Citation Nr: 1237641 Decision Date: 11/02/12 Archive Date: 11/09/12 DOCKET NO. 08-26 338 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for residuals of cold injury to the upper and lower extremities. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Vietnam Veterans of America WITNESS AT HEARINGS ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran had active service from January 1951 to January 1954. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision issued by the above Department of Veterans Affairs (VA) Regional Office (RO). In August 2010, the Veteran and his wife presented testimony relevant to this appeal at a Travel Board hearing before a Veterans Law Judge (VLJ) who has since retired from the Board. A transcript of the hearing is associated with the record. In September 2010, the Board dismissed the Veteran's claim for residuals of cold injury to the right index finger, denied the Veteran's claims seeking service connection for PTSD and bilateral hearing loss, and remanded the Veteran's claims for cold injury residuals and tinnitus for further evidentiary development. The Veteran appealed the September 2010 Board decision denying service connection for PTSD and bilateral hearing loss to the U.S. Court of Appeals for Veterans Claims (Court). In February 2012, the Court issued a Memorandum Decision ordering that the Board's decision be set aside and remanded for readjudication. In March 2012, the Veteran presented testimony before the undersigned at a video Board hearing regarding the previously remanded issues of entitlement to service connection for cold injury residuals and tinnitus. A transcript of that hearing is also of record. The hearing was held prior to Court's mandate. The Veteran has since been afforded the opportunity to present testimony at another Board hearing regarding the issues of entitlement to service connection for bilateral hearing loss and PTSD but has stated that he did not want another Board hearing. See September 2012 response to August 2012 letter. Additional evidence was received through the Veteran's representative in January 2012, which was accompanied by waiver. 38 C.F.R. §§ 19.9, 20.1304(c). More evidence was received by the Board (i.e., evidence received at the RO in October 2010 that was forwarded to the Board) in March 2012 and in September 2012 in connection with the Veteran's appeal. The Veteran has subsequently waived his right to its initial consideration by the Agency of Original Jurisdiction (AOJ). See September 2012 Medical Opinion Response Form. In March 2011, the Board referred the Veteran's case to the Veterans Health Administration (VHA) for a medical expert opinion to address certain medical questions pertaining to the issue regarding cold injury residuals on appeal, and the medical opinion from a VA internist was obtained in July 2012. A copy of the medical opinion was sent to the Veteran in August 2012. Both the Veteran's claims folder and his electronic file located on the "Virtual VA" system have been reviewed by the Board in its evaluation of his appeal. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to service connection for: 1) tinnitus; 2) bilateral hearing loss; and 3) PTSD are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's account of having been exposed to extremely cold temperatures during his service in Korea is deemed credible. 2. The preponderance of the evidence weighs against finding that the Veteran currently suffers from cold injury residuals causally or etiologically related to his period of active military service, to include any incident or event therein. CONCLUSION OF LAW Cold injury residuals of the upper and lower extremities were not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2011). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the decision of the U.S. Court of Veterans Appeals (Court) in Dingess v. Nicholson, 19 Vet. App. 473 (2006), requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date. If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a Statement of the Case (SOC) or a Supplemental SOC (SSOC). Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Supreme Court has held that an error in VCAA notice should not be presumed prejudicial, and that the burden of showing harmful error rests with the party raising the issue, to be determined on a case-by-case basis. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Prior to the initial denial of claimed cold injury residuals, the RO advised the Veteran of what the evidence must show to establish entitlement to service-connected compensation benefits for his claimed disorder in a notice letter sent in September 2006. The RO also explained what evidence VA would obtain and make reasonable efforts to obtain on the Veteran's behalf in support of his claim. The RO further described what evidence that the Veteran should provide in support of his claim. Moreover, the RO advised the Veteran how VA determines the disability rating and effective date once service connection has been awarded, which satisfies Dingess notice requirements. Because the Veteran was provided with adequate notice with respect to his claim by way of the September 2006 pre-adjudication notice letter, the Board concludes that VA's duty to notify has been met with respect to that claim, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. To the extent the initial letter may have been defective in any respect, after the Board remanded the cold injury claims in 2010, another letter was sent to the Veteran in September 2010. That letter again advised the Veteran of what the evidence must show to establish entitlement to service-connected compensation benefits. The letter also explained what evidence VA would obtain and make reasonable efforts to obtain on the Veteran's behalf in support of his claim. The letter further described what evidence the Veteran should provide in support of his claim. Moreover, the letter again advised the Veteran how VA determines the disability rating and effective date once service connection has been awarded, which satisfies Dingess notice requirements. The Veteran and his representative were provided with copies of the above rating decision, the SOC, and the SSOCs, which include discussion of the facts of the claims, pertinent laws and regulations, notification of the bases for the decisions, and a summary of the evidence considered to reach the decisions. Regarding VA's duty to assist in claims development, the Board notes that the Veteran's service treatment records (STRs) are included in the claims folder and appear to be complete. The Veteran does not contend otherwise. The Veteran's service personnel records (SPRs) are also of record. Additionally, the Board notes that the record contains all available evidence pertinent to these claims. VA has requested records identified throughout the claims process. The Veteran was given appropriate notice of his responsibility to provide VA with any treatment records pertinent to his claimed disorders and the record contains sufficient evidence to make a decision on the claims. Pertinent post-service treatment records adequately identified as relevant to the Veteran's claims have been obtained, to the extent possible, or otherwise submitted and are associated with the record. Upon review, there are no additional pertinent treatment records found in the Veteran's electronic record through Virtual VA. Moreover, the Veteran and his representative have submitted several written statements in connection with his claims and during the course of his appeal. In September 2010, the Board remanded claimed cold injury residuals in order to schedule the Veteran for a medical examination and obtain a medical opinion regarding the presence and etiology of his claimed residuals of cold injuries to the upper and lower extremities. Thereafter, the claim was to be readjudicated. Pursuant to the Board's remand, the Veteran was afforded with a medical examination for his claimed cold injury residuals in September 2010. Because the examiner did not provide a medical opinion at that time, the Appeals Management Center (AMC) requested an addendum from the examiner. The September 2010 examiner provided an opinion in May 2011. The AMC then requested further rationale from the examiner to support his opinion, and that opinion was obtained in September 2011. Upon review, the AMC again found the medical opinion to be insufficient and asked the examiner to consider certain in-service and post-service evidence in providing a supplemental opinion. The supplemental medical opinion was obtained in November 2011. Regarding the medical findings included in the September 2010 VA medical examination report pertaining to the Veteran's upper and lower extremities, the Board finds that the diagnoses are adequate. Neither the Veteran nor his representative contend otherwise. However, the Veteran's representative believed that the November 2011 medical opinion obtained in connection with the appeal was inadequate, on several bases: 1) the November 2011 medical opinion did not address the two positive opinions rendered in May and September 2011; 2) the reviewer wrongly discounted the Veteran's account of being exposed to cold temperatures; and 3) the opinion request form was tainted in the way it requested the opinion (i.e., stating that exposure to extreme cold was not conceded because the Veteran's service was not during the Chosen Reservoir Campaign when the Veteran was competent to report such exposure and pointing out the fact that there was no documentation for any in-service injuries and/or fractures requiring surgery, which he argues is irrelevant). The representative also notes that the reviewer uses the opinion request statement almost verbatim in his rationale for his unfavorable opinion, which highly suggests that the wording of the opinion request improperly influenced the determination of the reviewer. See January 2012 Informal Hearing Presentation; see also 2012 hearing transcript, page 2. After carefully considering each of the arguments set forth by the Veteran's representative, the Board agreed that the November 2011 medical opinion was inadequate because it did not adequately consider the Veteran's competent lay account of in-service cold exposure, which is consistent with the circumstances and hardships of his service. As a result, we sought a medical expert opinion from a VA internist, which was obtained in July 2012. The medical opinion is well-articulated and supported by adequate rationale based on review of the record. It is deemed adequate for the purposes of this adjudication. The Veteran has asserted that the VA internist who provided the July 2012 medical opinion failed to provide adequate consideration of the effects of extremely cold temperatures on the body. The Veteran's representative further argues that the internist failed to explore the possibility that the Veteran was more likely to be injured in the post-service vehicular accident that the physician identified as the primary cause of his current conditions because of his cold weather injuries. However, we find both arguments to be without merit and no further opinion is needed. The internist accepted as fact that the Veteran was exposed to extreme cold while serving in Korea and had debilitating arthritic symptoms currently. He also specifically cited several medical articles discussing the effects of cold injury. However, after considering the medical evaluations provided to the Veteran both during and after service, he found no documentation in the record to show significant or chronic neurovascular changes indicative of prior cold exposure. He specifically considered the Veteran's complaints of cold sensitivity and color changes of his hands and feet but found that it was not sufficient to meet the criteria for a phenomenon known to be associated with cold exposure. The internist adequately considered the effects of cold injury and found that such was not demonstrated by the Veteran. Furthermore, the internist has provided more than adequate rationale as to why he does not believe that the Veteran currently suffers or ever suffered from cold injury residuals. Simply put, he stated that the Veteran's disabilities, as demonstrated by the evidence, were more consistent with sequelae related to post-service injuries and related treatment. There is no need for him to provide further explanation. The basis for his conclusion is clearly articulated. Neither the Veteran nor his representative has made the RO or the Board aware of any other evidence relevant to his appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims adjudicated herein. The Board further finds that there has been substantial compliance with its prior remand. Despite the inadequacy of the medical opinions obtained in connection with the ordered examination, there is no prejudice to the Veteran in proceeding with appellate review because we have obtained an adequate VHA expert medical opinion in this case. II. Service Connection It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). The Board has thoroughly reviewed all the evidence in this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). However, continuity of symptoms is required where a condition in service is noted but is not, in fact, chronic or where a diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Further, service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson 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 (Fed. Cir. 2007). Lay persons can also provide an eye-witness account of an individual's visible symptoms. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that a layperson may comment on lay-observable symptoms). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert, 1 Vet. App. at 57. The Veteran filed the current claim seeking disability benefits for cold injury residuals involving the upper and lower extremities in August 2006. At that time, he wrote that he suffered frostbite to his hands and feet due to the exposure to extremely cold temperatures while serving in Korea during the Korean War. He later explained that he was exposed to extreme severe winter weather conditions (i.e., temperatures below zero) during the war and that such conditions caused cold injuries to his hands, feet, joints, and skin. The Board initially notes that the Veteran is competent to report having been exposed to cold temperatures during his period of service in Korea and there is no indication that his account of such exposure is not credible. It appears to be consistent with the circumstances and hardships of his service, which included service in Korea during the winter of 1951-52. Therefore, we find his account of cold exposure to be credible and it is accepted as fact. While the Board is remanding the remaining claims for further evidentiary development in order to make a determination as to the Veteran's combat status, we find no prejudice to the Veteran in proceeding with evaluating this claim at this time. In this case, we have concluded that the Veteran's exposure to cold temperatures in Korea is consistent with the hardships of his service and accept his account of such exposure as fact. We have also obtained a medical expert opinion that accepts the Veteran's competent account of such cold exposure as fact. The presumption afforded combat veterans only allows their statements regarding combat injuries to be accepted as sufficient proof of incurrence of the alleged in-service injury. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). There still has to be competent evidence of a nexus between service and the current claimed disability. See Wade v. West, 11 Vet. App. 302 (1998) (holding that evidence of a causal nexus between an in-service event and a current disability is still required even when a veteran is shown to have participated in combat); Collette v. Brown, 82 F.3d 389, 392 (1996). The Veteran, while competent to state that he was exposed to extremely cold temperatures in service, is not competent to identify any current disability as a cold injury residual. Thus, as we have already conceded cold exposure in service, the additional development ordered below would have absolutely no bearing on the outcome of this claim. In consideration of the foregoing, we now turn to the question of in-service incurrence of cold injury residuals. However, as explained below, a preponderance of the evidence weighs against finding that the Veteran has cold injury residuals causally or etiologically related to his period of active military service. First, the Board notes that no cold injury or residuals related thereto were clinically identified during the Veteran's period of active service. The Veteran's STRs appear to be complete and are completely devoid of any complaint, finding, or treatment for cold injury. The Veteran through his representative even indicated at the 2012 Board hearing that he neither reported nor received treatment for cold injury in service. See hearing transcript, page 4 (stating that most troops did not report cold injuries due to lack of medical services, etc., and there was not a lot of documentation for little things like frostbite; also speculating that the Veteran may have "long-term and delayed" sequelae). When asked at his 2010 hearing whether he sought treatment during service for cold injuries, he replied that he had not. The SPRs further show that the Veteran performed military service in Korea from August 1951 to July 1952. STRs show that he received medical treatment during this period for cellulitis involving the left leg in December 1951. However, the Veteran did not make one mention of having any problems involving his extremities due to cold exposure, and no medical examiner found evidence of cold injury at those times. It is also notable that the Veteran remained in service approximately one and a half years after serving in Korea and went to sick call on multiple occasions for various medical problems, to include lacerations involving the left hand and rash on the feet. However, again, there is absolutely no reference to cold-related injury involving the extremities or frostbite. The Board further notes that the January 1954 discharge examination report shows that the Veteran's vascular system, upper extremities, feet, lower extremities, skin, and neurologic system were all clinically evaluated as normal, and there is no notation referable to a cold injury at that time. Thus, the STRs show that the Veteran received medical treatment involving the upper and lower extremities at various times throughout his period of service, to include his time in Korea, but include absolutely no finding of cold injury or even mention any problems related to cold exposure. Because the medical treatment received by the Veteran during service often involved his hands and/or lower extremities and there was also physical evaluation of his upper and lower extremities at the time of discharge, the Board finds that a cold injury is the kind of injury that would have been observed and recorded during service if it had occurred. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (citing Fed. R. Evid. 803(7) for the proposition that the absence of an entry in a record may be evidence against the existence of a fact if it would ordinarily be recorded). Additionally, review of post-service treatment records from 1977 to 2006 (i.e., prior to filing his claim seeking service connection benefits) reveal that the Veteran never even mentioned having a history of cold injury or frostbite to any medical provider treating him for problems relating to the extremities during the period. He only referenced post-service injuries or events in reporting his medical history. For example, when the Veteran presented with complaint of fractured left tibia and fibula in January 1977, he explained that he fell while ice skating on January 22, 1977 injuring his left leg. The Veteran did not report at that time or any time from February 1977 to September 1977 when seeking treatment for residuals of the fracture that he had had prior cold injury involving the extremities. Less than a year later, when the Veteran received treatment for multiple injuries involving the left forearm, wrist, right tibia, and right femoral shaft in October 1977, he reported that he was driving home from work when another vehicle ran a stop sign and crashed into his vehicle. He stated that the steering column hit his thorax and upper abdomen and he injured his right thigh. He again made absolutely no mention of service or having had a prior cold injury involving the extremities at that time or in subsequent treatment notes related thereto dated from December 1977 to January 1982. Also, when reporting the history of present illness regarding his complaint of left hip pain in December 1983, the Veteran acknowledged having a history of multiple musculoskeletal problems but only reported post-service injuries and events such as a cervical disk excision in April 1983, a left medial meniscectomy in May 1978, a fractured right femur in October 1977, and a fractured left tibia and fibula in January 1977. He also stated that he had six months of left hip symptoms. He made absolutely no mention of service and specifically denied having any weather-related symptoms or cold weather symptoms. When seeking medical treatment for right knee pain in May 1985, he stated that he has had right knee problems since he was involved in a car wreck, also fracturing the right femur. He reported that he reinjured the knee in mid-April 1985 when he slipped on a carpet and fell down some stairs, which caused him to hyperflex the knee. Again, the Veteran made absolutely no mention of service or prior cold-related injury. In a private treatment record dated in January 1991, the Veteran presented for pre-operative evaluation prior to right total knee replacement. At that time, he was noted to have a history significant for arthritis secondary to trauma. However, the medical provider referenced the fact that the Veteran had been involved in a motor vehicular accident approximately 12 years before (i.e., in 1979) and subsequently had trauma involving his knees, wrists, and shoulders. The medical provider then wrote that the Veteran had surgery at that time for multiple fractures and subsequently over the years developed arthritis procedures for stabilization of the joints. The Veteran made no mention of having prior cold injury to the hands or feet and specifically denied having any history of rashes, ulcerations, easy bruising, or difficulty with wound healing on review of system related to his skin. The medical provider noted, on physical examination of the Veteran's extremities, that the Veteran had marked evidence of degenerative joint disease involving the shoulders, wrists, knees, and hips. When the Veteran sought orthopedic treatment for pain in the right index finger in June 2006, less than two months before filing his current claim, he stated that he had experienced increasing pain and disability related to the index finger metacarpal phalangeal joint over the course of the last ten years, which would place the onset of such pain approximately 42 years after service. He specifically denied having a specific history of trauma and made no mention of his period of active service or prior cold injury. In this regard, it is notable the Veteran withdrew his appeal for cold injury residuals involving the right index finger at the August 2010 Board hearing, on the bases that it was part and parcel of his claim for cold injury residuals involving the right upper extremity. See 2010 Board hearing transcript, page 2. Thus, after his discharge from service, the Veteran has suffered multiple injuries involving the upper and lower extremities beginning in 1977 and has received an extensive amount of medical treatment for residuals related thereto. However, the Veteran consistently related the onset of his pain to post-service injuries or events when seeking medical treatment, and not service, prior to filing the claim with VA. It is likely that the Veteran would be truthful about his history of cold-related symptomatology when seeking medical treatment, particularly when seeking treatment for his extremities. The Board also notes that the Veteran even denied having any weather-related symptoms or cold weather symptoms when reporting his medical history in 1983. More recently, in 2006, he denied having any specific history of trauma involving the right index finger and reported having pain and disability related thereto for approximately 10 years. The Veteran's reported history is further diminished in probative weight by his testimony in 2010. He was asked if he had incurred any serious injuries in motor vehicle accidents, and he replied, "Outside of getting knocked around, no." He was then asked if he had incurred any fractures, worn a cast, or anything like that, and he replied, "No." He then said he had been injured in one accident, but that it only involved his chest. When asked if it involved any of his extremities, he replied, "no, no." His attempt to deny post-service injuries to his extremities is patently false, as shown by the medical records that document left tibia/fibula fracture and a fractured right femur. In fact, following the right femur fracture, he was in traction for six weeks, followed by a cast for approximately six weeks. Whether the Veteran was purposely minimizing his medical history in conjunction with a claim for benefits, or whether his memory had simply dimmed with the passage of time, the fact remains that this very significant false testimony calls into question his credibility. While the Veteran is considered competent to report any observable symptomatology related to his claimed cold injury (i.e., cold sensitivity), his account is not deemed to be credible when weighed against the absence of any reference to cold injury in the STRs, as well as in post-service treatment records, when treated for problems involving the upper and lower extremities during those periods. See Buczynski, supra. Also, statements made by the Veteran before filing the current claim that consistently related his problems to post-service injuries and events weigh against his claim of cold injury residuals related to service. He even denied having any history of trauma related to his right index finger a little more than a month before filing his claim, despite the fact that he has alleged in-service cold injury related thereto during the course of this appeal. See Cartwright, supra. Furthermore, we find that the only probative medical opinion evidence of record weighs against finding that the Veteran currently has cold injury residuals due to in-service cold exposure. Indeed, after reviewing the evidentiary record and providing a thorough summary of the evidence relevant to the claim, the reviewing internist concluded that it was unlikely that the Veteran had current residuals of cold injury involving the upper or lower extremities related to his period of active service. The reviewing internist noted that he accepted as fact that the Veteran was exposed to extreme cold temperatures while serving in Korea and that he currently has debilitating arthritic symptoms in his bilateral knees, hips, left ankle, right wrist, shoulders and fingers. However, he was unable to make a connection between the Veteran's cold exposure in service and his current disability. He stated that the preponderance of the evidence suggested that the Veteran's current disabilities were directly related to both traumatic injuries that occurred after service and complications related thereto. In support of the conclusion, the reviewing internist noted that the Veteran's medical records did not show any significant diagnoses or complaints until 1977 when he fractured his left tibia and fibula while ice skating, and his right femur in a car accident. He noted that trauma to any joint is a known risk factor for the development of arthritis and, in the years following 1977, the chart documented progressive arthritic symptoms in his knees and left ankle, ultimately leading to numerous orthopedic surgeries on these joints. He noted that the sequelae of the surgeries also likely significantly contributed to the progression of his lower extremity joint degeneration due to alteration of his biomechanics. The reviewing internist then stated that the Veteran's right wrist injury and subsequent surgeries appeared to be directly related to a September 1986 injury. He noted that osteoarthritis of the hands and shoulders were common in adults over the age of 50 and, due to the late age at onset of the symptoms and their overall prevalence in the general population, it would be speculation to suggest a causal link to previous cold exposure. He noted that it would seem more likely that the symptoms were either due to post-traumatic degeneration from one of his previous traumatic events or occupational overuse. He further commented that there was no documentation in the Veteran's medical record concerning significant or chronic neurovascular changes, which could be attributed to his previous cold exposure. He acknowledged the Veteran's mention of cold sensitivity and color changes at his 2011 medical examination but found that such symptomatology is not sufficient to meet the criteria for definite Raynaud's phenomenon, which includes repeated episodes of biphasic color changes upon cold exposure, as well as numbness or parethesias. Furthermore, the Veteran was noted to have a normal neurovascular examination in 2006. The reviewing internist then concluded by stating that the Veteran's current upper and lower extremity disabilities appeared to be more likely than not associated with the documented events which occurred after his military service and unlikely with the accepted history of cold exposure while in service. The reviewing internist has the requisite medical expertise to provide a medical opinion regarding the likelihood of a relationship between the Veteran's current disabilities involving the extremities and in-service cold exposure. He also provided sound rationale for his conclusion based on a thorough review of the record and known medical principles. There is no indication that the medical opinion is inadequate. While the Board has considered the articles submitted by the Veteran pertaining to high rates of cold injury for Korean War veterans, they do not show that this Veteran suffered from cold injury as a result of his service. The facts presented in this Veteran's case weigh against such a finding for reasons explained above. Furthermore, while there are two favorable medical opinions of record finding that the Veteran's multiple joint arthritis was as likely as not residuals of in-service cold injury (i.e., the May 2011 VA medical opinion and the September 2011 VA medical opinion), the medical opinions are inadequate because they did not contain sufficient rationale. While the May 2011 and September 2011 examiner confirmed review of the claims file, he did not reconcile evidence contained therein that appeared to contradict his conclusion. See January 8, 1991 private consultation note (noting a past history significant for arthritis secondary to the trauma involving the major joints of the Veteran's body related to a motor vehicular accident that had occurred 12 years earlier); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that a medical opinion that contains only data and conclusions without any supporting analysis is accorded no weight). See Coburn, supra. Therefore, the medical opinions are afforded no probative value. As for the Veteran's belief that his exposure to cold during service resulted in some residual injury, this is simply not competent evidence. The determination as to whether cold exposure affected the body internally to such a degree that it later resulted in a medical condition is one that is too complex for a lay person such as the Veteran to opine on. Rather, here, an internist - a medical doctor who specializes in the disorders and diseases that affect the body - is the one who provides the most probative opinion on this issue. Moreover, it is not entirely clear whether the Veteran is asserting that he has experienced a continuity of symptomatology since service. At the 2012 hearing, his representative argued that the Veteran had "long-term and delayed" sequelae (see transcript, page 4) and the Veteran even testified at the Board hearing that his cold injury "[went] away" before his 1977 accident (see transcript, page 6), which would suggest no continuity of symptomatology. However, the Veteran also indicated at the Board hearing that he had symptomatology when he left service. He stated that he felt "so cold" during that first winter that he actually thought he was paralyzed a couple of times. Id. Nonetheless, the Board does not find the Veteran's account of continuity of symptomatology to be credible due to the absence of any mention of any cold related injury allegedly related to service until 2006, inconsistent statements of the Veteran regarding the onset of his symptomatology, and the unfavorable probative medical opinion evidence. Thus, in consideration of the foregoing, we find that the preponderance of the evidence weighs against the Veteran's claim. As such, service connection is not warranted for residuals of cold injury of the upper and lower extremities. In reaching the above conclusion, the Board notes that under the provisions of 38 U.S.C.A. § 5107(b), the benefit of the doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. Because the preponderance of the evidence, however, is against the claim, that doctrine is not applicable. [Continued on next page] ORDER Entitlement to service connection for residuals of cold injury of the upper and lower extremities is denied. REMAND Pursuant to the Court's Memorandum Decision, we must remand the issues of entitlement to service connection for bilateral hearing loss and PTSD. Adjudication of the issue of entitlement to service connection for tinnitus is also deferred pending the outcome of the ordered development below. The Veteran has alleged that his unit participated in combat from September 11 to 25, 1951 and in April 1952 seeks status as a combat Veteran. According to service records, the Veteran was assigned to H&SCo,1stAMTracBn,FMF during this period. The Court has ordered the Board to seek his unit records for the identified period and determine whether the Veteran has combat status. There are some unit records in the file, but it is not clear whether they completely cover the time periods needed. Following such development and a determination as to whether the Veteran is a combat Veteran, we must then assess whether he is entitled to a VA medical examination for his PTSD. Regarding hearing loss, the Court has ordered the Board to make a determination regarding the credibility of the Veteran's assertion that he was exposed to combat noise during his period of active service, as he contends. Thereafter, we must assess whether he is entitled to a VA medical examination for his hearing loss. In consideration of the foregoing, we find that we must defer adjudication of the Veteran's claim for hearing loss until evidence contained in his unit records may be considered as it will likely have a bearing on our credibility determination as it relates to the Veteran's assertion of in-service noise exposure. Although the issue of entitlement to service connection for tinnitus was not before the Court, the ordered development clearly relates to the claim. The Board similarly has to make a credibility determination regarding in-service noise exposure when adjudicating that claim. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). Expedited handling is requested.) 1. Obtain unit records for (a) September 11 to 25, 1951, and (b) April 1952, which are the periods the Veteran asserts that his unit (H&SCo, 1st Amphibian Tractor Battalion, Fleet Marine Force) participated in combat. Any negative responses should be properly documented in the record, to include following the procedures outlined in 38 C.F.R. § 3.159(e), if appropriate. 2. Thereafter, make a determination regarding whether the Veteran has combat service. 3. If and only if the Veteran is determined to have combat status or his claimed stressor event(s) is/are otherwise deemed sufficiently verified, schedule the Veteran for appropriate medical examination to determine whether he currently suffers from PTSD. All relevant documents and records (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be made available to and reviewed by the examiner in rendering the opinion. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner/reviewer must confirm that the record was reviewed in the examination report. Based on review of the appropriate records and evaluation of the Veteran, the examiner should answer the following questions: 1) Does the Veteran currently suffer from PTSD or any other psychiatric disability? 2) If so, is it at least as likely as not (i.e., to at least a 50-50 probability) that the Veteran's PTSD/psychiatric disability is causally or etiologically related to service, to include any event or incident therein; or, alternatively, is any such relationship to service unlikely (i.e., less than a 50-50 probability)? The examiner must specify which of the Veteran's claimed stressor events involving his service are sufficient to support the PTSD diagnosis. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. The examiner should fully explain how he or she arrived at the answers provided. If the examiner cannot answer any question without resorting to unsupported speculation, the examiner should so state, and explain why that is so. 4. If and only if the Veteran is determined to have combat status or is otherwise shown to have been exposed to combat noise in service, schedule the Veteran for appropriate medical examination regarding his claimed hearing loss and tinnitus. All relevant documents and records (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be made available to and reviewed by the examiner in rendering the opinion. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner/reviewer must confirm that the record was reviewed in the examination report. Based on review of the appropriate records and evaluation of the Veteran, the examiner should answer the following question: Is it at least as likely as not (i.e., to at least a 50-50 probability) that the Veteran's hearing loss and/or tinnitus is causally or etiologically related to service, to include any event or incident therein (the Veteran alleges acoustic trauma resulting from in-service noise exposure); or, alternatively, is any such relationship to service unlikely (i.e., less than a 50-50 probability)? Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. The examiner should fully explain how he or she arrived at the answers provided. If the examiner cannot answer the question without resorting to unsupported speculation, the examiner should so state, and explain why that is so. 5. After the above has been accomplished to the extent possible, readjudicate the Veteran's claims. Should the benefits sought on appeal remain denied, provide the Veteran and his representative with a Supplemental Statement of the Case (SSOC) and an appropriate period of time for response. Thereafter, return the case to the Board, if in order. This case is REMANDED for further evidentiary development and to ensure due process. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs