Citation Nr: 1035239 Decision Date: 09/17/10 Archive Date: 09/21/10 DOCKET NO. 02-15 138A ) DATE ) ) On appeal from the U.S. Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for residuals of a back injury. 2. Entitlement to service connection for cardiovascular disease, to include hypertension, coronary artery disease (CAD), and residuals of rheumatic heart disease. REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Attorney WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Thomas A. Pluta, Counsel INTRODUCTION The Veteran had active service from September 1960 to November 1963. This appeal to the Board of Veterans Appeals (Board) arises from a February 2002 rating action that denied service connection for residuals of a back injury and for cardiovascular disease. In October 2002, the Veteran testified at a hearing before a decision review officer at the RO. In February 2004, he testified at a Board hearing before the undersigned Veterans Law Judge (VLJ) in Washington, D.C. In April 2004, the undersigned VLJ granted the veteran's March 2004 motion to advance this case on the Board's docket pursuant to the provisions of 38 U.S.C.A. § 7107(a)(2) (West 2002) and 38 C.F.R. § 20.900(c). By decisions of May 2004, June 2006, and December 2007, the Board remanded the issues on appeal to the RO for further development of the evidence and for due process development. By decision of July 2008, the Board denied service connection for residuals of a back injury and for cardiovascular disease. The appellant appealed the denials to the U.S. Court of Appeals for Veterans Claims (Court). By June 2009 Order, the Court vacated the Board's July 2008 decision and remanded the matter to the Board for compliance with instructions contained in a June 2009 Joint Motion for Remand of the appellant and the VA Secretary. By decision of February 2010, the Board remanded the issues on appeal to the RO for further development of the evidence and for due process development. The issue of service connection for residuals of a back injury is addressed in the REMAND portion of the decision below, and is REMANDED to the RO. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim for service connection for cardiovascular disease on appeal has, to the extent possible, been accomplished. 2. A chronic cardiovascular disease, to include hypertension and CAD, was not shown present in service or for several years thereafter, and the most persuasive, competent medical evidence establishes no nexus between any such current cardiovascular disease and the veteran's military service or any incident thereof. 3. According to competent medical opinions, the Veteran does not currently have a heart murmur or residuals of pre-service rheumatic fever or rheumatic heart disease. CONCLUSION OF LAW The criteria for service connection for cardiovascular disease, to include hypertension, CAD, and residuals of rheumatic fever or rheumatic heart disease, are not met. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113, 1131, 1137, 1153, 5103, 5103A. 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303(d), 3.304, 3.306, 3.307, 3.309, 4.104 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) (See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2009)) essentially includes, upon the submission of a substantially-complete application for benefits, an enhanced duty on the part of the VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify him what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, it defines the obligation of the VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). Considering the record in light of the above criteria, the Board finds that all notification and development action needed to render a fair decision on the claim for service connection for cardiovascular disease on appeal has, to the extent possible, been accomplished. September 2001 pre-rating and a May 2004 post-rating RO letters informed the Veteran of the VA's responsibilities to notify and assist him in his claims, and what was needed to establish entitlement to service connection. Thereafter, he was afforded opportunities to respond. The Board thus finds that the Veteran has received sufficient notice of the information and evidence needed to support his claims, and has been provided ample opportunity to submit such information and evidence. Additionally, those RO letters provided notice that the VA would make reasonable efforts to help the Veteran get evidence necessary to support his claims, such as medical records (including private medical records), if he gave it enough information, and if needed, authorization to obtain them. Those letters further specified what evidence the VA was responsible for obtaining, to include Federal records, and the type of evidence that the VA would make reasonable efforts to get. The Board thus finds that those letters collectively satisfy the statutory and regulatory requirement that the VA notify a claimant what evidence, if any, will be obtained by him and what evidence will be retrieved by the VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). In the decision of Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that proper VCAA notice should notify a veteran of: (1) the evidence that is needed to substantiate a claim; (2) the evidence, if any, to be obtained by the VA; and (3) the evidence, if any, to be provided by him. As indicated above, all 3 content of notice requirements have been met in this appeal. Pelegrini also held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided at the time that, or immediately after, the VA Secretary receives a complete or substantially complete application for VA-administered benefits. In that case, the Court determined that the VA had failed to demonstrate that a lack of such pre-adjudication notice was not prejudicial to the claimant. In the service connection matter now before the Board, the September 2001 document fully meeting the VCAA's notice requirements was furnished to the Veteran before the February 2002 rating action on appeal. More recently, in March 2006, during the pendency of this appeal, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all 5 elements of a service connection claim (veteran status, the existence of a disability, a connection between the veteran's service and that disability, the degree of disability, and the effective date pertaining thereto). In this case, the veteran's status and the degree of disability are not at issue, and he was furnished notice pertaining to the effective date information in a December 2007 RO letter, thus meeting the notice requirements of Dingess/Hartman. Additionally, the Board finds that all necessary development on the claim for service connection for cardiovascular disease currently under consideration has, to the extent possible, been accomplished. The RO, on its own initiative and pursuant to the Board remands, has made reasonable and appropriate efforts to assist the appellant in obtaining all evidence necessary to substantiate his claim, to include obtaining all available service medical, administrative, and personnel records, and post- service VA and private medical records up to 2010. In view of the apparent unavailability of some service medical records, the RO by letter of May 2004 notified the Veteran of alternate sources of records and forms of evidence to support his claim, and undertook comprehensive attempts to search alternate and secondary military record sources. In 2002, affidavits were received from a service comrade and the veteran's nephew attesting to pertinent facts with respect to the veteran's claimed disabilities in service and shortly after separation therefrom, respectively. In January 2003, November 2004, and March 2007, the National Personnel Records Center stated that no additional service medical records could be located. In May 2004, the U.S. Naval Reserve Personnel Center in New Orleans, Louisiana stated that no documents pertaining to the Veteran were available at that facility. In July 2006, the U.S. Department of the Air Force at Andrews Air Force Base, Maryland stated that no records pertaining to the Veteran were available at that facility. A copy of the July 1996 Social Security Administration decision awarding the Veteran disability benefits, together with the medical records underlying that determination, have been associated with the record. Transcripts of the veteran's October 2002 RO and February 2004 Board hearing testimonies have been associated with the claims folder and considered in adjudicating this claim. The Veteran was afforded comprehensive VA examinations in June 2004 (with June and July 2005 addenda), June 2007, January 2008, and March 2010 (with a May 2010 addendum). Significantly, the Veteran has not identified, nor does the record otherwise indicate, any existing, pertinent evidence, in addition to that noted above, that has not been obtained. In March 2006, the Veteran stated that he had no additional evidence or information to submit in connection with his claim. The record also presents no basis for further development to create any additional evidence to be considered in connection with the matter currently under consideration. At the 2002 RO and 2004 Board hearings, the Veteran testified that records of private physicians who reportedly treated him for his claimed disabilities shortly after separation from service were unavailable, as those doctors had died. Under these circumstances, the Board finds that the Veteran is not prejudiced by appellate consideration of the claim for service connection for cardiovascular disease on appeal at this juncture, without directing or accomplishing any additional notification and/or development action. II. Analysis Under the applicable criteria, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131. Such a determination requires a finding of a current disability that is related to an injury or disease incurred in service. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Where a veteran served continuously for 90 days or more during a period of war or during peacetime service after 31 December 1946 and cardiovascular disease, including essential hypertension, becomes manifest to a degree of 10% within 1 year from the date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of it during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Hypertension or isolated systolic hypertension must be confirmed by readings taken 2 or more times on at least 3 different days. The term hypertension means that diastolic blood pressure is predominantly 90 mm. or greater, and isolated systolic hypertension means that systolic blood pressure is predominantly 160 mm. or greater with diastolic blood pressure of less than 90 mm. 38 C.F.R. § 4.104, Diagnostic Code 7101. A veteran is considered to be in sound health when examined, accepted, and enrolled for service - except as to defects, infirmities, or disorders noted at the time of entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior to service, and was not aggravated by such service. See 38 U.S.C.A. § 1111. In precedent opinion VAOPGCPREC 3-2003, the VA General Counsel (VAGC) discussed the requirements for rebutting the presumption of sound condition when entering military service under 38 U.S.C.A. § 1111 and 38 C.F.R. § 3.304. The VAGC held that, to rebut the presumption of sound condition under 38 U.S.C.A. § 1111, the VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service, and that it was not aggravated by service. The veteran claimant is not required to show that the disease or injury increased in severity during service before the VA's duty under the second prong of this rebuttal standard attaches. (The provisions of 38 C.F.R. § 3.304 were later amended and are now consistent with 38 U.S.C.A. § 1111.) The VAGC also held that the provisions of 38 C.F.R. § 3.306(b), providing that aggravation may not be conceded unless the pre- existing condition increased in severity during service, are not inconsistent with 38 U.S.C.A. § 1111. 38 C.F.R. § 3.306(b) properly implements 38 U.S.C.A. § 1153, which provides that a pre-existing injury or disease will be presumed to have been aggravated in service in cases where there was an increase in disability during service. The requirement of an increase in disability in 38 C.F.R. § 3.306(b) applies only to determinations concerning the presumption of aggravation under 38 U.S.C.A. § 1153, and does not apply to determinations concerning the presumption of sound condition under 38 U.S.C.A. § 1111. 38 U.S.C.A. § 1111 requires the VA to bear the burden of showing the absence of aggravation. A pre-existing injury or disease will be considered to have been aggravated by service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Where the evidence shows that there was an increase in disability during service, there is a presumption that the disability was aggravated by service. In order to rebut the presumption of aggravation, there must be clear and unmistakable evidence (obvious or manifest) that the increase in severity was due to the natural progress of the disability. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. See Wagner v. Principi, 370 F. 3d 1089, 1097 (Fed. Cir. 2004). There is no aggravation of a pre-existing disease or injury if the condition underwent no increase in severity during service on the basis of all of the evidence of record pertinent to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, will not be considered service connected unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1). Intermittent or temporary flare-ups during service of a pre-existing injury or disease do not constitute aggravation; rather, the underlying condition, as contrasted with symptoms, must have worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Accordingly, a lasting worsening of the condition - i.e., a worsening that existed not only at the time of separation, but one that still exists currently - is required. See Routen v. Brown, 10 Vet. App. 183, 189 (1997); see also Verdon v. Brown, 8 Vet. App. 529, 538 (1996). The Veteran contends that cardiovascular disease, including hypertension, CAD, and residuals of rheumatic fever or rheumatic heart disease, either had its onset in service or, if pre- existing service, was aggravated thereby. He presented hearing testimony to that effect at the RO in October 2002 and at the Board in February 2004. In this case, the available service medical records are negative for findings or diagnoses of any cardiovascular disease, including hypertension. On November 1959 pre-service examination for enlistment for Reserve service, the Veteran denied a history of shortness of breath, pain or pressure in the chest, palpitation or a pounding heart, and high or low blood pressure. The vascular system was normal on examination, and a blood pressure reading of 136/82 was recorded. Examination of the heart showed a soft grade I systolic apical murmur which was not transmitted and which disappeared with exercise and forced breathing. This was not considered disabling or disqualifying, and the Veteran was found physically qualified for military duty. On September 1960 examination for entry into active service, the Veteran denied a history of shortness of breath, pain or pressure in the chest, palpitation or a pounding heart, and high or low blood pressure. The heart and vascular system were normal on examination, and a blood pressure reading of 132/78 was recorded. The Veteran was found physically qualified for active service. On September 1963 separation examination, the heart and vascular system were normal, and blood pressure readings of 140/76 and 148/70 were recorded. The first evidence of cardiovascular disease appears to be the hypertension for which P. L., M.D.,'s April 1996 medical report and the June 2005 VA medical report indicate the Veteran began treatment in 1966, some 3 years following separation from service. The evidence of the onset of treatment post service is corroborated by the veteran's own statements in his February 2001 claim for VA compensation benefits that he began treatment for high blood pressure in December 1963, and for hypertension in 1966, as well as his nephew's October 2002 affidavit attesting to his knowledge that the Veteran took medication for high blood pressure at some indeterminate time following separation from service. In July 1985, J. C., M.D., noted a history of hypertension since 1975, some 12 years post service. In July 1993, the Veteran underwent coronary artery bypass grafting at the Fairfax Hospital after the recent onset of angina pectoris; June 1993 cardiac catheterization showed a 90% stenosis in the left anterior descending coronary artery and a significant lesion in the right coronary artery. The diagnoses included atherosclerotic coronary artery occlusive disease, recent onset angina pectoris, ventricular arrhythmia, and hypertension, but there was no opinion relating any such diagnosed cardiovascular disease to the veteran's military service or any incident thereof. In April 2002, A. K., M.D., noted the veteran's longstanding lifetime history of hypertension, hyperlipidemia, and ventricular arrhythmias, but there was no opinion relating any such diagnosed cardiovascular disease to the veteran's military service or any incident thereof. On June 2004 VA examination, the physician noted that the Veteran had been hypertensive for many years and also had significant CAD. In a June 2005 addendum to the 2004 examination report, the doctor noted the veteran's history of rheumatic fever, a heart murmur, and elevated blood pressure prior to service, that he was not treated for his blood pressure in service, and that he was first treated for hypertension in 1966, some 3 years post service. However, in the absence of service medical records for review, the examiner stated that it was impossible to state whether or not military service worsened the veteran's hypertension. The physician stated that the Veteran developed arteriosclerotic heart disease in the 1970s along with atrial fibrillation, which the Board notes is not evidence of the inservice onset of such cardiovascular disease. In a subsequent July 2005 statement, the doctor stated that additional comment was not possible in the absence of pertinent records for review. After June 2007 VA examination wherein another physician reviewed the claims folder and the veteran's history of elevated blood pressure prior to service and a diagnosis of CAD in the 1980s, service medical records showing a blood pressure reading of 148/70 in September 1963 and no mention of hypertension, and current examination of the Veteran, the diagnoses included hypertension which by the veteran's history pre-dated his military service, and CAD which began in the 1980s, and the doctor opined that it was not likely that the CAD was related to military service. In January 2008, the Veteran was again examined by the same VA physician who previously examined him in June 2004. After a review of the claims folder including the veteran's history of rheumatic heart disease as a child and documentation of a heart murmur on 1959 Reserve service enlistment examination, and current examination of the Veteran, the examiner noted that it was impossible to state whether the murmur worsened during his military service, because no specific tests such as an electrocardiogram were done; however, he did opine that the heart murmur was not a significant factor in the veteran's cardiovascular disease picture. He also opined that there was no evidence that the veteran's reported childhood rheumatic heart disease worsened during his military service. With respect to hypertension, the doctor noted the lack of hard facts documented in the records, with only anecdotal evidence from the veteran's history indicating pre-service hypertension, and elevated blood pressure at the time of service discharge, but no evidence of treatment of hypertension in military service. The physician opined that it was impossible to state with any clarity whether symptoms of rapid heartbeat and flushing 45 years previously were due to hypertension. The doctor also noted the onset of CAD in the 1970s, and that there was no evidence that the Veteran had CAD in military service. On March 2010 VA examination, a physician who had not previously examined the Veteran reviewed his medical records and claims folder, noting that he had been found intermittently on routine testing to have slightly high blood pressure, and that he had been formally diagnosed and treatment begun in approximately the early 1970s. Also noted was a history of rheumatic fever in the 1940s, prior to entrance into military service, for which he reportedly stayed in bed for 2 months. After current examination including a chest X-ray, and reviews of an August 2007 echocardiogram and a September 2009 stress test, the diagnosis was hypertension. Noting that the formal diagnosis of hypertension was based on the average of at least 3 blood pressure readings, and after reviewing the blood pressure readings recorded in the veteran's service medical records, the doctor opined that the average did not meet the criteria for hypertension. In view of the unavailability of some service medical records or a record of the veteran's blood pressure readings in the years immediately following his discharge from service, the physician stated that she could not render opinions as to whether any currently-diagnosed cardiovascular disease had its onset in military service, or whether any cardiovascular disease found to have existed prior to service increased in severity during service without resorting to mere speculation. In a May 2010 addendum to her March 2010 examination report, the VA physician noted that isolated systolic and diastolic hypertension was considered to be present when blood pressure was 140/90, and opined that the Veteran currently had hypertension. She reiterated that the formal diagnosis of hypertension was based on the average of at least 3 blood pressure readings, and, after reviewing the blood pressure readings recorded in the veteran's service medical records, opined that the average of his inservice blood pressures did not meet the criteria for hypertension. Therefore, she opined that it was less than likely that any currently-diagnosed cardiovascular disease including hypertension had its onset in military service. With respect to the veteran's history of rheumatic fever prior to military service, the doctor opined that it left no sequelae and did not increase in severity during service, as evidenced by 1991 echocardiogram results showing a normal ejection fraction and no valvular defects or abnormality. With respect to the veteran's CAD, the examiner noted that 2 episodes of CAD occurred in 1993 and 2004, after the Veteran left military service, and opined that it bore no relationship to service, as there were no complaints or findings during service. Having reviewed the complete record, the Board finds that the most persuasive, competent medical evidence reveals that chronic cardiovascular disease, including hypertension and CAD, was first manifested more than 1 year post service, and that there is no relationship between any such disabilities and the veteran's military service or any incident thereof, including any pre- service rheumatic fever, rheumatic heart disease, or heart murmur. As noted above, Dr. P. L. in April 1996 and the June 2005 VA medical report indicated that the Veteran first began treatment for hypertension in 1966, some 3 years following separation from service. The Veteran corroborated the post- service onset of hypertension in his February 2001 claim for VA compensation benefits, variously noting that he began treatment for high blood pressure in December 1963 and for hypertension in 1966, and his nephew in an October 2002 affidavit attested to his knowledge that the Veteran took medication for high blood pressure at some indeterminate time following separation from service. In June 2007, a VA physician noted that the veteran's CAD began in the 1980s, and opined that it was not likely that it was related to his military service. In January 2008, a VA physician noted the onset of CAD in the 1970s, and opined that there was no evidence that the Veteran had CAD in military service. In March 2010, a VA physician noted that the formal diagnosis of hypertension was based on the average of at least 3 blood pressure readings, and after reviewing the blood pressure readings recorded in the veteran's service medical records, she opined that the average did not meet the criteria for hypertension. In a May 2010 addendum to her March 2010 examination report, the VA physician reiterated that the formal diagnosis of hypertension was based on the average of at least 3 blood pressure readings, and, after reviewing the blood pressure readings recorded in the veteran's service medical records, opined that the average of his inservice blood pressures did not meet the criteria for hypertension. Therefore, she opined that it was less than likely that any currently-diagnosed cardiovascular disease including hypertension had its onset in military service. With respect to the veteran's CAD, the VA physician in May 2010 noted that 2 episodes of CAD occurred in 1993 and 2004, after the Veteran left military service, and opined that it bore no relationship to service, as there were no complaints or findings during service. Although in June 2007 a VA examiner diagnosed hypertension which by the veteran's history pre-dated his military service, the Board finds that this is not persuasive evidence of the pre- service existence of hypertension. The Board notes that this diagnosis is based on an inaccurate factual premise, i.e., the erroneous assumption that the Veteran had hypertension prior to service. Thus, that inaccurate history is not a reliable indicator of a pre-service etiology of his current hypertension. The VA is not required to accept medical opinions that are based upon an appellant's recitation of medical history. Godfrey v. Brown, 8 Vet. App. 113, 121 (1995). As a medical opinion can be no better than the facts alleged by a Veteran, an opinion based on an inaccurate factual premise has no probative value. See Reonal v. Brown, 5 Vet. App. 460, 461 (1993); Swann v. Brown, 5 Vet. App. 229, 233 (1993); Black v. Brown, 5 Vet. App. 179, 180 (1993). On the basis of the lack of hard facts documented in the available records, a VA physician in January 2008 noted that there was no evidence of treatment of the Veteran for hypertension in military service, and he opined that there was only anecdotal evidence from the veteran's history indicating pre-service hypertension. Thus, the Board finds that the June 2007 diagnosis of pre-existing hypertension does not provide persuasive support for the Veteran's claim for service connection for that cardiovascular disability. Rather, the Board finds that the more persuasive post-service medical evidence from April 1996, June 2005, and March and May 2010, noted above, shows the onset of hypertension several years post-service. See Nieves- Rodrigues v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims folder was reviewed). See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (the probative value of medical evidence is based on an examiner's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). With respect to the findings and medical notations of rheumatic fever, rheumatic heart disease, and a heart murmur, the Board notes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. § 1110. Where, as here, the competent evidence consisting of numerous post-service medical records does not show the current existence of a heart murmur or chronic residuals of rheumatic fever or rheumatic heart disease for which service connection is sought (and hence, no evidence of a nexus between any such disability and service), there can be no valid claim for service connection. See Gilpin v. West, 155 F. 3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Although a heart murmur was found on one occasion on 1959 pre-service examination for enlistment for Reserve service, this abnormality was not considered a disabling or disqualifying disability at that time, and was never again objectively demonstrated in numerous subsequent service and post-service medical records from 1960 to 2010. In January 2008, a VA physician noted the documentation of a heart murmur on the veteran's 1959 military examination report, and after current examination of the Veteran, opined that such heart murmur was not a significant factor in the veteran's current cardiovascular disease picture, and that there was no evidence that his reported childhood rheumatic heart disease worsened during his military service. With respect to the veteran's history of rheumatic fever prior to military service, a VA physician in May 2010 opined that it left no sequelae and did not increase in severity during service, as evidenced by 1991 echocardiogram results showing a normal ejection fraction and no valvular defects or abnormality. In the absence of current medical evidence of a heart murmur or chronic residuals of rheumatic fever or rheumatic heart disease, the Board finds that service connection for any such cardiovascular disorder not warranted. In addition to the medical evidence, the Board has considered the veteran's assertions and testimony; however, such does not provide a reliable basis for allowance of a claim for any cardiovascular disease. While the Veteran may believe that he currently has a cardiovascular disability including hypertension that is related to his military service, the most persuasive, competent medical evidence, noted above, weighs against that conclusion. The Board emphasizes that the appellant is competent to offer evidence as to facts within his personal knowledge, such as his own symptoms. However, medical questions of diagnosis and etiology are within the province of trained medical professionals. Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As a layman without the appropriate medical training or expertise, the appellant simply is not competent to render an opinion on such medical matters. See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) (a layman is generally not capable of opining on matters requiring medical knowledge). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) the layman is competent to identify the medical condition; (2) the layman is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (Fed. Cir. 2007). An appellant is competent to testify to factual matters of which he had first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Board cannot disregard an appellant's testimony without assessing its credibility concerning his symptoms or articulating an adequate basis for failing to assess his credibility. Id.; see Buchanan v. Nicholson, 451 F. 3d 1331, 1337 (Fed. Cir. 2006) (the Board cannot find that lay evidence lacks credibility merely because it is not accompanied by contemporaneous medical evidence). In October 2002, the Veteran testified that he was informed that he had high blood pressure on numerous occasions during visits to sick bay in military service, but the Board finds that this is not a reliable indicator of the onset of chronic hypertension in service, when viewed in the context of all the evidence of record, which shows inconsistencies that diminish the reliability of the veteran's recollections as to the date of onset of hypertension. While claimants are competent to testify to a contemporaneous medical diagnosis, as noted above, the available contemporaneous service medical records are negative for findings or diagnoses of any cardiovascular disease, including hypertension. Dr. P. L. in April 1996 and the June 2005 VA medical report indicated that the Veteran first began treatment for hypertension in 1966, some 3 years following separation from service. Moreover, the Veteran corroborated the post-service onset of hypertension in his February 2001 claim for VA compensation benefits, variously noting that he began treatment for high blood pressure in December 1963 and for hypertension in 1966. In January 2008, a VA physician noted that there was no evidence of treatment of the Veteran for hypertension in military service. Significantly, in March 2010 a VA physician noted that the formal diagnosis of hypertension was based on the average of at least 3 blood pressure readings, and after reviewing the blood pressure readings recorded in the veteran's service medical records, she opined that the average did not meet the criteria for hypertension. In a May 2010 addendum to her March 2010 examination report, the VA physician reiterated that the formal diagnosis of hypertension was based on the average of at least 3 blood pressure readings, and, after reviewing the blood pressure readings recorded in the veteran's service medical records, opined that the average of his inservice blood pressures did not meet the criteria for hypertension. On that evidentiary record, the Board finds that the veteran's nonspecific October 2002 hearing testimony regarding his high blood pressure, and the January 2008 VA physician's comment that elevated blood pressure was found on the veteran's discharge physical examination are outweighed by other post-service medical evidence showing the onset of chronic hypertension several years post service. In this regard, the Board notes that isolated high blood pressure readings are not necessarily an indicator of chronic hypertension, and that this was considered by the 2010 VA physician in reaching her conclusion that it was less than likely that any currently-diagnosed cardiovascular disease including hypertension had its onset in military service. There is no indication in his January 2008 examination report that the VA physician reviewed the numerous specific blood pressure readings recorded in the available service medical records. The Board thus accords greater probative value to the 2010 VA physician's findings and well-reasoned conclusions, inasmuch as they were based on her thorough review of the veteran's service medical records, including specific blood pressure readings documented therein, as well as the post-service evidence, and current examination of the Veteran. Based on the veteran's conflicting statements and testimony, the Board finds that he is not credible to the extent that he reports the onset of his hypertension. Caluza v. Brown, 7 Vet. App. 498, 510-11 (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of witness testimony). Neither does the veteran's nephew's October 2002 affidavit provide persuasive support for the veteran's claim that any cardiovascular disease had its onset in service. Rather, the nephew attested to his knowledge that the Veteran took medication for high blood pressure at some indeterminate time following separation from service. For all the foregoing reasons, the Board finds that the claim for service connection for cardiovascular disease, to include hypertension, CAD, and residuals of rheumatic heart disease, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for cardiovascular disease, to include hypertension, CAD, and residuals of rheumatic heart disease, is denied. REMAND The VCAA (38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) includes enhanced duties to notify and assist claimants. Considering the record in light of the duties imposed by the VCAA and its implementing regulations, and the Court's June 2009 Order, the Board finds that all notice and development action needed to fairly adjudicate the claim for service connection for residuals of a back injury on appeal has not been accomplished. A remand by the Board confers upon a veteran, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran contends that he injured his back on 2 occasions in service, and that his current low back disability is a result of those injuries. In an April 2002 affidavit, a service comrade attested to the veteran's fall off of a crate and complaints of back problems in service in 1961, and the Veteran gave testimony to that effect in February 2004; he also testified that he injured his back on another occasion in service when he fell over a cement cauldron. Available service medical records are negative for findings or diagnoses of any back injury, and the spine was normal on September 1963 separation examination. Post service, in November and December 1987, J. C., M.D., noted a current herniated nucleus pulposus and sciatica. May 1988 Fair Oaks Hospital records indicated the onset of the veteran's low back and bilateral leg pain in November 1987 after shoveling snow, with 1987 Fairfax Hospital magnetic resonance imaging showing effacement with left- sided disc herniation. In April 1996, P. L., M.D., noted the veteran's history of an inservice back injury, noting that, while there was considerable soft tissue injury, there was no fracture; after current examination, multi-level lumbar disc disease with sciatica was diagnosed. In November 2003, S. C., M.D., noted the veteran's history of back injuries in service, and lumbar disc disease with arthritis was diagnosed. In June and July 2005, a VA physician opined that it was more likely than not that the veteran's low back problem, degenerative disc disease, was related or made worse by his military service. Lumbar disc disease was diagnosed on June 2007 VA examination and again referenced on January 2008 VA examination. By decision of February 2010, the Board remanded this case to the RO to afford the Veteran a VA orthopedic examination and a medical opinion as to whether it was at least as likely as not (i.e., there was at least a 50% probability) that any currently- diagnosed back disability was a result of injury in military service, or a result of intercurrent post-service injury. The Veteran was afforded a VA examination by C. T. McMurtry, M.D., at the Richmond, Virginia VA Medical Center (VAMC) in March 2010, with a May 2010 addendum, but she failed to provide all the medical opinions requested by the Board, stating that she could not render them without resorting to mere speculation. If an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. 38 C.F.R. § 4.2 (2009). A medical opinion that is unsupported and unexplained is purely speculative and does not provide the degree of certainty required for medical nexus evidence. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Bloom v. West, 12 Vet. App. 185, 187 (1999). The failure of an examiner to respond to a question posed for adjudication purposes is characterized as "non- evidence," including the use of equivocal language such as "may or may not." See Tirpak v. Derwinski, 2 Vet. App. 609 (1992); Sklar v. Brown, 5 Vet. App. 140 (1993); Perman v. Brown, 5 Vet. App. 237, 241 (1993). An examiner's conclusion that a diagnosis or etiology is not possible without resort to speculation is a medical conclusion just as much as a firm diagnosis or a conclusive opinion. However, the examiner must explain the basis for such an opinion, or the basis must otherwise be apparent in the Board's review of the evidence. Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). Where the record does not adequately reveal the current state of a disability, the fulfillment of the duty to assist includes providing a thorough and contemporaneous medical examination that considers the claimant's prior medical examinations and treatment. See Floyd v. Brown, 9 Vet. App. 88, 93 (1996); Ardison v. Brown, 6 Vet. App. 405, 407-08 (1994). Inadequate medical evaluation frustrates judicial review. Hicks v. Brown, 8 Vet. App. 417, 422 (1995). Under the circumstances, the Board finds that this case must thus be remanded to the RO to obtain a supplemental statement from Dr. McMurtry to resolve the issue on appeal. The RO is advised that a new examination of the Veteran is not necessary unless Dr. McMurtry is unable to furnish the medical opinion in the manner requested by the Board for any reason, including without another examination of the Veteran, or she is unavailable, and a new examination by another physician is necessary. The Veteran is hereby advised that failure to report for any scheduled VA examination, without good cause, may result in denial of the claim for service connection for residuals of a back injury. See 38 C.F.R. § 3.655 (2009). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. Id. If the Veteran does not report for any scheduled examination, the RO must obtain and associate with the claims folder a copy of any notice of the date and time of the examination sent to him by the VA medical facility at which it was to have been conducted. The action identified herein is consistent with the duties imposed by the VCAA. However, identification of specific action requested on remand does not relieve the RO of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the action requested above, the RO should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claim remaining on appeal. Accordingly, this case is hereby REMANDED to the RO for the following action: 1. The RO should return the claims folder to C. T. McMurtry, M.D., at the Richmond VAMC for a detailed medical statement to supplement her prior March and May 2010 medical opinions regarding the etiology of the veteran's current residuals of a back injury. Dr. McMurtry should review and address the service and post-service medical records and render an opinion for the record as to whether it is at least as likely as not (i.e., there is at least a 50% probability), or it is not at least as likely as not (i.e., there is less than a 50% probability) that any currently- diagnosed low back disability is a result of injury in military service, or a result of intercurrent post-service injury. It is imperative that the doctor's opinion reflects consideration and specific discussion of all pertinent medical evidence and events reflected in the record, to include the statements of the Veteran and a service comrade attesting to inservice back injuries; the veteran's available service medical records, including the September 1963 separation examination report; the November and December 1987 and May 1988 post-service medical records documenting an intercurrent post-service back injury after shoveling snow in 1987; Dr. P. L.'s April 1996 medical report; and the June and July 2005, June 2007, and January 2008 VA physicians' reports. If Dr. McMurtry is unable to furnish the medical opinion in the manner requested by the Board for any reason, including without another examination of the Veteran, or she is unavailable, the RO should schedule the Veteran for a new examination by another physician to obtain the requested answers to the specific abovementioned medical questions. The examining physician must set forth all examination findings, along with the complete rationale for all comments expressed and conclusions reached, in a typewritten report. 2. To help avoid future remand, the RO must ensure that all requested action has been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall, 11 Vet. App. at 271. 3. After completing the requested action, and any additional notification and/or development deemed warranted, the RO should readjudicate the claim for service connection for residuals of a back injury on appeal in light of all pertinent evidence and legal authority. 4. If the benefit sought on appeal remains denied, the RO must furnish the appellant and his attorney an appropriate Supplemental Statement of the Case that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims folder is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process; it is not the Board's intent to imply whether the benefit requested should be granted or denied. The appellant needs take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate timeframe. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs