Citation Nr: 1301656 Decision Date: 01/15/13 Archive Date: 01/23/13 DOCKET NO. 06-21 317 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a lung disability, to include chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis, pulmonary hypertension, and pulmonary edema associated with the lung disability. 2. Entitlement to service connection for a heart disability, to include angina, congestive heart failure, coronary artery disease (CAD), and hypertensive heart disease associated with the heart disability. 3. Entitlement to service connection for an acquired psychiatric disability. 4. Entitlement to an initial compensable rating for bilateral hearing loss. 5. Entitlement to an initial rating in excess of 10 percent for tinnitus. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD Andrew Mack, Counsel INTRODUCTION The Veteran had active military service from August 1957 to July 1959. This case comes before the Board of Veterans' Appeals (Board) on appeal from December 2005 and October 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In November 2008, the Board denied service connection for the lung and heart disability issues on appeal, as well as for asthma, shortness of breath, and sleep apnea. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In September 2009, the parties submitted a Joint Motion requesting a partial remand of the issues. The Veteran indicated that he did not wish to appeal the Board's decision denying service connection for asthma, shortness of breath, and sleep apnea, and withdrew his appeal with respect to those issues. The Court granted the Joint Motion, vacated the Board's decision with respect to the issues still on appeal, and remanded the matters for additional development. The heart and lung disability issues were remanded by the Board in December 2009 and October 2011 for further development. They have been returned for further appellate review. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. The Board has reorganized the Veteran's claims in order to better address the Veteran's contentions in a clear and concise manner. All issued cited by the Board in October 2011 are being addressed within this decision. The issues of service connection for a psychiatric disability, an initial compensable rating for bilateral hearing loss, and an initial rating in excess of 10 percent for tinnitus 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. In a July 2011 statement, the Veteran raised the issue of entitlement to service connection for a neurological disability, but such issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. No lung disability, including COPD, emphysema, chronic bronchitis, pulmonary hypertension, and pulmonary edema, is related to in-service lead exposure, or to service in any other way. 2. No heart disability, including angina, congestive heart failure, CAD, and hypertensive heart disease, is related to in-service lead exposure, or to service in any other way. CONCLUSIONS OF LAW 1. The criteria for service connection for a lung disability, to include COPD, emphysema, chronic bronchitis, pulmonary hypertension, and pulmonary edema, have not been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. The criteria for service connection for a heart disability, to include angina, congestive heart failure, CAD, and hypertensive heart disease, have not been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. 3.303(b). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including cardiovascular disease and organic diseases of the nervous system, will be presumed to have been incurred in service if they had become manifest to a degree of ten percent or more within one year of the Veteran's separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Routen, 10 Vet. App. 183. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. As reflected in his September 2004 claim and in numerous subsequent written statements, the Veteran essentially contends that that lung and heart disabilities are due to direct contact with paint fumes while assigned to a paint locker in service from August 1957 to July 1959, more than 50 years ago. Specifically, the Veteran has contended that he was extensively exposed to lead through paint fumes, chips, and dust while in charge of a paint locker aboard a seafaring vessel during his active service, where his duties included opening and mixing cans of paint, and that such lead exposure resulted in his claimed lung and heart disabilities, and the residuals problems cited above. Service treatment records reflect no complaints or treatment related to any heart or lung problems. The July 1959 report of examination for the Veteran's separation from service reflects a normal clinical evaluation of the heart, lungs and chest, with no heart or lung problems noted. The Veteran's blood pressure at that time was measured as 118/54, and chest X-rays at the time were noted to be negative, providing limited evidence against these claims. The Veteran's service personnel records, including his DD Form 214 (Report of Transfer or Discharge) reflect that the Veteran served one year, eight months, and 25 days on foreign or sea service, but reflect no noted military occupational specialty. Naval Reserve Administrative Remarks dated in July 1960 reflect that the Veteran's performance of duty while in training duty status from July 4, 1960, to July 16, 1960, was unsatisfactory for the reason of "Lack of Aptitude." A January 2001 private treatment record reflects that the Veteran presented for possible Alzheimer's disease. The Veteran reported a change of mood over the last year, becoming more irritable and argumentative, but denied any particular problems with memory, and reported running his business a usual. His past medical history was noted to have been hypothyroidism, rosacea, asthma, arthritis, and being hit by motor vehicles at age seven. It was noted that the Veteran's father had Alzheimer's. The diagnosis was memory disturbance, noted to be minor, if at all present, by history, and it was noted that the Veteran checked out very well by the mini-mental state examination. A June 2001 private treatment note reflects that the Veteran was seen for problems with his right knee. It was noted that X-rays appeared unremarkable. The earliest indication in the medical record of any heart or lung disability other than asthma is private treatment records dated in July 2001, related to surgery to repair a right medial meniscus tear. July 11 chest X-rays revealed normal heart size with ecstatic calcified aorta but no mediastinal mass or adenopathy and no plural disease. There was noted to be an eventration of the right anterior hemidiaphragm producing elevation of the diaphragm, and prominent peribronchial markings suggesting bronchitis with calcified granulomatous disease. Following his surgery on July 13, the Veteran was treated for respiratory failure, and it was noted that postoperatively the Veteran had an episode of desaturation and had to be reintubated. It was noted that the Veteran's wife reported a history of lung disease, that the Veteran was dyspneic on exertion, that he stopped smoking 20 years before, and that he reported no chest pain or palpitations. It was noted that the Veteran's history was only significant for lung disease and that he denied any hypertension or history of heart disease or central nervous system disease. His blood pressure was noted to be 130/80. The diagnoses were postoperative respiratory failure, suspected to be a side effect of anesthetics, and underlying COPD. July 13, 2001, chest X-rays revealed that peribronchial thickening and bronchitis with prominent lung markings in the bases appeared worsened with increasing atelectasis, and pulmonary vasculature in the upper lung field significantly worsened with a larger heart size, and it was noted that there may be mild failure with bibasilar infiltrates; the impression was ET tube with prominent heart size and suggestion of mild failure with bibasilar infiltrates. July 15 chest X-rays revealed the left base showing much improved infiltrates with mild residual prominence of markings and mild residual on the right, with no plural disease seen. A September 10, 2003, private treatment record reflects that the Veteran was seen for cardiac evaluation after having shortness of breath and having "apparently" been diagnosed with congestive heart failure in the past. It was noted that a couple of years prior, during knee surgery, he had sustained a cardiac arrest, and was not aware of a cardiac work up in the past. He also related chest tightness and fluttering on a daily basis. His reported past medical history was noted to have been positive for angina, congestive heart failure, and pulmonary edema. His cardiac risk factors were noted to have been hypertension or diabetes, and smoking for 24 years but quitting 24 years prior. After evaluation, the Veteran was assessed as having symptoms compatible with left sided heart failure, with angina symptomatology, palpitations, long history of smoking, family history of CAD, and history of hypertension and diabetes. A September 15, 2003, stress gated myocardial perfusion study revealed negative stress electrocardiogram (EKG) for ischemia, although less specific due to abnormal baseline EKG, negative stress gated myocardial perfusion study for ischemia, and modern global left ventricular systolic dysfunction with a regional variation. On September 22, the Veteran underwent right and left heart catheterization, selective coronary angiography, and left ventriculography. Following the procedures, the impression was trivial CAD, possible catheter-induced spasm of the proximal right coronary artery versus atherosclerotic plaquing, mild pulmonary hypertension, and possible symptomatology based on sleep apnea. An October 2003 private treatment record reflects that the Veteran presented after his cardiac catheterization had demonstrated mild pulmonary hypertension and trivial CAD. It was noted that he had sleep apnea and hypertensive heart disease. After examination, it was noted that the Veteran appeared to have hypertensive heart disease with mild pulmonary hypertension, possibly pulmonary hypertension due to sleep apnea, coughing possibly from ACE inhibitor, and history of hypertension and hypertension heart disease. An April 2004 VA primary clinic note reflects that the Veteran sought to establish treatment at a VA Medical Center. After evaluation, the diagnoses included chronic cough with history of smoking, likely chronic bronchitis, and hypertension, controlled. A May 2004 VA treatment record includes an assessment of COPD. An April 2004 private treatment record reflects that the Veteran was seen for shortness of breath, that he had been diagnosed with COPD and wheezing, and that he was told that he had congestive heart failure in 2001. He did have some sleep apnea and woke up with shortness of breath, and was able to walk slowly and could only go about 100 yards due to shortness of breath. It was noted that he had given up smoking about 17 years before. The examining physician stated that most of the Veteran's shortness of breath was probably pulmonary in origin, but that he could have had some underlying heart failure. March 2006 chest examination by the Veteran's private physician, Dr. Kumar, reflects that chest X-rays showed low lung volumes, elevated right hemidiaphragms, and no confluent infiltrate or pleural effusion identified. Chest fluoroscopy resulted in a diagnosis of paralysis of the right diaphragm. In a statement received in connection with his June 2006 substantive appeal, the Veteran expressed that his claim for service connection was based on extreme exposure to paint fumes, paint chips, and dust while in charge of paint locker aboard a seafaring vessel during his active military service, where his duties included opening and mixing cans of paint. The Veteran also summarized articles relating to the effects of lead exposure, which stated that lead components are found in paint, human exposure occurs when dust and fumes are inhaled, lead entering the respiratory system is released to the blood and distributed through the body, more than 90 percent of total body burden of lead is accumulated in the bones where it is stored for decades, 30 years or more, and lead in the bones may be released to the blood and reexposed to organ systems long after the initial environmental exposure. The articles noted by the Veteran further stated that the most important aspects of lead toxicity were its effects on the central nervous system, which may be irreversible, but that lead affected all organs and functions of the body to varying degrees, and that the frequency and severity of symptoms among exposed workers depended on the level of exposure. The Veteran further asserted that chronic high exposure to lead is associated with an increased incidence of hypertension and cardiovascular disease, from which he suffered. The articles noted by the Veteran also stated that historically lead paint was favored and specifically required by the federal government, that once lead pigment was proven to be a health hazard, regulations went into effect to ban lead from paints in 1978, long after the Veteran's service, and that it was not possible of the body to rid itself of all the lead that had entered it, as lead will remain stored in the bones for decades beyond the initial exposure period. The articles summarized by the Veteran further stated that symptoms of lead poisoning were frequently mistaken for a cold or flu virus, and that, furthermore, symptoms could come and go for several months or years, and that tiredness, sleep problems, weakness, dizziness, clumsiness, irritability, difficulty concentrating, forgetfulness, nervousness, and joint and muscle pain and numbness may be signs of lead poisoning; the Veteran noted that he suffered from sleep apnea, Parkinson's disease, and osteoarthritis. The articles also indicated that some of the medical effects of lead poising in adults included easy fatigability, dizziness, rapid heartbeat, neurological effects, irritability, insomnia, headache, memory impairment, tremor, apathy, fatigue, drowsiness, concentration problems, hypertension, and gouty arthritis, and the Veteran asserted that he suffered from these conditions. In the Veteran's statement, he also asserted that although his service treatment records did not indicate treatment for lead poisoning symptoms, he did not know at the time that he was in charge of the paint locker that his breathing problems were the result of lead-based paint exposure, and did not seek military medical help but rather sought over-the counter assistance such as breathing assistance devices and various medications. In a statement received in June 2007, the Veteran again asserted that his breathing problems due to inhalation of lead-based paint fumes had an immediate onset, but that he self-treated for such breathing problems. The Veteran submitted a letter from Dr. Kumar, dated in July 2006, reflecting that it was Dr. Kumar's understanding that the Veteran was in charge of a paint locker for a seafaring vessel on active military duty, and that on reviewing the Veteran's medical records and the Veteran's research into the possible medical conditions associated with lead poisoning and exposure to lead, it was Dr. Kumar's opinion that some of his medical conditions, including his paralyzed diaphragm, may be related to exposure from lead-based paints. Another letter from Dr. Kumar, dated in November 2006, reflects that Dr. Kumar reviewed the Veteran's entire medical record and did lengthy research on medical conditions associated with lead poisoning and exposure to lead, and that the Veteran had COPD and a paralyzed diaphragm and suffered from frequent chronic bronchial disorders. Dr. Kumar stated that based on his education, with special studies and emphasis on lung diseases, along with his extensive medical background and years of practice, he was of the opinion that it was his exposure to lead that caused these medical conditions. The Veteran also submitted a statement from his service comrade, J.L., received in December 2008, asserting that when J.L. was in the Navy, he had to do a lot of painting about the ship, and had to go to the paint locker to check paint out and back in again when he needed it. J.L. stated that most of the time the Veteran was in the locker logging the pain in and out, and that sometimes when he would be in there the Veteran would be coughing and gagging because the smell and fumes were very strong. The report of a January 2007 VA examination reflects that the Veteran reported serving from 1958 to 1960 aboard a ship, where he was in charge of the paint locker. He reported that he could not breathe well, that he could only walk a block or two before become short of breath, and that he had started to get short of breath about three or four years prior. He reported that in 2003 he was diagnosed with obstructive sleep apnea. The Veteran reported smoking half a pack a day for about 10 years but quitting in 1974. The VA examiner diagnosed COPD, obesity, obstructive sleep apnea, well-controlled hypertension, questionably controlled diabetes mellitus, and shortness of breath most likely secondary to COPD, rule out congestive heart failure. Chest X-rays revealed normal cardiomediastinal silhouette with normal pulmonary vasculature, no infiltrates and effusion, and right diaphragmatic eventuation, stale since April 2004. In a March 2007 addendum opinion, after reviewing the claims file, the January 2008 VA examiner stated that although there was a connection between paint exposure and development of asthma, it usually occurred either during the exposure or immediately therafter and certainly within the first two years. It appeared to the examiner that by the records the Veteran did not have any symptoms during the time he was on active duty and his examinations did not mention any complaints of asthma or difficulty breathing. The examiner further noted that on separation examination there was no mention of breathing difficulties, and that if the Veteran had had breathing problems from lead paint exposure he would have exhibited some symptoms either at that time or shortly thereafter. The examiner opined that it was therefore less likely than not that the Veteran's lung problems were related to lead paint fumes in service, that chronic asthma was the cause of the Veteran's COPD, and that the Veteran's paralyzed diaphragm was not related to his lead pain exposure during active duty service. Private treatment records dated in July 2008 reflect that, on examination, the Veteran had respiratory symptoms of cough and shortness of breath, but that, on neurological examination, the Veteran was negative for dizziness, tingling, tremors, sensory change, speech change, focal weakness, seizures, loss of consciousness, weakness and headaches. In May 2010, the Veteran was noted to have had normal reflexes, no cranial nerve deficit, normal muscle tone and coordination and strength, but a right facial droop. The diagnosis was encephalopathy. The report of a May 2010 VA examination reflects that the Veteran had a previous history of smoking estimated at 24 years, but that he quit in 1979, and that the service treatment records did not show any physical complaints during the time he was in service. It was noted that the Veteran had a long history of progressive shortness of breath, that following arthroscopic surgery of the right knee in approximately 2000, he had sudden desaturation and respiratory arrest occurring in the recovery room, was reintubated, and taken to the intensive care unit at this time, and that there was documentation that his wife stated that he had had a long history of lung disease and dyspnea on exertion. It was also noted that is emphysema was well-established by the year 2000-2001, by his history, and that he had cardiac workup in 2003 with heart catheterization and echocardiogram, and he was evaluated for left heart failure and found to have had mild cardiomyopathy. It was noted that heart catheterization showed trivial non-obstructive CAD, and he had mild pulmonary hypertension. It was further noted that the Veteran was diagnosed with obstructive sleep apnea in May 1995, and his cardiologist felt that mild pulmonary hypertension was related to such sleep apnea. The VA examiner noted that the Veteran claimed that his heart and lung problems were related to inhaling fumes from lead paint in service, but that the Veteran had never had any history of lead toxicity, never had lead levels measured and never exhibited neurological signs of lead toxicity, and therefore that it was only speculation that any of his cardiac conditions or pulmonary emphysema could be related to lead exposure. The examiner stated that the service treatment records were silent for any health complaints and specifically neurological complaints. The diagnoses were COPD/emphysema directly related to cigarette smoking and the aging process; acute respiratory failure following surgery in July 2001 without any recurrence; mild pulmonary hypertension secondary to COPD, asthma and right ventricular dysfunction; mild right ventricular dysfunction likely secondary to chronic obstructive sleep apnea by opinion of his cardiologist; no current evidence of pulmonary edema, with current X-rays normal; no current evident of congestive heart failure, with chest X-ray currently and three years ago showing normal cardiac silhouette; non-obstructive CAD showing on cardiac catheterization, but of no clinical significance, as it was not ischemic and was likely related to inherited genetic factors, history of cigarette smoking, and essential hypertension; and hypertensive heart disease not found, with some congestive heart failure in the past likely related to essential hypertension. The examiner opined that the Veteran's main problem was his concerns with progressive COPD and emphysema, which was related to his cigarette smoking, and that physical examination did not indicate cardiac failure or pulmonary edema. The examiner further stated there was no evidence that exposure to lead paint fumes in service had any effect on his current health conditions, and that any assertion of lead paint fumes related to current heart disease or COPD and emphysema was pure speculation. At the time, chest X-rays revealed lungs clear and heart size normal, with no congestive heart failure or pleural effusion, bones and upper abdomen soft tissues normal and stable since January 2007 with no change, and eventration of the right hemidiaphragm again noted. In a March 2011 addendum to the May 2010 VA examination report, the VA examiner opined that it was unlikely that the Veteran's COPD with emphysema was related to his military service, as, while the Veteran had a long history of shortness of breath aggravated by exertion, he smoked for many years, stopping in 1979, and there was no documentation of pneumonia, exposure to asbestos or other substances that could cause COPD or emphysema. The examiner stated that there was no information in the claims file indicating that the Veteran had ever had pulmonary edema, which was acute build up of fluid from the circulation in the small airways of the lungs, usually due to sudden left heart failure. The examiner also opined that while the Veteran was treated for viral respiratory illness during service, such illnesses were common in younger individuals in the military but did not cause COPD. The examiner further opined that while congestive heart failure was listed as a past medical condition in an early clinical note, the condition had not been diagnosed in the last five years, and that echocardiograms performed by the Veteran's private cardiologist did not determine that he had left ventricular failure, the most common cause of congestive heart failure, and thus that it was unlikely that the Veteran had congestive heart failure. The examiner explained that the Veteran was found to have mild secondary pulmonary hypertension, or high pressure within the vessels of the lungs, which may accompany severe obstructive sleep apnea and could also be seen in severe COPD. The examiner noted that the Veteran was diagnosed by his private cardiologist with mild right-sided congestive heart failure caused by pulmonary hypertension, and that this was a type of heart failure in which there was peripheral edema, or swelling of the lags, but no build up of fluid in the lungs, commonly referred to as right-sided heart failure or cor pulmonale, and that as this was likely due to the Veteran's obstructive sleep apnea and was unlikely related to his military service. The examiner opined that CAD discovered in 2005 was unlikely related to the Veteran's service as it took many years to develop. The examiner further explained that hypertensive heart disease is a condition caused by hypertension, characterized by left ventricular hypertrophy, and that pulmonary hypertension develops in the lung circulation, usually as a secondary disorder to either extensive scarring in the lungs or constriction of the lung arteries, brought on by hypoxia, as in obstructive sleep apnea, which can become symptomatic when it is severe enough to cause right heart failure, and that it was likely that the Veteran had a mild version of this disorder as evidenced by the echocardiogram and cardiac eventration in 2004 and 2005. The examiner further stated that, as the Veteran completed his service in 1959, it was highly unlikely that any of his heart or lung disorders had their onset while he was on active duty and would not have been caused by his military service. The examiner stated, that regarding Dr. Kumar's letter suggesting that exposure to lead paint would have caused the Veteran's disabilities, this appeared to able a wildly speculative claim and no documentation was offered, and that it could be stated with reasonably certainty that lead poisoning was not a cause of the Veteran's medical problems. The examiner stated that chronic lead poisoning could lead to neuropathy with weakness in certain muscles, as well as anemia, but that the Veteran had not been documented to have these. The Veteran was afforded another VA examination in November 2011. The report of examination reflects that the Veteran had diagnoses of CAD, hypertensive heart disease, and cardiomyopathy beginning in 2003, but that none of the Veteran's heart conditions qualified as ischemic heart disease. He also had the diagnoses of emphysema, COPD, and chronic bronchitis, with onset date of 2000, and pulmonary hypertension, with diagnosis date of 2003. It was noted that the Veteran had a history of COPD (emphysema and chronic bronchitis) dating back to about 2000, and a history of prior tobacco use, with about 24 pack years until 1979. It was also noted that the Veteran had a history of pulmonary hypertension diagnosed on coronary catheterization in about 2003. November 2011 X-rays revealed normal chest in appearance. The VA examiner, after reviewing the Veteran's claims file, remarked that the Veteran's COPD, which was a combination of chronic bronchitis and emphysema, had been diagnosed since at least 2000, and that the most common cause in about 90 percent of cases of COPD was cigarette smoking, but that other causes included chronic lung infections, long-term exposure to asbestos or other lung irritants, and genetic deficiencies. The examiner remarked that she could not find complaints of shortness of breath, difficulty breathing, or wheezing in the Veteran's service treatment records, but noted that he had been treated for acute viral respiratory illness, but no chronic infections or severe respiratory problems. The examiner noted that the Veteran had a normal chest X-ray in April 1959 and July 1959 and again had no complaints of respiratory problems. The examiner further noted that several years following discharge from the military the Veteran had a "knee condition" for which a progress note in June 2001 notes that X-ray of the knee was unremarkable, with no findings of lead on film of the knee, and no mention of dense metaphyseal lines. The examiner noted that in adults, 94 percent of absorbed lead is deposited in the bones and teeth, and that the estimated half-life of lead in bone was 20 to 30 years. The examiner therefore opined that it was less likely than not that the Veteran's COPD, chronic bronchitis, and emphysema were related to his military service, as there was no evidence documented suggesting lead toxicity in the Veteran. Regarding the Veteran's claimed pulmonary edema and pulmonary hypertension, the examiner stated that pulmonary edema was typically a result of congestion of fluid from circulation in the lungs and typically resulted from acute left-sided heart failure, and the examiner was unable to locate any findings or documentation of left heart failure or documentation of pulmonary edema in the Veteran's medical records. The examiner noted that in September 2003, the Veteran underwent an echocardiogram with findings of normal left ventricle systolic function with a mild diastolic relaxation abnormality, and that the Veteran underwent coronary catheterization September 2003 which documented normal left ventricular ejection fracture, with no indication of left heart failure. The Veteran was found to have trivial CAD and mild pulmonary hypertension, but his symptomatology at the time was felt to be secondary to sleep apnea at the time of the Veteran's CAD and pulmonary hypertension. The examiner stated that the Veteran's symptomatology was felt secondary to sleep apnea at the time of his coronary catheterization, and that the Veteran underwent sleep study in May 2005, which documented sleep apnea. The examiner noted that there could be many causes of pulmonary hypertension such as left heart disease, lung diseases or hypoxemia, embolic or other diseases or familial, but that the likely etiology of mild pulmonary hypertension in the Veteran, as his cardiologist suggested, was from his sleep disordered breathing and chronic hypoxia from his obstructive sleep apnea. Regarding the Veteran's claimed angina, CAD and congestive heart failure, the examiner stated that angina was defined as chest pain caused by ischemia or inefficient oxygen delivery to the cardiac muscle. The examiner stated that the records did not show that the Veteran had significant CAD to cause obstruction or ischemia to the heart, and it was not likely that the Veteran's subjective history of chest pain was related to lack of oxygen delivery to the heart muscle as this was not demonstrated on the Veteran's coronary catheterization. The examiner also noted that the Veteran also underwent a nuclear stress test in 2003, and there was no scintigraphic evidence of ischemia at that time, and concluded that there was no evidence documenting significant CAD or angina secondary to ischemia in the Veteran. The examiner further stated that congestive heart failure occurred when there was congestion of fluid in the lungs and general circulation, which typically caused generalized edema but especially to the lower extremities ranging from trace to pitting edema. The examiner explained that there were numerous causes of congestive heart failure, but the examiner could not find evidence documenting clinically significant congestive heart failure in Veteran's file. The examiner stated that CAD developed over many years and was caused by cholesterol-containing deposits or plaque build-up in the coronary arteries, and that risk factors for CAD included older age, male gender, family history, smoking, hypertension, high cholesterol, diabetes, obesity, sedentary lifestyle, and high stress. The examiner stated that the Veteran's mild CAD was more likely related to his multiple risk factors than military service. The examiner further stated that significant congestive heart failure in the Veteran had not been documented and was therefore not related to military service. Regarding the Veteran' s claimed hypertensive heart disease, the examiner stated that it occurred due to the complication of longstanding hypertension or high blood pressure, as the workload of the heart was increased manifold and over a long period of time the heart muscle thickened and became less compliant. The examiner stated that the Veteran's cardiac echocardiogram documented diastolic dysfunction, which was decline in performance of one or both ventricles of the heart during the time or phase of a diastole, and that hypertensive cardiovascular disease was a direct result of longstanding hypertension. The examiner stated that the Veteran's had mild hypertensive heart disease that was not likely caused by military service and instead was more likely a direct result of his longstanding hypertension. The examiner further stated that while the Veteran had claimed respiratory and cardiovascular problems secondary to lead toxicity, and while lead toxicity may lead to multi-symptom conditions, typically lead toxicity caused the greatest impact on the neurologic system, and lead toxicity in adults would generally involve complaints of headache, abdominal pain, memory loss, mood disorder, decline in mental function, seizures, loss of consciousness, decreased appetite, anorexia, pain, numbness, or tingling of the extremities or generalized fatigue or malaise. The examiner noted that she could not locate any reported neurologic complaints in service treatment records, there were no measurements or serosal measurement serum lead levels to reference the Veteran's service treatment records or in the Veteran's claims file during his military service, following discharge, around the time of onset of is cardiovascular or respiratory problems, or following diagnosis of such conditions. The only pertinent evidence found by examiner was an unremarkable knee X-ray that did not mention any lead lines or indication of lead toxicity in the Veteran. The examiner stated that, regarding the opinion of Dr. Kumar that the Veteran's respiratory problems were a result of his in-service exposure to lead, the Veteran did not make any respiratory complaints consistent with lead toxicity during his military service or indicate any respiratory problems on his exit history and physical examination, did not make any neurologic complaints consistent with lead toxicity during military service or on exit examination. The examiner further stated that she had reviewed multiple credible sources of literature regarding lead toxicity in adults, but could not find any credible literature that documented a clear link to the respiratory and cardiovascular conditions claimed by the Veteran at a time period several years later and in the absence of any documented complaints or evidence of neurologic manifestations of lead toxicity, and could not find any credible literature to substantiate lead toxicity as the etiology of the respiratory and cardiovascular conditions claimed by the Veteran. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the Veteran's claims for service connection must be denied. While the record reflects lung disabilities including COPD, emphysema, chronic bronchitis, and mild pulmonary hypertension, and heart disabilities including mild CAD and mild hypertensive heart disease, such disabilities are not related to in-service lead exposure, or to service in any other way. Initially, the evidence does not establish the existence of any chronic disability of the lung or heart either in service or until many years after the Veteran's service. Service treatment records reflect no findings related to any heart or lung problems, and the Veteran's July 1959 separation examination report reflects a normal clinical evaluation of the heart, lungs and chest, with no heart or lung problems noted, blood pressure of 118/54, and negative chest X-rays. The earliest indication of any heart or lung disability other than asthma is the July 2001 private treatment records related to knee surgery, dated more than 40 years after the Veteran's separation from service, which indicate that the Veteran denied any hypertension or history of heart disease. While at that time it was noted that the Veteran's history was significant for lung disease, there was no indication given that such lung disease dated back to the Veteran's period of service; rather, the only pertinent history related to lung disease given was the Veteran's history of smoking. Even assuming the credibility of the December 2006 statement of J.L. that J.L. often visited the paint locker in service, that the smell of the fumes was very strong, and that sometimes he witnessed the Veteran coughing and gagging, such statement does not establish the existence of any chronic lung disability. Also, while in his June 2006 and June 2007 statements, the Veteran stated that his breathing problems due to inhalation of lead-based paint fumes had an immediate onset but that he did not seek military medical help and rather sought over-the counter assistance such as breathing assistance devices and various medications, the Board does not find such statements to be credible. Again, despite the Veteran's assertions that significant breathing problems began in service while inhaling fumes, there is no report related to breathing problems in the service treatment records. Furthermore, and more importantly, such history of breathing problems due to inhalation of fumes was never given by the Veteran in reporting his medical history related to his lung problems prior to the date of his claim, including during his July 2001 surgery complications; his September 2003 private treatment for shortness of breath where his risk factors were noted to have been hypertension or diabetes and smoking for 24 years (but no history of exposure to paint fumes noted); the April 2004 VA note where diagnoses included chronic cough and likely chronic bronchitis and history of smoking noted (but no history of exposure to paint fumes noted); and the April 2004 private treatment record reflecting that the Veteran was seen for shortness of breath, where the Veteran's history of heart failure in 2001, sleep apnea, and smoking was noted, but not any history of fume inhalation or any other event related to service. Despite his prior treatment for lung and heart problems, the Veteran reported no history of inhaling fumes or exposure to lead, or any other instance of breathing problems in service, until after he filed his September 2004 claim. The Board, on a factual basis, finds it unlikely, in the extreme, that if the Veteran were having such problems for over 40 years he would not have reported those problems to his private health care providers prior to the filing of his claims during important and serious treatment of nonservice connect disabilities. The Veteran is simply found to not be an accurate historian of his disabilities for these reasons. Thus, neither chronic lung disease nor heart disease in service nor continuity of symptoms related to lung or heart problems after discharge has been shown in the record, and the evidence establishes that none of the Veteran's lung and heart disabilities on appeal were incurred until many years after service. The presumptive service connection provisions of 38 C.F.R. §§ 3.307 and 3.309 are therefore not applicable. The Board recognizes the Veteran's assertions that during a significant portion of his service from August 1957 to July 1959, he was in charge of paint locker aboard a seafaring vessel where his duties included opening and mixing cans of paint, and where he was exposed to lead paint fumes, as well as the December 2006 statement of J.L. that J.L. often visited the paint locker, that the smell of the fumes were very strong, and that sometimes he witnessed the Veteran coughing and gagging. However, even assuming the credibility of these statements (which are now in serious question, notwithstanding the statements he has submitted in support of his claims, in light of the finding above that the Veteran is not an accurate historian), and that the Veteran was exposed to lead paint fumes that caused occasional coughing and gagging, the Board nonetheless finds that a preponderance of the evidence is against the Veteran's claims. The medical opinion evidence, specifically the VA examiners' opinions of record and the July and November 2006 private opinions of Dr. Kumar, are conflicting as to whether any of the Veteran's claimed disabilities are related to in-service lead exposure. However, the Board finds that the probative and persuasive medical evidence in this case weighs against the Veteran's claims. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). In this case, the Board finds that the most probative and persuasive evidence regarding whether the Veteran's lung and heart disabilities on appeal are the result of in-service lead exposure is the report of the November 2011 VA examiner. The examiner's report includes opinions with thorough and persuasive rationales and explanation, extensive citation to the record, discussion of pertinent medical literature and principles, and application of such principles to the facts of the case. It also addresses and fully discusses the opinion letters of Dr. Kumar. In determining that the Veteran's lung and heart disabilities were not the result of lead exposure, the November 2011 VA examiner explained that while lead toxicity may lead to multi-symptom conditions, typically lead toxicity will cause the greatest impact on the neurologic system, and lead toxicity in adults would generally involve complaints of headache, abdominal pain, memory loss, mood disorder, decline in mental function, seizures, loss of consciousness, decreased appetite, anorexia, pain, numbness, or tingling of the extremities or generalized fatigue or malaise, none of which was documented in service. The examiner also pointed out that while 94 percent of absorbed lead is deposited in the bones and teeth, and that the estimated half-life of lead in bone is 20 to 30 years, the June 2001 private treatment note indicates that the Veteran had an unremarkable knee X-ray, with no findings or mention of dense metaphyseal lines or lead toxicity. The Board finds this explanation persuasive. Moreover, such rationale is consistent with the literature summarized by the Veteran in his June 2006 statement, including that the effects of lead poisoning most prominently manifest neurologically, and that total body burden of lead is accumulated in the bones where it is stored for decades, 30 years or more. Furthermore, the November 2011 VA examiner offered persuasive alternative likely etiologies of the Veteran's claimed lung and heart disabilities. Regarding the Veteran's diagnosed COPD, a combination of his emphysema and chronic bronchitis, the examiner noted that the most common cause in about 90 percent of cases of COPD was cigarette smoking, but that other causes include chronic lung infections, long-term exposure to asbestos or other lung irritants, and genetic deficiencies. The Veteran has consistently been noted to have had a 24 pack-year history of smoking. Regarding the Veteran's claimed pulmonary edema, the examiner was unable to locate any findings or documentation of left heart failure or documentation of pulmonary edema in the Veteran's medical records. The May 2010 VA examiner likewise found no evidence of pulmonary edema on examination and, in the March 2011 addendum opinion, stated that there was no information in the claims file indicating that the Veteran had ever had pulmonary edema Regarding the Veteran's pulmonary hypertension, the November 2011 VA examiner stated that the likely etiology of mild pulmonary hypertension in the Veteran was from his sleep disordered breathing and chronic hypoxia from his obstructive sleep apnea, and noted that this had been previously suggested by the Veteran's cardiologist. In September and October 2003, the Veteran's private physician, following cardiac catheterization, noted possible pulmonary hypertension due to sleep apnea. Regarding the Veteran's claimed angina, the November 2011 VA examiner stated that the records did not show significant CAD to cause obstruction or ischemia to the heart, and it was not likely that the Veteran's subjective history of chest pain was related to lack of oxygen delivery to the heart muscle as this was not demonstrated on the Veteran's coronary catheterization, and on nuclear stress test in 2003 there was no scintigraphic evidence of ischemia. Regarding his congestive heart failure the November 2011 VA examiner stated that she could not find evidence documenting clinically significant congestive heart failure in Veteran's file. In this regard, the record reflects no diagnosis of current congestive heart failure since the Veteran's September 2004 claim for service connection. While the Veteran has reported a history of congestive heart failure, and the September 10, 2003, private treatment note reflects that the Veteran had "apparently" been diagnosed with congestive heart failure in the past, the only evidence of such heart failure in the record is the July 13, 2001, chest X-rays indicating that there may have been mild failure and an impression of prominent heart size and suggestion of mild failure, which resulted from postoperative respiratory failure, suspected to be a side effect of anesthetics and underlying COPD. Also, the March 2010 VA examiner opined that there was no current evident of congestive heart failure, with chest X-ray currently and three years ago showing normal cardiac silhouette, and, in the May 2011 addendum, further opined that while congestive heart failure was listed as a past medical condition in an early clinical note, the condition had not been diagnosed in the last five years, and that echocardiograms performed by the Veteran's private cardiologist did not determine that he had left ventricular failure, the most common cause of congestive heart failure, and thus that it was unlikely that the Veteran had congestive heart failure. Regarding the Veteran's CAD, the November 2011 examiner stated that CAD developed over many years and was caused by cholesterol-containing deposits or plaque build-up in the coronary arteries, and that risk factors for CAD included older age, male gender, family history, smoking, hypertension, high cholesterol, diabetes, obesity, sedentary lifestyle, and high stress, and that the Veteran's mild CAD was most likely related to his multiple risk factors than military service. The record reflects a history of smoking and hypertension in the Veteran, as well as family history of heart disease, and his CAD was diagnosed more than 40 years after his period of service. Finally, regarding the Veteran's hypertensive heart disease, the examiner stated that it occurred due to the complication of longstanding hypertension or high blood pressure, which the Veteran had, as the workload of the heart was increased manifold and over a long period of time the heart muscle thickened and became less compliant. Conversely, the Board finds that the July 2006 and November 2006 opinions from Dr. Kumar are of little probative value. Dr. Kumar stated that he was of the opinion that it was his exposure to lead that caused bronchial disorder, including COPD and a paralyzed diaphragm, based on his education, with special studies and emphasis on lung diseases, along with his extensive medical background and years of practice, and that he reviewed the Veteran's entire medical record and did lengthy research on medical conditions associated with lead poisoning and exposure to lead. However, while the Board acknowledges the medical expertise and experience of Dr. Kumar, Dr. Kumar's opinion is nonetheless a bare assertion with no supporting rationale or explanation. This particularly diminishes the probative value of the opinion considering the lack of any explanation of the factors noted by the November 2011 examiner weighing against the Veteran's claim, such as the June 2001 X-ray with no reports of evidence of lead, as well as the absence of a diagnosis of COPD or paralyzed diaphragm until more than 40 years after the Veteran's period of service. See Maxson, 230 F.3d at 1333 (evidence of a prolonged period without medical complaint can be considered as a factor in service connection cases, along with other factors). Furthermore, lay persons may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation. Jandreau, 492 F.3d 1372. However, while the Veteran might believe that a lung or heart disability is medically related to service, the question of causation in this case extends beyond an immediately observable cause-and-effect relationship, and is one that requires medical expertise to answer. As such, the Veteran is not competent to address etiology in the present case. The Board recognizes the Veteran's assertion made in a November 2012 statement that the Naval Reserve Administrative Remarks dated in July 1960 reflecting that the Veteran's performance of duty while in training duty status from July 4, 1960, to July 16, 1960, was unsatisfactory for the reason of "Lack of Aptitude" is indicative of a form of mental illness and/or deficiency or defect, and that such deficiency was caused by the Veteran's contact with lead-based paint in service. However, the Veteran is not competent to determine that the assessment of "Lack of Aptitude" reflects mental illness, deficiency or defect due to lead exposure, and no other evidence of record supports this assessment. See Id. The Board also recognizes the Veteran's assertion that he has shown other neurological symptoms indicating lead poisoning. As asserted by the Veteran in June 2006, the articles summarized by the Veteran suggest that tiredness, sleep problems, weakness, dizziness, clumsiness, irritability, difficulty concentrating, forgetfulness, nervousness, and joint and muscle pain and numbness may be signs of lead poisoning. The Veteran noted that he suffered from sleep apnea, Parkinson's disease, and osteoarthritis. However, there is no competent evidence of record reflecting that sleep apnea, Parkinson's disease, or osteoarthritis is related to lead exposure. Also, the Board notes that evidence of neurological symptomatology in the Veteran is not consistent. The January 2001 private treatment record reflects that the Veteran presented for possible Alzheimer's disease, as his father had Alzheimer's, and he reported a change of mood over the past year, becoming more irritable and argumentative, but denied any particular problems with memory, and reported running his business a usual; the Veteran's diagnosis, however, was memory disturbance, noted to be minor, if at all present, by history, and it was noted that the Veteran checked out very well by the mini-mental state examination. In June 2001, the Veteran denied any history of central nervous system disease. July 2008 private neurological examination was negative for dizziness, tingling, tremors, sensory change, speech change, focal weakness, seizures, loss of consciousness, weakness and headaches, but in May 2010, while the Veteran was noted to have had normal reflexes, no cranial nerve deficit, and normal muscle tone and coordination and strength, he was noted to have had a right facial droop, and the diagnosis was encephalopathy. However, even considering any such neurological findings of record, such findings began more than 40 years after the Veteran's period of service. In this regard, both the May 2010 VA examiner and November 2011 VA examiner found it to be significant that neurological symptoms did not develop shortly after the Veteran's alleged lead exposure, as service treatment records did not reflect any neurological findings. Moreover, both VA examiners reviewed the entire record, and each determined that the Veteran had not exhibited neurological signs of lead toxicity. Additionally, even considering any such neurological findings of record, evidence such as the June 2001 unremarkable knee X-ray with no findings or mention of dense metaphyseal lines or lead toxicity, relied on by the November 2011 VA examiner in formulating her opinions, weighs heavily against the Veteran's claim. Thus, despite Veteran's assertions, the Board finds that the totality of the evidence weighs against the Veteran's claims. Accordingly, the claims for service connection for a lung disability, including COPD, emphysema, chronic bronchitis, pulmonary hypertension, and pulmonary edema, and for a heart disability, including angina, congestive heart failure, CAD, and hypertensive heart disease, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, a section 5103(a) notice should also advise a claimant of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In the present case, required notice was provided by letters dated in April 2004 and September 2005, which informed the Veteran of all the elements required by the Pelegrini II Court as stated above. Although the notice provided did not address either the rating criteria or effective date provisions that are pertinent to the Veteran's claim, such error was harmless given that service connection is being denied, and hence no rating or effective date will be assigned. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran's service treatment records, VA medical treatment records, identified private medical records, private medical opinions, and a lay statement from the Veteran's service comrade have been obtained. While the Veteran, in a July 2011 statement, asserted that crucial medical records were destroyed in a fire, the Veteran has not identified what records were destroyed or how such records were crucial, and there is no other indication in the claims file that any pertinent medical records have been destroyed. Also, the Veteran was provided VA examinations and opinions in January 2007, May 2010, and November 2011. These examinations were adequate because, together, they provided sufficient information to decide the appeal. The November 2011 opinion, specifically, was based on examination of the Veteran and a review of the relevant medical records by an examiner with appropriate expertise, was thorough and adequate, and provided a sound basis on which to base a decision with regard to the Veteran's claims. 38 C.F.R. § 3.159(c)(4) (2012); Barr v Nicholson, 21 Vet. App. 303 (2007). As reflected in a November 2012 informal hearing presentation from the Veteran's representative, the Veteran has alleged that his November 2012 VA examination, and his VA examinations in general, have been inadequate. The Veteran asserts that the November 2011 VA examination report failed to discuss the positive private opinions in a substantive fashion, that the examiner's reasoning was incomplete, as the examiner stated that she reviewed multiple credible sources of literature regarding lead toxicity in adults, but did not list these resources, and that the opinion was written by a physician's assistant. However, as discussed above, the November 2012 VA examiner substantively and fully addressed and discussed the private opinions of Dr. Kumar, and the Veteran has not identified any aspect of Dr. Kumar's opinions that was not addressed or fully discussed in the November 2012 examination report. Also, as noted above, the literature discussed by the November 2011 VA examiner is consistent with the medical evidence submitted by the Veteran himself regarding the nature of lead-based exposure and toxicity, and the Veteran has provided no evidence that the examiner did not review the appropriate literature regarding lead toxicity in adults in formulating her opinions. See Ashley v. Derwinski, 2 Vet. App. 307 (1992) (it is presumed that government officials have properly discharged their official duties, and clear evidence to the contrary is required to rebut this "presumption of regularity"). Finally, as discussed above, the November 2011 VA examiner provided a thorough explanation for her opinions and thoroughly examined the Veteran and reviewed the claims file, the Board has considered her medical expertise, and finds it sufficient to render the requested opinions. The Board is, furthermore, "entitled to assume the competence of a VA examiner." Cox v. Nicholson, 20 Vet. App. 563, 596 (2007). See also, Hilkert v. West, 12 Vet. App. 145, 151 (1999). The Veteran has not identified anything substantively in the opinion that would render it inadequate or that would indicate that the November 2012 VA examiner did not have appropriate expertise to provide the opinion. Furthermore, the RO has substantially complied with the Board's December 2009 and October 2011 remand instructions. The Veteran was provided an adequate VA examination of his claimed disabilities in November 2011, which addressed his claimed lung and heart disabilities, and, as discussed above, addressed the private opinions of Dr. Kumar and medical evidence submitted by the Veteran purporting to link lead paint exposure to his heart disabilities, and addressed medical examination evidence related to possible lead poisoning in the Veteran. As noted above, the November 2011 VA report was based on examination of the Veteran and a review of the relevant medical records by an examiner with appropriate expertise, was thorough and adequate, and provided a sound basis on which to base a decision with regard to the Veteran's claims. Under these circumstances, the Board finds that there has been substantial compliance with the December 2009 and October 2011 remand instructions, and an additional remand to comply with the Board's directives is not required. See D'Aries v. Peake, 22 Vet. App. 97, 104-106 (2008); Stegall v. West, 11 Vet. App. 268 (1998). Therefore, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER Service connection for a lung disability, to include COPD, emphysema, chronic bronchitis, pulmonary hypertension, and pulmonary edema, is denied. Service connection for a heart disability, to include angina, congestive heart failure, CAD, and hypertensive heart disease, is denied. REMAND In an October 2012, the agency of original jurisdiction (AOJ) denied service connection for a psychiatric disability, granted service connection for bilateral hearing loss with an assigned noncompensable (0 percent) initial rating, and granted service connection for tinnitus with an assigned 10 percent initial rating. In a statement received by the AOJ in November 2012, the Veteran expressed disagreement with the October 2012 denial of service connection for a psychiatric disability, and with the assigned initial ratings for bilateral hearing loss and tinnitus. Because the filing of a notice of disagreement initiates appellate review, the claim must be remanded for the preparation of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999); Godfrey v. Brown, 7 Vet. App. 398, 408-10 (1995). Accordingly, the case is REMANDED for the following action: Issue a statement of the case, and notify the Veteran of his appellate rights with respect to the issue of entitlement to service connection for a psychiatric disability, an initial compensable rating for bilateral hearing loss, and an initial rating in excess of 10 percent for tinnitus. 38 C.F.R. § 19.26 (2012). In the notice and statement of the case, remind the Veteran that to vest the Board with jurisdiction over the issue, a timely substantive appeal to the October 2012 rating decision must be filed. 38 C.F.R. § 20.202 (2012). If the Veteran perfects an appeal as to the issue, return the case to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the 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. 2012). ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs