Citation Nr: 1211549 Decision Date: 03/30/12 Archive Date: 04/05/12 DOCKET NO. 09-15 862 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for systemic lupus erythematosus and its residuals. 2. Entitlement to service connection for systemic lupus erythematosus and its residuals. 3. Entitlement to service connection for coronary artery disease, to include as secondary to systemic lupus erythematosus. 4. Entitlement to service connection for a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome, to include as secondary to systemic lupus erythematosus. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD N. T. Werner, Counsel INTRODUCTION The Veteran served on active duty from August 1966 to May 1968, from June 1989 to September 1989, and in April 2003. The Veteran also had almost twenty two years of service with various reserve components from May 1968 to May 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2008 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada. In September 2011, the Veteran testified at a video hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing has been associated with the claims file. FINDINGS OF FACT 1. A September 2005 rating decision earlier denied a claim of service connection for systemic lupus erythematosus and its residuals; the Veteran did not appeal that decision or submit new and material evidence within the one year appeal period. 2. Evidence received since the time of the final September 2005 rating decision is new, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for systemic lupus erythematosus and its residuals. 3. The most competent and credible evidence of record shows that the Veteran has not had systemic lupus erythematosus at any time during the pendency of the appeal. 4. The Veteran's coronary artery disease is not related to service and it was not caused or aggravated by a service connected disability. 5. The Veteran's chronic disability manifested by dry eyes and mouth including Sjogren's syndrome is not related to service and it was not caused or aggravated by a service connected disability. CONCLUSIONS OF LAW 1. The September 2005 rating decision is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2005); currently 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2011). 2. Evidence submitted to reopen the claim of entitlement to service connection for systemic lupus erythematosus and its residuals is new and material, and therefore, the claim is reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2011). 3. Systemic lupus erythematosus and its residuals was not incurred in or aggravated by military service nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 101(24), 106, 1101, 1110, 1112, 1113, 1131, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306, 3.307, 3.309 (2011). 4. Coronary artery disease was not incurred in or aggravated by military service nor was it caused or aggravated by a service connected disability. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. § 3.310 (2008); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306 (2011). 5. A chronic disability manifested by dry eyes and mouth including Sjogren's syndrome was not incurred in or aggravated by military service nor was it caused or aggravated by a service connected disability. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. § 3.310 (2008); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2011). Specifically, under 38 U.S.C.A. § 5102 VA first has a duty to provide an appropriate claim form, instructions for completing it, and notice of information necessary to complete the claim if it is incomplete. Second, under 38 U.S.C.A. § 5103(a), VA has a duty to notify the claimant of the information and evidence needed to substantiate and complete a claim, i.e., existence of a current disability, the degree of disability, and the effective date of any disability benefits. The appellant must also be notified of what specific evidence he is to provide and what evidence VA will attempt to obtain. Third, VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. This includes obtaining all relevant evidence adequately identified in the record and, in some cases, affording VA examinations. 38 U.S.C.A. § 5103A. In Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006), the United States Court of Appeals for Veterans Claims (Court) observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (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. See 38 U.S.C. § 5103(a). As to all the issues on appeal, the Board finds that there is no issue as to whether the Veteran was provided an appropriate application form or issue as to whether the claimant has veteran status. As to the claim to reopen, the Board finds that discussion of the VCAA notice provided to the Veteran is unnecessary given the fully favorable decision below since any deficiency in the timing or content of such notice would constitute harmless error. As to the service connection claims, the Board finds that a letter dated in October 2007, prior to the June 2008 rating decision, along with a letter dated in May 2008 provided the Veteran with notice that fulfills the provisions of 38 U.S.C.A. § 5103(a) including notice of the laws and regulations governing disability ratings and effective dates as required by the Court in Dingess, supra. Moreover, the Board finds that even if the above letters did not provided adequate 38 U.S.C.A. § 5103(a) notice that this notice problem does not constitute prejudicial error in this case because the record reflects that a reasonable person could be expected to understand what was needed to substantiate the claims after reading the above letters as well as the rating decision, the statement of the case, and the supplemental statements of the case. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009). As to the duty to assist, the Board finds that VA has secured all available and identified pertinent in-service and post-service evidence including the Veteran's service and reserve component treatment records and post-service treatment records from the Social Security Administration (SSA), the Reno VA Medical Center, John DeWeerd, Jr., M.D., G. Kim Bigley, M.D., Joseph E. Johnson, M.D., University of Tennessee Memorial Hospital, Renown Regional Medical Center, Renown Heart Physicians Group, and Family Eye Care. The record also shows that the Veteran filed in support of his claims opinion letters from Craig N. Bash, M.D., Neuro-Radiology, and Katy Searle, FNP. As to the claim of service connection for systemic lupus erythematosus, in November 2010 the Veteran was provided with a VA examination in connection with his appeal. Moreover, in November 2011 the Board requested and received back a medical expert opinion. In December 2011, the Veteran was provided with a copy of the November 2011 medical opinion as well as advised of his right to provide the Board with additional evidence in support of his appeal. In January 2011, the Board received the Veteran's reply as to the November 2011 medical opinion along with a waiver of agency of original jurisdiction of this evidence. The Board finds that the above VA examination and medical opinion are adequate to adjudicate the claim of service connection for systemic lupus erythematosus because, after a review of the record on appeal and/or a comprehensive examination of the claimant, the physicians provided opinions as to whether the claimant had systemic lupus erythematosus due to his military service which opinions were supported by citation to relevant evidence found in the claims file. See 38 U.S.C.A. § 5103A(d); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board also finds that the Veteran was provided all required notice of the medical expert opinion and that VA has no further duty to assist with respect to this opinion. As to the claims of service connection for coronary artery disease and a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome, the Veteran was not afforded VA examinations in connection with his claims. In this regard, the Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted under this statute. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service would not suffice to meet this standard as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Given the above standard, the Board finds that a remand for a VA examination is not required because service treatment records are negative for the claimed disorders, the post-service record is negative for the claimed disorders for many years after his separation from his last period of active duty, the Board finds the lay statements from the Veteran and others regarding a nexus between current disabilities and service conclusory generalized statements for reasons that will be explained below, the Board does not find the lay statements from the claimant and others regarding continuity of symptomatology competent and credible evidence for reasons that will be explained below, and the Veteran is not service connected for systemic lupus erythematosus for reasons that will be explained below. See 38 U.S.C.A. § 5103A(d); Also see Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (holding that VA was not required to provide a medical examination when there is no credible evidence of an event, injury, or disease in service when the Board does not find his statements credible); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In summary, the facts relevant to this appeal have been properly developed and there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. §§ 5103(a), 5103A or 38 C.F.R. § 3.159. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of the appeal. See Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). In adjudicating the claims below, the Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims files shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). II. The Claim to Reopen The Veteran and his representative contend that the claimant's systemic lupus erythematosus starting while the claimant was on active duty in the late 1960's and has continued to the current time. In this regard, the RO initially denied service connection for systemic lupus erythematosus and its residuals in a September 2005 rating decision. The Veteran did not appeal the September 2005 rating decision. Moreover, the record does not show that the Veteran, following this rating decision, submitted medical documentation, lay statements, or other evidence constituting new and material evidence within the one-year appeal period. 38 C.F.R. § 3.156(b) (2005). Therefore, the Board finds that the September 2005 rating decision is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2005); currently 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2011). As to reopening a prior final decision, the law provides that if new and material evidence has been presented or secured with respect to matters which have been disallowed, these matters may be reopened and the former disposition reviewed. 38 U.S.C.A. § 5108. 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, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court has held that in determining whether the evidence is new and material, the credibility of the newly presented evidence is to be presumed. Kutscherousky v. West, 12 Vet. App. 369, 371 (1999) (per curiam). The Board is required to give consideration to all of the evidence received since the most recent denial of the claim in the September 2005 rating decision in light of the totality of the record. See Hickson v. West, 12 Vet. App. 247, 251 (1999). Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2011). Additionally, service connection may be granted for disability resulting from disease or injury incurred or aggravated while performing active duty for training (ACDUTRA), or from injury incurred or aggravated while performing inactive duty training (INACDUTRA). 38 U.S.C.A. §§ 101(24), 106, 1110, 1131 (West 2002). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b). In addition, service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 C.F.R. § 3.303(d). Other specifically enumerated disorders, including systemic lupus erythematosus, will be presumed to have been incurred in service if they manifested to a compensable degree within the first year following separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2011). Service connection may also be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310 (2008). This includes disability made chronically worse by service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). In summary, in order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007 In evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Klekar v. West, 12 Vet. App. 503, 507 (1999); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). With the above criteria in mind, the Board notes that the September 2005 rating decision denied the claim of service connection for systemic lupus erythematosus and its residuals because service treatment records did not show treatment for systemic lupus erythematosus while on active duty or within the presumptive period as well as because the record did not show a relationship between the claimant's post-service systemic lupus erythematosus and his active duty service. However, in a December 2007 letter from Dr. Bash and in a January 2008 letter from Nurse Searle, it was opined, in substance, that the Veteran's had a current diagnosis of systemic lupus erythematosus and it was caused by his military service. As noted above, in order to establish service connection for systemic lupus erythematosus and its residuals, there must be, among other things, medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson, supra. Therefore, the Board finds the letters from Dr. Bash and Nurse Searle, the credibility of which must be presumed (see Kutscherousky, supra), are both new and material evidence as defined by regulation. See 38 C.F.R. §§ 3.156(a), 3.303; Shade v. Shinseki, 24 Vet. App. 110 (2010) (holding that the language of 38 C.F.R. § 3.156(a) created a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim."); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992) (establishing service connection requires finding a relationship between a current disability and events in service or an injury or disease incurred therein). The claim of entitlement to service connection for systemic lupus erythematosus and its residuals is therefore reopened. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). III. The Service Connection Claims i. Systemic Lupus Erythematosus As noted above, the Veteran contends that his systemic lupus erythematosus and its residuals were caused by his military service. Specifically, it is claimed that the Veteran first manifested the symptoms of his systemic lupus erythematosus while on active duty in the late 1960's and, even though he was not diagnosed with systemic lupus erythematosus until approximately 2001, he continued to have these symptoms until the current day. Given the above standard, the Board will first look to see if the record contains a competent and credible diagnosis of systemic lupus erythematosus at any time during the pendency of his appeal. See 38 U.S.C.A. §§ 101(24), 106, 1110, 1131; 38 C.F.R. §§ 3.303, 3.306; McClain, supra. In this regard, the record on appeal, including the Veteran's active duty and reserve component treatment records, is negative for a diagnosis of systemic lupus erythematosus until 2001. Specifically, starting in late 2000 medical records noted that the Veteran's Anti Nuclear Antibody (ANA) panel was positive and that he was therefore going to be tested for lupus. Subsequent medical records starting in 2001 thereafter showed the Veteran being periodically diagnosed with systemic lupus erythematosus. Moreover, in December 2007 and May 2008 letters from Dr. Bash as well as the January 2008 letter from Nurse Searle, it was opined that the Veteran had systemic lupus erythematosus. As to Dr. Bash, he reported in his December 2007 letter that while he was a medical doctor and had special knowledge in the area of auto-immune disorders, his specialty was in Neuro-Radiology. He next reported that he had reviewed the Veteran's service medical records and post-service medical records. Next, Dr. Bash reported that the claimant had symptoms of systemic lupus erythematosus while on active duty according to Nurse Searle and his lay claims. Next, it was noted that service treatment records showed problems with gastritis, hyperhydrosis, an upper respiratory infection, and pneumonia; an October 1966 chest X-ray showed infiltrate density in the anterior right lung base; March 1969 records showed his treatment for cramps and diarrhea; and February 1979 records showed his treatment for pneumonia and thereafter for irritable bowel syndrome. Dr. Bash thereafter opined that the Veteran has a diagnosis of systemic lupus erythematosus because it was diagnosed by a Dr. DeWeerd based on a ANA positive double DNA and it was also diagnosed by a VA physician. It was also opined that the Veteran's current systemic lupus erythematosus began in service because of the following: he had systemic lupus erythematosus while in service; medical literature documents an association between early symptoms and the end stage disease; his record does not contain a more likely etiology of his systemic lupus erythematosus; his long-term signs and symptoms are consistent with the finding of early systemic lupus erythematosus; his in-service chest films dated in October 1966 are consistent with findings of early systemic lupus erythematosus (i.e., Specifically, the infiltrate density in the anterior right lung base); and his in-service bowel signs and symptoms are consistent with early stages of systemic lupus erythematosus. As to Nurse Searle letter, she reported that the Veteran had continuing signs and symptoms of connective tissue syndrome and autoimmune syndrome, including systemic lupus erythematosus, for many years; the average time it takes to diagnosis systemic lupus erythematosus is seven years; and the claimant had symptoms since his early 20's in the 1970's (i.e., hyperhydrosis, chronic lupus liker dermatitis, chronic gastrointestinal problems including gastritis, colitis, and intestinal spasms, and upper respiratory problems including sinusitis, pneumonia, and bronchitis) which were either precursors to systemic lupus erythematosus or actual systemic lupus erythematosus. On the other hand, the Board notes that a number of the post-2001 medical records found in the claims file noted that the Veteran did not have a diagnosis of systemic lupus erythematosus despite the diagnoses found in his medical records and despite the positive ANA panel because attempts to show the presence of the lupus antibody to double strand DNA were negative and/or because he did not show the required adverse symptomatology. Moreover, after a review of the record on appeal and an examination of the claimant, the November 2010 VA examiner (a medical doctor and a Primary Care Physician), opined that the Veteran did not have systemic lupus erythematosus because his variety of different illnesses and medical conditions did not fit the American College of Rheumatology (ACR) criteria for a diagnosis of systemic lupus erythematosus. The examiner reached this conclusion because the Veteran did not have at least 4 of the 11 ACR criteria. Specifically, the examiner noted that he had arthritis. However, he did not have any of the adverse skin pathology (i.e., skin photosensivity, a malar rash, and/or discoid rash) and his eczema did not count. He also did not have a psychosis/seizure in the absence of other causes. Likewise, he did not have renal involvement, blood cell deficits, oral ulcers, spontaneous serositis, higher ANA titers, or positive antibodies to double strand DNA. It was also opined that the Veteran's inflammatory markers (ESR, CRP) have been repeatedly normal. Lastly, it was opined that the Veteran's past history of gastroenteritis, pneumonia, sinusitis, intestinal spasms, and irritable bowel syndrome do not qualify as ACR criteria for systemic lupus erythematosus. It was also opined that, because the Veteran did not have a diagnosis of systemic lupus erythematosus, it could not have been caused by his military service. Lastly, in the November 2011 medical expert opinion (provided by a medical doctor and the Chief, Rheumatology Section), it was noted after a review of the claims file that the Veteran's medical history included eczematous dermatitis, a thoracic nerve injury, a rotator cuff tear, a motor vehicle accident with residual hand injuries, upper respiratory problems, a coronary stent, and dry eye. His medical history also showed that at one time ANA antibodies were present in significant titers and a single anti-DNA titer was mildly elevated. However, repeat anti-DNA testing was negative. At the time of this testing, a rheumatologist saw the Veteran and determined that he did not fulfill criteria for a diagnosis of systemic lupus erythematosus and no specific treatment for systemic lupus erythematosus was appropriate. When again seen by another a rheumatologist in 2004, it was likewise opined that he did not think that the Veteran had systemic lupus erythematosus. The November 2011 medical expert thereafter opined, after his review of the record on appeal, that these earlier rheumatologists' opinions that the Veteran did not have systemic lupus erythematosus were the correct assessment. Next, the November 2011 medical expert noted, that while the record showed that the Veteran was nonetheless given lupus specific treatment, the rational for giving this treatment to him is not clear from the record and was initiated by private providers who may have not had access to the above rheumatologists' opinions. It was next opined that the usual evidence of systemic lupus erythematosus is not found in the Veteran's treatment records. In this regard, his neurological problems appear to be traumatic in nature. Moreover, while he had had a creatine phosphokinase (CPK) elevation, it was not well characterized and electromyography (EMG) did not document myopathy. The November 2011 medical expert also opined that the November 2010 VA examiner was correct in noting that ANA and DNA determinations were most recently negative and opining that the Veteran's clinical and laboratory finding do not fulfill criteria for systemic lupus erythematosus. As to Nurse Searle letter, the November 2011 medical expert opined that, while she outlined his troubles well, these troubles do not support a diagnosis of systemic lupus erythematosus as they are not attributable to this disease process. As to Dr. Bash's letters, the November 2011 medical expert opined that they assumed the diagnosis of systemic lupus erythematosus is correct and, given the information cited above, this assumption is erroneous. In summary, the November 2011 medical expert opined that his review of the record on appeal reveals that the Veteran did not fulfill the classification criteria for systemic lupus erythematosus at any time. Initially, the Board finds the November 2011 opinion provided by the Chief of a Rheumatology Section that the Veteran did not ever meet the ACR criteria for a diagnosis of systemic lupus erythematosus more credible than either Dr. Bash's or Nurse Searle opinions. The Board has reached this conclusion because the Chief of the Rheumatology Section has more knowledge and skill in analyzing the medical data related to whether the claimant ever meet the ACR criteria for a diagnosis of systemic lupus erythematosus than either a Neuro-Radiologist like Dr. Bash or a nurse. 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). The Board also finds the November 2011 opinion more credible than either Dr. Bash's or Nurse Searle opinions because it specifically points to the evidence found in the record that demonstrated that Dr. Bash and Nurse Searle opinions that the claimant had systemic lupus erythematosus were in error. See Madden v. Gober, 125 F.3d. 1477 1481 (Fed. Cir. 1997) (holing that the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Black v. Brown, 5 Vet. App. 177, 180 (1995) (holding that a medical opinion is inadequate when it is unsupported by clinical evidence); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative). Likewise, the Board finds the November 2010 VA examiner's opinion and the November 2011 medical expert opinion more competent and credible that the diagnoses of systemic lupus erythematosus found in the post-2001 treatment records because none of these treatment records specifically commented on whether his diagnosis met the ACR criteria for a diagnosis of systemic lupus erythematosus or provided a clear reasons and bases for their diagnosis. 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); 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."). Therefore, the Board finds the November 2010 VA examiner's and the November 2011 medical expert opinion, that the Veteran did not ever meet the ACR criteria for a diagnosis of systemic lupus erythematosus, the most competent and credible medical evidence of record. Moreover, while the Veteran and others as lay persons are competent to report on the claimant's observable symptoms because this requires only personal knowledge as it comes to them through their senses, the Board finds more competent and credible the expert opinion obtained by VA in November 2010 and November 2011, than these lay claims. See Black, supra. The Board also finds that these lay claims have no probative value because they are not competent to provide a diagnosis of systemic lupus erythematosus because such an opinion requires medical expertise which they do not have. See Jandreau, supra; Buchanan, supra; Charles, supra; Espiritu, supra. As to the medical treatise evidence filed by the Veteran, the Board notes that medical treatise evidence can provide important support when combined with an opinion of a medical professional. Mattern v. West, 12 Vet. App. 222, 228 (1999); Rucker v. Brown, 10 Vet. App. 67, 73-74 (1997) (holding that evidence from scientific journal combined with doctor's statements was "adequate to meet the threshold test of plausibility"). Moreover, medical treatise evidence that discusses with certainty the facts of a specific case may be used to meet the requirement for a medical nexus. Wallin v. West, 11 Vet. App. 509 (1998). However, an attempt to establish a medical nexus between service and a disease or injury solely by generic information in a medical journal or treatise "is too general and inclusive." Sacks v. West, 11 Vet. App. 314, 317 (1998) (a medical article that contained a generic statement regarding a possible link between a service-incurred mouth blister and a present pemphigus vulgaris condition did not satisfy the nexus element). In this case, the Board finds that the medical treatise evidence filed by the Veteran does not discuss with certainty the facts of his appeal. Moreover, while it may provide important support when combined with an opinion of a medical professional, the Board has already explained why the medical opinions provided by Dr. Bash and others that the claimant has a current diagnosis of systemic lupus erythematosus are not the most credible evidence of record. Therefore, the medical treatise evidence is only entitled to limited probative value because it is not supported by any definitive or concrete medical opinions. In summary, even in light of this additional evidence, the Board finds that the most competent evidence shows that the Veteran was not diagnosed with systemic lupus erythematosus at any time during the pendency of the appeal. A condition precedent for establishing service connection is the Veteran being diagnosed with the claimed disease process at any time during the pendency of his appeal. However, the preponderance of the competent and credible evidence of record shows that the claimant did not have such as diagnosis despite some of his medical records reporting he had systemic lupus erythematosus. The Board has reached this conclusion because, as explained above, the most competent and credible evidence of record shows that these diagnoses did not meet the ACR criteria for systemic lupus erythematosus. Therefore, the Board finds that entitlement to service connection for systemic lupus erythematosus and its residuals must be denied on a direct and presumptive basis because the Veteran has not been diagnosed with the claimed disease process at any time during the pendency of his appeal. 38 U.S.C.A. §§ 101(24), 106, 1101, 1110, 1112, 1113 1131; 38 C.F.R. §§ 3.303, 3.306, 3.307, 3.309; Rabideau, supra; also see McClain, supra; Hickson, supra. ii. Coronary Artery Disease and Dry Eyes and Mouth As to service incurrence under 38 C.F.R. § 3.303(a), a September 1966 service treatment record documents the Veteran's complaints and treatment for chest pain. Moreover, reserve component examinations also noted a history of eye trouble in August 1980, November 1987, September 1991, and June 1994. Furthermore, the Board finds that the Veteran is both competent and credible to report on what he can see and feel such as observable symptoms of coronary artery disease (i.e., chest pain and fatigue) and Sjogren's syndrome (i.e., dry eyes and mouth), even when not documented in his medical records, because these symptoms come to him through his own senses. See Davidson, supra; Buchanan, supra; Jandreau, supra; Charles, supra. However, the September 1966 service treatment record that documented the Veteran's complaints and treatment for chest pain, diagnosed pneumonia. Likewise, the reserve component examinations that noted a history of eye trouble thereafter discussed a problem with refractive error and not dry eye. Furthermore, the Veteran's service and reserve component treatment records, including his February 1968, February 1976, August 1980, November 1987, September 1991, and June 1994 examinations, are otherwise negative for complaints or treatment for symptoms of and/or a diagnosis of coronary artery disease and/or a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome. In fact, these examinations were uniform in reporting that his examinations, as to the eyes, mouth, and heart, were normal. Furthermore, the Veteran's March 2003 chest X-ray was negative. The Board recognizes the fact that the Veteran is competent and credible to report on what he can see and feel, nonetheless, the Board finds more compelling the service and reserve component treatment records, including the examinations, which are negative for complaints, diagnoses, or treatment for coronary artery disease or a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome, than the appellant's claims that he had problems with chest pain and fatigue as well as dry eyes and mouth on active duty and since that time. See Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact). The Board also finds that the Veteran's report of medical history in these examinations, which indicated no history of heart problems or dry eyes and mouth, to be competent and credible evidence of his not having these disabilities while in service. Accordingly, the Board finds that entitlement to service connection for coronary artery disease and a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome must be denied based on service incurrence despite the Veteran's claims regarding having problems with observable symptoms of these disabilities while on in service. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131; 38 C.F.R. §§ 3.303(a), 3.306. As to post-service continuity of symptomatology under 38 C.F.R. § 3.303(b), the Board finds that the length of time between the Veteran's separation from his first period of active duty in 1968 and even his last period of active duty in 2003 and his first complaints and treatment for coronary artery disease and a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome in 2008, to be compelling evidence against finding continuity. Put another way, the many year gap between the Veteran's discharge from active duty and the first evidence of the claimed disorders weighs heavily against his claims. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the Veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of his low back condition). In this regard, the Board acknowledges, as it did above, that the Veteran is competent to give evidence about what he sees and feels; for example, the claimant is competent to report that he had problems with chest pain and fatigue as well as dry eyes and mouth since service. See Davidson, supra; Buchanan, supra; Jandreau, supra; Charles, supra. The Board also acknowledges that the Veteran's representative is competent to give evidence about what he can see such as the claimant appearing to be in pain or his eyes appearing to be dry. Id. However, upon review of the claims file, the Board finds that the Veteran's and his representative's assertions that the claimant has had his current coronary artery disease and a chronic disability manifested by dry eyes and mouth since service are not credible. In this regard, the Veteran and his representative's claims are contrary to what is found in the service and post-service records. The Board also finds that the service and reserve component examinations, dated in February 1968, February 1976, August 1980, November 1987, September 1991, and June 1994, which were uniform in reporting that his examinations of the eyes, mouth, and heart were normal, weighs heavily against the claims of continuity. The Board also finds that the March 1970 VA examination, which was negative for complaints regarding coronary artery disease or a chronic disability manifested by dry eyes and mouth, weighs heavily against the claims of continuity. In these circumstances, the Board gives more credence and weight to the negative service and reserve component examinations, the negative reports of medical history found in these examinations, and the negative post-service medical records including the March 1970 VA examination, which do not show complaints, diagnoses, or treatment for either of the claimed disorders for many years following his separation from active duty, than any claims by the Veteran and his representative to the contrary. Therefore, entitlement to service connection for coronary artery disease and a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome based on post-service continuity of symptomatology must be denied. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131; 38 C.F.R. §§ 3.303(b), 3.306. As for service connection based on the initial documentation of the disabilities after service under 38 C.F.R. § 3.303(d), the Board notes that the record is negative for a competent and credible medical opinion finding a causal association or link between the Veteran's coronary artery disease and a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome and an established injury, disease, or event of service. See 38 U.S.C.A. §§ 101(24), 106, 1110, 1131; 38 C.F.R. §§ 3.303(d), 3.306; Rabideau, supra. As to the Veteran's and his representative's assertions that the claimant's coronary artery disease and chronic disability manifested by dry eyes and mouth including Sjogren's syndrome were caused by his military service, the Board finds that diagnosing coronary artery disease and a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome requires because special equipment, testing, and/or medical training that neither the Veteran nor his representative have and therefore the presence of the disorders is a determination "medical in nature" and not capable of lay observation. See Davidson, supra; Buchanan, supra; Jandreau, supra; Charles, supra. Therefore, since laypersons are not capable of opining on matters requiring medical knowledge, the Board finds that their opinions that these disorders were caused by service is not competent evidence. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998); see also Bostain v. West, 11 Vet. App. 124, 127 (1998). Based on the discussion above, the Board also finds that service connection for coronary artery disease and a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome is not warranted based on the initial documentation of the disabilities after service because the weight of the competent and credible evidence is against finding a causal association or link between the post-service disorders and an established injury, disease, or event of service origin. See 38 U.S.C.A. §§ 101(24), 106, 1110, 1131; 38 C.F.R. §§ 3.303(d), 3.306; Rabideau, supra. As to service connection under 38 U.S.C.A. §§ 101(21), (24), 106, 1110 and 38 C.F.R. § 3.306 based on the Veteran's INACDUTRA with a reserve component, the Board notes that coronary artery disease and a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome are diseases and not injuries. Therefore, service connection for coronary artery disease and a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome based on the Veteran's INACDUTRA with a reserve component must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). As to service connection under 38 C.F.R. § 3.310 based on the Veteran's coronary artery disease and chronic disability manifested by dry eyes and mouth including Sjogren's syndrome being secondary to his systemic lupus erythematosus, the Board notes that for reasons explained above the claimant is not entitled to service connection for systemic lupus erythematosus and its residuals. Therefore, since a condition precedent for establishing secondary service connection is the Veteran being service connected for the disability he is claiming caused or aggravated his other disability, the Board finds that entitlement to service connection for coronary artery disease and a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome secondary to systemic lupus must also be denied. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131; 38 C.F.R. § 3.310. Accordingly, the Board must conclude that the weight of the evidence is against the claims of service connection for coronary artery disease and a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome on a direct and a secondary basis. See 38 U.S.C.A. §§ 101(21), (24), 106, 1110; 38 C.F.R. §§ 3.303, 3.306, 3.307, 3.309, 3.310. III. Conclusion In reaching the above conclusions, the Board also considered the doctrine of reasonable doubt. 38 U.S.C.A. § 5107(b). However, as the preponderance of the evidence is against the claims, the doctrine is not for application. See also, e.g., Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER New and material evidence having been submitted, the Veteran's claim for entitlement to service connection for systemic lupus erythematosus and its residuals is reopened, and to that extent only, the appeal is granted. Entitlement to service connection for systemic lupus erythematosus and its residuals is denied. Entitlement to service connection for coronary artery disease is denied. Entitlement to service connection for a chronic disability manifested by dry eyes and mouth including Sjogren's syndrome is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs