Citation Nr: 1312280 Decision Date: 04/15/13 Archive Date: 05/02/13 DOCKET NO. 09-25 686 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for osteoarthritis of the left hip with status-post total arthroplasty, to include as secondary to service-connected cervical disc disease with mild left hemiparsis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD James A. DeFrank, Counsel INTRODUCTION The Veteran served on active duty from August 1979 to August 1983. This case comes before the Board of Veterans' Appeals (Board) on appeal of a November 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia. The Veteran was scheduled for a hearing at the Decatur RO before a Decision Review Officer (DRO) in August 2010. However, he failed to report for this hearing. Thus, his hearing request is deemed withdrawn. In November 2012, the Board requested a Veterans Health Administration (VHA) medical opinion on this matter. This opinion has been associated with the claims file and is now returned to the Board for review. The Veteran was notified of this medical opinion in a January 15, 2013 letter, and afforded 60 days from the date of this letter to respond. FINDING OF FACT The Veteran's osteoarthritis of the left hip with status-post total arthroplasty was not incurred in service and is not attributable directly to, or aggravated by, his service-connected cervical disc disease with mild left hemiparsis. CONCLUSION OF LAW Entitlement to service connection for osteoarthritis of the left hip with status-post total arthroplasty, to include as secondary to service-connected cervical disc disease with mild left hemiparsis, is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION 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 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Notice should be sent prior to the appealed rating decision or, if sent after the rating decision, before a readjudication of the appeal. A Supplemental Statement of the Case, when issued following a notice letter, satisfies the due process and notification requirements for an adjudicative decision for these purposes. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In this appeal, the RO provided notice to the Veteran in a December 2008 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 December 2008 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 2008 letter, and opportunity for the Veteran to respond, the August 2010 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). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter on appeal. The Board notes that the Veteran's service treatment records are unavailable and that further attempts to find such records would be futile. See Formal Finding on the Unavailability of Service Records (April 27, 2009). With regard to the missing service treatment records, the Court of Appeals for Veterans Claims (Court) has held that in cases where records once in the hands of the Government are lost, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board's analysis of the claims has been undertaken with this heightened duty in mind. The case law does not, however, lower the legal standard for proving a claim for service connection but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the appellant. See Russo v. Brown, 9 Vet. App. 46 (1996). Moreover, there is no presumption, either in favor of the appellant or against VA, arising from missing records. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) [the Court declined to apply an "adverse presumption" where records have been lost or destroyed while in Government control which would have required VA to disprove a claimant's allegation of injury or disease in service in these particular cases]. There is no indication that any additional action is needed to comply with the duty to assist the Veteran. The RO has obtained VA treatment records and in January 2013, a VHA medical opinion was provided based on a review of the claims file and supported by a detailed rationale. As such, the Board finds the January 2013 VHA opinion is sufficient upon which to base a decision with regard to this claim. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Also of record and considered in connection with the appeal are the various written statements provided by the Veteran and by the Veteran's representative. The Board finds that no additional RO action to further develop the record on the claim is warranted. Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Law 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, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden for certain chronic disabilities such as arthritis is through a demonstration of continuity of symptomatology. 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). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Certain diseases, to include arthritis, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C.A. §] 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). 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). Under 38 C.F.R. § 3.310(a), service connection may be granted for disability that is proximately due to or the result of a service- connected disease or injury. Such permits a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation to a nonservice- connected disability by a service- connected disability. Id. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310(b). 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. 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 The Veteran asserts that he has a left hip disability that was either caused or aggravated by his service-connected cervical spine disability. As noted above, the Veteran's service treatment records are unavailable. The Veteran underwent a VA examination in January 1989. He presented with complaints of constant pain in his neck and his shoulder. While the Veteran reported pain in his neck that would result in his left leg giving out, the examiner found no abnormality of the left leg. No complaints pertaining to his left hip are noted on the examination report. The Veteran underwent a VA examination in February 1991. He was diagnosed with a mild left hemiparesis and a visual deficit. The examination report contains findings pertaining to the Veteran's knees; however, there were again no complaints specifically related to his left hip. The Veteran underwent a VA examination in August 1993. He presented with complaints of a knot on his left hip since 1980. He reported swelling about 3 times a week on his left hip area which improved after taking muscle relaxants and anti-inflammatory medicines. On examination of the left hip, no swelling or redness was present and he had a full range of motion. The Veteran underwent a VA examination in February 1998. He presented with complaints of pain and paresthesias in his left hip. On examination, he was able to ambulate without significant difficulty. The examiner noted that while the Veteran responded to the examination in a manner where he was completely unable to flex his left hip against the examiner's resistance, when the Veteran was asked to remove his clothing, he was easily able to flex his left hip. All sensory findings were negative except for areas of his left shoulder. The diagnosis was a back disorder. The examiner noted that the Veteran's subjective complaints did not follow the physical examination determination. A February 1999 VA treatment note indicated that the Veteran had full range of motion of his hips bilaterally. In July 2003, the Veteran presented with complaints of hip pain of a questionable etiology. A July 2003 x-ray revealed moderate degenerative osteoarthritis involving both hips. The Veteran underwent a VA examination in June 2004. The examiner noted that the Veteran was a poor historian. He presented with complaints of arthritis in his left hip. In June 2006, the Veteran underwent a left total hip arthroplasty. In a December 2008 letter, a VA physician noted that the Veteran had been treated at the VA clinic for several years for his lumbar degenerative disc disease, lumbago, degenerative joint disease of the right hip and severe degenerative joint disease of the left hip which resulted in a left hip arthroplasty in June 2006. The physician opined that "it was certainly conceivable and as likely as not that the osteoarthritic changes in the hip may have been exacerbated" by the Veteran's intevetebral disc disease. There were several influences inside and outside of a weight-bearing joint that may considerably alter the impact created by daily activities of exercise. The exact nature and contribution of these stress modifying factors on the risk of osteoarthritis was difficult to quantitate as the interaction between exercise, activity, altered biomechanics due to lumbar disc disease and osteoarthritis of the hip joint is complex. As noted above, the Board solicited an expert medical opinion from a VHA medical expert to determine whether the Veteran's left hip arthritis was due to service to include being caused or aggravated by the Veteran's service-connected cervical disc disc disease. In a January 2013 letter, a VHA orthopedist, after reviewing the Veteran's claims folder, opined that it was less likely than not that the Veteran's left hip osteoarthritis had clinical onset in service or was otherwise related to his active duty from August 1979 to August 1983. He noted that the first encounter that mentioned the left hip was an August 1993 treatment note in which the Veteran reported a "knot" in his left hip dating back to 1980. However, on examination there was no loss of motion and no complaints of pain. The VHA reviewer noted that because the hallmark of hip osteoarthritis is pain and loss of motion and the Veteran did not have these complaints on this examination, there was no evidence to support any hip osteoarthritis at this time. Swelling was not a finding consistent with hip osteoarthritis as the joint has such a large soft tissue envelope. There would be no reason to relate this complaint with hip osteoarthritis. The VHA examiner also opined that it was less likely than not that the Veteran's left hip osteoarthritis was the residual of the in-service cervical spine injury that occurred in 1980 when the Veteran was struck in the head by a barrel. Although no service treatment records were available, it appeared that the Veteran suffered cervical radiculopathy with myelopathy from this injury. The myelopathy presented as mild left sided hemiplegia. The VHA reviewer noted that the February 1998 examiner expressed concern that the Veteran did not give a full effort on the examination. In particular, the 1998 examiner noted that, while the Veteran responded to the examination in a manner where he was completely unable to flex his left hip against the examiner's resistance, the Veteran was easily able to flex his left hip when asked to remove his clothing. Nevertheless, the VHA reviewer indicated that this point is somewhat moot as a review of the orthopedic literature showed no link between myelopathy, leg weakness or gait abnormalities and the development of hip osteoarthritis. Any speculation that the cervical condition caused or exacerbated his left hip would be speculative. The VHA reviewer also opined that it was less likely than not that the Veteran's service-connected cervical disc disease with mild left hemiparesis caused or permanently increased the severity of the left hip disability. There were no studies that show a causative relationship between cervical conditions and the development or progression of hip osteoarthritis. The only theoretical link would be a gait abnormality due to the hemiparesis somehow affecting the hip but again, there was no study, or even expert opinion, that showed a causative relationship between gait disturbances and hip osteoarthritis. The VHA reviewer noted that a VA internist in December 2008 opined that it was at least as likely as not that the Veteran's hip condition was exacerbated by his spine conditions. However, the internist did not give any evidence to support her opinion but did state that there "there were several influences inside and outside of a weight-bearing joint that may considerably alter the impact created by daily activities or exercise. The exact nature and contribution of these stress modifying factors on the risk of osteoarthritis was difficult to quantitate as the interaction between exercise, activity, altered biomechanics due to lumbar disc disease and osteoarthritis of the hip joint is complex." The VHA reviewer noted that the Veteran was not service-connected for any lumbar disc disease. In addition, he opined that the December 2008 VA internist's opinion was speculation and not supported by any orthopedic literature or expert orthopedic opinion. The VHA reviewer concluded that it was less likely than not that the Veteran's service-connected cervical disc disease with mild left hemiparesis caused or permanently increased the severity of the left hip disability. Therefore, no portion should be attributed to his service-connected neck disability. Analysis When considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that service connection for a left hip disability as secondary to a service-connected cervical spine disability is not warranted. As noted above, there is a current diagnosis of degenerative joint disease of the left hip which resulted in a left total hip arthroplasty; hence, the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). Initially, as noted above, service connection may be granted on a presumptive basis for certain chronic diseases, including arthritis, if such diseases are shown to be manifest to a degree of 10 percent or more within one year following the Veteran's separation from active military service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). In this instance however, service connection for arthritis on a presumptive basis is not warranted as the first evidence of arthritis of the left hip is the July 2003 VA x-ray report. While the Veteran maintains that he had complaints of a knot on his left hip since 1980, the record does not demonstrate hip complaints or a diagnosis of arthritis within a year of the Veteran's service separation. The earliest treatment records available in 1989 and 1991 demonstrate that the Veteran presented with complaints of neck and shoulder symptoms, but they are negative for complaints related to hip pain. Additionally, the January 2013 VHA reviewer noted that because the hallmark of hip osteoarthritis is pain and loss of motion and the Veteran did not have these complaints on a 1993 examination, there was no evidence to support any hip osteoarthritis at this time (1993). As the record does not show manifestations of arthritis within one year of the Veteran's service separation, service connection for arthritis on a presumptive basis is not warranted. With regard to service connection on a direct basis for the Veteran's left hip disability, while the Veteran's service treatment records are unavailable the Board notes that the first post-service evidence of left hip complaints is a VA examination in August 1993 indicating that the Veteran had a knot in his left knee since 1980. The Board finds it significant that, despite his complaints, the Veteran had no loss of motion or swelling in his hip during the examination. Further, while diagnosing other musculoskeletal conditions, the examiner did not diagnosis a left hip disability. To the extent that the Veteran is asserting a continuity of symptomatology since service, the Board does not find the Veteran to be credible with regard to any assertions that he has had symptoms of a left hip disability since service. While the Veteran reports hip complaints since 1980, as noted above, his first post-service treatment reports are completely negative for treatment related to his hips as he made no mention of hip pain or symptoms related to his hips. Specifically, the Veteran complained of neck and shoulder pain during examination in 1989 with no complaints of left hip pain. Likewise, despite complaining of left hemiparesis in 1991, he did not complain of left hip symptoms. One would expect that if the Veteran were experiencing problems with his left hip at the time, he would have reported such complaints to the examiners. The Board finds that his documented medical history is in conflict with his current assertions that his current symptoms have continued since service. Additionally, the Board notes that on VA examination in June 2004, the VA examiner noted that the Veteran was a poor historian. As the Veteran was not diagnosed with a left hip disability until many years after service and there was a significant period between his service and his post-service complaints where the medical record was silent for complaints of a left hip disability, the Board concludes that the weight of the evidence is against a finding of continuity of symptomatology since service. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000). The Board also finds that the weight of the evidence is against a finding that the Veteran's current left hip disability is etiologically related to the Veteran's military service on a direct basis. In fact, the only medical opinion addressing the etiology of the left hip disability on a direct basis weighs against the claim as the January 2013 VHA reviewer opined that it was less likely than not that the Veteran's left hip osteoarthritis had clinical onset in service or was otherwise related to his active duty from August 1979 to August 1983. None of the competent medical evidence currently of record refutes this conclusion, and the Veteran has not presented or identified any such existing medical evidence or opinion. Regarding service connection on a secondary basis, the Board notes that there are conflicting medical opinions of record addressing the possibility of such a relationship. As noted above, the December 2008 VA internist opined that "it was certainly conceivable and as likely as not that the osteoarthritic changes in the hip may have been exacerbated" by the Veteran's intevetebral disc disease. Conversely, the VHA reviewer in his January 2013 letter concluded that it was less likely than not that the Veteran's service-connected cervical disc disease with mild left hemiparesis caused or permanently increased the severity of the left hip disability. In this regard, 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). In this instance, the Board finds that the January 2013 opinion of the VHA reviewer's to be the most probative. Regarding the December 2008 letter of the VA internist that indicated that, "it was certainly conceivable and as likely as not that the osteoarthritic changes in the hip may have been exacerbated" by the Veteran's intevetebral disc disease; the Board notes that an examiner's opinion that a current disorder "could be" related to, or that there "may be" some relationship with, symptomatology in service makes the opinion of the examiner too speculative in nature and of little probative value. See Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a causal relationship). See also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (a doctor's statement framed in terms such as "could have been" is not probative). Additionally, as noted by the January 2013 VHA reviewer, no rationale was provided for this December 2008 opinion and the VA physician did not provide any specific evidentiary or medical basis for the opinion. Additionally, the Board also notes that the physician noted that "the exact nature and contribution of these stress modifying factors on the risk of osteoarthritis was difficult to quantitate as the interaction between exercise, activity, altered biomechanics due to lumbar disc disease and osteoarthritis of the hip joint is complex". However, as detailed by the January 2013 VHA reviewer, the Veteran was not service-connected for any lumbar disc disease as he is instead service-connected for cervical disc disease with mild left hemiparsis. A medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461(1993). In contrast, the January 2013 VHA reviewer had the benefit of a review of the Veteran's claims file, and provided a more detailed rationale than the December 2008 VA physician's opinion. The January 2013 VHA reviewer also specifically addressed the December 2008 VA physician's opinion and determined that the opinion was speculative and not supported by any orthopedic literature or expert orthopedic opinion. In making this determination, the VHA reviewer specifically noted that a review of the orthopedic literature showed no link between myelopathy, leg weakness or gait abnormalities and the development of hip osteoarthritis and any speculation that the cervical condition caused or exacerbated his left hip would be speculative. Additionally, he noted that there were no studies that show a causative relationship between cervical conditions and the development or progression of hip osteoarthritis. The VHA reviewer also addressed the timing of the Veteran's symptoms, as he noted that while the Veteran reported a "knot" in his left hip dating back to 1980, on examination at the time of these complaints there was no loss of motion and no complaints of pain which were the hallmark of hip osteoarthritis. Thus, there was no evidence to support any hip osteoarthritis at the time of the Veteran's reports of ongoing left hip pain. The examiner also provided a rationale for his conclusions when determining that it was less likely than not that the service-connected cervical spine disorder caused or aggravated the left hip disability. For these reasons the Board finds the January 2013 VHA examiner's opinion to be the most probative regarding the issue of whether the Veteran's current left hip disability is related to service, to include as secondary to his service-connected cervical spine disability. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) ("It is the responsibility of the BVA to assess the credibility and weight to be given the evidence.") (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 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). Based on the foregoing, the Board has placed greater probative weight on the January 2013 VHA opinion. Given that the most probative opinion is against a finding of a relationship between a left hip disability and his service, to include his service-connected cervical spine disorder, the Board finds that service connection is not warranted. In reaching this conclusion, the Board has considered the lay evidence offered by the Veteran to VA. This includes his statements and the statements of his representative in which they asserted their belief that the Veteran's claimed left hip disability is related to his service-connected cervical spine disability. A layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995). However, lay persons are generally not competent to opine as to medical etiology or render medical opinions. See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998), Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir. 2007) ("Sometimes the layperson will be competent to indentify the condition where the condition is simple, for example a broken leg, and sometimes not, for example a form of cancer."). That is, the Veteran is competent to report that he has left hip symptoms; however, he is not competent to state that his left hip disability is the result of his service or is a result of his service-connected cervical spine disability. Accordingly, the Board has placed greater probative weight on the conclusions reached by the VHA reviewer, who, as a medical professional, is competent to render opinions regarding medical matters. As the preponderance of the evidence is against the Veteran's claim, service connection must be denied. 38 C.F.R. §§ 3.1(m) & (n), 3.102, 3.301. ORDER Entitlement to service connection for osteoarthritis of the left hip with status-post total arthroplasty, to include as secondary to service-connected cervical disc disease with mild left hemiparsis is denied. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs