Citation Nr: 1308306 Decision Date: 03/12/13 Archive Date: 03/20/13 DOCKET NO. 05-31 659 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a bilateral hip disability, to include avascular necrosis as secondary to service-connected diabetes mellitus, and as secondary to herbicide exposure. 2. Entitlement to service connection for a bilateral shoulder disability to include as secondary to service-connected diabetes mellitus, and as secondary to herbicide exposure. 3. Entitlement to a total rating for compensation based on individual unemployability (TDIU) prior to October 26, 2011. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD James A. DeFrank, Counsel INTRODUCTION The Veteran had active duty service from August 1967 to September 1970, to include service in the Republic of Vietnam from August 1968 to May 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an October 2004 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Veteran and his spouse testified before the Veterans Law Judge at a March 2010 Travel Board hearing. A copy of that hearing transcript has been associated with his claims file. In a September 2010 decision, the Board, in part, remanded these issues for additional development. In March 2012, the Board sent a letter to the Veteran informing him that the VLJ before whom he had testified in March 2011 was no longer employed at the Board and advising him that he had a right to a new hearing before another VLJ that would decide his case. See 38 U.S.C.A. § 7107(c) (West 2002) (providing that the member or members designated to conduct a hearing shall participate in making the final determination of a claim on appeal). In an April 2012 correspondence, the Veteran indicated that he did not wish to appear at a hearing and he wished for his case to be considered by the evidence of record. In August 2012, the Board requested a Veterans Health Administration (VHA) medical opinion on these matters. This September 2012 VHA opinion has been associated with the claims file and is now returned to the Board for review. Additionally, in October 2012, the Board requested an addendum to the September 2012 VHA opinion which was provided and has been associated with the claims file. The Veteran was notified of this medical opinion and afforded 60 days from the date of this letter to respond. The Veteran submitted additional argument and evidence which was accompanied by a waiver. The issues of whether new and material evidence has been received to reopen a claim for service connection for a low back disorder has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issue of entitlement to a TDIU prior to October 26, 2011, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The most probative medical evidence of record does not show a bilateral hip disability to be etiologically related to a disease, injury, or event in service, to include a service-connected disability and herbicide exposure. 2. The most probative medical evidence of record does not show a bilateral shoulder disability to be etiologically related to a disease, injury, or event in service, to include a service-connected disability and herbicide exposure. CONCLUSIONS OF LAW 1. A bilateral hip disability was not incurred in or aggravated by service, is not proximately due to or the result of any service-connected disability, and may not be presumed to have been incurred in or aggravated by service to include as due to herbicide exposure. See 38 U.S.C.A. § 1110, 1116, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. A bilateral shoulder disability was not incurred in or aggravated by service, is not proximately due to or the result of any service-connected disability, and may not be presumed to have been incurred in or aggravated by service to include as due to herbicide exposure. See 38 U.S.C.A. § 1110, 1116, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). In this appeal, the RO provided notice to the Veteran in a December 2006 letter that explained what information and evidence was needed to substantiate a claim for service connection, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The letter also provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). After issuance of the December 2006 letter, and opportunity for the Veteran to respond, the March 2012 supplemental statement of the case (SSOC) reflects readjudication of the claim. Hence, the Veteran is not shown to be prejudiced by the timing of the latter notice. See Mayfield, 20 Vet. App. at 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). VA has also fulfilled its duty to assist in obtaining the identified and available evidence needed to substantiate the claims adjudicated in this decision. The RO has either obtained, or made sufficient efforts to obtain, records corresponding to all treatment for the claimed disorders described by the Veteran. Additionally, he was afforded VA examinations in May 1991, March 2011 and December 2011. In September 2012, a VHA medical opinion was provided based on a review of the claims file and a VA addendum opinion was provided in October 2012. As the VHA examiner thoroughly addressed the relevant issues, and provided a rationale for the conclusions provided, the Board concludes that the examinations were adequate. Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007) In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed.Cir.2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Secondary service connection shall be awarded when a disability "is proximately due to or the result of a service-connected disease or injury." 38 C.F.R. § 3.310(a). Also, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Effective October 10, 2006, 38 C.F.R. § 3.310 was amended to implement the holding in Allen v. Brown, 7 Vet. App. 439 (1995) for secondary service connection on the basis of the aggravation of a nonservice-connected disorder by service- connected disability. See 71 Fed. Reg. 52744 (2006). The amendment essentially codifies Allen with language that requires that a baseline level of severity of the nonservice-connected disease or injury must be established by medical evidence created before the onset of aggravation. If a Veteran was exposed to a herbicide agent during active military, naval, or air service, certain diseases shall be service connected if the requirements of 38 U.S.C.A. § 1116 and 38 C.F.R. § 3.307(a) (6) (iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113; 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e) (2012). In this regard, it is noted that a "Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service." 38 U.S.C.A. § 1116(f) (West 2002); 38 C.F.R. § 3.307(a) (6) (iii) (2012). The diseases alluded to above include AL amyloidosis, chloracne or other acneform diseases consistent with chloracne, Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemia, multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e) (2012). Notwithstanding the foregoing presumptive provisions, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that a claimant is not precluded from establishing service connection for a disease averred to be related to herbicide exposure, as long as there is proof of such direct causation. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). See also Brock v. Brown, 10 Vet. App. 155, 160-61 (1997), vacated on other grounds (Fed. Cir. Dec. 15, 2000). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Factual Background and Analysis The Veteran has alleged suffering from bilateral hip avascular necrosis and bilateral shoulder avascular necrosis as a result of service or his service-connected diabetes mellitus. The Veteran has also contended that his bilateral hip avascular necrosis and bilateral shoulder avascular necrosis disabilities are a result of his exposure to Agent Orange during his service. In November 1984, the Veteran was hospitalized after flipping backwards over a three wheel bicycle. He presented with complaints of shoulder pain and severe fatigue. The discharge diagnosis was fibromyalgia, impaired glucose tolerance, prostatitis and meatel stenosis. In May 1985 he presented to a Pain Management Clinic with complaints of chronic pain involving his shoulders, back and legs. He reported that in 1984 he was reaching out his right hand and suddenly felt sharp pain across his right shoulder. Since then, his pains had started to occur daily. The likely diagnosis was fibromyalgia. In December 1988 the Veteran presented with complaints of pain in both of his hips. The Veteran had bilateral avascular necrosis and the left hip showed a collapse of the upper portion of the femoral head. He underwent a total left hip replacement as a result of his complaints of pain. In May 1991, the Veteran underwent a general VA examination. He denied diabetes but noted that he had orthopedic problems. X-rays of the right hip demonstrated stage one avascular necrosis. X-rays of the left hip showed signs of ifemoral loosening post surgery. In March 1994, the Veteran presented with left hip pain as he needed a revision of his left total hip. He denied having diabetes. In August 2002, the Veteran underwent a right total hip replacement. A December 2002 hospital note indicated that the Veteran had diabetic peripheral neuropathy. In a December 2002 treatment note, a private physician noted that the Veteran had a history of diabetes and fibromyalgia. A February 2003 treatment report noted that the Veteran had undergone right hip replacement surgery. A March 2003 treatment note from Dr. V.C. reported that the Veteran had no history of diabetes. An April 2003 private treatment note assessed the Veteran with "probable diabetes". In an August 2003 treatment note from the Springfield Neurosurgical Associates, the Veteran reported that he did not have diabetes. An August 2003 treatment note diagnosed the Veteran with ostonecrosis of the shoulders. An X-ray of the right shoulder in September 2003 revealed abnormal appearance of the humeral head without flattening. It was noted that the findings "could be due to avascular necrosis". An October 2003 MRI revealed avascular necrosis of the right shoulder. A November 2003 letter from the Mayo Clinic noted final diagnoses of avascular necrosis of both hips and the right shoulder, neck and low back pain, chronic pain, untreated obstructive sleep apnea, peripheral neuropathy and health maintenance issues. In a July 2004 letter, Dr. G. W. noted that the Veteran had some peripheral neuropathy with numbness that was most likely secondary to his exposure to Agent Orange or chemicals in Vietnam. Dr. G. W. also noted that the Veteran had avascular necrosis of the right shoulder but made no mention of its etiology. In another July 2004 letter, Dr. G.W. concluded that it was reasonable to think that the Veteran had been exposed to the immutoxilogical effects of Agent Orange during his service in Vietnam. In an October 2004 treatment report, Dr. G. W. indicated that the Veteran had a past history of hypertension, avascular necrosis and peripheral neuropathy. He had family history of cancer, heart disease and diabetes. A November 2006 VA treatment note diagnosed the Veteran with diabetes with neuropathy. In a January 2007 letter, Dr. E.P. noted that the Veteran had been diagnosed with avascular necrosis of both hips and shoulders as well as diabetes. From the Veteran's personal history, he stated that he was exposed to Agent Orange during his service. In a March 2007 letter, a VA nurse indicated that in February 2006 the Veteran presented to their clinic with chronic problems of diabetes mellitus type II. The Veteran underwent a VA examination for diabetes in August 2007. He reported that he was first diagnosed with diabetes in 1984 but that he was not treated for this condition until 2006. A March 2009 VA examination for diabetes noted that the Veteran had bilateral avascular necrosis of both hips with bilateral hip replacements. He also had chronic back pain with morbid obesity. In an April 2010 letter, the Veteran's private primary care physician Dr. G. W. indicated that diabetes mellitus "can cause avascular necrosis which is a concern". An undated article published by the Mayo Clinic submitted by the Veteran reflects that diabetes mellitus increases the risk of developing avascular necrosis. The Veteran underwent a VA examination in March 2011. The examiner, a VA family nurse practitioner, noted that the Veteran reported that in 1988, 4 years after he was diagnosed with diabetes mellitus, he noticed acute right groin pain. He was subsequently diagnosed with avascular necrosis which led to bilateral hip surgeries. In 2000, he was diagnosed with avascular necrosis of the bilateral shoulders. The examiner opined that there was a most likely probability that the diagnosed hip and shoulder disorders had their onset following a formal diabetes mellitus diagnosis in 1984 and presumed exposure to herbicides. The Veteran reported that his hip disability was diagnosed in 1988 which was 4 years after his treatment for diabetes. He also denied any trauma or history of joint dislocation. A literature review also supported diabetes as a risk factor and hidden cause for avascular necrosis. From a medical standpoint, the examiner was most inclined to believe that the avascular necrosis was a result of herbicide exposure ultimately causing diabetes mellitus which further worsened the hip and shoulder disorders beyond their natural progression. In a December 2011 VA examination regarding the Veteran's congestive heart failure and his employability, the VA family nurse practitioner opined that it was at least as likely as not that a pathophysiological relationship existed between the Veteran's diabetes mellitus and his diagnosed hip and shoulder disorders. It was noted that the Veteran reported experiencing initial joint complications in 1988 which was 4 years after his formal treatment for diabetes. The examiner noted an extensive review of literature in which one research study suggested that poor glycemic control and other complications associated with diabetes mellitus could contribute to limited joint mobility and strain. Literature also supported diabetes as a risk factor for increased vulnerability for avascular necrosis as the hypothesis was that bone death can occur from depleted blood supply from damaged arteries which have ultimately resulted from accumulation of glucose sugars within the vascular system. In July 2012 the Board solicited an expert medical opinion from a VHA medical expert. In a July 2012 letter, a VHA reviewer noted that the Veteran's service treatment records noted no abnormality of the hips or shoulders during his active duty. He also noted the October 1984 treatment report which noted an abnormal glucose tolerance test. However, diabetes mellitus was not diagnosed at that time. An August 1998 MRI scan showed avascular necrosis of both hips. An August 2003 treatment note identified avascular necrosis of the right shoulder on x-ray. The VHA reviewer noted that the Veteran contends that his Agent Orange exposure during his military duty caused his diabetes mellitus which caused his avascular necrosis of the hips and shoulders. He opined however that the avascular necrosis of the hips and shoulders which was first noted in August 1988, 18 years after his military duty, was less likely than not related to active military duty. He noted that diabetes mellitus was first formally diagnosed in 2006, 36 years after his active duty. During this time, the Veteran was struggling with obesity, fibromyalgia and peripheral neuropathy. He opined that the diabetes mellitus was less likely related to the military service being identified 36 years post active duty with a variety of intervening conditions between exposure to Agent Orange and development of diabetes and avascular necrosis. Medical records also indicated that the Veteran was on oral Prednisone, a known cause of avascular necrosis from January 1985 to April 1985. He also struggled with obesity for many years prior to the diagnosis of diabetes. Obesity was a common predecessor for diabetes. The VHA reviewer concluded that avascular necrosis and the diabetes were unlikely related to military duty. In August 2012, the Board again requested a medical opinion from a VHA specialist as it determined that the July 2012 VHA opinion largely did not address the Board's questions but rather addressed the etiology of the Veteran's diabetes. Thus, the Board again solicited an expert medical opinion from a VHA medical expert to determine whether the Veteran's avascular necrosis of the hips and shoulders was either caused or aggravated by the Veteran's service-connected disabilities to include diabetes mellitus or was otherwise related to the service or a service-connected disability. In a September 2012 opinion, a VHA reviewer determined that there was no presumptive condition of avascular necrosis associated with herbicide exposure. He also noted that there was no evidence that the Veteran's avascular necrosis was either caused or permanently aggravated by his service-connected diabetes mellitus or any other service-connected disabilities. The reviewer noted that in November 1984 the Veteran was admitted for further workup which revealed a random glucose of 135 which was in the upper limits of normal. He had a 5 hour glucose tolerance test which showed a glucose of 64 at the 3 hour mark which was felt to be mild hypoglycemia. He saw Dr. D. of internal medicine who felt that he could not make a diagnosis of diabetes and he felt that the Veteran should lose weight and watch his diet. In October 1984 he was admitted for a urological procedure and his glucose was 94 which was well within the normal range. It was noted that he had avascular necrosis of the hips diagnosed in 1988 and had obesity and morbid obesity for "many, many years". The VHA reviewer also noted that in October 2003 the Veteran was seen by an endocrinologist, which is a diabetic specialist. He had glucose of 110 and the endocrinologist diagnosed the Veteran with avascular necrosis of the hips and shoulders, neck and back pain, chronic pain syndrome, sleep apnea, peripheral neuropathy, etiopathic and health maintenance issues. Specifically, there was no diagnosis or mention of diabetes mellitus. Another note dated December 2002 reported that the past medical history was negative for diabetes. In July 2004, Dr. G.W. diagnosed peripheral neuropathy. The VHA reviewer noted that if the Veteran had diabetes at this time, it would have been the primary reason for his condition. The reviewer also noted that the first diagnosis of diabetes was in March 2002. The Veteran was on no medications at the time and further lab reports in October 2003 showed the Veteran with glucose of 110. An April 2003 treatment report noted probable diabetes but further notes dated January 2004 had no mention of diabetes in his medical report listing his current problems. A problem list dated August 2005 was also negative for diabetes. The first note of any actual diagnosis or treatment for diabetes was in October 2006. At the time, the Veteran reported that he had known about this diagnosis for several years but had decided to ignore the diagnosis. The VHA reviewer also made note of the fact that the operative report of December 1988 for his left hip avascular necrosis was also negative for past medical history medications or symptoms related to diabetes. A July 1997 sinus surgery note also indicated that he had a past history of benign prostatic hypertrophy but it was negative for diabetes. The reviewer noted that the March 2011 VA examiner, a family nurse practitioner, had found that the Veteran's avascular necrosis of the hips and shoulders were due to diabetes mellitus which had been caused by his Agent Orange exposure. However, the VHA reviewer opined that there was "absolutely no evidence" that the Veteran had documented diabetes mellitus until at least 2002 or 2003 when he was diagnosed with probable diabetes. The March 2011 VA examiner's opinion was therefore not well grounded based on her facts and good medical principles. It was noted again that the Veteran had no treatment for his diabetes until 2006. The reviewer noted that the most common cases of avascular necrosis with very strong evidence to that effect, is trauma to include blood damage to blood vessels, steroid use, high alcohol use, abnormally thick blood or vasculitiis. Diabetes was 17th on the list of factors that may increase avascular necrosis. Most of the articles reviewed do not even list diabetes mellitus as a risk factor for avascular necrosis. Prednisone use is a common known risk factor for avascular necrosis with very strong evidence to that effect. The VHA reviewer indicated that the Veteran did not have a confirmed diagnosis of diabetes until at least 2002 or 2003. He had avascular necrosis of his hips in 1988 and his shoulders in 2003. There was "absolutely no association whatsoever between his diabetes and his avascular necrosis". More likely the avascular necrosis of the hips and shoulders was due to either Prednisone use in 1985 and/or is etiopathic. If avascular necrosis would have been secondary to his diabetes, his diabetes would have been longstanding with other evidence of diabetic complications such as nephropathy, retinopathy and peripheral neuropathy. He had none of these at the time of his avascular necrosis diagnosis. The VHA reviewer concluded that it was less likely than not that the Veteran's avascular necrosis of the hips and shoulders were attributable to his presumed exposure to herbicides or to his diabetes mellitus. There was no evidence that his service-connected diabetes aggravated his avascular necrosis of the hips and shoulders. They were diagnosed many years before his diabetes mellitus was diagnosed. It was also less likely than not that his avascular necrosis was caused or aggravated by any of his other service-connected disabilities as there was no association between avascular necrosis and any of his service-connected conditions. In October 2012, the Board again requested an addendum from the VHA specialist who authored the September 2012 VHA as it determined that the September 2012 VHA opinion was insufficient in the sole aspect of addressing avascular necrosis as a presumptive condition. Thus, the Board again solicited an addendum to the September 2012 opinion from the VHA medical expert in order for him to provide rationale for his conclusion that avascular necrosis of the hips and shoulders was less likely than not attributable to presumed herbicide exposure beyond the fact that avascular necrosis was not a condition subject to service connection as presumptively attributable to presumed herbicide exposure. In an October 2012 addendum, the VHA reviewer noted that he had thoroughly reviewed medical literature regarding Agent Orange, specifically in herbicide exposure from the Institute of Medicine, Research in Vietnamese populations, Australian and New Zealand studies, Korean medical literature, VA research, National Academy of Science, the American Cancer Society Environmental science reports as well as reports in the Journal of American Medical Association. The reviewer found "absolutely no association between herbicide exposure and avascular necrosis of bones". The most common risk factor in the Veteran's case for avascular necrosis is the use of steroids, rather heavy doses, for approximately 3 to 3 1/2 months, a couple of years prior to the development of avascular necrosis. Medical science did not support the claim that avascular necrosis is associated with herbicide exposure, specifically Agent Orange exposure. He thoroughly researched mostly available medical articles relating to herbicide exposure as well as Agent Orange specifically. There was no evidence of herbicides causing avascular necrosis in adults exposed to these compounds. There was no obvious nexus between herbicide exposure and the Veteran's avascular necrosis of the hips and shoulders. Having carefully reviewed the record, the Board concludes that service connection is not warranted for the claimed avascular necrosis of the hips and shoulders to include as secondary to a service-connected disability or as secondary to herbicide exposure. As noted above, the Veteran does not contend that he incurred his avascular necrosis of the hips and shoulders directly in service. In this regard, the Board notes that a review of his service treatment records discloses no complaints or assessments regarding the hips or shoulders. The Veteran rather asserts that he has avascular necrosis of the hips and shoulders that was either caused or aggravated by his service-connected diabetes mellitus. In the alternative, he contends that his avascular necrosis of the hips and shoulders was a result of his exposure to Agent Orange while serving in Vietnam. The Board notes that there is conflicting evidence on the issues of whether the Veteran's his avascular necrosis of the hips and shoulders was caused or aggravated by his service-connected diabetes mellitus or was a result of his exposure to Agent Orange while serving in Vietnam. The Board may favor the opinion of one competent medical professional over that of another so long as an adequate statement of reasons and bases is provided. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). An evaluation of the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusion reached. The credibility and weight to be attached to such opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed by the physicians and whether or not and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). Regarding service connection for avascular necrosis of the hips and shoulders as secondary to a service-connected disability, in an April 2010 letter, the Veteran's private primary care physician Dr. G. W. indicated that diabetes mellitus "can cause avascular necrosis which is a concern". However, the Board notes that Dr. G.W.'s opinion here is not directed towards the particular facts and circumstances of the Veteran's case, but rather speaks only in very general terms as to the possibility of a relationship between avascular necrosis and diabetes mellitus. This fact, in combination with the relatively speculative nature of the opinion limits its probative value. The Board has considered that on VA examinations in March 2011 and December 2011, a VA family nurse practitioner opined that there was a most likely probability that the diagnosed hip and shoulder disorders had their onset following a formal diabetes mellitus diagnosis in 1984. Thus, she concluded that the Veteran's avascular necrosis of the hips and shoulders disabilities were due to diabetes mellitus. Conversely, in a September 2012 opinion, a VHA specialist opined that there was no evidence that the Veteran's avascular necrosis was either caused or permanently aggravated by his service-connected diabetes mellitus or any other service-connected disabilities. In this instance, the Board finds that the the September 2012 opinion of the VHA reviewer to be the most probative. While the March 2011 and December 2011 opinions of the VA family nurse practitioner related the Veteran's avascular necrosis of the hips and shoulders to diabetes mellitus, the Board notes that the basis for this conclusion is the unsubstantiated history given by the Veteran that he was first diagnosed with diabetes in 1984. The VA nurse practitioner opined that there was a most likely probability that the diagnosed hip and shoulder disorders had their onset following a formal diabetes mellitus diagnosis in 1984. She noted that the Veteran reported that his hip disability was diagnosed in 1988 which was 4 years after his treatment for diabetes. However, the most credible evidence of record indicates that the Veteran was first diagnosed with diabetes in the year 2002 or 2003 at the earliest. While a November 1984 treatment report noted impaired glucose tolerance, in his September 2012 VHA opinion, the reviewer noted that an internal specialist could not provide a diagnosis of diabetes. The VHA reviewer then detailed the Veteran's medical history since the impaired glucose tolerance diagnosis in 1984 which did not demonstrate a diagnosis of diabetes until March 2002 at the earliest. The evidence also reveals that on numerous occasions since 1984, the Veteran himself reported that he did not have diabetes. While multiple records since 1984 noted that the Veteran had a family history of diabetes, the record demonstrates that the first actual diagnosis of diabetes occurred in 2002. As the VHA reviewer noted, the Veteran's avascular necrosis of the hips and shoulders were diagnosed many years before his diabetes mellitus was diagnosed. As noted above, the basis for the March 2011 and December 2011 opinions of the VA nurse practitioner was that the service-connected diabetes preceded the Veteran's avascular necrosis as the diabetes was diagnosed in 1984 per the Veteran's reports. However, given the contemporaneous evidence of record showing that he was found to have only impaired glucose in 1984, the Veteran's own subsequent denials of having a diabetes mellitus, and the treatment records noting 2002 as the earliest diagnosis, the Board concludes that any assertion by the Veteran had diabetes prior to the onset of avascular necrosis is not credible. The Board notes that although it may not disregard a favorable medical opinion solely on the rationale that it was based on a history given by the Veteran (Kowalski v. Nicholson, 19 Vet. App. 171 (2005)), reliance on a veteran's statements renders a medical opinion not credible if the Board rejects the statements of the Veteran as lacking credibility. Coburn v. Nicholson, 19 Vet. App. 427 (2006). Thus, while the VA family nurse practitioner reports in March 2011 and December 2011 provide competent medical evidence regarding the Veteran's current disability, it does not provide credible evidence of a nexus between that disability and diabetes account because it is based on inaccurate information regarding the onset of his diabetes mellitus. Consequently, on the matter of whether the Veteran's avascular necrosis of the hips and shoulders as secondary to a service-connected disability, the Board finds that the September 2012 opinion of the VHA reviewer to be the most probative. The September 2012 VA reviewer provided a detailed medical opinion supported by a pertinent rationale based upon a review of the Veteran's claims file to include the positive nexus opinion of the VA nurse practitioner, when concluding that the Veteran's avascular necrosis of the hips and shoulders was not secondary to a service-connected disability. Significantly, the reviewer addressed the timing of the Veteran's diabetes diagnosis in a detailed manner which chronicled the Veteran's glucose levels since his initial diagnosis of impaired glucose tolerance in 1984. The VHA reviewer also specifically addressed the March 2011 and December 2011 positive opinions of the VA nurse practitioner when noting that there was no evidence that the Veteran had documented diabetes mellitus until at least 2002 or 2003 when he was diagnosed with probable diabetes. He indicated that the VA nurse practitioner's opinion was not well grounded based on her facts and good medical principles. While the VA nurse practitioner indicated that a literature review also supported diabetes as a risk factor and hidden cause for avascular necrosis, the VHA reviewer noted that diabetes was 17th on the list of factors that may increase avascular necrosis while most of the articles reviewed do not even list diabetes mellitus as a risk factor for avascular necrosis. He also noted that Prednisone use is a common known risk factor for avascular necrosis with very strong evidence to that effect. As noted above, the Veteran was on Prednisone from January 1985 to April 1985 and he also struggled with obesity, a common predecessor for diabetes, for many years prior to the diagnosis of diabetes. Given the detailed explanation for the opinion rendered, which included a discussion of medical literature on the subject in light of the facts and circumstances of the Veteran's particular case, the Board finds the September 2011 VHA reviewer's assessment to be the most probative. In this regard, the Board has taken note of the medical treatise evidence discussed by and submitted by the Veteran on the matter of a relationship between avascular necrosis and diabetes mellitus. The Board notes that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998). In this case, the treatise evidence does speak generally to a causal correlation between diabetes mellitus and avascular necrosis. Thus, the Board finds that it is of some probative value. Nevertheless, the Board finds that it is ultimately far outweighed by the opinion of the VHA examiner who acknowledged such a correlation, but also considered the facts and circumstances of the Veteran's case, including the date of onset of his diabetes and the presence of other risk factors. Accordingly, the Board finds that service connection for avascular necrosis of the hips and shoulders as secondary to a service-connected disability is not warranted. As noted above, in the alternative the Veteran also contends that his avascular necrosis of the hips and shoulders was a result of his exposure to Agent Orange while serving in Vietnam. The Board notes that exposure to herbicide agents such as Agent Orange is conceded in this case, as the service personnel records show that the Veteran did serve in the Republic of Vietnam. However, the Veteran's diagnosed avascular necrosis is not an enumerated disease associated with Agent Orange exposure under 38 C.F.R. § 3.309(e) (2012). Thus, a grant of service connection based on direct causation or presumptive basis for avascular necrosis is not warranted. However, in addition to the presumptive regulations, a veteran may establish service connection based on exposure to Agent Orange with proof of actual direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange); Combee; supra; Brock ; supra. The Board again notes that there are conflicting opinions on whether the Veteran's avascular necrosis is directly related to his conceded Agent Orange exposure. As noted above, on VA examination in March 2011, a VA family nurse practitioner opined that she was most inclined to believe that the avascular necrosis was a result of herbicide exposure ultimately causing diabetes mellitus which further worsened the hip and shoulder disorders beyond their natural progression. However, while the family nurse practitioner found that there was a connection between the Veteran's avascular necrosis and herbicide exposure, no rationale was provided for this opinion and the family nurse practitioner did not provide any specific evidentiary or medical basis for the opinion. Conversely, in an October 2011 addendum, the VHA specialist opined that he found "absolutely no association between herbicide exposure and avascular necrosis of bones". Notably, the VHA reviewer indicated that he reviewed substantial literature from numerous sources regarding a potential relationship between avascular necrosis and herbicides. He specifically found that medical science did not support the claim that avascular necrosis is associated with herbicide exposure, specifically Agent Orange exposure as there was no evidence of herbicides causing avascular necrosis in adults exposed to these compounds. He concluded that there was no obvious nexus between herbicide exposure and the Veteran's avascular necrosis of the hips and shoulders. For these reasons the Board finds the October 2012 VHA addendum opinion to be the most probative regarding the issue of whether the Veteran's current avascular necrosis disability is secondary to herbicide exposure. See Hayes, supra. ("It is the responsibility of the BVA to assess the credibility and weight to be given the evidence.") (citing Wood, supra. See also Guerrieri, supra, (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). Given that the most probative opinion is against a finding of a relationship between avascular necrosis and conceded herbicide exposure, the Board finds that service connection on this basis is not warranted. Finally, the Board has considered the Veteran's contentions that his current avascular necrosis dysfunction was caused by his service-connected diabetes mellitus or in the alternative, was a result of his herbicide exposure. As noted above, the Board acknowledges that the Veteran is competent to give evidence about what he physically experienced. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, in most cases, the Veteran is not competent to render an opinion as to the cause or etiology of any current disorder because he does not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence). In this instance, therefore, the Veteran as a lay person has not been shown to be capable of making medical conclusions, especially as to complex medical diagnoses such as a link between his current avascular necrosis and his diabetes mellitus and exposure to herbicides. As such, the Board ascribes far more weight to the conclusions of the VHA medical professional who concluded that the Veteran's current avascular necrosis was not caused or aggravated by his diabetes mellitus and was not caused by exposure to herbicides. See Jandreau, 492 F.3d at 1377. In short, the most probative medical evidence specifically rules out a relationship between the Veteran's current avascular necrosis and his diabetes mellitus, another service-connected disability or herbicide exposure. The Board places more weight on the opinions of the competent VA medical professional who provided the September 2011 and October 2011 opinions, based on review of the medical records and claims file, interview of the Veteran, and extensive research of medical literature than on the March 2011 and December 2011 opinions of the VA nurse practitioner. In light of the foregoing, the Board finds that the preponderance of the evidence is against the claim, and the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). ORDER Entitlement to service connection for a bilateral hip disability, to include avascular necrosis as secondary to service-connected diabetes mellitus, and as secondary to herbicide exposure is denied. Entitlement to service connection for a bilateral shoulder disability to include as secondary to service-connected diabetes mellitus, and as secondary to herbicide exposure is denied. REMAND It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate, "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a) (1), 4.15 (2012). "Substantially gainful employment" is that employment, "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore (Robert) v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). A claim for a total disability rating based upon individual unemployability, "presupposes that the rating for the [service-connected] condition is less than 100%, and only asks for TDIU because of 'subjective' factors that the 'objective' rating does not consider." Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In evaluating a veteran's employability, consideration may be given to his level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or impairment caused by non service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. A TDIU may be assigned if the schedular rating is less than total when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability, ratable at 60 percent or more, or as a result of two or more disabilities, provided that at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Disabilities resulting from common etiology are considered as one disability for the purpose of satisfying the percentage standards set forth in 38 C.F.R. §4.16(a). In this case, service connection is in effect for ischemic heart disease rated as 100 percent disabling, posttraumatic stress disorder (PTSD) rated as 70 percent disabling, Type II diabetes mellitus rated as 40 percent disabling, peripheral neuropathy of the right upper extremity rated as 40 percent disabling, peripheral neuropathy of the left upper extremity rated as 30 percent disabling, peripheral neuropathy of the left lower extremity rated as 20 percent disabling, peripheral neuropathy of the right lower extremity rated as 20 percent disabling and dermatitis which is assigned a noncompensabe rating. The Veteran's combined disability rating is 100 percent. Prior to 2008, the Board treated a 100 percent schedular rating as subsuming the need for TDIU consideration on the basis that the 100 percent schedular rating delivered more benefits than could be obtained by a TDIU rating. The Board's treatment in this regard stemmed primarily from a June 1999 opinion of VA's General Counsel (GC), which held that receipt of a 100 percent scheduler rating for a service-connected disability rendered moot any pending claim for a TDIU and required dismissal of the TDIU claim. See VA O.G.C. Prec. Op. No. 6-99; Green v. West, 11 Vet. App. 472, 476 (1998); Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In 2008, however, the Court issued Bradley v. Peake, 22 Vet. App. 280 (2008), which is contrary to GC's previously noted precedent opinion, since withdrawn in response to Bradley. According to Bradley, although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of a TDIU predicated on a single disability (perhaps not ratable at the schedular 100 percent level) when considered together with another disability separately rated at 60 percent or more may warrant payment of special monthly compensation (SMC) under 38 U.S.C.A. § 1114(s). The Court reasoned that it might therefore benefit the Veteran to obtain or retain a TDIU rating even where a 100 percent schedular rating is already in effect. SMC is payable at the (s) rate when a veteran has a single service-connected disability rated as 100 percent disabling and, in addition: (1) has a service-connected disability or disabilities independently ratable at 60 percent, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C.A. § 1114(s) (West 2002). These benefits are not available when the 100 percent disability rating is based on multiple disabilities, none of which is rated 100 percent disabling, or which arise from a single etiology or accident. Buie v. Shinseki, 24 Vet. App. 242, 249-50 (2010); Bradley v. Peake, 22 Vet. App. 280, 290-91 (2008). Here, service connection was granted for ischemic heart disease rated as 100 percent disabling, effective October 26, 2011. Pursuant to Bradley, such an award does not automatically moot the pending appeal for a TDIU. However, the Board finds that this case is distinguishable from Bradley in that the Veteran is also evaluated as 70 percent disabled due to PTSD and he has been granted SMC under 38 U.S.C.A. § 1114(s). Therefore, the concerns raised in Bradley are not present here and the claim for a TDIU is moot as of October 26, 2011. The Board is concerned, however, that the claim for TDIU has been pending for some period of time prior to October 26, 2011. For this reason, the Board finds that this claim is akin to a staged rating case in an increased rating claim in so far as the issue of entitlement to a TDIU prior to October 26, 2011 remains pending. Prior to that date, service connection was in effect for PTSD rated as 70 percent disabling, Type II diabetes mellitus rated as 40 percent disabling, peripheral neuropathy of the right upper extremity rated as 0 percent disabling, peripheral neuropathy of the left upper extremity rated as 0 percent disabling, peripheral neuropathy of the left lower extremity rated as 10 percent disabling, peripheral neuropathy of the right lower extremity rated as 10 percent disabling and dermatitis which is assigned a noncompensabe rating. In this regard, the Board notes that in October 2008 and April 2010 letters, Dr. G. W. opined that the Veteran was unemployable due to a variety of disabilities. However, some of the disabilities which he addressed are not service-connected. As a result, in its September 2010 remand, the Board remanded the issue so an examiner should opine as to whether it is at least as likely as not that any of the Veteran's service-connected disabilities either alone, or together, renders him unable to secure or follow a substantially gainful occupation. Per the remand instructions, in March 2011 and December 2011 opinions, a VA family nurse practitioner opined that from a medical standpoint, the Veteran was unemployable. However, the March 2011 and December 2011 opinions were based on the Nurse Practitioner's positive relationship between the Veteran's claimed bilateral hip and bilateral shoulder disabilities and service. As determined above, the Board has found that service connection is not warranted for the Veteran's claimed bilateral hip and bilateral shoulder disabilities. As a result, it appears that like the October 2008 and April 2010 letters of Dr. G. W. which found the Veteran unemployable, the opinion of the VA nurse practitioner in her March 2011 and December 2011 examination reports accounts for both service-connected and nonservice-connected disabilities. As a result, an opinion is still needed as to whether the Veteran's service-connected disabilities alone, without consideration of the nonservice-connected disabilities, precluded the Veteran from obtaining or maintaining any gainful employment prior to October 26, 2011. Thus, a VA opinion is required to determine whether the Veteran was unemployable due solely to his service-connected disabilities (without regard to the heart disease for which service connection was granted as 100 percent disabling on October 26, 2011). Accordingly, the case is REMANDED for the following action: 1. The claims file should be provided to an appropriate examiner for an opinion regarding the impact of his service-connected disabilities on his employability. The Veteran's claims folder and a copy of this remand must be made available to the examiner for review in conjunction with the opinion. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Based on a review of the evidence contained in the claims file, the examiner is asked to comment on whether it is at least as likely as not that the Veteran is unable to obtain or maintain substantially gainful employment solely as a result of the cumulative effect of his service-connected disabilities (except for his service-connected heart disease). In making this determination, the examiner must consider the Veteran's level of education, experience, and occupational background in determining whether he is unable to obtain or maintain substantially gainful employment in light of the severity of his service-connected disabilities (standing alone). The examiner must be advised that the opinion should exclude consideration of the impact of his service-connected heart disease. Please note that if the Veteran is found to have some degree of unemployability due to nonservice-connected disabilities, please nevertheless include a clear explanation of the current degree (if none, please explain) of unemployability attributable only to the Veteran's service-connected disabilities. 3. Then, readjudicate the Veteran's claim. If his claim remains denied, he should be provided with a Supplemental Statement of the Case (SSOC). After the Veteran and his representative have been given the applicable time to submit additional argument, the claim should be returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs