Citation Nr: 1310693 Decision Date: 04/01/13 Archive Date: 04/11/13 DOCKET NO. 07-04 031 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an initial compensable disability evaluation for cesarean section scar. 2. Entitlement to service connection for atrial septal defect. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Y. Hawkins, Counsel INTRODUCTION The Veteran served on active duty from July 2001 to September 2003. These matters come before the Board of Veterans' Appeals ("Board") on appeal from a March 2004 rating decision issued by the Department of Veterans Affairs ("VA") Regional Office ("RO") in St. Louis, Missouri, which, in pertinent part, granted service connection for a cesarean section scar with an initial noncompensable rating, effective September 28, 2003, and denied service connection for atrial septal defect. The Board has previously considered these claims. In January 2010, the Board remanded the claims to the agency of original jurisdiction ("AOJ") for evidentiary development, including a VA examination. The claims were again remanded to the AOJ by the Board in February 2012. Following another VA examination, the claims were denied by the AOJ in an October 2012 Supplemental Statement of the Case ("SSOC"). The claims have now been returned to the Board for additional appellate proceedings. The Veteran alleges that aside from scarring, she has abdominal cramping and pain as a result of her cesarean section in service and had to undergo a hysterectomy. The matter of service connection for additional residuals (aside from scarring) stemming from the cesarean section to include a hysterectomy has not been reviewed by the RO in the first instance. Therefore, the Board does not have jurisdiction over this matter and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran's cesarean scar does not meet the minimum surface area requirements for a compensable evaluation, and is not otherwise unstable, painful, or productive of limitation of function. 2. The Veteran's atrial septal defect is a congenital defect and was not subject to a superimposed injury or disease during active duty with resultant permanent and additional disability. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for cesarean scar have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.118, Diagnostic Codes 7801-7805 (2002); Diagnostic Codes 7801-7805 (2008). 2. The criteria to establish service connection for atrial septal defect are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 ("VCAA") With respect to the Veteran's claim decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). A.) Duty to Notify Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) ("Pelegrini II"), the United States Court of Appeals for Veterans Claims ("Court") held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his or her possession that pertains to the claim. Element (4), the requirement of requesting that the claimant provide any evidence in his or her possession that pertains to the claim, was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini, effective May 30, 2008). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability and effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). With regard to the Veteran's claim of entitlement to service connection for an atrial septal defect , a letter dated March 2004 afforded the Veteran notice of the types of evidence needed in order to substantiate her service connection claim, the division of responsibility between herself and VA for obtaining the required evidence, and requested that she provide any information or evidence in her possession that pertained to such claim. 38 U.S.C.A. §5103(a); 38 C.F.R. § 3.159(b). Additionally, a January 2010 letter satisfied the requirements of Dingess by advising the Veteran of how VA determines the disability rating and effective date elements of a claim. However, since the Board has concluded that the preponderance of the evidence is against the Veteran's claim, any questions as to the appropriate disability rating or effective date to be assigned are rendered moot, and no further notice is needed. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). With regard to the Veteran's claim to an initial compensable rating for a cesarean scar, service connection has already been established, and the current appeal arose, in part, from a disagreement with the initial rating assigned. The Court has held that where service connection has been granted, and the initial rating has been assigned, the service connection claim has been more than substantiated - it has been proven. See Dingess/Hartman v. Nicholson, supra. As such, 38 U.S.C.A. § 5103(a) notice is no longer required, since the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. Therefore, any defect as to notice is nonprejudicial. See Dingess, 19 Vet. App. at 490-91; Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also Goodwin v. Peake, No. 05-876 (U.S. Vet. App. May 19, 2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). Nevertheless, the Board notes that, in a letter dated in October 2005, the Veteran was informed of the evidence necessary to support a claim of entitlement to an increased rating. In addition, a January 2007 Statement of the Case ("SOC") informed the Veteran of the specific diagnostic codes applicable to her service-connected scar. See Dingess/Hartman, supra; see also Mayfield v. Nicholson, 20 Vet. App. 537 (2006), citing Mayfield v. Nicholson, 444 F.3d at 1333-34 (holding that providing the claimant with notice followed by a readjudication of the claim in an SOC or SSOC "cures" any timing problem associated with the lack of notice prior to an initial adjudication). Moreover, a February 2012 letter provided the Veteran with notice of the most recent VA regulations pertaining to the diagnostic codes used to evaluate scars. B.) Duty to Assist The Board is satisfied that the duty to assist has been satisfied. The claims folder contains the Veteran's service and post-service treatment records, several VA examination reports, and the Veteran's statements in support of her claims. The Veteran has not referenced any outstanding, available records that she wanted VA to obtain or that she felt were relevant to the claim that have not already been obtained and associated with the record. Review of the VA examination reports reveal that, although examinations performed in January 2004 and October 2010, respectively, did not provide the complete information necessary to fully adjudicate the claim of entitlement to service connection for atrial septal defect, the March 2012 examination report shows that the examiner reviewed the pertinent evidence of record, elicited from the Veteran her history of chest pain, shortness of breath and other associated symptomatology, performed a comprehensive examination along with a review of diagnostic test results, and provided the results of the examination, including clear and concise reasons and bases for his conclusion that the Veteran's atrial septal defect is a congenital disorder which was not subject to additional permanent disability stemming from a superimposed injury or disease in service. For these reasons, the Board concludes that the March 2012 examination report is adequate upon which to base a decision in this matter. With regard to the claim of an initial compensable rating for the Veteran's cesarean scar, VA examination reports dated in January 2004, August 2006, and October 2010 show that the examiners reviewed the Veteran's pertinent treatment reports, performed physical examinations of the scar and the surrounding area, and reported the findings from their examinations. For these reasons, the Board concludes that the examination reports are adequate upon which to base a decision for this claim. In short, the Board has carefully considered the provisions of the VCAA in light of the record on appeal, and for the reasons expressed above, finds that the development of the claims has been consistent with the provisions of the VCAA. There has been substantial compliance with both the 2010 and 2012 remands in that the Veteran has been afforded the requested VA examinations, relevant records have been obtained, and the Veteran has been informed of the regulatory changes pertaining to the skin. The appellant has been provided with every opportunity to submit evidence and argument in support of her claims and to respond to the VCAA notice. The purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of her appealed claims. Accordingly, the Board will proceed to a decision on the merits. II. Analysis The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). Under 38 U.S.C.A. § 1154(a), VA is also required to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. In Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit ("Federal Circuit") held that "[l]ay 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." (footnote omitted). However, the Court has held that "[t]he type of evidence that will suffice to demonstrate entitlement to service connection, and the determination of whether lay evidence may be competent to satisfy any necessary evidentiary hurdles, depends on the type of disability claimed." Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). A. Entitlement to an initial compensable disability evaluation for cesarean section scar. Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, and by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries, and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate Diagnostic Codes ("DC") identify the various disabilities and the criteria for specific ratings. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2011). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue, and such symptoms warrant different evaluations, staged evaluations may also be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2008). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). During the pendency of this appeal, VA amended the rating schedule for evaluating scars under 38 C.F.R. § 4.118. In Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit (Federal Circuit) overruled Karnas v. Derwinski, 1 Vet. App. 308 (1991), to the extent it conflicts with the precedents of the United States Supreme Court and the Federal Circuit. According to General Counsel Opinion VAOPGCPREC 7-2003, Karnas is inconsistent with Supreme Court and Federal Circuit precedent insofar as it provides that, when a statute or regulation changes while a claim is pending before VA or a court, whichever version of the statute or regulation is most favorable to the claimant will govern unless the statute or regulation clearly specifies otherwise. Accordingly, the rule adopted in Karnas no longer applies in determining whether a new statute or regulation applies to a pending claim. Id. However, neither of the above cases, nor the General Counsel Opinion prohibit the application of a prior regulation to the period on or after the effective date of a new regulation. Thus, the rule that a veteran is entitled to the most favorable of the versions of a regulation that was revised during his or her appeal allows application of the prior versions of the applicable diagnostic codes at 38 C.F.R. § 4.118 to the period on or after the effective dates of the new regulations. Prior to October 23, 2008, the rating schedule for evaluating scars read as follows: Scars, other than head, face, or neck, that are deep or that cause limited motion are rated as follows: area or areas exceeding 144 square inches (929 sq. cm.) are rated as 40 percent disabling; area or areas exceeding 72 square inches (465 sq. cm.) are rated as 30 percent disabling; area or areas exceeding 12 square inches (77 sq. cm.) are rated as 20 percent disabling; and area or areas exceeding 6 square inches (39 sq. cm.) are rated as 10 percent disabling. 38 C.F.R. § 4.118, DC 7801 (2008). A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801, Note 2. Scars, other than head, face, or neck, that are superficial and that do not cause limited motion covering an area or areas of 144 square inches (929 sq. cm.) or greater are rated as 10 percent disabling. 38 C.F.R. § 4.118, DC 7802 (2008). A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7802, Note 2. DC 7803 provides that a 10 percent rating is warranted for scars that are superficial and unstable. 38 C.F.R. § 4.118, DC 7803 (2008). Note 1 to DC 7803 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 to DC 7803 provides that a superficial scar is one not associated with underlying soft tissue damage. Scars which are superficial and painful on examination are rated as 10 percent disabling. 38 C.F.R. § 4.118, DC 7804 (2008). A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7804, Note 1. Other scars are rated based upon limitation of function of affected part. 38 C.F.R. § 4.118, DC 7805. Effective October 23, 2008, the rating schedule was revised. The amendments apply to all applications for benefits received by VA on or after October 23, 2008, or, in the case of a veteran rated under DCs 7800-7805, if review is requested under the clarified criteria. Here, the Veteran requested application of the October 2008 revisions in an October 2012 statement. First, the Board will discuss the pertinent medical evidence and apply the criteria for the old skin regulations. In January 2004, the Veteran was afforded a VA examination pursuant to her claim for service connection. She recounted a history of delivery of a baby by cesarean section in February 2003, during service, with normal healing, but aching in the lower abdomen and pelvis that lasted two to three months. However, she specifically reported that she was experiencing no scar pain at the time of the examination. Upon physical evaluation, the abdomen was soft and non-tender. There was a healed abdominal pfannenstiel incision that resulted in a scar 12.5 centimeters long with very little subcutaneous induration. The examiner noted that the scar was at most 2 millimeters wide, non-tender and without redness. The diagnosis was healed pfannenstiel surgical incision, narrow, non-tender and asymptomatic. During her August 2006 examination, the Veteran reported that she had had a second baby by cesarean section in December 2004. She said the incision had become infected, resulting in dehiscense of the wound. Upon physical examination, the clinician noted a flesh-colored, well-healed scar, 12.5 centimeters in length in the low pelvic area. The mid-portion was mildly adherent to the underlying tissues. The area directly over the scar was numb without palpable tenderness in the adnexal regions bilaterally. During the October 2010 VA compensation examination, the Veteran denied having any symptoms associated with the scar. On examination, she had no tenderness on palpation of the scar which measured 12.5 by .2 centimeters. It was superficial. There was no keloid formation; it was described as well-healed. It was noted that she did have some tenderness above the scar, which was directly attributed to her 2008 endometriosis. The endometriosis was described as not related to service. In addition to the VA compensation and pension examination reports in 2004, 2006, and 2010, the claims folder also contains VA outpatient treatment reports, showing that the Veteran sought treatment for pelvic and lower abdominal pain. However, there is no indication that she reported experiencing symptoms directly related to her cesarean section scar. In fact, these records demonstrate that her cesarean section scar was well-healed and asymptomatic. See, e.g., VA gynecological outpatient record, September 2012. VA treatment reports of record contain no evidence that contradicts or enhances any of the findings cited in the VA examination reports. In this case, because the Veteran has been found to only have one scar, found to be superficial, stable and essentially asymptomatic on objective examination, under the scar codes in effect August 30, 2002 to October 22, 2008, the Veteran does not warrant a compensable initial disability evaluation. As an initial matter, the surface area requirements pursuant to DCs 7801 and 7802 are clearly not met, given the relatively small size of the scar and the lack of evidence showing that such causes limited motion. Moreover, the scar has been described as superficial and well-healed, and is not unstable pursuant to DC 7803. Nor is there objective evidence that the scar is painful, such as would warrant application of DC 7804. The Veteran has regularly described the scar as not causing any problems, and examiners have regularly concluded that the scar is asymptomatic. There is also no objective evidence of limitation of function attributable to the service-connected scar, pursuant to DC 7805. In sum, none of the essential criteria under which a compensable evaluation may be assigned for a service-connected scar are satisfied in this instance. The Board has considered medical evidence to include from VA examinations conducted in 2004, 2006, and 2010, and more recent treatment records which similarly reflect a lack of associated symptoms. Thus, the current noncompensable evaluation represents the best approximation of the extent of the service-connected disability. Under the 2008 revisions, DCs 7801 and 7802 were not changed in a manner that is outcome determinative in this case, DC 7801 and 7802 are for rating deep and superficial scars of a certain size -the dimensions of the Veteran's scar do not meet the criteria for even a minimum rating. Diagnostic Code 7803 was removed. 38 C.F.R. § 4.118 , DCs 7801, 7802(2010). Diagnostic Code 7804 provides that five or more scars that are unstable or painful warrant a 30 percent rating, three or four scars that are unstable or painful warrants a 20 percent rating, one or two scars that are unstable or painful warrant a 10 percent rating. Note (1): An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118 , DC 7804 (2010). Note (2): If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3): Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. Given the clinical findings here that show the Veteran has one scar that has not been objectively described painful, the Board finds that a higher rating is not warranted. Diagnostic Code 7805 provides that any other scars, including linear scars are to be rated based on any disabling effect(s). 38 C.F.R. § 4.118 , DC 7805 (2010). The current version of DC 7805 is inapplicable as the evidence does not show that the Veteran's cesarean section scar produces any disabling effects. The Board has considered the Veteran's statements throughout his appeal as to the severity of her symptoms. However, the Board attaches greater probative weight to the clinical findings of skilled, unbiased professionals. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board acknowledges that, the Veteran has, at times, indicated she experiences pain associated with her scar. However, pain has not been objectively demonstrated. For example, according to the 2004, 2006, and 2010 VA examination reports, and during VA treatment the scar was consistently noted as not tender and asymptomatic. The Board fully acknowledges that the Veteran has consistently and credibly reported abdominal pain. In fact, such pain was noted as above the actual cesarean scar on VA examination in 2010 and attributed to her endometriosis. This matter has been referred to the RO for further development. In denying the Veteran's claim for a higher rating under the old and new criteria, the Board also has considered whether she is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule for Rating Disabilities will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Id. In this case, although the Veteran has complained of internal abdominal and pelvic pain, she has consistently reported that her cesarean section scar has been non-tender and without limitation of function. The diagnostic codes used herein to evaluate this disability consider the symptoms reported and objectively demonstrated. In other words, there are no symptoms that are unusual or different from those contemplated by the schedular criteria. The Veteran does not demonstrate exceptional or unusual disability; she merely disagrees with the assigned evaluation for her level of impairment. Furthermore, there is no evidence that the Veteran has undergone repeated hospitalizations or multiple surgical procedures solely for her service-connected scar during the period on appeal. As such, the record does not demonstrate hospitalizations of such frequency or length as to warrant extraschedular consideration. Moreover, the evidence does not establish that her disability markedly interfere with her employment or employability beyond that contemplated by the Schedule for Rating Disabilities. Rather, as discussed above, the evidence shows that any limitations associated with the cesarean section scar beyond those compensated by the current disability rating are potentially due to the Veteran's additional residuals stemming from the cesarean section, not the scar, for which she is now seeking service connection. Accordingly, given the lack of evidence showing unusual disability not contemplated by the rating schedule, the Board concludes that referral for an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1) is not warranted. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). For the reasons stated above, the Board has concluded that the preponderance of the evidence is against the Veteran's claim. As such, the benefit-of-the-doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application in the instant case. See generally Gilbert, supra; see also Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Staged ratings are not applicable. See Hart v. Mansfield, supra. B. Entitlement to service connection for atrial septal defect. In order to establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) the in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Alternatively, under 38 C.F.R. § 3.303(b), service connection may be awarded for a "chronic" condition when (1) a chronic disease manifests itself and is identified as such in service, or within the presumptive period under 38 C.F.R. § 3.307, and the veteran presently has the same condition; or (2) a chronic disease as listed in 38 C.F.R. § 3.309(a) manifests itself during service, or during the presumptive period, but is not identified until later, and there is a showing of continuity of related symptomatology after discharge, and medical evidence relates that symptomatology to the Veteran's present condition. Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013)." That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity in diseases listed in 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b) (2012); Id. Service connection is also available for a preexisting condition provided it was aggravated during service beyond the course of its natural progression. 38 U.S.C.A. § 1153 (West 2002 & Supp. 2012); 38 C.F.R. § 3.306 (2012). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during service. In order to rebut the presumption of aggravation, there must be clear and unmistakable evidence that the increase in severity was due to the natural progress of the disability. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Under VA regulations, every person employed in the active military, naval, or air service shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1111, 1137 (West 2002 & Supp. 2012). Only such conditions as are recorded in examination reports are considered as noted at enlistment. 38 C.F.R. § 3.304(b). A preexisting injury or disease will be considered to have been aggravated by active military service, where there is an increase in disability during such service, unless there is a finding that the increase in disability is due to the natural progress of the disease. However, aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all of the evidence of record. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. Congenital or developmental defects are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c) , 4.9. VA General Counsel has held that service connection can be granted for congenital diseases which are aggravated by service. See VAOPGCPREC 82-90 (July 18, 1990) (a disease considered by medical authorities to be of familial (or hereditary) origin by its very nature preexist claimants' military service; however, service connection for congenital, developmental or familial diseases could be granted if manifestations of the disease in service constituted aggravation of the condition). A defect is a structural or inherent abnormality or condition, which is more or less stationary in nature. A disease may be defined as any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. Id. Congenital or developmental "defects" automatically rebut the presumption of soundness and are therefore considered to have preexisted service. 38 C.F.R. §§ 3.303(c) , 4.9 . However service connection is generally precluded by regulation for such "defects", because they are not "diseases" or "injuries" within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c) , 4.9, 4.127; Terry v. Principi, 340 F.3d 1378, 1383-84 (Fed. Cir. 2003); Palczewski v. Nicholson, 21 Vet. App. 174, 179 (2007). Thus, the presumption of soundness does not apply to congenital defects because such defects "are not diseases or injuries" within the meaning of 38 U.S.C.A. §§ 1110 and 1111. See 38 C.F.R. § 3.303(c) ; see also Quirin v. Shinseki, 22 Vet. App. 390, 394, 396, 397 (2009); Terry, 340 F.3d at 1385-86 (holding that the presumption of soundness does not apply to congenital defects); Winn v. Brown, 8 Vet. App. 510, 516 (1996) (holding that a non-disease or non-injury entity such as a congenital defect is "not the type of disease- or injury-related defect to which the presumption of soundness can apply"). Service connection is only possible for a congenital defect if there is evidence of additional disability due to aggravation during service of the congenital defect by superimposed disease or injury. See VAOPGCPREC 82-90; Monroe v. Brown, 4 Vet. App. 513, 514- 15 (1993); Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); VAOPGCPREC 67-90; and VAOPGCPREC 11-99. The Veteran contends that she did not have any type of heart disorder when she entered active duty service and that her current atrial septal defect is a result of service. Review of the Veteran's service treatment records shows that, during her June 2001 enlistment examination, findings for the heart were normal. However, in May 2002, after blacking out while she was pregnant, the Veteran underwent an echocardiogram. The impression was a probable small, patent foramen ovale with a minimal amount of left to right shunting, though a small atrial septal defect could not be excluded as a possibility; the echocardiogram was otherwise normal. A June 2002 electrocardiogram ("EKG") was interpreted as "borderline," and showed a normal sinus rhythm with a rightward axis. In July 2002, the Veteran received a provisional diagnosis of systolic heart murmur. In December 2002, she was seen for complaints of tightness and heaviness in the chest. An EKG revealed a normal sinus rhythm and a Holter monitor study was ordered; the study, performed in January 2003, was interpreted as showing "rare isolated ventricular and supraventricular ectopic during the recording." Although the Veteran reported two episodes of shortness of breath during the study, there was no correlation of her symptoms to dysrrhythmias. Rather, the dysrrhythmias identified were deemed as benign and not requiring any treatment. A May 2003 EKG was interpreted as showing a normal sinus rhythm with occasional premature atrial complexes and a small, patent foramen ovale, but "otherwise normal." During her July 2003 separation examination, heart findings were noted as normal, although on her report of medical history, the Veteran reported having experienced pain or pressure in the chest, palpitation and heart trouble or murmur. In January 2004, the Veteran was afforded a VA general medical examination. During the examination, she complained of occasional shortness of breath and "minimal if any" chest pain with upper anterior chest pain that somewhat simulated heartburn; she added that she believed the pain may be related to her anxiety. On physical examination, heart tones were regular and the examiner was unable to hear the left sterna border murmur referenced in the treatment records. A chest x-ray revealed the heart to be normal. The diagnosis was history of patent foramen ovale with possibility of an atrial septal defect, now relatively asymptomatic. VA treatment records show that, in October 2004, the Veteran underwent an EKG for clinical findings of systolic heart murmur of uncertain etiology. The results demonstrated a normal left ventricular size with a normal ejection fraction of 65 percent with trace mitral regurgitation and trace pulmonary regurgitation. Subsequent VA treatment records show no evidence that the Veteran complained of, or received treatment for continuing heart problems. For example, during a May 2005 primary care follow-up, she indicated that she had no medical complaints. However, treatment records show that, during a June 2008 hospital admission for an unrelated medical issue, it was noted that she then had or had a history of a heart murmur. Yet, during a May 2010 outpatient visit, it was noted that her S1 and S2 heart sounds were regular and without evidence of a murmur. In October 2010, the Veteran was afforded a second VA examination, at which time, clinical findings showed a regular heart rate and rhythm and normal heart sounds without skips, gallops or murmurs. There was no peripheral edema or jugular venous distention, and peripheral pulses were positive with good capillary refill. An EKG showed a normal size left atrium with atrial septal defect, ejection fraction at 55 percent and an otherwise normal test. A November 2010 echocardiogram revealed normal left ventricular systolic function with an ejection fraction of 55 percent, no regional wall motion abnormalities, normal diastolic function, trace mitral regurgitation, trace tricuspid regurgitation and trace pulmonary regurgitation. Palpitations could not be calculated on the study. The right ventricle was not optimally visualized, but in the subcostal views, it appeared normal in size with retained function. A chest x-ray was normal. The examiner diagnosed the Veteran as having a small, patent foramen ovale with occasional irregularity of heartbeat, and opined that she was most likely born with this condition. The Board observes, however, that the VA examiner did not provide an opinion as to whether there had been aggravation of this pre-existing congenital defect by superimposed disease or injury during service. See VAOPGCPREC 82-90, supra. VA treatment records show that during a September 2011 outpatient clinic visit for an unrelated medical condition, the Veteran was found to be negative for chest pain, palpitations and syncope. Her blood pressure was normal at 126/79. In March 2012, the Veteran was afforded a third VA examination. The examiner noted that her most recent EKG in November 2010 had showed atrial septal defect, but did not show mitral valve prolapse. He further noted that past EKGs had been relatively unremarkable with some premature atrial contractions and incomplete right bundle branch block, which he said was not new. The Veteran reported that she walked a few times per week for exercise and denied any heart problems with exercise. She also stated that she was on no continuous medication for control of her heart condition. She was found to be negative for myocardial infarction, congestive heart failure, arrhythmia, heart valve condition, infections, pericardial adhesions, and surgical or non-surgical procedures or hospitalizations. Upon physical examination, the examiner noted an abnormal systolic murmur. During an interview-based METs test, it was noted that there was METs level limitation as a result of de-conditioning. The examiner diagnosed the Veteran with atrial septal defect and opined that it was less likely than not that the condition was proximately due to, or the result of the Veteran's military service. He added that the condition "clearly and unmistakably existed prior to service, [and] was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event or illness." His rationale was that, while the current premature atrial complexes on EKG were at least as likely as not related to the atrial septal defect, they were not of clinical significance and were not secondary to military service. Moreover, he noted that individuals with atrial septal defects are at increased risk for developing symptoms during pregnancy (including arrhythmias), as this Veteran did during service, though there is no long-term sequelae secondary to this and was not caused by her service (adding that it would have been just as likely for her to have the same symptoms during pregnancy had she never entered the service). He further stated that, although the Veteran's congenital atrial septal defect was currently asymptomatic, it could become symptomatic later in life if she developed significant shunting through the defect, though this would also be unrelated to her time in service and would be following the nature course of a congenital atrial septal defect. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Based on a review of the complete evidence of record, the Board concludes that the competent and probative evidence is against granting the Veteran's claim of entitlement to service connection for atrial septal defect. At the foundation of this determination is the underlying fact that the Veteran's heart disorder has been diagnosed as an atrial septal defect, which is understood to be a congenital cardiac defect. Under principles of VA law, a congenital defect is generally not a condition for which service connection may be granted, inasmuch as it is deemed to have preceded any period of military service. See 38 C.F.R. § 3.303(c) (providing that congenital or developmental defects, refractive error of the eye, personality disorders and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation); the presumption of soundness does not apply. However, as stated above, service connection is possible for a congenital defect if there is evidence of additional disability due to aggravation of the congenital defect by superimposed disease or injury during service. See VAOPGCPREC 82-90; Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993); Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); VAOPGCPREC 67-90; and VAOPGCPREC 11-99. Here, the May 2012 examiner did in fact note that individuals who have atrial septal defects are at increased risk for developing symptoms during pregnancy (including arrhythmias) as the Veteran was shown to have during active duty. The distinction to be made, however, is that the Veteran's congenital defect was not subject to a superimposed disease or injury that was productive of permanent aggravation. Rather, it was pointed out that she had no long-term sequelae stemming from pregnancy in service, and that at the time of the VA examination, her atrial septal defect was asymptomatic. Despite the Veteran's assertions to the contrary, the Board finds that there is no evidence to support a finding that her atrial septal defect was permanently aggravated by a superimposed disease or injury during service. Here the Board finds the most probative evidence to be the opinion of the March 2012 VA examiner, who not only provided a well-reasoned rationale for his opinion that it was less likely than not that the Veteran's atrial septal defect was the result of service, but also explained that it is very common for persons with an atrial septal defect to manifest temporary symptomatology during pregnancy, as did the appellant. The examiner went on to conclude that the Veteran did not have any long-term sequelae as a result of the pregnancy in service, and at the time of the VA examination was asymptomatic. In addition to the medical evidence, the Board has also considered the Veteran's contention that her atrial septal defect is related to active duty service. In this regard, the Court has repeatedly held that a veteran is competent to describe symptoms of which he or she has first-hand knowledge. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). As the Board finds that chest pain is a symptom the Veteran is competent, as a lay person, to describe, her statements carry some probative weight. See Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Falzone v. Brown, 8 Vet. App. 398, 405 (1995). Nonetheless, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), a complex cardiac disorder, such atrial septal defect, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." Accordingly, the Board places greater probative weight on the opinion of the VA examiner, a competent, experienced medical professional, than on the Veteran's lay statements as to nexus. Accordingly, the Board concludes that the probative evidence of record does not support the Veteran's claim of entitlement to service connection for atrial septal defect. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt rule enunciated in 38 U.S.C.A. § 5107(b). However, as there is not an approximate balance of probative evidence, that rule is not applicable in this case. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). ORDER Entitlement to an initial compensable disability evaluation rating for cesarean scar is denied. Entitlement to service connection for atrial septal defect is denied. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs