Citation Nr: 1306844 Decision Date: 02/28/13 Archive Date: 03/01/13 DOCKET NO. 09-09 313 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to service connection for hypertension, for purposes of accrued benefits. 2. Entitlement to service connection for hypertensive cardiovascular disease, for purposes of accrued benefits. 3. Entitlement to service connection for osteoarthritis, also claimed as rheumatoid arthritis, for purposes of accrued benefits. 4. Entitlement to service connection for post cerebrovascular accident, for purposes of accrued benefits. 5. Entitlement to service connection for a condition manifested by dizziness, for purposes of accrued benefits. 6. Entitlement to service connection for a shrapnel wound of the left leg, for purposes of accrued benefits. 7. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD), for purposes of accrued benefits. 8. Entitlement to a compensable evaluation for a residual scar from shrapnel wound to the back, for purposes of accrued benefits. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD A. Fagan, Associate Counsel INTRODUCTION The Veteran had active service from January 1945, to March 1946. He died on January [redacted], 2008. The appellant is his widow. This matter comes before the Board of Veterans' Appeals (Board) from a June 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines. As an initial matter, the Board notes that in March 2002, the Veteran filed what the Board construes to be a timely notice of disagreement with the March 2002 rating decision that established service connection for residuals of a shrapnel wound to the back and assigned an initial 0 percent disability rating, effective June 25, 1998. Therefore, as that claim remained pending at the time of the Veteran's death, the Board finds that period on appeal for the increased rating claim for purposes of accrued benefits extends back to June [redacted], 1998, the date of service connection. Similarly, the Board observes that in May 2003, the Veteran filed a timely notice of disagreement with a July 2002 rating decision in which the RO denied on the merits claims for service connection for hypertensive cardiovascular disease, post cerebrovascular accident, a condition manifested by dizziness, hypertension, and osteoarthritis. As such, the July 2002 rating decision did not become final, and the service connection claims decided therein remained pending at the time of the Veteran's death in January 2008 for purposes of accrued benefits. Additionally, as the claims for service connection for hypertension and osteoarthritis on the merits were pending at the time the Veteran attempted to "reopen" those claims, the Board will not address whether new and material evidence has been submitted to reopen those claims, but instead decide those claims on the merits. As a final introductory matter, the Board has rephrased the issue of service connection for PTSD to one of service connection for an acquired psychiatric disorder, to include PTSD, pursuant to the precedent of Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). See id. (instructing that service connection claims for PTSD should be construed broadly to encompass any mental disorder that may be reasonably encompassed by the claimant's description of the claim, reported symptoms, and other information of record). FINDINGS OF FACT 1. The evidence of record at the time of the Veteran's death did not establish that the Veteran's hypertension or hypertensive cardiovascular disease was causally related to his active service or to any incident therein; manifested within one year of discharge; or was caused or aggravated by a service-connected residual scar from shrapnel wound to the back. 2. The evidence of record at the time of the Veteran's death did not establish that either rheumatoid arthritis or osteoarthritis was causally related to his active service or to any incident therein; manifested within one year of discharge; or was caused or aggravated by a service-connected residual scar from shrapnel wound to the back. 3. The evidence of record at the time of the Veteran's death did not establish that the Veteran's cerebral vascular accident, or residuals thereof, were causally related to his active service or to any incident therein, or caused or aggravated by a service-connected residual scar from shrapnel wound to the back. 4. The evidence of record at the time of the Veteran's death did not establish the existence of a condition manifested by dizziness that was causally related to his active service or any incident therein, or caused or aggravated by a service-connected residual scar from shrapnel wound to the back 5. The evidence of record at the time of the Veteran's death did not establish the existence of a disability from an in-service left leg shrapnel wound. 6. The evidence of record at the time of the Veteran's death did not establish that the Veteran had a diagnosis of PTSD pursuant to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994). 7. The evidence of record at the time of the Veteran's death did not establish that the Veteran's psychiatric disorders manifested during service, were related to any period of active service or to any incident therein; or were caused or aggravated by a service-connected residual scar from shrapnel wound to the back. 8. The evidence of record at the time of the Veteran's death failed to show that the Veteran's back scar was poorly nourished with repeated ulceration, was tender and painful on objective demonstration, caused limitation of motion, or covered an area exceeding 6 square inches. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension, for purposes of accrued benefits, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1153, 1154, 5103, 5103A, 5107(b), 5121 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, .3.309, 3.1000 (2012). 2. The criteria for service connection for hypertensive cardiovascular disease, for purposes of accrued benefits, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1153, 1154, 5103, 5103A, 5107(b), 5121 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.1000 (2012). 3. The criteria for service connection for arthritis, to include osteoarthritis and rheumatoid arthritis, for purposes of accrued benefits, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1153, 1154, 5103, 5103A, 5107(b), 5121 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.1000 (2012). 4. The criteria for service connection for post cerebral vascular accident, for purposes of accrued benefits, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1153, 1154, 5103, 5103A, 5107(b), 5121 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.1000 (2012). 5. The criteria for service connection for a condition manifested by dizziness, for purposes of accrued benefits, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1153, 1154, 5103, 5103A, 5107(b), 5121 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.1000 (2012). 6. The criteria for service connection for shrapnel wound to the left leg, for purposes of accrued benefits, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1153, 1154, 5103, 5103A, 5107(b), 5121 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.1000 (2012). 7. The criteria for service connection for a psychiatric disorder, to include PTSD, for purposes of accrued benefits, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1153, 1154, 5103, 5103A, 5107(b), 5121 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.1000 (2012). 8. The criteria for a compensable rating for a scar of the back, for purposes of accrued benefits, have not been met. 38 U.S.C.A. § 1155, 5121 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.1000, 4.1, 4.2, 4.7, 4.118, Diagnostic Codes 7803, 7804, 7805 (as in effect prior to August 30, 2002), 7801, 7802, 7803, 7804, 7805 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and to Assist The Veterans Claims Assistance Act of 2000 (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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). VA has met its duty to notify for this claim. In a February 2008 letter, the appellant was provided notice as to the elements necessary to establish entitlement to accrued benefits, namely, that the existing ratings, decisions, or evidence of record at the time of the Veteran's death must show entitlement to the claimed benefits; that such benefits had not been paid; and that the appellant is the Veteran's surviving spouse. To the extent that the appellant was not provided proper notice as to any of her claims, the Board finds that she has not been prejudiced thereby. In this regard, the appellant's claims for accrued benefits are derivative of the Veteran's claims at the time of his death and, therefore, she could not offer any further evidence in support of the claims. See Zevalkink v. Brown, 102 F.3d 1236, 1241-42 (Fed. Cir. 1996); Jones v. West, 136 F.3d 1296, 1299 (Fed. Cir. 1998). In other words, further notice would not benefit the appellant in any way, as the resolution of her claims for purposes of accrued benefits is entirely dependent upon the application of statutes and regulations to the evidence (or facts) of record at the time of the Veteran's death. See Kane v. Principi, 17 Vet. App. 97, 103 (2003); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001). Similarly, with respect to the duty to assist, no further evidence may be obtained in connection with the appellant's claims for accrued benefits. Moreover, there have been no arguments that the appellant has been prejudiced by any possible defects in notice or assistance. In the circumstances of this case, a remand would serve no useful purpose, as it would unnecessarily impose additional burdens on VA with no benefit to the appellant. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). VA has satisfied its duties to inform and assist the appellant at every stage in this case; at least insofar as any errors were not harmful to the essential fairness of the proceedings. As such, the appellant will not be prejudiced by a decision on the merits of her claims. II. Analysis Upon the death of a veteran, his or her lawful surviving spouse may be paid periodic monetary benefits to which the Veteran was entitled at the time of death, and which were due and unpaid, based on existing rating decisions or other evidence that was on file when the Veteran died. To prevail on an accrued benefits claim, the record must establish that: (1) the appellant has standing to file a claim for accrued benefits, (2) the Veteran had a claim pending at the time of his or her death, (3) the Veteran would have prevailed on the claim if he or she had not died, and (4) the claim for accrued benefits was filed within one year of the Veteran's death. See 38 U.S.C.A. §§ 5101, 5121; 38 C.F.R. § 3.1000; see also Jones v. West, 136 F.3d 1299 (Fed. Cir. 1998). In this case, as the Veteran died in January 2008, after December 16, 2003, an accrued beneficiary may receive the full amount of any award for accrued benefits. See Veterans Benefits Act of 2003, Pub. L. No. 108-183, § 104, 117 Stat. 2651 (Dec. 16, 2003), codified at 38 U.S.C. § 5121(a) (repealing the two-year limit on accrued benefits effective December 16, 2003). Here, the appellant is the surviving spouse of the Veteran. Further, the Veteran had filed claims prior to his death for service connection and an increased rating, and each of those claims remained pending at the time of his death in January 2008. Thereafter, the appellant filed a claim for accrued benefits within one year of the Veteran's death. As such, the appellant has standing to pursue a claim for accrued benefits. The Board will now turn to the merits of each of the claims, for accrued purposes. Service Connection In seeking VA disability compensation, a veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131. "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with active service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303 (2012). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). Secondary service connection may be granted for a disability which is proximately due to, or the result of, a service-connected disorder, or for increased in disability caused by a service connected disorder. 38 C.F.R. § 3.310(a). Service connection may also be granted on a presumptive basis for certain chronic disabilities, including arthritis, cardiovascular-renal disease, and hypertension, when they are manifested to a compensable degree within the initial post service year. 38 C.F.R. §§ 3.307, 3.309. In cases where a Veteran asserts service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C.A. § 1154(b) (West 2002) and its implementing regulation, 38 C.F.R. § 3.304(d) (2012), are applicable. This statute and regulation ease the evidentiary burden of a combat Veteran by permitting the use, under certain circumstances, of lay evidence. If the Veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that in the case of a combat Veteran not only is the combat injury presumed, but so is the disability due to the in-service combat injury. Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). To establish service connection, however, there must be the evidence of a current disability and a causal relationship between the current disability and the combat injury. Id. (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). When all the evidence is assembled, the determination must be made as to whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Hypertension and Hypertensive Cardiovascular Disease At the time of his death, the Veteran sought service connection for hypertension and hypertensive cardiovascular disease. The Veteran's exact theory of contention is not entirely clear from the record. However, in various written statements, the Veteran appears to have attributed his overall deteriorating health to his service-connected residual from a shrapnel wound sustained during service. He also asserted entitlement to service connection for hypertension on a presumptive basis. For the reasons that follow, these claims shall be denied. First, the Board acknowledges that, at the time of his death, the Veteran was diagnosed with hypertension and cardiovascular disease. While objective findings are not of record to confirm those diagnoses, various private medical certificates indicate that the Veteran received a diagnosis of and treatment for hypertension as early as 1995, and cardiovascular disease as early as 2000. There is, however, no evidence of the Veteran's suffering from those conditions during his active service. His available service records, consisting primarily of a February 1946 affidavit for Philippine Army personnel, reflect that the Veteran reported his only wound or illness incurred during the period from December 1941 to February 1946 as a June 1945 shrapnel wound to the back. He did not report any other injuries or illnesses, to include hypertension. Nor is there evidence that the Veteran's hypertension or cardiovascular disease manifested to a compensable degree within one year of service. Post service, the first evidence of hypertension is a June 1999 medical certificate from a private clinic that relates treatment of the Veteran for hypertension and a mild stroke in 1995, nearly 50 years after service. The June 1999 private medical certificate reflects that the Veteran was also treated for a transient ischemic attack and hypertension in 1997. Thereafter, a December 2000 private medical certificate shows treatment for cardiovascular disease and hypertension in November 2000, over 50 years post service. Subsequent medical statements dated in October 2003 and July 2004 note that the Veteran was found to be hypertensive in 1975, apparently based on the Veteran's reported history. Significantly, however, none of the treatment providers linked the Veteran's hypertension or hypertensive cardiovascular disease to his service or his service-connected shrapnel wound to the back. The Board observes that the Veteran himself did not specifically report that he first experienced the symptoms of hypertension or cardiovascular disease during service and that his symptoms have persisted since service. But see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (a lay person is competent to report symptoms based on personal observation when no special knowledge or training is required). Rather, he hypothesized that his hypertension and cardiovascular disease were related to service, or alternatively, caused or aggravated by his service-connected shrapnel wound to the back. However, an opinion as to the etiology of hypertension is a complex medical question for which lay testimony is not competent evidence. Accordingly, his assertion as to causation is neither competent nor probative evidence supporting his claim. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24 Vet. App. 428 (2011). There otherwise is no medical evidence of record supporting such theories. Thus, while the Board specifically acknowledges its consideration of the lay evidence of record, including the Veteran's contentions regarding his theories of entitlement, the Board finds that this lay evidence cannot provide a basis for granting the Veteran's claim. To the extent that the Veteran reported that he was found to be hypertensive in 1975, the Board acknowledges that the Veteran was competent to report receiving a diagnosis of or treatment for hypertension. See id.; Layno, 6 Vet. App. at 469-71. Significantly, no treatment records or providers relating to that treatment were identified by the Veteran to substantiate that assertion. Nevertheless, even if the credibility of the Veteran's report was conceded, that report would still place the onset of hypertension nearly 30 years after the Veteran's period of active service. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd 230 F.3d 1330 (Fed. Cir. 2000) (holding that service connection may be rebutted by the absence of medical treatment for the claimed condition for many years after service). Here, neither the assembled VA records nor the private medical certificates and statements show that any doctor or medical professional has stated that the Veteran's hypertension or cardiovascular disease was due to service, or caused or aggravated by his service-connected scar from a shrapnel wound to the back. Further, prior to his death, the Veteran did not supply any opinion evidence in support of his hypertension and cardiovascular claims beyond his own statements in support of his contentions. In summary, the Board finds that the evidence of record fails to reflect any hypertension or cardiovascular disease during or soon after service, and there are no medical opinions of record linking the Veteran's hypertension or cardiovascular disease to service or a service-connected disability. Therefore, a basis for granting service connection for hypertension and cardiovascular disease has not been presented. Accordingly, service connection for hypertension and cardiovascular disease is not warranted. Osteoarthritis and Rheumatoid Arthritis At the time of his death, the Veteran sought service connection for arthritis, claimed both as osteoarthritis and rheumatoid arthritis. In written statements, he asserted that he suffered from back pain and knee pain due to arthritis, which he contended was caused by a shrapnel wound to the back. In a July 2004 letter, for instance, the Veteran stated that the history of illnesses discussed in a July 2004 medical certificate (including arthritis) could be traced back to the shrapnel injury to his back during active service. Additionally, in June 2000 and March 2002 affidavits, neighbors and individuals who served with the Veteran related their observations that the Veteran suffered from rheumatoid arthritis and back pain for many years as a result of the shrapnel wound to the back in service. There is no evidence of the Veteran suffering from any form of arthritis during his active service or within the one-year period follow service. The February 1946 affidavit for Philippine Army personnel is negative for any report or finding of arthritis. The first evidence of arthritis is a June 1999 private medical statement, which reflects that the Veteran was treated at a private clinic for rheumatoid arthritis. In March 2002, the Veteran sought treatment for complaints of right knee and back pain. A lumbar spine x-ray at that time was unremarkable. Nevertheless, it appears that osteoarthritis was diagnosed the same month, as noted in a March 2002 private medical statement. Subsequent private medical statements continue to show generally diagnoses of osteoarthritis and rheumatoid arthritis. In a June 2006 private medical certificate, a physician noted that the Veteran had suffered from osteoarthritis since 1999 and that x-rays of the left knee and back showed traumatic osteomyelitis. That physician added that "contributing to [the Veteran's] leg pain could be his past trauma during his military time." Private radiology reports dated in June 2006 and February 2007 reflect findings of traumatic osteomyelitis in the left knee and sclerotic changes consistent with osteoarthritis in the lumbar spine. During a July 2007 VA examination for aid and attendance, an examiner noted that the Veteran suffered from severe arthritis. Following x-rays of the left knee which showed knee contracture and osteoporosis, the examiner diagnosed osteoarthritis with knee contractures. Significantly, however, no VA or private medical professional linked the Veteran's osteoarthritis or rheumatoid arthritis to active service, to include an in-service shrapnel wound to the back. Nor did any medical professional indicate that any arthritis was caused or aggravated by the Veteran's service-connected residual scar from a shrapnel wound to the back. After reviewing the evidence of record, the Board finds that service connection for arthritis, to include osteoarthritis and rheumatoid arthritis, is not warranted. At the outset, the Board has considered the contentions of the Veteran, his neighbors, and individuals who served with the Veteran, that the Veteran's arthritis was caused or aggravated by his in-service shrapnel wound to the back. However, as laypersons without medical or specialized training, the Veteran and the other individuals noted, are not competent to provide an opinion as to the etiology of his arthritis. While the Board accepts the Veteran's statements regarding the symptoms of his arthritic conditions, determining their medical etiology requires specialized training and information that neither the Veteran nor his acquaintances have. Jandreau, 492 F.3d at 1377. Accordingly, the assertions of the Veteran and his acquaintances regarding the etiology of the Veteran's pain are afforded no probative weight. The Board further recognizes that, in written statements, the Veteran and his neighbors attested to years of back pain and knee pain experienced by the Veteran. To the extent that the Veteran's statements can be construed as claiming a continuity of back pain since service, the Veteran was competent to report the onset and continuity of his symptomatology. See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (a lay person is competent to report symptoms based on personal observation when no special knowledge or training is required). However, the Board does not find that any reports of pain since service to be credible, as they are inconsistent with other statements regarding the onset of pain. See Cromer v. Nicholson, 19 Vet. App. 215 (2005) (finding a history, provided by a veteran, that had varied over time was not credible). Foremost, on his February 1946 affidavit, the Veteran did not report any permanent injury from his in-service shrapnel wound to the back, and during his August 2005 VA PTSD examination, the Veteran reported that his shrapnel wounds had healed. Additionally, the Veteran reported during October 2003 private treatment that he began having joint pain in 1999. Consequently, any subsequent reports of a continuity of pain since service made by the Veteran, his neighbors, or acquaintances, are contradicted by other statements made by the Veteran in furtherance of treatment and, therefore, are deemed not credible. Moreover, the Board finds it significant that the Veteran was first diagnosed with arthritis in 1999, over 50 years after his discharge from service. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd 230 F.3d 1330 (Fed. Cir. 2000) (holding that service connection may be rebutted by the absence of medical treatment for the claimed condition for many years after service). The Board is cognizant of the private physician's June 2006 statement that the Veteran's past military trauma 'could have' contributed to his leg pain. While arguably suggestive of a nexus between some unspecified military trauma and unidentified leg pain, the opinion is speculative in nature, unsupported by any rationale, and vague in that it specifies neither the disability causing leg pain nor the service-related trauma that could have contributed to leg pain. See Sklar v. Brown, 5 Vet. App. 140 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993); Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); Swann v. Brown, 5 Vet. App. 229, 232 (1993). Accordingly, the June 2006 statement is accorded no probative weight. Based on the foregoing, the Board finds that there is no competent evidence that his osteoarthritis or rheumatoid arthritis are related to active service, to include a shrapnel wound therein, or secondary to or aggravated by his service-connected residuals from a shrapnel wound to the back. Nor is there evidence of arthritis within the one-year period following service, such that service connection is warranted on a presumptive basis. Accordingly, service connection for arthritis is denied. Post Cerebrovascular Accident The Veteran asserted entitlement to service connection for residuals of a cerebrovascular accident (CVA) prior to his death. The Veteran's service records fail to reference any cerebrovascular accident. Post-service private records show that the Veteran first suffered a stroke in 1995. Specifically, June 1999 and June 2006 private medical certificates show that the Veteran suffered a mild stroke, also noted as a transient ischemic attack, first in 1995, and then again in 1997. Thereafter, a March 2002 medical certificate notes a diagnosis of post-CVA syndrome. Notably, none of the treatment providers linked the Veteran's diagnosed post-cerebrovascular accident syndrome to service or to his service-connected residual scar from a shrapnel wound to the back. The Board notes that the Veteran did not report that he first experienced the symptoms of his post-cerebrovascular accident syndrome during service and that his symptoms had persisted since service. But see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (a lay person is competent to report symptoms based on personal observation when no special knowledge or training is required). Rather, he again hypothesized that his post-cerebrovascular accident syndrome was related to service or to a service-connected disability. An opinion as to the etiology of his CVA, however, is a complex medical question for which lay testimony is not competent evidence. Accordingly, his assertion is neither competent nor probative evidence supporting his claim. See Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77; see also Kahana v. Shinseki, 24 Vet. App. 428 (2011). There otherwise is no competent medical evidence of record his contentions. See Jandreau, 492 F. 3d 1372. Instead, the medical evidence of record seems to associate the Veteran's cerebrovascular accident to his hypertension, for which service connection has not been established. In sum, as the evidence of record fails to reflect any cerebrovascular accident or post-cerebrovascular accident syndrome during or soon after service, and there are no medical opinions of record linking the Veteran's post-cerebrovascular accident syndrome to service or to a service-connected disability, a basis for granting service connection for post-cerebrovascular accident syndrome has not been presented. Accordingly, service connection for post-CVA is denied. Dizziness With regard to the Veteran's service connection claim for a disorder manifested by dizziness, the Board notes that the threshold requirement for establishing entitlement to service connection is evidence of a currently-diagnosed disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (holding that in the absence of proof of a present disability, there can be no valid claim). Here, the record fails to reflect that the Veteran was diagnosed with a chronic disorder manifested by dizziness at the time of his death. Moreover, the Board notes that while the symptoms of dizziness may be capable of lay observation, a chronic underlying disorder manifested by dizziness may not be diagnosed by layperson, such as the Veteran. See Layno, 6 Vet. App. at 469-71; see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (holding that a lay person is not considered competent to testify regarding medically complex issues). C.f. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (distinguishing situations in which a layperson is competent to identify the medical condition). To the extent that the Veteran experienced dizziness associated with his hypertension, as noted in a June 2006 medical certificate, service connection for hypertension has not been established. Furthermore, the June 2006 private physician who noted the Veteran's dizziness did not render a diagnosis in conjunction with the Veteran's reported subjective symptomatology. As there is no competent evidence of a currently diagnosed chronic disorder manifested by dizziness, the Board finds that a basis for service connection has not been presented. Accordingly, service connection for dizziness is denied. Shrapnel Wound to the Left Leg At the time of his death, the Veteran was seeking service connection for a shrapnel wound to the left leg. In support of his claim, the Veteran submitted a June 2000 affidavit from individuals stating that they served with the Veteran and were aware of his in-service injuries, to include a shrapnel injury to the right knee and complaints of pain related thereto. These individuals did not report knowledge of any left leg injury. The Veteran's available service records, consisting of a February 1946 affidavit for Philippine Army personnel, reflect that he reported his only wound or illness incurred from December 1941 to February 1946 was a June 1945 shrapnel wound to the back. He did not report any other shrapnel wounds, injuries, or illnesses. The Veteran's post-service private treatment of record also fails to reflect treatment for disability related to a left leg shrapnel wound. During an August 2005 VA PTSD examination, in discussing his combat experience, the Veteran reported sustaining shrapnel wounds to his back and left lower leg, but noted that they eventually healed. He similarly reported sustaining an in-service shrapnel wound to the left lower leg during private mental health evaluations in March 2005 and February 2007, however, no associated disability was identified. Interestingly, a June 2006 private medical certificate notes the presence of a scar on the Veteran's left knee; however the physician did not indicate the etiology of the scar. Thereafter, during VA examinations in July 2006 and July 2007 to evaluate the Veteran's service-connected back scar, there was no mention of any shrapnel wounds or scars other than the Veteran's back scar, to include any scar from shrapnel wound to the left lower leg. The Veteran's statement to the August 2005 VA PTSD examiner seems to acknowledge that he did not currently have any residual disability resulting from his claimed left leg shrapnel wound. Further, the record did not establish any objective evidence of disability or residual symptoms from a shrapnel wound to the left leg, to include any scarring. While the June 2006 private physician noted the presence of a scar on the left knee, the physician did not relate the scar to an in-service shrapnel wound. The threshold criterion for establishing service connection for a claimed condition is the presence of a current diagnosis. In the instant case, the evidence of record at the time of the Veteran's death failed to reflect that the Veteran either reported, sought treatment for, or was clinically assessed with any residual disability resulting from his reported in-service shrapnel wound to the left lower leg. The Board notes that, in the absence of a currently diagnosed disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, absent a diagnosis of a residual disability resulting from the Veteran's in-service shrapnel wound to the left leg, a basis for granting service connection for this claimed disorder has not been presented. Thus, the appellant's appeal of that issue is denied. Psychiatric Disorder Prior to his death, the Veteran also sought service connection for an acquired psychiatric disorder, claimed as PTSD. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). In this case, the Veteran's stressor is conceded. Pursuant to VA regulation, if the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(2); see also Cohen v. Brown, 10 Vet. App. 128 (1997). The Veteran submitted statements describing his service during World War II with the Recognized Guerillas, including witnessing his uncle get shot in the stomach, identifying persons killed and wounded in action, and sustaining shrapnel wounds himself during an attack in June 1945. The Veteran's February 1946 service affidavit notes his report of sustaining a shrapnel wound to the back in June 1945, for which he was granted service connection prior to his death. Therefore, the Board finds that the Veteran served in combat and that his combat-related stressors should therefore be conceded. Despite conceding his stressor, service connection for PTSD must be denied because the evidence of record at the time of the Veteran's death did not establish that the Veteran had a valid diagnosis of PTSD. The Veteran submitted a March 2005 examination report and a June 2005 follow-up report from a single psychiatrist, both of which show a diagnosis of PTSD. Those examination reports note the Veteran's report of in-service shrapnel wounds to the back and left leg, and his complaints of nightmares. In March 2005, the Veteran denied a prior history of mental illness and was noted to be euthymic, though with poor attention, concentration, judgment, impulse control, and volition. In the June 2005 addendum report, the private psychiatrist discussed generally the nature and symptoms of PTSD and discussed in particular some of the Veteran's symptoms as they related to PTSD criteria. The psychiatrist also noted that the Veteran suffered from a mental disorder as a result of his shrapnel wound in-service, but also later indicated that the Veteran could have been influenced by hereditary factors. However, the psychiatrist offered no elaboration on that conclusion. The Veteran underwent a VA PTSD examination in August 2005, which included a battery of psychological testing. The examiner reviewed the Veteran's claims file and medical records. The Veteran reported his history of sustaining shrapnel wounds in service and an onset of intermittent anxiety symptoms immediately after the incident, but indicated that they disappeared and allowed him to be productive for a number of years. The examiner noted the Veteran's diagnosis of PTSD by his private psychiatrist. However, after performing a mental status examination and reviewing the results of the psychological tests, the examiner found that the Veteran did not meet the DSM-IV diagnostic criteria for PTSD. Instead, the examiner diagnosed the Veteran as suffering from age-related cognitive decline and opined that the Veteran's age-related cognitive decline was independently responsible for whatever impairment the Veteran was experiencing. In June 2006, the Veteran was evaluated by a different private psychiatrist. He reported that his condition started after being hit by shrapnel in his back and lower left leg while in combat. He reported that, after the incident, he started experiencing anxiety attacks, suspiciousness of others, and wanted to end his life. He also reported nightmares. He stated that his symptoms eventually waned and then one year prior to that treatment, he started to have a relapse of symptoms. In addition to the foregoing symptoms, the Veteran recently became unable to care for his personal hygiene alone, became messy when eating by himself, and began soiling himself. Following a mental status examination, the psychiatrist diagnosed Alzheimer's disease and rule out normal pressure hydrocephalus, and ordered a cranial computed tomography (CT) scan. In a subsequent February 2007 report, the same private psychiatrist who conducted the June 2006 evaluation diagnosed dementia and rule out normal pressure hydrocephalus. Then, following a June 2007 CT scan, which showed a small infarct of the left thalamus, cerebral and cerebellar atrophy, and arteriosclerosis, the psychiatrist changed her diagnoses to PTSD and vascular dementia. The psychiatrist offered no explanation or reasoning for the PTSD diagnosis. Nor did the psychiatrist address the VA examiner's finding that a diagnosis of PTSD was not warranted. When there is an apparent difference of medical opinion, it is the Board's responsibility to weigh the credibility of the evidence of record. Hayes v. Brown, 5 Vet. App. 60, 69 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-193 (1992)). In assessing medical evidence, whether a physician provides a basis for his medical 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, 448-89 (2000). The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Sklar v. Brown, 5 Vet. App. 140 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993); Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); Swann v. Brown, 5 Vet. App. 229, 232 (1993). The Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Further, to be considered probative evidence, a conclusion from a doctor or other medical professional must be enhanced by sufficient commentary so as to allow for weighing of that conclusion. Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (holding that "a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor's opinion."); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("The Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion."); Miller v. West, 11 Vet. App. 345, 348 (1998) ("A bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record."). "Neither a VA medical examination report nor a private medical opinion is entitled to any weight in a service-connection or rating context if it contains only data and conclusions." Nieves-Rodriguez, 22 Vet. App. at 304. In this case, the Board finds the August 2005 VA examiner's opinion that the Veteran did not meet the diagnostic criteria for PTSD to have greater probative value than the diagnoses rendered by the private psychiatrists in reports dated in March 2005, June 2005, and June 2007. In contrast to the VA examiner's assessment, the private opinions were not based on a review of the claims file and did not include a full discussion of the relevant DSM-IV diagnostic criteria as it related to the Veteran. In this regard, the Board finds probative the fact that the June 2007 private psychiatrist apparently interviewed the Veteran on three occasions, but failed to render a diagnosis of PTSD or rule out PTSD following the first two evaluations in June 2006 and February 2007. Instead, at those times Alzheimer's disease, rule out normal pressure hydrocephalus, and dementia were assessed. Then, in June 2007, the private psychiatrist diagnosed PTSD in addition to vascular dementia, but provided no explanation or rationale for the additional diagnosis. Nor did the psychiatrist include any discussion of the DSM-IV criteria for diagnosing PTSD at that time. Further, it appears that the private diagnoses of PTSD were based on limited review of the Veteran's medical history that was provided by the Veteran himself. In this regard, the Board notes that the Veteran's reports regarding the history of his psychiatric symptoms were inconsistent. See Cromer v. Nicholson, 19 Vet. App. 215 (2005) (finding a history, provided by a veteran, that had varied over time was not credible). For example, during his initial March 2005 private examination, the Veteran denied any prior history of mental illness. However, during his subsequent June 2006 private evaluation, the Veteran reported experiencing psychiatric symptoms immediately following his in-service shrapnel wound. Even further, the Board observes that the Veteran was diagnosed with Alzheimer's disease in June 2006, and later, dementia, thereby calling into question his reliability as a historian. Given the inconsistencies in the Veteran's reports, the Board finds that the diagnoses of PTSD based solely on the history supplied by the Veteran are of lesser probative value. In contrast to the private opinions of record, the August 2005 opinion is much more detailed and cites to specific evidence in the claims file, including private medical certificates and a prior diagnosis of PTSD. The opinion also includes a full discussion of the diagnostic criteria for PTSD and the Veteran's symptoms related thereto. Furthermore, the August 2005 opinion was based on a battery of psychological testing, in addition to a thorough clinical evaluation of the Veteran. For these reasons, the Board finds the opinion of the August 2005 examiner, indicating that the Veteran did not meet the diagnostic criteria for PTSD, to be of greater probative value than those of the private psychiatrists who rendered the PTSD diagnoses in March 2005, June 2005, and June 2007. Based on the discussion above, the Board finds that the competent and credible medical evidence of record does not establish that the Veteran was suffering from PTSD at the time of his death. It is axiomatic that "in the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As the evidence did not establish that the Veteran was suffering from PTSD, there is no basis upon which to award service connection for PTSD. Finally, though the Veteran appealed his denial of service connection for PTSD, the Board has broadened his claim to one for service connection for an acquired psychiatric disorder in general. In February 2009, the Court of Appeals for Veterans Claims (Court) ruled that when a claimant seeks service connection for PTSD and nothing more, such a claim must be "considered a claim for any mental disability that may reasonably be encompassed by several factors including: the claimant's description of the claim; the symptoms the claimant describes, and the information" submitted by the claimant or obtained by VA. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Here, as noted above, the Veteran was diagnosed with an age-related cognitive disorder, Alzheimer's disease, and vascular dementia at the time of his death. The claim is thus broadened to one for an acquired psychiatric disorder. At the time of the Veteran's death, there was no competent evidence of a link between these other psychiatric diagnoses and his active duty service. Indeed, the Veteran was afforded a VA examination in August 2005, pursuant to which he was diagnosed with cognitive decline related to his advancing age. Neither the August 2005 examiner nor the private psychiatrist who diagnosed Alzheimer's disease and dementia even suggested a link between those diagnoses and his active service or his service-connected disability. To the extent that the Veteran attributed his dementia, Alzheimer's disease, and cognitive decline to service, the determination of what particular psychiatric condition a person suffers from and its etiology are not issues susceptible to lay observation. Therefore, the Veteran was not competent to attribute his current psychiatric conditions to his active service. Furthermore, to the extent that the Veteran reported an onset of psychiatric symptoms in service following his shrapnel wound, the Board finds those reports not credible, as they were contradicted by other evidence of record. Specifically, the Veteran did not report any psychiatric symptoms on his February 1946 service affidavit, and during his initial post service psychiatric treatment in March 2005, the Veteran denied any previous history of mental illness. Absent any competent and credible evidence of an in-service occurrence of a psychiatric disorder or any evidence indicating that his post-service diagnoses are related to service, the Board must conclude that service connection for an acquired psychiatric disorder in general is not warranted. In summary, the Board finds that the evidence at the time of the Veteran's death did not establish that the Veteran suffered from PTSD, and that the Veteran's other psychiatric conditions were incurred long after his active service and were not related to service or to a service-connected disability. Accordingly, the Board concludes that the criteria for service connection for an acquired psychiatric disorder (including PTSD) have not been met. Increased Rating Finally, at the time of his death, the Veteran was seeking an initial compensable rating for a service-connected back scar, a residual from a shrapnel wound. Disability ratings are determined by applying a schedule of ratings based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Further, examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. While the Veteran's entire history is reviewed when making a disability determination, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). At the time of the March 2002 rating action from which the Veteran's appeal arose, 10 percent ratings were assigned for scars not affecting the head, face or neck that were superficial and poorly nourished, with repeated ulceration; or that were superficial, tender, and painful on objective demonstration. See 38 C.F.R. § 4.118, Diagnostic Codes 7803, 7804 (1997). Alternatively, scars could be assigned a rating based on the limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805 (1997). During the course of the Veteran's appeal, the regulations for rating disabilities of the skin were revised effective August 30, 2002. 67 Fed. Reg. 49,596 (July 31, 2002). Under the revised criteria, 10 percent ratings are assigned for scars, not affecting the head, face, or neck, that (1) are deep and cover an area exceeding 6 square inches (39 sq. cm.) (a deep scar is one associated with underlying soft tissue damage); (2) cause limited motion and cover an area exceeding 6 square inches; (3) are superficial, do not cause limited motion, and cover an area of 144 square inches or greater (a superficial scar is one not associated with underlying soft tissue damage); (4) are superficial and unstable (an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar); or (5) are superficial and painful on examination. See 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805 (2008). The rating criteria for scars were amended again during the course of the appellant's appeal, effective October 23, 2008. See 73 Fed. Reg. 54,708 (2008) (presently codified at 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (October 23, 2008)). The summary in Federal Register notes that the applicability date of the amendment is for all claims received by VA on and after October 23, 2008. As the Veteran's claim was filed prior to this date, the revised rating criteria do not apply in this case, unless the Veteran requested review under the revised regulations, and the appellant made no such request. The primary relevant evidence of record consists of VA scars examinations conducted during the relevant appeal period, as they are the most comprehensive assessments of the Veteran's back scar. A July 2006 VA scars examination report reflects that the Veteran's back scar was located on the posterior trunk in the mid-portion of the back and was measured as 0.4 centimeters wide and 2 centimeters long. There was no tenderness to palpation, limitation of motion or loss of function, underlying soft tissue damage, or skin ulceration or breakdown over the scar. The Veteran denied symptoms of pain, or any breakdown of his skin. The diagnosis was healed scar, back, residuals of shrapnel wound. A July 2007 VA scars examination report reflects that the Veteran's back scar measured as 0.5 centimeters wide and 1.8 centimeters long. The examiner further noted that the scar was not tender to palpation, was not associated with underlying tissue damage, and did not result in limitation of motion or loss of function. Additionally, there was no ulceration or breakdown over the scar. The examiner diagnosed a healed scar of the lower back due to shrapnel wound. After reviewing the evidence of record, the Board finds no basis upon which to award a compensable rating for the Veteran's back scar under any of the applicable rating criteria. In this regard, the Board observes that, while the Veteran asserted back pain from his shrapnel wound to his back, he did not specifically report his residual scar to be painful. Nevertheless, to the extent that the Veteran's statements of back pain from his shrapnel wound could broadly be construed as relating to his service-connected scar, the medical assessments of record failed to note any corresponding objective evidence of pain on examination. In addition, the Veteran's back scar was not noted to be deep, nor did it meet the requisite circumference measurements for a compensable rating for superficial scars. Furthermore, there was no objective evidence of pain or tenderness on examination and at no time was the back scar assessed as poorly nourished, evidence ulceration, unstable, or causing limitation of motion. In summary, the Board finds that the evidence of record at the time of the Veteran's death did not show that the Veteran's service-connected scar from a shrapnel wound to the back satisfied any of the applicable criteria for a compensable disability rating. Accordingly, the Board concludes that the criteria for a compensable rating for a back scar were not met. The Board has also considered whether a referral for an extraschedular evaluation is warranted with regard to the Veteran's back scar increased rating claim. The threshold factor for extraschedular consideration is a finding on part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993); 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B (5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extraschedular consideration is required. See VAOGCPREC 6-1996 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology and provides for additional or more severe symptoms than currently shown by the evidence; thus, the Veteran's disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. Consequently, referral for extraschedular consideration is not warranted. The Board also notes that, although the Veteran was unemployed prior to his death, the evidence of record does not suggest that it was due to his service-connected back scar. Nor did the Veteran specifically claim entitlement to a total disability due to individual unemployability (TDIU). Accordingly, consideration of entitlement to TDIU benefits is not warranted. ORDER Service connection for hypertension, for purposes of accrued benefits, is denied. Service connection for hypertensive cardiovascular disease, for purposes of accrued benefits, is denied. Service connection for arthritis, to include osteoarthritis and rheumatoid arthritis, for purposes of accrued benefits, is denied. Service connection for post-cerebrovascular accident syndrome, for purposes of accrued benefits, is denied. Service connection for a condition manifested by dizziness, for purposes of accrued benefits, is denied. Service connection for shrapnel wound to the left leg, for purposes of accrued benefits, is denied. Service connection for a psychiatric disorder, to include PTSD, for purposes of accrued benefits, is denied. A compensable rating for a residual scar from shrapnel wound to the back, for purposes of accrued benefits, is denied. ____________________________________________ D. JOHNSON Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs