Citation Nr: 1316599 Decision Date: 05/21/13 Archive Date: 05/29/13 DOCKET NO. 06-16 419 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for temporal arteritis with headaches. 2. Entitlement to compensation benefits under the provisions of 38 U.S.C.A. § 1151 for temporal arteritis with headaches. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel INTRODUCTION The Veteran served on active duty from July 1972 to July 1976. This appeal comes to the Board of Veterans' Appeals (Board) from a rating decision by of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana, which denied service connection for temporal arteritis and denied entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for temporal arteritis. In March 2008, the Veteran testified before a Veterans Law Judge (VLJ) at a videoconference hearing. A transcript of that hearing is of record. However, that VLJ is no longer employed by the Board. Consequently, in April 2012, the Board advised the Veteran by letter that the law requires that the VLJ who conducts a Board hearing on appeal must participate in any decision on that appeal. 38 C.F.R. § 20.707 (West 2002). In addition, the Veteran was asked whether he desired to have a new Board hearing. In April 2012, the Veteran indicated that he did not want another hearing on this matter. This case was previously before the Board in July 2008 and March 2011, wherein it was remanded for additional development. The record indicates that the RO complied with the Board's requests in the most recent Board remand; the Veteran was provided with an additional VA examination with regard to his claims in June 2011. Subsequently, in December 2012, an independent medical opinion was obtained in connection with his claims. The Board finds that there has been substantial compliance with the directives of the remand, such that an additional remand to comply with such directives is not required. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has not only reviewed the Veteran's physical claims file, but also the Veteran's file on Virtual VA, to ensure a total review of the available evidence. FINDINGS OF FACT 1. The Veteran did not engage in combat with the enemy during service. 2. The Veteran did have symptoms of temporal arteritis with headaches during service. 3. The Veteran did not experience symptoms of temporal arteritis with headaches for many years after service. 4. The post-service symptoms diagnosed as temporal arteritis with headaches are not related to service. 5. The Veteran does not have additional disability due to the carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing medical care. 6. The Veteran does not have additional disability of temporal arteritis with headaches, proximately caused by an event not reasonably foreseeable. CONCLUSIONS OF LAW 1. The criteria for service connection for temporal arteritis with headaches are not met. 38 U.S.C.A. §§ 1110, 1154, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). 2. The Veteran is not entitled under the law to compensation benefits under to the provisions of 38 U.S.C.A. § 1151 for of temporal arteritis with headaches, claimed to be proximately caused by negligence on the part of VA in furnishing medical care or an event not reasonably foreseeable. 38 U.S.C.A. §§ 1151, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.154, 3.159, 3.361 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose 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). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. 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. In this case, the agency of original jurisdiction (AOJ) issued notice letters, dated in August 2002 and August 2008, to the Veteran. These letters explained the evidence necessary to substantiate the Veteran's claims for service connection, as well as the legal criteria for entitlement to such benefits. The letters also informed him of his and VA's respective duties for obtaining evidence. The AOJ decision that is the basis of this appeal was decided after the issuance of an initial, appropriate VCAA notice. As such, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA also has a duty to assist a veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). In this case, the claims file contains the Veteran's service treatment records and a report of private and VA post-service treatment and evaluation, as well as the Veteran's own statements in support of his claims. The Veteran was examined by VA in connection with his service connection and 38 U.S.C.A. § 1151 claims in May 2009, June 2010, and June 2011 The May 2009 VA examination reports contain all the findings needed to decide the claim for service connection, including history of injury and symptoms, clinical examination finding, diagnoses, and etiology opinions for disabilities found. With regard to the claim for benefits under 38 U.S.C.A. § 1151, the June 2010 and June 2011 VA examinations offered opinions as to the whether the Veteran suffered additional disability due to VA negligence or fault. Nevertheless, questions remained, and a VA medical opinion was obtained to address inadequacies in the VA examinations. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). In response to the Board's request, the Chief of Neurology at the New York VAMC provided the requested medical opinion. Although he had not performed any of the examinations of the Veteran, he provided a summary of the relevant facts contained in the record as it related to the Veteran's history of treatment for temporal arteritis with headaches and provided sound rationale for the medical opinion. The VA neurology expert was provided with the opportunity to furnish an adequate medical opinion addressing the questions posed by the Board. Collectively, there is sufficient medical evidence to adjudicate the claim on appeal. The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran's claims. For these reasons, the Board finds that the VCAA duties to notify and assist have been met. Factual Background The Veteran's current symptoms began in approximately July 1998 when he began to experience severe headaches. He sought treatment at VA in October 1998 and he was referred to the eye clinic as well as the neurology department and a thyroid blood panel was done. In November 1998, he complained of left-sided headaches and eye pain, which VA described as temporal headaches and diagnosed rule out migraine/tension headaches. In December 1998, the Veteran again sought treatment at VA for headaches. He complained of weakness, fatigue and inability to sleep. He also reported headaches that were almost constant, 10 pounds of weight loss in the last two weeks, as well as insomnia for one week, low grade fever, chills, and no appetite. An MRI was performed and showed that his pituitary was in the upper limits of normal and the infundibulum was thickened. The MRI also showed that punctate areas of increased signal in bilateral frontal and parietal lobes may reflect viral infection, migraine, focal ischemia, or atypical demylienating disease. The MRI also included a diagnosis of sphenoid sinusitis. The Veteran also underwent a dubplex scan of the carotid arteries. The results were abnormal with an impression of minimal soft plaque in the proximal portion of the right internal carotid artery with no evidence of significant hemodynamic stenosis. He also underwent a CT brain scan which produced normal results. A sinus CT scan also indicated sinusitis. Another December 1998 VA treatment record indicated an assessment of chronic headaches with sphenoid sinusitis probable stress and/or migraine headaches and status post fracture and repair of right shoulder with chronic pain. A January 1999 VA outpatient record indicates that the Veteran complained of worsening vision and symptoms of diabetes insipidus with frequent urination, dehydration, and weakness. He was admitted for a workup. The January 1999 VA inpatient treatment record indicated that the Veteran was admitted with a diagnosis of diabetes insipidus. On admission, he complained of headaches and double vision. At the time of admission, the Veteran reported that he had spots on the brain. A record dated two days later indicated that he was discharged home after reporting job-related stress. He was instructed to take nutritional supplements for his weight loss. During his hospitalization, he was also noted to have a pituitary lesion for which he underwent a lumbar puncture. Another inpatient record indicated that he had a diagnosis of headaches. He also had an eye patch on his right eye on the day he was discharged. An April 1999 transcription regarding the January 1999 hospital course and lumbar puncture noted that the Veteran's sedimentation rate was mildly elevated at 28; his carotid dopplers were performed which demonstrated less than 15% stenosis. The April 1999 transcription also noted that a PPD test was positive but the Veteran reported that it had already been positive. The transcription also noted that the Veteran's headaches improved while in the hospital in January 1999. There was no evidence of dehydration with stable sodium and no evidence of diabetes insipidus. A February 1999 VA addendum indicated that the Veteran had chronic headaches of uncertain etiology with diplopia. The Veteran had also experienced weight loss and a recent three week episode of dysphagia to solids that resolved. He was also being worked up for possible myasthenia gravis. The Veteran was in considerable pain at the time of the February 1999 addendum. He was prescribed pain relieving medication. In February 1999, the Veteran sought private treatment for his headaches. He reported that he had double vision and weight loss for six months. He reported that he was advised by VA that he had enlargement of the pituitary gland and white spots on the brain. He was advised that all of his neurology and neurosurgery tests were normal. The Veteran also reported that he was evaluated by a VA ear, nose and throat specialist and advised that there was nothing to be done. Similarly, the ophthalmology department initially advised that there was an abnormality but later told him that nothing could be found. The private physician, Dr. E., noted that VA did not do a cerebral angiogram and that no cause was found for the 25 pound weight loss. Dr. E. noted that the Veteran's headaches were located in the vertex and temple, occurred constantly and were characterized as though something were expanding inside the Veteran's head. The Veteran reported that the headaches got worse as the day progressed but that they were not as bad as they used to be. He also reported that his double vision had improved over the past six months and that he was able to see farther than he used to without diplopia. He also reported that the diplopia was vertical in nature. He reported right ocular pain. At the time of the February 1999 private treatment, the Veteran reported no history of a head injury although as noted above, it has been documented that he underwent a fall in service. Following examination of the Veteran's cranial nerves, Dr. E. noted an impression of headache diplopia, multiple cranial nerve palsies. In early March 1999, the Veteran underwent a private temporal artery biopsy and three vessel cerebral angiogram. The final diagnosis was temporal arteritis. In late March 1999, the Veteran underwent three VA examinations, for his eyes, general medical and peripheral nerves, respectively. All of the VA examination reports indicated that Veteran had a diagnosis of temporal arthritis, or giant cell arthritis, rather than temporal arteritis or giant cell arteritis. The March 1999 VA examination report regarding the eyes indicated sight in both eyes. At that time, the Veteran reported that he smoked half a pack of cigarettes per day and took pain medication. There was an impression of phoresis, right lateral rectus, secondary to cerebrovascular accident, as well as myopia astigmatism, and diplopia. The March 1999 VA general medical examination report noted a history of giant cell arthritis involving the right side with decreased vision and diplopia. The Veteran reported that he was then currently taking steroid medication as well as pain medication. The diagnosis was giant cell arthritis with decreased vision and complaints of diplopia, status post temporal artery biopsy, and anemia, macrocytic questionable relation to the above versus multifactorial. The March 1999 VA examination report regarding peripheral nerves reviewed the Veteran's lab records and noted that in November 1998, his sedimentation rate had been 6 and in early February 1999, was 42. Two days after the March 1999 VA examination, the Veteran was admitted to a private hospital for an intractable headache and pain control. He was treated by Dr. E. At that time, Dr. E. noted that the Veteran had a diagnosis of temporal arteritis and intractable headaches which had failed to respond to outpatient conservative therapy consistent with nonsteroidal anti-inflammatories, steroids and narcotic analgesics. The Veteran had already undergone a workup of MRI of the brain, CT scan, lumbar puncture and temporal artery biopsy and was on 20 mg of Prednisone. Dr. E. also noted that infectious disease consultation was requested and rendered by Dr. C. The Veteran was also seen by the oral surgery department because of spasms of his temporomandibular joint. His white blood cell count was 15,000 and sedimentation rate was 62. A SPECT scan of the brain was performed and Dr. E. noted it was probably normal. Neurological consultation was requested and rendered by Dr. B. with regard to control of the headaches. The Veteran was also seen by the ear, nose and throat department and scheduled for readmission for nasopharyngeal biopsy. The April 1999 discharge noted final diagnoses of temporal arteritis, rule out callosa hunt syndrome and posterior nasopharyngeal mass. The Veteran was also treated by the VA eye clinic in March 1999. At that time, the VA physician consulted with Dr. E. and noted that per Dr. E., the Veteran had a history of intracranial arteritis pain. Later, in April 1999, the Veteran was hospitalized again for private treatment. At that time, he underwent a right temporal craniectomy, exploration of the right middle skull base, biopsy of the dura, bone biopsy of the Gasserian ganglion, drainage of the Gasserian ganglion abscess, and insertion of a lumbar drain. The preoperative diagnosis was right trigeminal neuropathy and the postoperative diagnoses were right trigeminal neuropathy, trigeminal abscess, and meningitis. The Veteran was treated by Dr. E. again in June 1999 and the assessment was trigeminal neuropathy, osteomyelitis skull base, and craniotomy drainage. In March 2003, the Veteran underwent a VA MRI. The report indicated foci of increased T2 signal within the subcortical white matter and centrum semiovale which could be microvascular ischemia or post-viral in nature; and small caliber right internal carotid artery when compared with the left without evidence of any stenoses. A May 2003 VA treatment record indicates that the Veteran had a history of temporal arteritis now with symptoms more suggestive of neuropathic but also tension type headache. The Veteran complained of a chronic headache that began at the site of his craniotomy and spreads. He also reported loss of consciousness at work. He was prescribed medication for his symptoms. In August 2004, the Veteran sought VA treatment for his headaches again. The treatment record indicated that symptoms of trigeminal neuralgia may have happened after the trigeminal nerve dissection. The assessment was history of temporal arteritis, trigeminal nerve dissection, meningeal abscess on exploratory craniectomy in 1999, controlled with prescription therapy. A new prescription was provided. The treatment record also noted that the Veteran was blind in one eye. In May 2009, the Veteran underwent a VA examination. At that time, the VA examiner, Dr. A.F., indicated that temporal arteritis was less likely than not service related. While the examiner cited research from WebMD, the examiner did not explain why the WebMD material would indicate that the Veteran's cranial disorder (claimed as temporal arteritis) was less likely than not related to service. For example, the examiner cited the theory that the etiology of temporal arteritis holds that a maladaptive response to endothelial injury leads to an inappropriate activation of cell-mediated immunity via immature antigen-presenting cells, which ultimately results in vessel wall damage, intimal hyperplasia, and eventual stenoic occlusion. The examiner did not address whether the Veteran's report of a fall in service (injury) could have resulted in vessel wall damage and the current complaints. The May 2009 VA examiner, Dr. A.F., concluded that the Veteran's headaches were a result of his brain surgery, but did not address the well-documented complaints of headache pain prior to the brain surgery. In a July 2009 addendum opinion, the examiner opined that based on medical literature and personal practice, the Veteran's temporal arteritis was not related to service, accidents, or previous conditions because temporal arteritis usually develops at a later age than when the Veteran was in the military. The examiner also opined that the Veteran's right eye blindness was related to his glaucoma. Again, the examiner indicated that the Veteran's headaches were related to his brain surgery and reflex sympathetic dystrophy (RSD). However, again, the Board notes that it is well-documented that the Veteran complained of headaches prior to his brain surgery. Additionally, the VA examiner noted that the Veteran's facial numbness was right sided, not left sided, but did not offer an opinion regarding facial numbness and any relationship to the cranial disorder or to service. In April 2010, the VA examiner submitted an addendum opinion that the Veteran was diagnosed with temporal arteritis and abscess of the ganglion sheath. The examiner further opined that the Veteran may have RSD. The examiner opined that none of those disorders were related to service. The examiner further opined that the RSD was more likely than not related to the surgery for persistent pain and that his trigeminal nerve was cut. Regarding the issue of benefits due to VA fault during its medical treatment and/or hospitalization of the Veteran, a different May 2009 VA examiner, Dr. K.F., declined to comment. Similarly, Dr. A.F., submitted an addendum opinion in April 2010 indicating that he could not offer an exact opinion regarding liability issues as medical literature would not address a case such as this. However, Dr. A.F. indicated that if there was a question as to medical liability, then three opinions should be obtained, including one by an infectious disease physician. In June 2010, Dr. A.F. submitted another addendum opinion indicating that the Veteran does not have temporal arteritis. (The Board acknowledges that the examiner also noted that the Veteran did not have temporal arthritis and that there is no such medical term. The Board accepts that the references to a diagnosis of temporal arthritis in the March 1999 VA reports were typographical errors.) The examiner opined that none of the Veteran's complaints are related to service. The examiner opined that the Veteran does not have right eye blindness even though the same examiner had previously reported that the Veteran had right-eye blindness and that it was due to glaucoma. Additionally, the examiner indicated that the Veteran did not complain of headaches at his May 2009 VA examination but rather, complained of facial pain. The examiner did not offer a rationale for why headaches or facial pain were not related to service. The examiner also noted that the Veteran complained of a surgical scar on the left side of his head although, surgery was on the right side of his head. Similarly, even though the Veteran has noted facial numbness on the right side, the examiner noted that numbness was on the left side. The examiner indicated that the numbness was due to a surgery outside the VA facility. Similarly, the examiner stated that RSD was done outside the VA facility. The examiner opined that neither the facial numbness nor the RSD were due to VA carelessness, negligence, lack of proper skill, or error in judgment. The opinion was based on the examination of the Veteran and review of his medical records. The examiner did not explain why he reached the conclusion that there was no error on the part of VA regarding the Veteran's current conditions. In other words, the examiner did not address whether the Veteran could have avoided the private brain surgery and resulting facial numbness, scarring, RSD and any other effects of the private surgery, if VA had offered him different medical treatment during, or prior to, his January 1999 hospitalization. Additionally, Dr. A.F.'s June 2009 addendum did not explain why the Veteran would have had a final diagnosis of temporal arteritis in March 1999, but then had a different diagnosis in April 1999. In his June 2011 addendum, the examiner explained why he believed the Veteran did not have a diagnosis of temporal arteritis but rather had intracranial arteritis due to a trigeminal abscess. However, a review of the record demonstrates that in VA outpatient treatment records as well as private treatment records, the Veteran was assigned a final diagnosis of temporal arteritis. In June 2011, the VA examiner, Dr. A.F., submitted another addendum opinion. At that time, Dr. A.F. noted that the Veteran did not ever have temporal arteritis. The examiner explained that a note in the Veteran's file indicated that a temporal artery biopsy revealed senescent arteritis. The examiner noted that senescent arteritis is associated with intracranial arteritis. However, as noted above, the March 1999 private report regarding the temporal artery biopsy listed the final diagnosis as temporal arteritis. Regardless of whether the Veteran's correct diagnosis was temporal arteritis or intracranial arteritis, the examiner did not address why the Veteran's disorder was not related to service. Additionally, the examiner opined that the Veteran's complaints and elevated sedimentation rate were the result of his intracranial arteritis which was the result of his trigeminal abscess. However, the examiner did not explain whether the trigeminal abscess was related to the fall in service or any fault of VA. Further, in the June 2011 addendum opinion, the examiner opined that there was no negligence on the part of VA in evaluating and treating the Veteran because at the time of his care in January 1999, his symptoms did not point to a trigeminal abscess and his workup was normal. The examiner stated that the trigeminal abscess could not be foreseen by VA during the January 1999 hospitalization and rationalized, at least in part, that the Veteran's workup was normal. However, the December 1998 VA MRI scan done shortly before his inpatient admission was abnormal. Importantly, the VA examiner did not address the abnormal MRI scan or address the significance, if any, of the lack of a cranial angiogram at the time of the January 1999 hospitalization, or any medical treatment by VA in 1998 and 1999 leading up to the January 1999 inpatient admission. As such, the Board finds that the examiner did not provide adequate rationale for his conclusions. The aforementioned VA medical expert opinion was obtained from the Chief of Neurology at the New York VAMC in December 2012. According to the report, the neurologist opined that Veteran's symptoms of headaches and diplopia are consistent with a diagnosis of chronic basilar pachymeningitis secondary to a chronic non-infectious inflammatory process (such as sarcoidosis, collagen vascular disease, or lymphoma); the VA neurologist further opined that the diagnosis of temporal arteritis was in error. The VA neurologist explained that the diagnostic impression from the biopsy was "senescent temporal arteritis" which indicates the absence of an inflammatory infiltrate in the vessel wall and that the average age for a diagnosis of temporal arteritis is 72 years old, and never younger than 50 (the Veteran was 46 at the time of diagnosis). The VA neurologist noted that a diagnosis of temporal arteritis is questionable when there is another active inflammatory process that might affect the vessel and that the Veteran's repeated serum ESR's were normal, which reliably excludes a diagnosis of temporal arteritis in all but 5 percent of patients. The VA neurologist opined that the Veteran's current illness, however diagnosed, is not related the fall with dental injury in service, as a remote episode of trauma has never been implicated in the pathogenesis of the illnesses being considered (i.e., sarcoidosis, temporal arteritis, collagen vascular disease, or lymphoma). The VA neurologist also stated that VA's diagnostic evaluation and medical care from October 1998 through January 1999 was expeditious, comprehensive, multidisciplinary and thoughtful; the appropriate diagnostic studies were obtained in a timely manner and considered. The abnormal findings, which were later evident, were not revealed at that time, and the standard of medical care was met by VA providers in their clinical assessment and diagnostic investigations. The VA neurologist further opined that a cerebral angiogram was not indicated during the January 1999 VA hospitalization; when the procedure was performed in March 1999, the results did not advance the diagnosis or avoid the ultimate required investigation. Legal Criteria for Service Connection It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). In this case, the Board has thoroughly reviewed all of 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, all of the evidence submitted. 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). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. 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, 1 Vet. App. at 57. Service connection may be granted for disability or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection for a disability on the basis of the merits of such claim requires (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In addition, the law provides that, where a veteran served ninety days or more of active service, and certain chronic diseases, such as arthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. 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 disease 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. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative 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). Although the Veteran's disorder was characterized as chronic basilar pachymeningitis by the VA expert neurologist, who also placed his claimed disorder in the same category as sarcoidosis, the Veteran has not actually been diagnosed with a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply to the claim for service connection. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See 38 U.S.C.A. § 1153(a) (West 2002); 38 C.F.R. § 3.303(a); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) and Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Service Connection for Temporal Arteritis As regards the claim for service connection, the Veteran alleges that temporal arteritis may have also been due directly to a fall in service in which he lost teeth. Service treatment records confirm that the fall occurred and that two teeth were affected. He has also been granted entitlement to dental treatment due to the same trauma in service. Thus, element regarding an injury in service has been met. After a review of all the evidence, lay and medical, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience ongoing symptoms of temporal arteritis in the interim years between service and his first complaint of headaches in 1998. The evidence shows that the Veteran's symptoms of temporal arteritis with headaches first manifested many years after service in 1998; notably, in the interim, he was not seen for any related complaints. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (service incurrence may be rebutted by the absence of medical treatment for the claimed condition for many years after service). The Board has also considered the statements of the Veteran, attesting that he has a history of related symptoms since his service; the Board finds that these recent assertions of the Veteran made for compensation purposes are not credible because the recent assertions are inconsistent with, and outweighed by, the evidence showing an absence of complaints or treatment for temporal arteritis with headaches after service, the Veteran's own histories made for treatment purposes prior to filing his 2000 claim for VA compensation, and the Veteran's own reported histories when seeking treatment in the intervening years. See Cromer v. Nicholson, 19 Vet. App. 215, 217 (2005). Prior to the 2000 claim for benefits, it is significant that the Veteran did not make any assertions of temporal arteritis with headaches in service or since service, and he did not assert a link between his service and his symptoms or assert an in-service onset at that time. Such evidence weighs against findings of temporal arteritis with headaches in service or symptoms since service. Significantly, the Board assigns probative value to the December 2012 VA medical expert opinion obtained from the Chief of Neurology at the New York VAMC. The neurologist opined that the Veteran' symptoms were more accurately diagnosed as chronic basilar pachymeningitis secondary to chronic non-infectious inflammatory process such as sarcoidosis, collagen vascular disease, or lymphoma. According to the VA expert neurologist, the Veteran's disorder, however diagnosed, is unrelated to the Veteran's fall with dental injury during his military service. The VA expert neurologist further opined that a remote episode of trauma has never been implicated in pathogenesis of the illnesses under consideration. The Board finds that the weight of the lay and medical evidence of record reflects that the Veteran's claimed temporal arteritis with headaches had post-service onset and is not related to the Veteran's active service. 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. Gabrielson v. Brown, 7 Vet. App. 36 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Medical evidence is not limited to that which is provided by doctors. Cox v. Nicholson, 20 Vet. App. 563 (2007). However, the probative value of a medical opinion is also based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings. See Sklar v. Brown, 5 Vet. App. 140 (1993). The Board notes, however, that the absence of claims file review does not necessarily render an examination inadequate or reduce the probative value of a medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 305 (2008); Snuffer v. Gober, 10 Vet. App. 400 (1997). The weight of the competent evidence of record demonstrates that the Veteran's claimed temporal arteritis with headaches is not related to his service. The Board finds that the Veteran's assertions that his disorder began during or as a result of service are not substantiated by the evidence; there is no indication of in-service treatment or complaints, except related to the Veteran's acute fall and dental trauma, which are not causally related to temporal arteritis. Thus, the evidence does not reflect that the claimed temporal arteritis with headaches was incurred in service or aggravated during service. Additionally, the Veteran does not provide specificity as to the nature of such symptoms or otherwise provide a cogent rationale which links the Veteran's claimed temporal arteritis with headaches to his service, including the fall with dental trauma. Thus evidence does not reflect that claimed disorder was incurred in service or was aggravated during service; the Veteran has not submitted medical evidence explaining why there were no noted symptoms in service or for many years after service. Such assumptions further support the fact of post-service onset of the Veteran's disorder, and that he did not experience in-service or post-service symptoms. For these reasons, the Board finds that the lay and medical evidence that is of record weighs against the claim for service connection for temporal arteritis with headaches. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claims must be denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Legal Criteria for Compensation benefits under 38 U.S.C.A. § 1151 When a veteran suffers an injury or an aggravation of an injury resulting in additional disability or death as the result of VA training, hospitalization, medical or surgical treatment, or an examination furnished by the VA, disability compensation shall be awarded in the same manner as if such disability or death were service connected. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.361. In order to constitute a qualifying additional disability, the proximate cause of the additional disability must have been (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the facility furnishing the care, treatment, or examination, or (2) an event not reasonably foreseeable. These provisions of law apply to claims received by VA on or after October 1, 1997. 38 C.F.R. § 3.361(a). In determining whether a veteran sustained additional disability, VA compares the veteran's condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the veteran's condition after such care or treatment. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the veteran's additional disability or death. Merely showing that a veteran received care or treatment and that the veteran has an additional disability, or died, does not establish cause. 38 C.F.R. § 3.361(c)(1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease or injury for which the care or treatment was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). Additional disability or death caused by a veteran's failure to follow properly given medical instructions is not caused by hospital care, medical or surgical treatment, or examination. In addition, the proximate cause of death is the action or event that directly caused the death, as distinguished from a remote contributing cause. 38 C.F.R. § 3.361(c)(3). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability or death, it must be shown that the hospital care or medical or surgical treatment caused the veteran's death; and (1) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (2) VA furnished the hospital care or medical or surgical treatment without the veteran's informed consent. Determinations as to whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a veteran's additional disability or death was an event not reasonably foreseeable is determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable, but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. As specified in 38 C.F.R. § 3.361(d)(2), in determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. Analysis for Compensation benefits under 38 U.S.C.A. § 1151 Regarding the claim for benefits under 38 U.S.C.A. § 1151, the Veteran alleges that his cranial disorder was allowed to get to the severe stage and required brain surgery to correct. He states that this failure to recognize the severity of his condition constituted negligence on VA's part. After review of the lay and medical evidence of record, the Board finds that the weight of the evidence is against finding that the Veteran suffers from additional disability due to VA negligence or fault or an event not reasonably foreseeable. In the December 2012 medical opinion, the VA neurologist summarized the Veteran's relevant medical history and noted that the record reflected that the Veteran was more accurately diagnosed with chronic basilar pachymeningitis. The VA neurologist wrote that the necessary abnormal findings for proper diagnosis and treatment were not yet evident when he first sought treatment, and as such, VA's diagnostic evaluation and medical care were appropriate, expeditious, and comprehensive. The VA medical reviewer, thereafter, concluded that the Veteran's chronic basilar pachymeningitis was secondary to a chronic non-infectious inflammatory process, which was not the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA medical personnel, or an event not reasonably foreseeable; according to the VA neurologist, VA met the standard of medical care in their clinical assessment and diagnostic investigations. The VA medical reviewer based his medical opinion on review of the record. The summary provided by the medical reviewer of the relevant treatment records is consistent with the record. The VA medical reviewer also provided a sound rationale in support of the conclusion. There is no competent medical opinion to the contrary of record. For these reasons, the reviewer's opinion is afforded great probative value. Although the Veteran has repeatedly contended that he suffers from additional damage (brain surgery) due to VA fault or an event not reasonably foreseeable, by virtue of a lack of intervention until his disorder was severe, the Board affords the opinion provided by the December 2012 VA neurologist more probative value. The VA neurologist, unlike the Veteran, has medical training and expertise and is able to render a competent opinion with respect to the medical question of whether the Veteran has additional disability caused by VA negligence or fault or an event not reasonably foreseeable; therefore, the VA . The Veteran, as a layperson without relevant medical qualifications, is not competent to render such a medical opinion and, therefore, his opinion is afforded significantly less probative value. Furthermore, although the Veteran wrote in his April 2005 notice of disagreement that VA's failure to diagnosis him quickly left him with additional defects, the assertion is inconsistent with treatment records, which show that the Veteran's symptoms were not indicative of the underlying disorder, and the multiple evaluations came back normal. The Board finds the medical records to be more credible and affords them greater probative value than the Veteran's lay assertion. Therefore, upon consideration of the foregoing, the Board finds that the preponderance of the evidence weighs against finding that the Veteran suffers from additional disability due to any negligence or fault of VA in administering treatment for temporal arteritis with headaches or an event not reasonably foreseeable. Because the Board concludes that the preponderance of the evidence is against the claim, entitlement to compensation benefits under 38 U.S.C.A. § 1151 is not warranted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for temporal arteritis with headaches is denied. Compensation benefits pursuant to the provisions of 38 U.S.C.A. § 1151 for temporal arteritis with headaches is denied. ____________________________________________ MATTHEW D. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs