerning weather conditions in the Pacific in 1945, from Western Pacific Hurricane Tracking Data, provided detailed descriptions of the various storms in the Western Pacific, including the specific dates, maximum wind conditions, and tracking (longitude/latitude) of the tropical storms and typhoons. The Veteran highlighted three specific storms, identified as Typhoons 14, 18, and 23, that he believed supported his claim that fallout from the nuclear blasts was carried to Okinawa. Typhoon 14 lasted from August 22 to 28, 1945. Typhoon 18 was from September 10 to 20, 1945, and Typhoon 23 was from October 2, to 20, 1945. Contrary to the Veteran's assertions, however, the storms did not track from the main island of Japan toward Okinawa, but in the opposite direction. That is, the three typhoons identified by the Veteran, including another typhoon (#13, which followed a similar path as #14), formed several hundred miles south and east of Okinawa (which the Veteran acknowledged is nearly 400 miles south of Nagasaki) and traveled primarily in a north and westerly direction toward the main island of Japan. While two of the typhoons (#'s 18 and 23) passed directly over Okinawa, both storms were moving toward the main island of Japan and away from Okinawa, and occurred more than a month after the atomic bombs were dropped. The third typhoon (#14), passed several hundred miles east of Okinawa, before turning north toward the main island of Japan. Thus, the basic premise of the Veteran's claim, that Okinawa was downwind of Nagasaki and Hiroshima, is not supported by the evidence of record. Furthermore, the first storms (numbered 13 and 14) occurred between 22 and 28 August 1945, weeks after the detonation in Hiroshima and Nagasaki. Thus, the evidence does not show the Veteran participated in a radiation risk activity, nor does any competent evidence show the veteran was exposed to ionizing radiation in service. The only evidence supporting such exposure is the Veteran's assertion. He is not competent to establish that fact. The evidentiary record includes opinions from three private physicians to the effect that the Veteran's lymphoma was caused by ionized radiation exposure while serving in the Pacific when the bombs were dropped on Hiroshima and Nagasaki. One private physician, Dr. L. S. Lessin, stated that ionizing radiation was well established as a causative factor in the development of non-Hodgkin's lymphoma, and opined that the Veteran's lymphoma was at least as likely as not related to his radiation exposure in service. However, the physician, like the Veteran, is not shown to have any expertise in ascertaining whether the Veteran was exposed to fallout from the atomic blasts over Hiroshima and Nagasaki. He simply assumes that fact in offering his medical opinion. Since the evidence does not establish that fact, his favorable medical opinion carries no evidentiary weight relating to the question of service connection. Another physician, Dr. A. M. Gordon, noted that radioactive fallout from the atomic blasts was carried downwind and contaminated drinking water and surrounding areas outside of the immediate blast area. This does not establish the Veteran's exposure to ionizing radiation, or even meaningfully address his exposure. Dr. Gordon included a discussion of the origins of Waldenstrom's macroglobulinemia and noted that it affects approximately 1500 people in the U.S. yearly, with a higher incidence in white males, (which describes the Veteran). The median age at diagnosis was 63 years. Dr. Gordon also stated that the pathogenic mechanisms of the disease process was not well understood, but that they were similar to those in myeloma, and that exposure to ionizing radiation was the strongest single factor linked to increased risk of myeloma, (which only tangentially addresses the cause of the Veteran's particular disease). The third physician, Dr. C. N. Bash, stated that the jet stream in the Western Pacific "often runs in a north to south direction at speeds of up to 200 miles an hour," and that it would have taken only three to four hours for fallout to reach Okinawa. While the medical credentials of Dr. Bash are not in question, he is not shown to posses any expertise concerning fallout rates or in the field of meteorology. Moreover, his assertions that Okinawa was downwind from the point of the atomic detonations appears contradicted by the Western Pacific Hurricane Tracking Data information provided by the Veteran. Thus, any assertion by Dr. Bash that the Veteran was exposed to ionizing radiation while on Okinawa carries no weight. In this regard, Dr. Bash also referred to an "e-mail" from a physicist to the effect that Okinawa received levels of fallout similar to all of Japan during the month of August 1945. Dr. Bash did not provide the document he stated asserted this fact, and in its absence his report as to its content carries no weight. In essence, there has been no evidence received from a competent source that the Veteran was exposed to ionizing radiation during service. The weather data he provided shows weather patterns originated south and/or east of Okinawa and traveled primarily in a north and westerly direction toward the main island of Japan and the Asia continent, i.e., away from Okinawa. Further, the Veteran's recent recollection of observing dust settling on flat surfaces in August 1945, is on its face, improbable, but nevertheless in no way establishes it as fallout from the atomic blasts. As to the private medical opinions, as indicated above, their conclusions are premised on the Veteran's exposure to ionizing radiation in service. They either do not offer an independent analysis and conclusion regarding the question of his exposure, or lack the credentials to do so. Further, a diagnosis or opinion by a health care professional is not conclusive or entitled to absolute deference. Indeed, the Court has provided guidance for weighing medical evidence. For example, in Bloom v. West, 12 Vet. App. 185, 187 (1999), the Court held that a medical opinion, based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. See also, Miler v. West, 11 Vet. App. 345, 348 (1998), (A bare conclusion, even when reached by a health care profession is not probative without a factual predicate in the record.) Given the facts in this case, the Board finds that the private medical opinions are speculative at best. The Veteran does not claim nor do the service records show that he was involved in atmospheric testing or was assigned duty as an occupying force in Hiroshima or Nagasaki at anytime in service. Rather, he contends that he was exposed to ionizing radiation from nuclear fall-out carried to Okinawa by tropical storms subsequent to the explosions. While the service records showed that the Veteran was stationed on Okinawa from April to October 1945, there is no competent evidence that he was exposed to ionized radiation from nuclear fall-out. As the Veteran did not participate in a radiation-risk activity during service, he is not a "radiation-exposed veteran" as defined by 38 C.F.R. § 3.309(d)(3). In the absence of competent evidence establishing that the Veteran was exposed to ionizing radiation, the claim is not required to be forwarded to the Under Secretary for Benefits. Wandel v. West, 11 Vet. App. 200 (1998). Thus, service connection for lymphoma may not be granted based upon the application of 38 C.F.R. § 3.311. Notwithstanding the foregoing, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has determined that a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). In order to prevail on the issue of service connection, there must be medical evidence of a current disability; medical, or in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed inservice disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999). In this regard, the Veteran's service treatment records are negative for any complaints, treatment, abnormalities, or diagnosis for any blood disorder or lymphoma, including Waldenstrom's macroglobulinemia in service or until 2000, some 54 years after service. Private medical records show that the Veteran has been treated for his hematologic problem since 2000. The favorable evidence in this case consists of the three private medical opinions discussed above. While the three physicians attributed the Veteran's lymphoma to radiation exposure in service, they did not provide any credible support for finding such exposure occurred, rendering any such opinion speculative, at best. The Board notes that medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Accordingly, the Board finds that the medical opinions do not provide a basis for service connection. As there is no credible evidence of a link between the Veteran's lymphoma and service, or any manifestations until several decades after discharge from service, there is no basis for a favorable disposition of the Veteran's appeal. Accordingly, the appeal is denied. Kidney Disorder The Veteran contends that he took atabrine for almost two years for the suppression of malaria when he was overseas in service, and that he finally succumbed to the disease several months after returning to the United States in 1946. He asserts that it is reasonable to assume that the malaria parasites had plenty of time to lodge in his kidneys, and believes that his current problems, including chronic renal failure, is due to his service-connected malaria. The Veteran indicated that he was not sure when his right kidney failed because he has normal function of the left kidney, and that he first learned of his right renal failure in 2006. In this case, the service treatment records, including his service separation examination in March 1946, were negative for any signs or symptoms of a kidney disorder. Laboratory studies at the time of his service separation examination were negative, and his genitourinary system was normal. The first evidence of any kidney problem, diagnosed as history of hydronephrosis with chronic, totally obstructed, nonfunctional right kidney was noted on a private medical report, dated in August 2007. At the personal hearing and in a letter dated in December 2009, Dr. Bash opined that the Veteran's kidney problem was most likely the result of medications and treatment he receives for his lymphoma. He also indicated that the Veteran had a recent relapse of malaria and that his current kidney problems could also be related, in part, to his service-connected malaria. When examined by VA in June 2008, the examiner indicated that the claims file was reviewed and included a detailed description of the Veteran's medical history. The examiner noted that the Veteran's malaria in 1946, was a benign tertian type due to Plasmodium Vivax, a parasite that rarely causes acute tubular necrosis. All other diagnostic and laboratory findings in service were negative and showed no evidence of renal failure or other kidney abnormalities. Although the Veteran reported that he had a relapse of malaria in March 2008, the examiner indicated that there was no evidence of any medical treatment or documentation showing a relapse of malaria at anytime since his discharge from service. It was also noted that blood studies as recent as 2000, were essentially within normal limits and showed no evidence of a kidney disorder or renal failure. The examiner opined that the Veteran's current kidney problems were not due to malaria or to any treatment for that disorder in service. Concerning Dr. Bash's opinion, the Board notes that while Dr. Bash asserted that the Veteran had a recent relapse of malaria and opined that his current kidney problems could be due, in part, to his longstanding Plasmodium Vivax, he offered no evidence or pointed to any specific treatment record to support his assertions. Although the Dr. Bash indicated that he had reviewed the Veteran's claims file, he offer no explanation for the absence of any treatment, abnormalities, or diagnostic evidence of active malaria since the Veteran's discharge from service, or of any kidney problems until nearly 60 years after service. Furthermore, the Board notes that the private physician who has been treating the Veteran for his lymphoma since 2000, considered the Veteran's assertion that he had a recent relapse of malaria in March 2008, but opined that the single episode of night sweats was unlikely due to relapsing malaria, and advised the Veteran to come in for a blood smear the next time he experienced any night sweats or other symptoms. (See April 2008 report from Dr. L. S. Lessin). In this case, the Board finds the VA opinion persuasive, as it was based on a thorough review of all of the evidence of record. The examiner included a detailed discussion of all relevant facts, and offered a rational and plausible explanation for concluding that the Veteran's current kidney problems and renal failure were not related in any way to the service-connected malaria. See Wray v. Brown, 7 Vet. App. 488, 493 (1995); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.). While the Veteran believes that his kidney problem, including chronic renal failure is related to his service-connected malaria, he has not presented any competent evidence to support his assertion. Where a determinative issue involves medical causation, competent medical evidence is required. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). While the Veteran is competent to provide evidence of experienced symptoms, he is not a medical professional competent to offer an opinion as to the nature or etiology of any claimed disability. Savage v. Gober, 10 Vet. App. 488, 495 (1997); see Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Direct service connection requires a finding that there is a current disability that has a definite relationship with an injury or disease or some other manifestation of the disability during service. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992). This has not occurred in this case. As to the opinion by Dr. Bash that the Veteran's current kidney problems were related to the medications taken for his lymphoma, the Board notes that the provisions of 38 C.F.R. § 3.310 apply only to service connection for secondary disabilities caused by a service-connected disability. In this case, service connection for lymphoma has been denied. Accordingly, there is no legal basis of entitlement to secondary service connection for a kidney disorder because the Veteran has not been granted service connection for the disability which he claims caused his renal failure. Therefore, with respect to any claim of secondary service connection, application of the law to the facts is dispositive, and the appeal must be terminated because there is no entitlement under the law to the benefit sought. See Sabonis v. Brown, 6 Vet. App. 426, 429-30 (1994). Based on the discussion above, the Board finds no basis for a favorable disposition of the Veteran's appeal. In reaching this decision, the Board considered the doctrine of reasonable doubt, but as the preponderance of the evidence is against the claim, the doctrine is not for application. Increased Rating Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The Veteran is currently assigned a noncompensable evaluation for malaria under Diagnostic Code (DC) 6304, which provides for a 100 percent evaluation for active malaria. The accompanying Note states that the diagnosis of malaria depends on the identification of the malarial parasites in blood smears. If the veteran served in an endemic area and presents signs and symptoms compatible with malaria, the diagnosis may be based on clinical grounds alone. Relapses must be confirmed by the presence of malarial parasites in blood smears. Thereafter rate residuals such as liver or spleen damage under the appropriate system. 38 C.F.R. § 4.88b, DC 6304 (2009). In this case, while the Veteran believes that he is entitled to a compensable evaluation for residuals of malaria, there is no medical evidence to support that assertion. None of the numerous medical reports of record make any mention of malaria other than by way of history since 1946, and anemia has not been noted. Similarly, there has been no indication of required hospital treatment, cerebral symptoms, enlarged spleen, abnormal liver, anemia, or like symptoms which are shown to be related to malaria. The Board notes that while the Veteran is shown to have additional disabilities, including biliary obstruction and essential hypertension, these problems are associated with the nonservice-connected lymphoma and/or medications taken for treatment of that disorder. While a lay witness can testify as to the visible symptoms or manifestations of a disease or disability, his or her belief as to its current severity under pertinent rating criteria or the nature of the service-connected pathology is not probative evidence because only someone qualified by knowledge, training, expertise, skill, or education, which the Veteran is not shown to possess, may provide evidence requiring medical knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994); Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). Based on the evidence of record, the Board finds that a compensable rating for malaria is not warranted. The record does not contain competent medical evidence that the Veteran has active malaria or any ascertainable residuals of malaria such as liver or spleen damage. All of the medical evidence associated with the claims file during the pendency of this appeal have failed to reveal any signs, symptoms or residuals of malaria. As there is no medical evidence of active disease or any residual disability, there is no basis to award a compensable rating. In light of the discussion above, the Board finds that the noncompensable evaluation assigned for the Veteran's malaria accurately depicts the severity of the condition for the entirety of the rating period on appeal, and there is no basis for higher staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Finally, the United States Court of Appeals for Veterans Claims (Court) has acknowledged that the Board cannot assign an extraschedular rating in the first instance, but found that the Board must specifically adjudicate whether to refer a case for such an evaluation when the issue is either raised by the claimant or is reasonably raised by the evidence of record. See Barringer v. Peake, 22 Vet. App. 242 (2008). Accordingly, the Board has considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extraschedular consideration under 38 C.F.R. § 3.321(b)(1) (2009). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the veteran's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. In this regard, the Veteran is not shown to have active malaria or any residuals thereof at anytime during the pendency of this appeal. Therefore, referral of this case for extraschedular consideration is not in order. See Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). ORDER Service connection for lymphoma (Waldenstrom's macroglobulinemia), is denied. Service connection for chronic renal failure, claimed as kidney damage, secondary to service-connected malaria is denied. An increased rating for malaria is denied. ____________________________________________ MICHAEL KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs