Citation Nr: 1313045 Decision Date: 04/18/13 Archive Date: 05/02/13 DOCKET NO. 09-08 088 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to service connection for a bilateral lower extremity disorder to include peripheral arterial disease and peripheral vascular disease. 2. Entitlement to service connection for a right lower extremity disorder to include below the knee amputation residuals. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD T. Blake, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1964 to September 1966. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada, which in pertinent part, denied service connection for coronary artery disease (CAD); right below the knee amputation residuals; and left leg peripheral vascular disease. In September 2008, the Veteran testified at a local hearing before a Decision Review Officer (DRO). In January 2010, the Veteran testified at a video conference hearing held before the undersigned Veterans Law Judge. A copy of each transcript is of record. In a January 2011 decision, the Board granted service connection for CAD secondary to the Veteran's presumed herbicide exposure; reframed the issue of service connection for left leg peripheral vascular disease as service connection for peripheral vascular disease of the lower extremities; and remanded that issue and the issue of service connection for right below the knee amputation residuals to the RO for additional development and adjudicative action. In an August 2012 decision, the Board remanded the claims on appeal again for additional development and adjudicative action. The case has been returned to the Board for further appellate review. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. The issue of entitlement to a total rating for compensation purposes based on individual unemployability (TDIU) due to the service-connected CAD has been raised by the record, specifically by the Veteran in a May 2008 VA Form 21-4138 and by the Appeals Management Center (AMC) in an internal memorandum following issuance of the May 2012 supplemental statement of the case (SSOC). This issue 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. FINDINGS OF FACT 1. All relevant evidence necessary to decide the Veteran's appeal has been obtained. 2. Peripheral arterial disease, peripheral vascular disease, and below the knee amputation residuals are not among the "chronic diseases" listed under 38 C.F.R. § 3.309(a) or among the diseases associated with exposure to certain herbicide agents listed under 38 C.F.R. § 3.309(e). 3. The Veteran was treated for thrombophlebitis of the right lower extremity while in service. 4. The Veteran's current bilateral lower extremity disorder, to include peripheral arterial disease and peripheral vascular disease, is not related to service or causally related to or aggravated by the service-connected CAD. 5. The Veteran's current right lower extremity disorder, to include below the knee amputation residuals, is not related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral lower extremity disorder, to include peripheral arterial disease and peripheral vascular disease, to include as secondary to the service-connected CAD, have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for a right lower extremity disorder to include below the knee amputation residuals, to include as secondary to the nonservice-connected peripheral vascular disease, have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under 38 C.F.R. § 3.303(a), service connection means that the facts, as shown by the evidence, establishes that a particular injury or disease was incurred coincident with service. It may be granting by affirmatively showing inception or aggravation during service. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection can also be established through application of statutory presumptions. Diseases subject to presumptive service connection are shown at 38 C.F.R. § 3.309. First, under 38 C.F.R. § 3.303(b), if a "chronic disease" is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative route to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this case, the Board finds that peripheral arterial disease, peripheral vascular disease, and below the knee amputation residuals are not among the "chronic diseases" listed under 38 C.F.R. § 3.309(a). As a result, service connection for the claims on appeal on a presumptive basis as due to a chronic disease is not available in this case. Next, a veteran, who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era, and has a certain listed disability, shall be presumed to have been exposed during such service to an herbicide agent (Agent Orange), unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during service. 38 C.F.R. §§ 3.307(a)(6)(iii), 3.309(e) (list of diseases) (2012); McCartt v. West, 12 Vet. App. 164, 166 (1999). Review of the record shows the Veteran served in Vietnam from January 4, 1966 to September 21, 1966; however, in light of whether he was exposed to an herbicide agent during service, peripheral arterial disease, peripheral vascular disease, and below the knee amputation residuals are not among the diseases associated with exposure to certain herbicide agents listed under 38 C.F.R. § 3.309(e). As a result, service connection for the claims on appeal on a presumptive basis as due to exposure to certain herbicide agents is not available in this case. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id.; see Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See 38 C.F.R. § 3.310(b) (2012); Allen v. Brown, 7 Vet. App. 439, 448 (1995); Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). In making all determinations, the Board must consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. See Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed, Cir. 2007). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of a veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). In the case of any veteran who engaged in combat with the enemy in active service and during a period of war, VA shall accept as sufficient proof of service connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of the veteran. Service connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b). Section 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to the current disorder. See Libertine v. Brown, 9 Vet. App. 521, 522-23 (1996). Section 1154(b) does not establish service connection for a combat veteran; it aids him by relaxing the adjudicative evidentiary requirements for determining what happened in service. A veteran must still establish his claim by competent medical evidence tending to show a current disability and a nexus between that disability and those service events. See Gregory v. Brown, 8 Vet. App. 563, 567 (1996); see also Kessel v. West, 13 Vet. App. 9, 17-19 (1999). The specific dates encompassing the "periods of war" are set by statute, to include the Vietnam Era beginning on February 28, 1961 and ending on May 7, 1975, in the case of a veteran who served in the Republic of Vietnam during that period. 38 U.S.C.A. § 101(29)(A). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims on appeal. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Analysis of Service Connection on a Direct Basis At the September 2008 DRO hearing, the Veteran testified that service connection should be granted for peripheral vascular disease because circulation in his lower extremities has been bad, started in service, and has continued to date. The Veteran also informed the DRO that service connection should be granted for knee amputation of the right leg because of an in-service injury to the groin area while aboard the U.S.S. Mitchell. The Veteran explained that on the first day of sail from San Francisco to Hawaii, which approximately lasted for five days, the ship was in an accident due to a storm and his right testicle was ruptured from an injury therein. He was reportedly on bed rest due to swelling for the remainder of the trip, and blood clots formed up and down the right leg. Upon arrival to Hawaii in approximately 1964 or 1965, he was hospitalized for 30 days, and was kept on blood thinners when he went to Vietnam in January 1966, during which he had no treatment for the right leg. The Veteran reported still having problems with the right leg even after the amputation, to include numbness. At the outset, the Board finds the Veteran was engaged in combat with the enemy in active service during the Vietnam War. His combat status is evidenced by receipt of the Combat Infantryman Badge and the Air Medal with three Oak Leaf Clusters. See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Review of the service treatment records show that upon entry to service in October 1964, the Veteran marked "yes" on a May 1964 report of medical history for having or ever having had a history of cramps in his legs. However, no pertinent abnormalities or existing disabilities were noted following the May 1964 examination for induction. A January 1965 service treatment record documents the Veteran was hospitalized for 15 days at the Triple General Hospital in San Francisco for a painful right leg. The reported history notes that, while aboard ship, the Veteran fell striking his right upper thigh and complaint of erythema, pain, and tenderness in that area the next morning. After four days of bed rest and elevation of the leg, there was no improvement in his symptoms. By the end of the first week of treatment, the ecchymosis had completely disappeared and there was a small area of mild tenderness along the lateral aspect of the right leg. At the time of discharge, the Veteran was walking about with no difficulty and returned to duty without any physical limitations. His final diagnoses were (1) thrombophlebitis, superficial, right lower extremity, secondary to trauma, and (2) lymphangitis due to unknown cause. Approximately three months later, an April 1965 in-service examination report reveals a normal clinical evaluation to include the lower extremities and vascular system. At the time of separation from service, a September 1966 separation examinations report also documents a normal clinical evaluation to include the lower extremities and vascular system. On the September 1966 report of medical history, the Veteran marked "no" for having or ever having had a history of cramps in his legs, foot trouble, or paralysis, providing factual evidence against his own claim. Following separation from service, the evidence of record shows the Veteran has been diagnosed with peripheral arterial disease and peripheral vascular disease. Specifically, private hospitalization records from April 2007 to May 2007 reveal the his discharge diagnoses included severe peripheral vascular disease, gangrenous right foot, and status post right common femoral artery thrombectomy. Following clinical evaluations at VA examinations, the Veteran was diagnosed, in pertinent part, with peripheral vascular disease in January 2008 and with severe peripheral arterial disease in February 2008. The April 2011 VA examiner diagnosed the Veteran with left leg and foot atherosclerosis affecting the arteries causing a weak posterior tibial and popliteal pulse on the left as well as status post right below the knee amputation. Current residuals of the amputation include pain exacerbated by ambulation, frequent phantom pains, and bruising from poor fit of prosthesis. VA outpatient treatment records also document his diagnosis of peripheral vascular disease. The Board finds that the weight of the evidence demonstrates the current bilateral lower extremity disorder to include peripheral arterial disease and peripheral vascular disease and right lower extremity disorder to include below the knee amputation residuals are not related to service. In January 2008, the Veteran underwent a VA general medical examination. After a review of the Veteran's claims file and medical records, the VA examiner summarized a history of the Veteran's bilateral leg condition, which included the following notations: The Veteran suffered a thrombophlebitis on the right leg after a fall aboard the ship. After treatment at the hospital, he got better, went back to base, and was put on light duty. There was no further recurrence until one and a half years ago (around 2006-2007) when the Veteran suddenly felt right leg stiffness and pain while playing golf. Upon further evaluation at a VA facility, the Veteran noticed his right foot turning "black" and was diagnosed to have peripheral vascular disease, bilateral but worse on the right than the left. After multiple surgical procedures, the Veteran underwent an emergency right below knee amputation in June 2007 due to gangrene of the right foot and severe peripheral vascular disease involving the right limb. Following the clinical evaluation, the January 2008 VA examiner concluded, in pertinent part, that the Veteran's current bilateral leg condition, to include peripheral vascular disease, and right leg amputation are not caused by or a result of the thrombophlebitis in service, providing highly probative evidence against this claim. It was explained that: Thrombophlebitis is a disease of the veins while peripheral vascular disease is a disease of the arteries; two completely distinct conditions. The [Veteran] having thrombophlebitis does not put him at risk for peripheral vascular disease or heart disease. Peripheral vascular disease is caused by cigarette smoking, hypertension; in patients with diabetes their risk is greater than a patient without this condition. In a May 2008 VA medical opinion, a VA outpatient treating physician opined that, with regard to the Veteran's severe peripheral vascular disease and history of reversed saphenous vein above-knee femoral-popliteal bypass and popliteal stent placement in the past, all these vascular problems are related to the thrombophlebitis the Veteran had while in the military. The Board acknowledges that this opinion is in favor of the Veteran's claim; however, it has limited probative value because is not supported by sufficient rationale. See Miller, 11 Vet. App. at 348. Subsequently, in April 2011, the Veteran underwent a VA examination through QTC Medical Services (QTC). Following the clinical evaluation and review of the claims file, the examiner opined, in pertinent part, that the Veteran's right knee condition is due to hypertension and atherosclerosis aggravated by chronic smoking. It was explained that the Veteran had several surgeries to improve the circulation in the right lower extremity and at the time he continued to smoke, providing more evidence against this claim of high probative value as it clearly indicates the cause of the disability is not the Veteran's service, but nonservice connected problems. The Board acknowledges the Veteran is competent to report symptoms that he experiences and observes at any time regarding the lower extremities because this requires personal knowledge as it comes through the use of his senses. See Layno, 6 Vet. App. at 470. He is not, however, competent and with the appropriate medical training and expertise to offer an opinion on a medical matter, including the etiology of the bilateral lower extremity disorder to include peripheral arterial disease and peripheral vascular disease and right lower extremity disorder to include below the knee amputation residuals. See Bostain v. West, 11 Vet. App. 124, 127 (1998); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). The question of causation, in this case, involves a complex medical issue that the Veteran is not competent to address. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Since there is no competent and probative nexus between service and the current bilateral lower extremity disorder to include peripheral arterial disease and peripheral vascular disease or between service and the current right lower extremity disorder to include below the knee amputation residuals, service connection cannot be granted on a direct basis. For the reasons and bases discussed above, the Board finds that a preponderance of the evidence is against the claims on appeal, and these claims must be denied on a direct basis. Because the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Analysis of Service Connection on a Secondary Basis The Board now turns to whether service connection is warranted on a secondary basis for the Veteran's claims on appeal. The Board finds that the weight of the evidence demonstrates that the current bilateral lower extremity disorder to include peripheral arterial disease and peripheral vascular disease is not causally related or aggravated by the service-connected CAD. The competent medical opinions of record, with regard to this claim on appeal, do not etiologically relate the Veteran's claimed disorders on appeal to his CAD. At the January 2010 Board hearing, the Veteran contends that peripheral vascular disease is now secondary to his CAD. The Board notes that the Board granted service connection for CAD in a January 2011 decision. In a January 2011 rating decision, the RO assigned the service-connected CAD a 60 percent disability rating effective August 7, 2007. The April 2011 VA QTC examiner also concluded that the Veteran's right knee condition is not related to the CAD in any direct fashion and was supported by the same rationale that "medical documentation in [the claims] file supports that the Veteran had several surgeries to improve the circulation in his right lower extremity and that at the time he continued to smoke." Moreover, the examiner opined that the peripheral vascular disease of the right lower extremity and amputation is less likely as not caused by or a result of service-connected CAD. In the August 2012 remand, the Board requested, in pertinent part, medical clarification as to whether CAD and peripheral vascular disease is a single disease entity and whether CAD and peripheral arterial disease is a single disease entity. Pursuant to the remand instructions, the following additional evidence was obtained and associated with the record: a May 2012 private medical opinion, an August 2012 VA outpatient vascular consultation report with medical opinion, and an August 2012 VA Disability Benefits Questionnaire (DBQ) medical opinion. The May 2012 private physician explained, via a prescription note pad, that "the process that causes the narrowing in your coronary arteries is the same process that causes narrowing in the anterior of your legs. Atherosclerosis causes artery disease in all parts of the body. . . . Atherosclerosis is a whole system disease." Following the August 2012 VA outpatient vascular consultation, the Air Force vascular surgeon acknowledged the Veteran's diagnoses of peripheral arterial disease and CAD, and opined that "atherosclerosis is a systemic disease and that the only difference between CAD and peripheral arterial disease is location. The disease process is the same. . . . CAD and peripheral arterial disease are diseases caused by the same mechanism, namely atherosclerosis." The Board notes that even if one disability is similar to another does not make it the same disability, especially when the symptomatology differ such as the location in this case. See generally Esteban v. Brown, 6 Vet. App. 259 (1994). Moreover, the Board finds this opinion is not pertinent to the element of a link between the currently claimed disorders on appeal and the service-connected CAD. Therefore, to the extent that the RO did not indicate review of this opinion in the February 2013 SSOC, the Board finds that a new SSOC is not needed in this case. This opinion does not support, or refute, the claim. In this regard, it is important for the Veteran to understand that the Board granted service connection for CAD not because there was any evidence associating CAD to service (there is not), but because the Veteran served in Vietnam and it is presumed that CAD, and CAD alone, is associated with herbicide exposure under VA law. Peripheral arterial disease is not on this list of presumptive disabilities and there is nothing in the medical record of the Veteran that associates this problem with service or exposure to herbicides in evidence, notwithstanding the fact that the two problems are similar (caused by the same mechanism). The Board efforts to determine if there was a connection over time has only provided limited evidence against this claim, indicating the Veteran's history of smoking caused one if not both problems. Approximately 5 days later, an August 2012 VA DBQ medical opinion reflects the claims file was reviewed and that "the claimed condition is less likely than not proximately due to or the result of the service-connected condition." It was explained, in pertinent part, that: CAD and peripheral vascular or arterial disease share common risk factors that lead to atherosclerosis. However, besides their different location and affected target organ/tissue, it is recognized in the medical literature that there are some differences in these conditions, in particular, the effect of smoking: 'the two most prominent risk factors for peripheral arterial disease are smoking and diabetes. Both of these risk factors are related to heart disease and stroke, but are even more specifically linked to peripheral arterial disease.' (citation) This is further supported by the fact, that there are cases where patients have CAD in the absence of having peripheral vascular disease. It is important to note that in this case, the Veteran had a long history of tobacco use and the Veteran is not diabetic. Although the August 2012 VA DBQ examiner provided sufficient rationale for the conclusion rendered, the Board finds the examiner's statement lacks probative value in favor of the claims due to the absence of an opinion regarding whether the service-connected CAD caused or aggravated the Veteran's current bilateral lower extremity disorder, to include peripheral arterial disease and peripheral vascular disease. It provides some evidence against this claim in that it clearly indicates the cause of this problem (smoking). The opinion also provides high probative evidence against the claim that the two problems are the same. Since there is no nexus between the service-connected CAD and the current bilateral lower extremity disorder, to include peripheral arterial disease and peripheral vascular disease, and as the evidence is likewise negative with respect to whether the service-connected CAD aggravated the Veteran's bilateral lower extremity disorder to include peripheral arterial disease and peripheral vascular disease, service connection cannot be granted on a secondary basis. The competent and probative medical opinions of record clearly not only indicate no connection between service and the current problem but also clearly indicate the source of the current problem as due to hypertension and smoking, specifically as indicated by the January 2008 and April 2011 VA examiners. Such evidence clearly indicating the reason for the current problem, well after service from October 1964 to September 1966, provides highly probative evidence against the claim of service connection based on aggravation. Next, the Board considers the Veteran's assertion made at the January 2010 Board hearing that the amputation of his right leg is secondary to his peripheral vascular disease. The Board acknowledges that in a May 2008 VA medical opinion, a VA outpatient treating physician reported that the Veteran's right below knee amputation is due to severe peripheral vascular disease. Moreover, the February 2008 VA examiner diagnosed the Veteran, in pertinent part, with severe peripheral arterial disease status post multiple vascular interventions resulting in right below knee amputation. at service connection for a right lower extremity disorder to include below the knee amputation residuals on a secondary basis. As noted above, in order for service connection to be granted on a secondary basis, three elements must be present: a current disability, a service-connected disability, and a medical nexus. See 38 C.F.R. § 3.310. As discussed above in this decision, the Board finds that a bilateral lower extremity disorder to include peripheral arterial disease and peripheral vascular disease is not related to service nor secondary to the service-connected CAD, thus service connection was denied. Since the Veteran has not been granted service connection for a bilateral lower extremity disorder to include peripheral arterial disease and peripheral vascular disease, to the extent he claims the amputation of the right lower extremity is secondary to the peripheral vascular disease, the claim must be denied on a secondary basis as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). Lastly, the Board acknowledges that at the January 2010 Board hearing, the Veteran also asserted that the "clot which caused the amputation may be under 38 C.F.R. § 3.306 which is also known as aggravation of the secondary." VA regulations provide that a preexisting injury or disease will be considered to have been aggravated by active military service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. See 38 C.F.R. § 3.306(a). As discussed above, the Veteran is presumed sound at the time of entry to service in October 1964 and there was no documented preexisting injury or disease noted at the time of entry regarding either lower extremity. Thus, the Board finds that application of 38 C.F.R. § 3.306 is not warranted in this case. For the reasons and bases discussed above, the Board finds that a preponderance of the evidence is against the claims on appeal, and these claims must be denied on a secondary basis. Because the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the 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); 38 C.F.R. § 3.159(b). VA must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. The Board finds that the VCAA notice requirements have been satisfied by a March 2011 letter. In this letter, VA informed the Veteran that in order to substantiate a claim for service connection, the evidence needed to show he had a current disability, a disease or injury in service, and evidence of a nexus between the post service disability and the disease or injury in service, which was usually shown by medical records and medical opinions. As to informing the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf, VA informed the Veteran it had to obtain any records held by any federal agency. This letter also informed the Veteran that on his behalf VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the letter told the Veteran that he could obtain private records himself and submit them to VA. Although the May 2011 notice was not issued before the April 2008 rating decision on appeal, the Veteran has not been prejudiced, as the claims were readjudicated in the May 2012 SSOC. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). The VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the March 2011 letter included the type of evidence necessary to establish a disability rating and effective date. Again, although this notice was not issued before the April 2008 rating decision on appeal, the Veteran has not been prejudiced, as the claim was readjudicated in the May 2012 SSOC. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In January 2010, the Veteran testified at a video conference hearing held before the undersigned Veterans Law Judge. Any deficiencies in development were addressed in the subsequent Board remands, as discussed below. See Bryant v. Shinseki, 23 Vet. App. 488 (2010) (holding that the VLJ who conducts a hearing fulfill the duty to fully explain the issues and the duty to suggest the submission of evidence that may have been overlooked). Regarding the duty to assist, VA must make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the claims on appeal, the evidence of record includes the Veteran's service treatment records, VA outpatient treatment records, private treatment records, May 2012 private medical opinion, September 2008 DRO hearing transcript, January 2010 Board hearing transcript, and VA examination reports dated January 2008, February 2008, April 2011, and August 2012. The VA examiners reviewed the Veteran's claims file and medical history, recorded pertinent examination findings, and provided conclusions with supportive rationale. The Board notes that the VA examination reports are probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). An April 2008 report of contact with Social Security Administration (SSA), documented via a VA Form 119, confirmed the Veteran's receipt of monthly SSA benefits. Pursuant to such confirmation, the RO requested the Veteran's outstanding records from SSA in May 2009 and June 2009. In June 2009, SSA indicated that the medical records requested do not exist. In a September 2009 supplemental statement of the case (SSOC), the Veteran was informed of the RO's unsuccessful efforts. Pursuant to the Board's January 2011 remand instructions, the RO sent the Veteran a March 2011 VCAA notice letter which complies with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159 and includes the information and evidence needed to substantiate a secondary service connection claim. Next, the RO did not send the Veteran a letter requesting that he clarify the status of his representative before VA in this appeal. Nonetheless, the RO indicates that in a January 2011 VA Form 21-4138 that the Veteran clarified his request to remove Disabled American Veterans as his representative and to leave Allied Veterans Organization Local as his designated third party representative. Lastly, the RO arranged for a VA QTC examination in April 2011. Since the April 2011 VA QTC medical opinion is deficient to the extent that it fails to clarify whether the Veteran's atherosclerosis of the coronary arteries and atherosclerosis of the arteries of the lower extremities constitute a single disease entity affecting multiple parts of the body, the claims were remanded for additional development. Pursuant to the Board's August 2012 remand instructions, the RO arranged for an August 2012 VA DBQ medical opinion. The opinion reflects the physician reviewed all of the pertinent evidence of record and rendered an opinion with a rationale. Although the examiner incorrectly cited 38 C.F.R. § 3.309, the Board notes that multiple attempts have been made to ensure the VA medical opinions of record are adequate and any future attempts would be futile. Instead, several examiners have indicated the cause of the disabilities is (smoking), a nonservice connected problem with no relationship to service or a service connected disability, providing highly probative evidence against this claim. A further remand of this case, beyond efforts already made, will not provide a basis to grant these claims. The VA has made extensive efforts to fulfill the duty to assist in the case, with limited results that have provided evidence, for the most part, against this claim. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claims on appeal. The evidence of record provides sufficient information to adequately evaluate the claims, all obtainable evidence identified by the Veteran relative to the claims has been obtained and associated with the claims file, and the Board is not aware of the existence of any additional relevant evidence which was not obtained. Therefore, no further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). ORDER Service connection for a bilateral lower extremity disorder to include peripheral arterial disease and peripheral vascular disease is denied. Service connection for a right lower extremity disorder to include below the knee amputation residuals is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs