Citation Nr: 1301702 Decision Date: 01/16/13 Archive Date: 01/23/13 DOCKET NO. 09-12 474 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Entitlement to service connection for mitral valve prolapse. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Patrick J. Costello, Counsel INTRODUCTION The appellant served on active duty from January 1978 to August 1993. This case is before the Board of Veterans' Appeals (BVA or Board), on appeal from a rating decision of February 2007 by the Department of Veterans Affairs (VA) Regional Office (RO), which denied the benefit sought on appeal. The record reflects that the Cheyenne, Wyoming, RO processed the appellant's request for benefits but subsequent action has been taken by the RO located in Denver, Colorado. In August 2011, the appellant proffered testimony at a hearing before the undersigned Acting Veterans Law Judge (AVLJ). A transcript of that hearing was prepared and has been included in the claims folder for review. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) requires that the VLJ or AVLJ who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the AVLJ noted that basis of the prior determinations and noted the elements of the claims that were lacking to substantiate the claim for benefits. In addition, the AVLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. Moreover, the appellant (or his accredited representative) has not asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) (2012) or identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim for service connection and the appellant, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for benefits. As such, the Board finds that, consistent with Bryant, the AVLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claim based on the current record Shortly after the appellant's claim was received by the Board, and upon reviewing the claims file, the Board referred this matter to the Veterans Health Administration (VHA) for an advisory opinion concerning the appellant's claimed mitral valve prolapse. This occurred in May 2012. The advisory opinion has been obtained and included in the claims file for review. It is noted that the appellant, along with his representative, were given the opportunity to provide any comments with respect to the VHA opinion and those comments have also been included in the claims file for review. FINDINGS OF FACT 1. During service, the appellant, while experiencing chest pains, irregular heartbeats, and tachycardia, was given a provisional diagnosis of mitral valve prolapse. 2. Since leaving service in 1993, the appellant has not received treatment for mitral valve prolapse. When the examiner underwent a private cardiology examination in May 2005, mitral valve prolapse was not diagnosed. 3. A VA examination of the appellant was performed in October 2006 that failed to produce a diagnosis of mitral valve prolapse. 4. The appellant's medical records have been reviewed by a VHA cardiologist who has determined that the appellant is not now suffering from mitral valve prolapse nor has he suffered from said condition as any time during the appellate period. CONCLUSION OF LAW Mitral valve prolapse was not incurred in or aggravated active duty service. 38 U.S.C.A. §§ 1112, 1131, 1137, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant 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 appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 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 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2011); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice 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) must ask the claimant to provide any evidence in their possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable rating decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). The Board finds that VA has substantially satisfied the duties to notify and assist, as required by the VCAA. The record indicates that the appellant was provided notice in a letter sent to him from the RO in July 2006. The letter informed the appellant that VA would assist him in obtaining any documents that it was made aware thereof that would assist in the decision-making process of the claim. He was further told that he could proffer any documents or statements in support of his claim, and that all items would be considered when a decision on the merits of his claim was made. In addition, he was also informed how a disability rating is determined and the basis for determining an effective date upon the grant of any benefit sought, in compliance with the holding in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). This letter was provided to the Veteran prior to the initial adjudication of his claim. All that the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (2012) (harmless error). In view of the foregoing, the Board finds that the appellant was notified and aware of the evidence needed to substantiate his claim, as well as the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. VA also fulfilled its duty to assist. In this instance, VA obtained the appellant's available medical treatment records, including requesting any treatment records from the facilities where the appellant had been treated, and those other records that VA was made aware thereof. Given the foregoing, the Board finds that VA has substantially complied with the duty to procure the necessary medical and other records. Additionally, VA has a duty to obtain a medical examination or opinion when such examination or opinion is necessary to make a decision on the claim. In this respect, the Board did obtain two such opinions - the first occurred in October 2006 and the second opinion was obtained from a VHA reviewer in July 2012. Both opinions have been included in the claims file for review. The reports involved a review of the claims folder and the appellant's available medical treatment records. Upon completion of the examination and then the review, both medical care providers provided a detailed analysis of the appellant's reported mitral valve prolapse disability. Therefore, the Board finds that these reports are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Given the foregoing, the Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the appellant's claim. The Board would further note that the appellant was provided with the opportunity to provide testimony before the Board in August 2011. At that time, the appellant described the symptoms that were produced by the purported disorder. He also gave his opinion concerning the etiology of the condition and he provided a brief time line of the condition. As such, the Board finds that the appellant has been given the opportunity to provide argument with respect to his claim, and that argument has been included in the claims folder for review. It seems clear that the VA has given the appellant every opportunity to express the appellant's opinion with respect to the issue now before the Board As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). Importantly, the Board notes that the appellant is represented in this appeal and over the course of the appeal, and the accredited representative has submitted argument on behalf of the appellant. See Overton v. Nicholson, 20 Vet. App. 427, 438 (2006). Moreover, the appellant has submitted argument and evidence in support of the appeal. Based on the foregoing, the Board finds that the appellant has had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication is not affected. II. Governing Law and Regulations Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110, 1131 (West 2002). 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. See 38 C.F.R. § 3.303(b) (2012). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2012). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of an evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. See 38 C.F.R. § 3.303(b) (2012). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. See 38 C.F.R. § 3.303(b) (2012); see also Savage v. Gober, 10 Vet. App. 488, 495-496 (1997). In Voerth v. West, 13 Vet. App. 117, 120 (1999), the Court stated that in Savage it had clearly held that 38 C.F.R. § 3.303 does not relieve the claimant of his burden of providing a medical nexus. Service connection may be granted for a disability which is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310(a) (2012); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). In order to establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). III. Discussion The appellant was on active duty in the United States Army from January 1978 to August 1993. After fifteen plus years of service, he was medically discharged from the service for a psychiatric disorder. Approximately thirteen years after his discharge from service, the appellant has come to the VA asking that service connection be granted for mitral valve prolapse - a condition he avers began in or was caused by or the result of his military service. A review of the appellant's service medical treatment records reveals that when the appellant originally enlisted in the Army in December 1977, his heart was found to be "normal". He did not report any history of cardiac symptoms, manifestations, or complaints when he completed the historical questionnaire on his health. Subsequent service medical treatment records reflect that he complained of chest pain, palpitations, and shortness of breath on several occasions. A treatment record dated in April 1980 showed a finding of incomplete right branch bundle block (RBBB). A report for a periodic exam, also in April 1980, indicated that the appellant had tachycardia and RBBB. Sinus tachycardia and RBBB were noted again in April 1982, following a complaint of chest pain and shortness of breath. Four years later, in 1986, the appellant received his first "diagnosis" of mitral valve prolapse based on his complaints and an intermittent systolic click that was heard on examination. Nevertheless, the diagnosis of mitral valve prolapse was not confirmed by echocardiogram testing accomplished in August 1986. A second echocardiogram was performed in December 1986 - while the test results showed incomplete RBBB, it did not show mitral valve prolapse. The remaining, and available, service medical records from 1991 to 1993 indicate that the appellant received inpatient treatment at the Noble Army Hospital in September 1991. The appellant has stated that this treatment occurred after he complained of chest pains and an increased heart rate. The discharge report from that time showed a discharge diagnosis of atypical chest pain. Subsequently, in April 1993, the appellant underwent a physical in conjunction with a Medical Evaluation Board. It was noted in the diagnoses portion of the examination report that the appellant had symptomatic mitral valve prolapse and essential, controlled hypertension. Shortly thereafter, the appellant was released from active duty. In conjunction with his claim for benefits, the appellant's available private medical treatment records have been obtained and included in the claims folder for review. These records report that the appellant had a "history" of mitral valve prolapse and tachycardia. Yet these same records, and specifically results from a May 2005 examination that was conducted as a follow-up after an EKG, diagnosed the appellant as actively suffering from benign hypertension, neck pain, tachycardia sinus, hyperlipidemia, and an abnormal glucose level. The appellant was not diagnosed as currently suffering from either the prodromas of or the actual condition of mitral valve prolapse. Following the appellant's claim for benefits, the VA scheduled the appellant for a VA examination in order to determine whether the appellant was suffering from mitral valve prolapse, and if he was, whether it was related to the condition he experienced while on active duty. Such an exam took place in October 2006. Upon completion of the examination, the medical doctor concludes that there was insufficient evidence to warrant or support a diagnosis of either acute or chronic mitral valve prolapse. The examiner noted that, based on two echocardiogram results contained in the claims folder, there was no evidence that the appellant was actually suffering from such a disorder. The examiner pointed out that even the appellant's private physician had not provided a recent diagnosis of mitral valve prolapse. In July 2012, a VA staff cardiologist provided a lengthy written response to the Board's May 2012 request for a VHA opinion. After review of the appellant's claims folder, including his service medical treatment records, the VHA reviewer, who is the Chief of Cardiology of the Boston VA Medical Center, provided the following analysis: The veteran contends that he has mitral valve prolapse (MVP) which is related to his military service. This cannot be true. Mitral valve prolapse is due to degeneration of the mitral valve. Furthermore, in this case, I believe there is some confusion (on the part of the Veteran) about the actual diagnosis of MVP. He was not noted to have MVP on his entrance examination in 1977. He was diagnosed with probably MVP in 1986, based on his symptoms of chest pain, palpitations, and shortness of breath. In the 1980s, this was a common diagnosis based on those symptoms, but as it turns out, many patients labeled as having MVP did not. Importantly, an echocardiogram did not confirm his diagnosis. In 2006, on a VA examination, it was deemed that he does not have MVP. Based on what evidence is available to me, I agree with that conclusion. 1. The Veteran does not have evidence of MVP (without a contemporary echocardiogram showing MVP, he simply cannot have the diagnosis.) 2. The complaints of recurrent palpitations, chest pain, and shortness of breath are subjective. It appears that no definitive diagnosis of heart disease has been made. 3. Sinus tachycardia and RBBB can be seen even in healthy populations. This would not qualify as having heart disease. 4. He does not have MVP, so that cannot be related to his service. The sinus tachycardia and RBBB are not related to his service. 5. The symptoms that are described could all be attributable to posttraumatic stress disorder (PTSD). They would not be expected from his degree of hypertension. At this point the Board notes that service connection for PTSD has been established. To support the appellant's claim for benefits, the appellant proffered supporting documents in the form of internet searches. More specifically, the appellant submitted an excerpt from the Mayo Clinic that he obtained from an internet search involving mitral valve prolapse. A review of the article indicates that it contains a discussion of the various symptoms and manifestations produced by an individual who has been diagnosed with mitral valve prolapse and the early prodromas of the disease. Yet, the excerpt itself does not discuss the appellant's case history, it does not reference the appellant's case history as a member of a population upon which the article is based thereon, and the author or authors of the article never examined the appellant (or reviewed his records). As reported, the appellant was released from active duty in August 1993. From 1993 to when the appellant filed for VA compensation benefits in 2006, the record is negative for any treatment for any type of heart condition immediately following service. That is, for the year following his release from service, there is no evidence that would suggest that the appellant sought treatment for or was diagnosed with mitral valve prolapse. Service connection may be granted on a presumptive basis for certain chronic disabilities when such is manifested to a compensable degree within the initial post-service year. See 38 U.S.C.A. § 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). The evidence fails to reflect that the appellant was diagnosed with a cardiovascular disease, i.e., mitral valve prolapse, within his first post-service year. As such, he is not afforded the presumption set forth under 38 C.F.R. §§ 3.307, 3.309(a) (2012). There is no additional positive or negative evidence contained in the claims folder for review. As an aside, the Board would note that it has reviewed the appellant's electronic records and there are no electronic records that either support or refute the appellant's assertions. Instead, the electronic records are merely electronic copies of the rating action and the notification letter to the appellant concerning the denial of benefits. In sum, the probative evidence is as follows. The appellant states that it is his opinion that he now suffers from mitral valve prolapse and that it began in or was caused by or the result of his military service. A VA doctor has opined that the appellant does not currently suffer from mitral valve prolapse. His private doctors have not diagnosed the appellant from currently suffering from such a condition. A second doctor, associated with VHA, has endorsed the VA doctor's opinion. No other evidence is of record except for the appellant's (and his representative's) lay assertions that he has suffered from the condition in service and he currently suffers from mitral valve prolapse. In determining whether evidence submitted by the appellant is credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). The appellant's lay statements during the course of this appeal have not been contradictory. Since the appellant filed his claim, his recitation of the assertions made has remained consistent and not at odds with other statements made by himself. Yet, it is also noted that despite the appellant's assertions, the medical records have not mirrored his nonexpert hypothesis concerning his mitral valve prolapse. Thus, the Board finds that the appellant's statements are, at the very least, credible, probative, and they add some minimal weight to the overall claim. See, e.g., Struck v. Brown, 9 Vet. App. 145, 155-156 (1996). In weighing the evidence on file, the Board notes that a VA examiner has reviewed the record and has rendered a medical opinion that the appellant does not now suffer from mitral valve prolapse. A VHA doctor has further concluded that the diagnosis of this condition that was provided in service to the appellant was not based upon echocardiogram results and that the diagnosis was faulty. The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). In determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997). In the case of Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008), the Court held that a claims file review, as it pertains to obtaining an overview of a veteran's medical history, is not a requirement for private medical opinions. A review of the claims file by a VA examiner, without more, does not automatically render the VA examiner's opinion competent or persuasive since the claims file is a tool to assist in familiarity for the physician with the claims file, and conversely a private medical opinion may not be discounted solely because the opining clinician did not review the claims file as there are other means by which a physician can become aware of critical medical facts, such as a history of treating the veteran for an extended period of time and/or reviewing pertinent medical literature. The relevant focus is not on whether the clinician had access to the claims file, but instead on whether the clinician was "informed of the relevant facts" in rendering a medical opinion. Thus, when VA refers to facts obtained from review of the claims file as a basis for crediting one expert opinion over another, it is incumbent upon VA to point out those facts and explain why they were necessary or important in forming the appropriate medical judgment. Certainly, the particular medical information contained in a claims file may have significance to the process of formulating a medically valid and well-reasoned opinion. The Court further held that a medical opinion that contains only data and conclusions is not entitled to any weight and a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion is derived. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). In sum, in Nieves-Rodriguez, the Court indicated that it is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion. In this instance, there are the two medical opinions concerning the existence, or the lack thereof, of the appellant's purported disorder (mitral valve prolapse). Both of these opinions have, without hesitation, found that the appellant is not currently suffering from said disorder. The VHA doctor has gone further to strongly suggest that the appellant was misdiagnosed in service and that the inservice diagnosis was based upon symptoms and not laboratory findings. Again, the Board notes that the appellant has not submitted any medical opinions that would tend to refute or contradict the opinions of the VA physicians. Per the reports, the examiners reviewed the complete claims folder including the statements provided by the appellant. In providing their opinions, the physicians were not equivocal, vague, or ambiguous with their opinions. Both VA doctors reviewed in detail the pertinent medical records, discussed the salient facts, and provided complete rationale for all conclusions presented, as noted in the discussion above. Accordingly, the Board attaches the most significant probative value to the VA opinions as they appear to be well reasoned, detailed, consistent with other evidence of record, and included an access to the accurate background of the service member. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.). To state the matter in a different way, the Board accepts the examiners' opinions as being the most probative medical evidence on the subject, as such was based on a review of all historical records, and contains detailed rationale for the medical conclusion. See Boggs v. West, 11 Vet. App. 334 (1998). Given the depth of the examination reports, and the fact that each opinion was based on a review of the applicable record, the Board finds such opinions are probative and material to the appellant's claim. See Owens v. Brown, 7 Vet. App. 429 (1995). There is no medical opinion to the contrary. With respect to the internet medical excerpt provided by the appellant, the Board finds that this piece of evidence is not probative with regard to the instant claim because it does not specifically address whether the appellant now suffers from mitral valve prolapse. See Sacks v. West, 11 Vet. App. 314, at 317 (1998); Mattern v. West, 12 Vet. App. 222, at 228 (1999). Moreover, the literature only provides generalized information concerning mitral valve prolapse and the prodromas of such a condition. Although there may be basic similarities to the medical history described in the article, the highly probative VA doctors' opinions establish the appellant's symptoms during service were inconclusive and not based upon acceptable medical laboratory findings, and it does not show that the appellant currently suffers from the purported disorder. Accordingly, the literature is too general and inconclusive, especially when considered in combination with the other evidence, to support the appellant's claim. With respect to the appellant's claim, the only other opinion addressing whether there is a link between the appellant's service and his current symptoms and manifestations is that of the appellant and endorsed by the accredited representative. Yet, the claim has merely been made that the appellant now suffers from mitral valve prolapse and that it is somehow related to his military service. There has not been a discussion of the salient facts nor has there been provided any type of rationale that would corroborate any of the appellant's lay conclusions. The Board finds that the statements provided by the appellant are too general in nature to provide, alone, the necessary evidence to show that the appellant now has mitral valve prolapse that resulted from his military service. See Sacks v. West, 11 Vet. App. 314, 316-17 (1998). The Board would further address the statements made by the appellant. The Federal Circuit has held that lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself. The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). This would include weighing the absence of contemporary medical evidence against lay statements. In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court indicated that varicose veins was a condition involving "veins that are unnaturally distended or abnormally swollen and tortuous." Such symptomatology, the Court concluded, was observable and identifiable by lay people. Because varicose veins "may be diagnosed by their unique and readily identifiable features, the presence of varicose veins was not a determination 'medical in nature' and was capable of lay observation." Thus, the appellant's lay testimony regarding varicose vein symptomatology in service represented competent evidence. Also, in Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007), the Federal Circuit determined that 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 (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (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. The relevance of lay evidence is not limited to the third situation, but extends to the first two as well. Whether lay evidence is competent and sufficient is an issue of fact. Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994), supra (distinguishing between 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 Barr. The Board does not doubt the credibility of the appellant in reporting his belief that he now suffers from mitral valve prolapse that he believes was caused by or the result of or began during his military service. However, the matter at hand involves complex medical assessments that require medical expertise. See Jandreau. The appellant is not competent to provide more than simple medical observations. He is not competent to provide complex medical opinions regarding the etiology, or even a definitive diagnosis, of the purported claimed disorder. See Barr. Moreover, due to the medical complexity of the issue involved, the Board finds that the appellant's assertions alone are insufficient to establish service connection. As a lay person the appellant has not been shown to be qualified through education, training, or expertise to offer an opinion on a medical diagnosis or on medical causation. Additionally, in view of the period without evidence of treatment from 1993 to 2005, and the lack of clinical findings, the Board finds that the evidence is against a finding of the existence of such a disorder and the continuity of treatment, which weighs heavily against the claim. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Thus, his lay assertions are of less probative value, and they are not competent or sufficient. In determining whether service connection is warranted, the VA must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case service connection must be denied. 38 U.S.C.A. § 5107 (West 2002 & Supp. 2010); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, competent and probative medical evidence that established that the appellant now suffers from mitral valve prolapse that is related to the cardiac symptoms and manifestations the appellant experienced during his fifteen years of active duty has not been presented. Therefore, after reviewing the appellant's claims folder, the Board finds that the record is without sufficient competent evidence showing that the purported disability in question became manifest or otherwise originated during his active duty service. Moreover, the record does not show the purported disorder exists or is etiologically related to his military service or any incident therein. Therefore, it is the conclusion of the Board that the preponderance of the evidence is against the appellant's claim. The evidence in this case is not so evenly balanced as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. § 3.102 (2012). The preponderance of the objective and probative medical and other evidence of record is against the appellant's claim for service connection for mitral valve prolapse, and his claim must be denied ORDER Entitlement to service connection for mitral valve prolapse is denied. ____________________________________________ JOHN L. PRICHARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs