Citation Nr: 1318768 Decision Date: 06/10/13 Archive Date: 06/21/13 DOCKET NO. 10-49 061 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied claim for entitlement to service connection for an acquired psychiatric disorder (other than posttraumatic stress disorder (PTSD)), to include dysthymic disorder. 2. Entitlement to service connection for coronary artery disease, to include as secondary to service-connected posttraumatic stress disorder (PTSD). 3. Entitlement to an effective date prior to August 3, 2009 for the award of a 100 percent evaluation for service connected PTSD. REPRESENTATION Appellant represented by: Nebraska Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from April 1980 to April 1983 and from December 1990 to May 1991. These matters come before the Board of Veterans' Appeals (Board) on appeal from November 2010 and September 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office in Lincoln, Nebraska (RO). As a matter of history, the RO denied the Veteran's service-connection claim for an acquired psychiatric disorder other than PTSD in a December 1994 rating decision. The Veteran did not appeal. In April 2011, the Veteran filed a claim for service connection for mental health conditions, other than PTSD. The RO denied the Veteran's request to reopen his claim in the above-mentioned September 2011 rating decision. In the same decision, the RO denied the Veteran's claim for service connection for coronary artery disease. The Veteran has perfected an appeal as to both issues. In a November 2009 rating decision, the RO increased the Veteran's assigned rating for his PTSD disability from noncompensable to 50 percent disabling, effective from August 3, 2009, the date of the claim for an increased rating. The Veteran appealed. By the way of the November 2010 rating decision, the RO again increased the Veteran's assigned rating from 50 to 100 percent disabling, effective from August 3, 2009. As the award of the 100 percent for PTSD disability is considered a full grant of the benefits sought on appeal, the issue is no longer before the Board. See AB v. Brown, 6 Vet. App. 35, 39 (1993). The Veteran appealed the assigned effective date of the 100 percent rating. In November 2012, the Veteran testified before the undersigned Veterans Law Judge during a hearing held at the RO. The Veteran was provided an opportunity to set forth his contentions at the hearing. The record reflects that at this hearing the undersigned set forth the issues to be discussed at the hearing, focused on the elements necessary to substantiate the claims, and sought to identify any further development that was required to help substantiate the claims. These actions satisfied the duties a Veterans Law Judge has to explain fully the issue and to suggest the submission of evidence that may have been overlooked. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010) (holding that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board). A copy of the hearing transcript has been associated with the claims folder. The Board notes that during the November 2012 hearing, the Veteran raised a claim of clear and unmistakable error (CUE) in a December 1994 rating decision that assigned a noncompensable evaluation following an award of service connection for PTSD. The Veteran asserted that the medical evidence at that time demonstrated that his PTSD symptomatology was more severe than that associated with the criteria for a noncompensable evaluation. The Veteran submitted his contentions in writing to the RO in a November 2012 statement. The RO denied the Veteran's CUE claim in a December 2012 rating decision. To date, the Veteran has not yet filed a notice of disagreement as to the denial of his claim and the matter is not on appeal. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. It appears from an April 2011 statement in support of the claim, that the Veteran seeks entitlement to service connection for sickle cell trait syndrome. To date, the Agency of Original Jurisdiction (AOJ) has not adjudicated this claim. Thus, the Board does not have jurisdiction over this issue and it is referred back for appropriate action. FINDINGS OF FACT 1. In an unappealed December 1994 rating decision, the RO denied the Veteran's claim of entitlement to service connection for acquired psychiatric disorder other than PTSD. 2. The evidence associated with the claims folder subsequent to the RO's December 1994 rating decision, by itself or considered with the previous evidence of record, does not relate to an unestablished fact necessary to substantiate the Veteran's claim of entitlement to service connection for dysthymic disorder. 3. The Veteran's coronary artery disease was not incurred or aggravated in military service, nor is not proximately due to or the result of his service-connected PTSD. 4. VA received the Veteran's claim for an increased rating for PTSD on August 3, 2009. 5. It is not factually ascertainable from the medical evidence of record that within the year prior to August 3, 2009, the Veteran's service-connected PTSD warranted a rating of 100 percent. CONCLUSIONS OF LAW 1. The December 1994 rating decision that denied the Veteran's service connection claim for acquired psychiatric disorder other than PTSD is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.1103 (2012). 2. Since the December 1994 rating decision, new and material evidence has not been received with respect to the Veteran's claim of entitlement to service connection for dysthymic; the claim is not reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 3. The criteria for entitlement to service connection for coronary artery disease have not been met. 38 U.S.C.A. §§ 1101, 1131, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 4. The criteria for an effective date earlier than August 3, 2009 for the assigned 100 percent rating for PTSD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.400, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159, provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim, defined to include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The record reflects that the originating agency provided the Veteran with the notice required under the VCAA and under Dingess by letters dated in September 2009, April 2011 and September 2011. The September 2009 notice addressed the PTSD claim and informed the Veteran on how VA assigns disability evaluations and effective dates. Specifically, in the September 2011 letter, the RO adequately advised the Veteran of the basis for the previous denial of his claim for service connection for dysthymic disorder, to determine what evidence would be new and material to reopen the claim as required by Kent v. Nicholson, 20 Vet. App. 1 (2006). Subsequently, in September 2011, the RO adjudicated the Veteran's claim in the first instance, and the Veteran filed a timely appeal as to the RO's determination. Accordingly, with respect to VCAA notice, there is no prejudice to the Veteran in the Board's proceeding with the determination of these claims. The VCAA duty to assist requires that VA make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim, and in claims for disability compensation requires that VA provide medical examinations or obtain medical opinions when necessary for an adequate decision. 38 C.F.R. § 3.159. In this case, the available record includes service treatment records, service personnel records, post-service VA medical treatment reports, and the Veteran's own statements. The Board finds that the notice requirements pertinent to the issues on appeal have been met and all identified and authorized records relevant to the matters have been requested or obtained. There is no evidence that any additional relevant treatment records exist, and the Veteran has not so alleged. VA provided the Veteran with a VA heart examination in June 2011 in conjunction with his coronary artery disease claim. The examination report reflects that the VA examiner reviewed the Veteran's past medical history, recorded his current complaints, conducted an appropriate examination, and rendered appropriate diagnoses consistent with the other probative evidence of record. The examiner then provided an appropriate medical nexus opinion on the questions on direct and secondary service connection. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations or opinions concerning the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board notes that VA examinations need not be provided for the Veteran's applications to reopen his service-connection claims for dysthymic disorder. In the absence of new and material evidence of record, the duty to assist by affording the Veteran a VA examination is not triggered. See 38 U.S.C.A. § 5103A(d), (g); Paralyzed Veterans of Am. v. Sec'y of Veterans Affairs, 345 F.3d 1334, 1353 (Fed. Cir. 2003) [holding that VA need not provide a medical examination or medical opinion until a claim is reopened]; Anderson v Brown, 9 Vet. App. 542, 546 (1996) [holding that unless the veteran has submitted new and material evidence warranting the reopening of his claim, the duty to assist does not attach]. As discussed below, the Board finds that new and material evidence has not been received, and reopening the Veteran's claims is not warranted. In short, the Board has carefully considered the provisions of the VCAA, in light of the record on appeal and, for the reasons expressed above, finds that the development of the appeal has been consistent with said provisions. The Board is satisfied that any procedural errors in the originating agency's development and consideration of the claims were insignificant and nonprejudicial to the Veteran. The Veteran has been accorded ample opportunity to present evidence and argument in support of his claims. See 38 C.F.R. § 3.103. He has retained the services of a representative, and he had the opportunity to testify before the undersigned during a hearing at the RO. Claim to Reopen The Veteran seeks entitlement to service connection for acquired psychiatric disorder other than PTSD. Implicit in this claim is the contention that new and material evidence which is sufficient to reopen previously disallowed claims of service connection for anal fissures has been received. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. In general, VA rating decisions or Board decisions that are not timely appealed are final. See 38 U.S.C.A. § 7105; 38 C.F.R. §§ 20.1100, 20.1103. Pursuant to 38 U.S.C.A. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. New evidence is defined as evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156(a). An adjudicator must follow a two-step process in evaluating a previously denied claim. First, the adjudicator must determine whether the evidence added to the record since the last final decision is new and material. If new and material evidence is presented or secured with respect to a claim that has been finally denied, the claim will be reopened and decided upon the merits. Once it has been determined that a claimant has produced new and material evidence, the adjudicator must evaluate the merits of the claim in light of all the evidence, both new and old, after ensuring that the VA's statutory duty to assist the appellant in the development of her claim has been fulfilled. See 38 U.S.C.A. § 5108 (West 2002); Elkins v. West, 12 Vet. App. 209 (1999); Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The Court has recently stated that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is presumed. See Justus v. Principi, 3 Vet. App. 510, 513(1992). Here, the RO originally denied the Veteran's claim for service connection for acquired psychiatric disorder other than PTSD in a December 1994 rating decision, because the record failed to establish that a dysthymic disorder was incurred in or related to his period of service. The Veteran did not appeal, and the RO's decision became final. 38 C.F.R. §§ 3.104, 20.1103. The Veteran now seeks to reopen his previously denied claim. At the time of the December 1994 rating decision, the evidence of record included an incomplete set of the Veteran's service treatment records, unrelated private treatment records dated in 1992 and 1993, and an October 1994 VA psychiatric examination. The Veteran's service records from his first and second period of service do not include any complaints of, or treatment for any mental health problems. The report of an April 1991 examination prior to separation from his second period of service shows that the Veteran received a normal psychiatric evaluation. He continued to receive a normal psychiatric evaluation at the time of a March 1993 periodic examination and he denied any symptoms of depression or nervousness on the associated report of medical history. At his October 1994 VA psychiatric examination, the examiner diagnosed the Veteran with PTSD and dysthymic disorder. The examiner noted that the Veteran described his PTSD disability as involving symptoms of sleep impairment, irritability, anger problems, concentration problems, hypervigilance, and panic attacks. The examiner found that the Veteran's PTSD disability was mild in nature. The examiner then found that the Veteran's dysthymic disorder manifested by having a depressed mood for most of the day or for more days than not, by observation of others and by his personnel account. The examiner noted that evidence of record show that after the Veteran came back from deployment in Saudi Arabia during his second period of service, he experienced symptoms of depression and fatigue, which did not exist prior to his deployment. However, the examiner did not provide an opinion on whether the Veteran's dysthymic disorder was incurred in or related to his period of service. The RO denied the Veteran's claim for service connection for dysthymic disorder in the December 1994 rating decision, because the record failed to establish that dysthymic disorder was incurred in or related to his period of survive. In the same rating decision, the Veteran was awarded entitlement to service connection for PTSD and assigned a noncompensable evaluation, effective from April 5, 1994. Since December 1994, VA has not received any lay or medical evidence material to the Veteran's dysthymic disorder claim. Indeed, ongoing VA mental health treatment records do not document a diagnosis of dysthymic disorder or any other diagnosed acquired psychiatric disorder other than PTSD, nor do they link any previous diagnosed dysthymic disorder to the Veteran's period of active duty service. None of the three subsequent VA psychiatric examination reports dated in October 2009, August 2010, and March 2012 reflect an Axis I or II diagnosis of an acquired psychiatric disorder other than PTSD, to include dysthymic disorder. Each VA examination report shows a diagnosis of PTSD, chronic with associated depressive symptoms. The March 2012 VA examiner specifically noted that the Veteran did not have any diagnosed mental health disorder other than PTSD. As such, the additional VA medical evidence is not material to the Veteran's acquired psychiatric disorder other than PTSD, to include dysthymic disorder claim. The Board has also considered the Veteran's lay statements and testimony that he has mental health disorders, other than PTSD, to include depression and anxiety. However, the Veteran's new statements are simply duplicative of his previous contentions raised in support of his claim. As an aside, the Board notes that it is abundantly clear that the Veteran in this case is already being compensated for the full level of severity of disability due to his service-connected psychiatric symptomatology, associated with his PTSD disability. It appears from the PTSD disability includes his symptoms of depression and anxiety, as well as other serious symptomatology that are indicative of a 100 percent disability evaluation. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Therefore, assigning a separate disability rating for another psychiatric disorder other than PTSD would very well constitute pyramiding, which is forbidden by law. See 38 C.F.R. § 4.130; Esteban v. Brown, 6 Vet. App. 259, 261 (1994). The Board recognizes that some of the Veteran's additional service treatment records were added to his claims file subsequent to the December 1994 rating decisions. Under 38 C.F.R § 3.156(c)(1), at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim notwithstanding the requirement to submit new and material evidence. However, these additional service treatment records do not contain any relevant new information pertaining to the Veteran's acquired psychiatric disorder other than PTSD claim. The additional records show that the Veteran denied any mental health problems in service and he received normal psychiatric evaluations. See April 1991 and September 1994 report of medical history and a September 1994 periodic service examination. Pertinently, these additional service treatment records do not indicate that the Veteran complained of mental health symptoms during service or in the year following, or that he was diagnosed with dysthymic disorder during that period. Since these service treatment records added to the folder are irrelevant to the Veteran's pending claim, the provisions of 3.156(c) are not applicable, and the Board is not required to reach the merits of the Veteran's service-connection claims. The Board is aware that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In light of the fact that the Veteran has not submitted any new lay statements of argument in support of his claim for dysthymic disorder, nor has he submitted medical evidence that demonstrates the presence of a current diagnosis of dysthymic disorder or any other mental health disorder, or a potential relationship between his previous diagnosed disorder and his military service, this low threshold is not met. The Board accordingly finds that the evidence added to the file since December 1994 is either cumulative of evidence already considered by the RO in its last final denial, or is simply not material. The evidence does not relate to unestablished facts necessary to substantiate the Veteran's claim. Accordingly, in the absence of such evidence, the claim may not be reopened, and the benefits sought on appeal remain denied. Service Connection for Coronary Artery Disease Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a 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. See 38 C.F.R. § 3.303(b). The chronicity provision of 38 U.S.C.A. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Certain chronic diseases, although not shown in service, may be presumed to have incurred in or aggravated by service if they become manifested to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. To prevail on the issue of service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In addition, a disability that is proximately due to or the result of a service-connected injury or disease shall be service connected. 38 C.F.R. § 3.310. When service connection is thus established for a secondary condition, the secondary condition shall be considered part of the original condition. 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) caused by or (b) aggravated by a service-connected disability. Id. A disability which is aggravated by a service-connected disorder may be service connected, but compensation is only available for the degree to which that condition was made worse by the service-connected condition - only to the degree that the aggravation is shown. 38 C.F.R. § 3.310. In such a situation, VA laws require that the medical evidence must show a baseline level of severity of the nonservice-connected disease or injury, which is established by medical evidence created before the onset of aggravation. Id. The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. In this case, the Veteran alleges entitlement to service connection for coronary artery disease. The Veteran asserts that he first experienced symptoms of chest pain, shortness of breath, and fatigue during his second period of service or shortly thereafter, which mark the onset of his current diagnosis of coronary artery disease. In the alternative, he asserts that his coronary artery disease is aggravated by the anxiety and stress associated with his service-connected PTSD. As noted above, in order to establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus or relationship between the two. See Shedden v. Principi, 381 F.3d at 1167. With respect to element (1), the medical evidence of record demonstrates that the Veteran has a current diagnosis of coronary artery disease, status post coronary artery bypass grafting (CABG) and stent implants. See the report of a June 2011 VA heart examination. It is clear that element (1), current disability, is satisfied. With respect to element (2), in-service disease or injury, the Veteran's service treatment records from both his periods of active service do not document any treatment or complaints involving the heart or heart-related problems, let alone findings indicative of coronary artery disease. At the time of an April 1991 examination prior to separation from his second period of service, the Veteran's heart was evaluated as normal and his blood pressure reading was 128/80. The associated report of medical history shows the Veteran denied any symptoms of chest pain or pressure, shortness of breath, heart palpitations, or heart trouble. There is no evidence of a heart disease or injury during the Veteran's periods of active service. Subsequent service treatment records from the Veteran's Army Reserve service show that he complained of chest, back, and neck pain after eating breakfast and walking from the mess hall in September 1992. He described the pain as starting in his back and then traveled to his chest. The Veteran denied symptoms of shortness of breath or chest pain other than the left poster lateral chest spasm. An electrocardiogram (EKG) test revealed no abnormalities. He was diagnosed with acute left paraspinal and lumbosacral back pain with improvement and he was subsequently discharged without pain or discomfort. The report of a March 1993 periodic examination shows normal heart and vascular evaluations and the Veteran denied any history of chest pain or pressure, heart palpitations, or heart trouble on the respective associated reports of medical history. A private treatment record dated in October 1993 shows that the Veteran presented with similar complaints of back pain and dispersed muscle pain leading to left lateral chest pain and difficulty breathing that were believed to be associated with a sickle cell crisis. His cardiovascular evaluation at that time was normal. Subsequent periodic service examination reports dated in September 1994 and in January 1997 continue to reflect normal heart and vascular evaluations and the Veteran denied any history of chest pain or pressure, heart palpitations, or heart trouble on the respective associated reports of medical history. The first medical evidence of heart problems is not shown until 2009 when the Veteran had a positive EKG stress test. In June 2009, he underwent a diagnostic left heart catheterization procedure which revealed findings of three value coronary artery disease with 50 percent tandem mid left anterior descending (LAD) lesions and he underwent percutanous coronary intervention. Subsequent records show that the Veteran required CABG and multiple stent implant procedures. Essentially, there is no evidence of a chronic heart disorder shown in service, and the first evidence of heart-related problems does not come until 18 years after his separation from his second period of service. See 38 C.F.R. §§ 3.303, 3.307, and 3.309. The Board acknowledges that the Veteran is competent to testify as to his own observable symptomatology and the onset as to those observable symptoms shortly after his separation from service in 1991. See Barr v. Nicholson, 21 Vet. App. 303 (2007). In this regard, the Board recognizes that the Veteran is a licensed nursed practitioner, and he is more than competent to assess that symptoms of chest pain, shortness of breath and fatigue, which he experienced shortly after his separation from his second period of service, are similar to his symptomatology associated with his current diagnosed coronary artery disease. Indeed, the medical records specifically indicate that the Veteran complained of chest pain, shortness of breath and fatigue shortly after his separation from his second period of service. However, those symptoms were attributed to other diagnosed conditions. His complaints of chest pain were associated with his episodes of sickle cell crisis as shown in the private treatment records dated in 1992 and 1993. The report of an October 1994 VA general medical examination report shows that the Veteran's complaints of shortness of breath were attributed to his history of pneumonia and right thorectomy in 1990. Further, the VA examiner from an October 1994 VA psychiatric examination opined that the Veteran's complaints of fatigue were related to his dysthymic disorder. Although the Veteran may believe that his previous symptoms marked the onset of his current diagnosed coronary artery, the contemporaneous medical records demonstrates that those symptoms were attributable to other medical conditions at that time. While the Veteran may have medical training as a licensed nurse practitioner, there is no indication in the record to suggest that he has specialized training in cardiology so as to be able to diagnosis coronary artery disease through his observation of his symptomatology alone. See 38 C.F.R. § 3.159(a)(2); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Notably, the diagnosis of coronary artery disease requires diagnostic testing and medical expertise to determine its very nature, which would extend beyond the Veteran's capabilities to assess coronary artery disease simply based on his observations of his symptomatology. Moreover, to the extent the Veteran is competent to render such a diagnosis, the diagnosis is less probative than the findings by VA and private physicians who treated him for those symptoms at those separate times and associated each symptom with other medical conditions. The competent evidence of record does not demonstrate that the Veteran's coronary artery disease had an onset during his periods of service or within the first year after his separation from service. Element (2), an in-service disease, has not been satisfied. The record does show that the Veteran has been awarded service-connection for PTSD. With respect to element (3), nexus or relationship, the more probative medical nexus opinion of record that weighs against a direct medical link between the coronary artery disease and the Veteran's period of service. The Board has an obligation to weigh the probative value of the medical opinions presented based upon factors such as personal examination of the patient, knowledge and skill in analyzing the data, the knowledge and expertise of the examiner, the expressed rationale forming the basis of the opinion, ambivalence and/or exactness of diagnosis, scope of review of the relevant records, bias, etc. See generally, Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In support of the claim are the Veteran's assertions that his coronary artery disease is related to his military service. While, in general, the opinion of a licensed nurse practitioner may be probative when considering some medical issues, the Board finds the Veteran's own opinion regarding whether his coronary artery disease was incurred in service to be of little probative weight as there is no evidence of record that he had any specific training or experience regarding cardiac conditions. The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Indeed, there is no adequate foundation in the current record to establish that the Veteran has the education, training, or clinical experience to offer a medical nexus opinion relative to the cause of cardiac disorders. Cf. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007). Moreover, in light of the Veteran's bias or personal interest in supporting his claim for benefits reinforces the Board's finding that his assertions have reduced probative value. In contrast, the June 2011 VA heart examiner's medical opinion is based on a more comprehensive review of the Veteran's medical history. The VA examiner opined that the Veteran's current diagnosed coronary artery disease was less likely than not related to his period of service, to include the episode of chest, back, and neck pain after eating breakfast in 1992 or the symptoms of chest pain and difficulty breathing in 1993. The VA examiner noted that the Veteran's in-service EKG was negative for any heart attacks and the 1993 episode was related to an acute sickle cell crisis and not coronary artery disease. Indeed, the Board has not ignored the Veteran's background as a licensed nurse practitioner; instead, the Board finds that his opinion regarding the etiology of his own condition is entitled to lower probative weight. Simply stated, the Veteran's contentions are outweighed by the medical opinion of the VA examiner, who is physician assistant, and unbiased by the outcome of the matter, as well as the facts cited above. As noted above in the legal criteria above, under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third service-connection element for certain chronic diseases is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also Savage, 10 Vet. App. at 495-97. Indeed, the Veteran has asserted at times during the appeal period that he first experienced symptoms of chest pain, shortness of breath, and fatigue since shortly after his separation from service, which is similar to the symptomatology associated with his current coronary artery disease. However, as discussed above, while the Veteran, as a licensed nurse practitioner, is competent to report his own observable symptomatology and the onset as to those observable symptoms, he is not competent to attribute that symptomatology to diagnosis of coronary artery disease. Such a diagnosis requires medical expertise that extends beyond the Veteran's competency as a licensed nurse practitioner. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006); see also Davidson v. Shinseki, 581 F.3d. 1313, 1315 (Fed. Cir. 2009). The evidence of record does not support the Veteran's contentions that he has had symptoms of coronary artery disease since his separation from service. With respect to the Veteran's alternative claim that his coronary artery disease was caused or aggravated by his service-connected PTSD, in order to prevail satisfy element (3), there must be evidence of a nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin, 11 Vet. App. at 512. Again, the more probative medical opinion of record weighs heavily against the finding that the Veteran's coronary artery disease to his service-connected PTSD. For the reasons discussed above, the Board finds that the Veteran's assertions as a licensed nurse practitioner contain less probative value than the June 2011 VA examiner's medical opinion. The June 2011 VA examiner's medical opining that the Veteran's coronary artery disease was less likely as not caused by or aggravated by his PTSD is based on a review of the medical evidence of record, including the Veteran's reported history. The examiner supported his medical conclusion by citing to medical literature that demonstrated coronary artery disease was usually associated with physiological risk factors, such as diabetes, high blood pressure, obesity, and age, and not psychiatric conditions like PTSD. Accordingly, element (3), a nexus or relationship between the current diagnosed disorder and injury in service, has not been satisfied, and the Veteran's service-connection claim fails on this basis. The benefit of the doubt rule is not for application because the evidence is not in relative equipoise. Earlier Effective Date The Veteran seeks an effective date earlier than the currently assigned August 3, 2009, for the award of a 100 percent evaluation for his service-connected PTSD. He essentially contends that the RO should have considered evidence prior to the effective date of his award and he was unaware of his ability to file a claim for increased rating prior to 2009. The effective date of an increase in disability compensation is the earliest date as of which it is factually ascertainable that an increase in disability has occurred if a claim is received within one year of such date. Otherwise, the effective date is the date of receipt of the claim. 38 C.F.R. § 3.400(o)(2). The Court has held that 38 U.S.C.A. § 5110(b)(2) and 38 C.F.R. § 3.400(o)(2) are applicable only where an increase in disability precedes a claim for an increased disability rating; otherwise the general rule of 38 C.F.R. § 3.400(o)(1) applies. See Harper v. Brown, 10 Vet. App. 125, 126 (1997). Three possible dates may be assigned depending on the facts of a case: (1) if an increase in disability occurs after the claim is filed, the date that the increase is shown to have occurred (date entitlement arose) (38 C.F.R. § 3.400(o)(1)); (2) if an increase in disability precedes the claim by a year or less, the date that the increase is shown to have occurred (factually ascertainable) (38 C.F.R. § 3.400(o)(2)); or (3) if an increase in disability precedes the claim by more than a year, the date that the claim is received (date of claim) (38 C.F.R. § 3.400(o)(2)). Harper, 10 Vet. App. at 126. Thus, determining an appropriate effective date for an increased rating under the effective date regulations involves an analysis of the evidence to determine (1) when a claim for an increased rating was received and, if possible, (2) when the increase in disability actually occurred. 38 C.F.R. §§ 3.155, 3.400(o)(2). The Board notes that a specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by VA. 38 U.S.C.A. § 5101(a); 38 C.F.R. § 3.151. Any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA from a claimant may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if the formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the claimant, it will be considered filed as of the date of the receipt of the informal claim. When a claim has been filed which meets the requirements of 38 C.F.R. § 3.151, an informal request for increase or reopening will be accepted as a claim. 38 C.F.R. § 3.155. Historically, by a December 1994 rating decision, service connection was granted for PTSD and a noncompensable rating was assigned effective April 5, 1994, the date the claim was received. The Veteran did not file an appeal and that rating decision became final. See 38 C.F.R. § 20.1103. VA received the Veteran's informal claim for an increased rating for his service-connected PTSD on August 3, 2009. In response, the RO did not provide an application to the Veteran to file on the matter; however, the RO addressed the informal claim in the November 2009 rating decision, in which the RO granted an increased from noncompensable to 50 percent, effective from the date of the informal claim, August 3, 2009. The Veteran appeal and in a November 2010 rating decision, the RO increased the assigned evaluation from 50 to 100 percent disabling, effective from August 3, 2009. The Veteran appealed the assigned effective date of the 100 percent award for his PTSD disability. After the informal claim of August 3, 2009, there are no formal claims from which to look back one year for a prior informal claim. There are also no previous communications indicating the Veteran' intent to apply for benefits based on a claim for an increased rating for PTSD between the date of the December 1994 rating decision and the August 3, 2009 informal claim. Therefore, August 3, 2009 is considered the date of receipt of the claim. See 38 C.F.R. § 3.155(a). August 3, 2009 will be found as the effective date of the increased rating award unless the evidence of record shows a factual ascertainable increase was warranted in the year prior to the date of receipt of that claim. See 38 C.F.R. § 3.400(o). In this case, the Board must review the record to determine whether an ascertainable increase in disability warranting a grant of a 100 percent disability rating occurred within one year prior to August 3, 2009 in order to assign an earlier effective than August 3, 2009. Here, the record contains no medical evidence pertaining to the Veteran's service-connected PTSD disability during the year prior to the date of his claim in August 3, 2009. Rather, the report of an October 2009 VA psychiatric report shows that the Veteran had not received treatment at the VA medical center since 2000 and he denied receiving any current treatment for his PTSD disability. During the November 2012 Travel Board hearing, the Veteran testified that he has experienced similar severe symptoms of anxiety and panic attacks since his period of service, but he did not seeking any mental health treatment for his condition. See November 2012 hearing transcript, pages 27, 28, 33, and 35. He further testified that he did not know that he could file a claim for an increase rating until he spoke with another veteran who felt that the Veteran could receive higher than a noncompensable rating for his PTSD disability. See hearing transcript, page 24. Essentially, the Veteran asserted that he should be entitled to a 100 percent evaluation back to the date of his original claim for service connection for PTSD of April 5, 1994, as his symptomatology has been consistently severe since then, albeit he did not receive any treatment for his condition. In the alternative, he argues that he was not aware of his ability to file for claims for service connection until he was recently advised that he could do so. The Board is sympathetic to the Veteran's contentions, however, the governing legal authority for establishing effective dates relies on very specific rules, and VA is bound by that authority. See 38 C.F.R. §§ 3.157(b), 3.400(o)(2). An effective date for an increased rating is the date the increased rating claim was received unless the evidence of record shows a factual ascertainable increase was warranted in the year prior to the date of receipt of that claim. 38 C.F.R. §§ 3.155, 3.400(o)(2). VA received the Veteran's claim for an increased rating for his PTSD disability on August 3, 2009, and there is no medical evidence with the year prior to that date of that claim that shows an increase in the Veteran's disability. As such, August 3, 2009 is earliest effective date warranted for the increased award to 100 percent for PTSD disability. The record does not contain probative evidence showing that it is factually ascertainable that an increase in disability, warranting a 100 percent rating, had occurred during the period prior to August 3, 2009. 38 C.F.R. § 3.400(o)(1) and (2); see also Harper v. Brown, 10 Vet. App. 125, 126 (1997). In reaching this conclusion, the Board once again acknowledges that a licensed nurse practitioner's opinion may be probative when considering some medical issues; however, the Board finds the Veteran's own opinion regarding whether the severity of his PTSD to be of little probative weight as there is no evidence of record that he had any specific training or experience regarding psychiatric conditions. Since the weight of the evidence does not support an increase prior to August 3, 2009, the effective date will be the date of VA receipt of the claim for increase rating, August 3, 2009. See 38 C.F.R. § 3.400(o). Therefore, an effective date earlier than August 3, 2009 for the grant of a 100 percent disability rating for PTSD disability is not warranted. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to an effective date earlier than April 10, 2006, for the assignment of a 100 percent rating for PTSD, is denied. See 38 U.S.C.A. § 5107. ORDER As new and material evidence has not been received, the petition to reopen the previously denied claim for entitlement to service connection for dysthymic disorder is denied. Entitlement to service connection for coronary artery disease is denied. Entitlement to an effective date prior to August 3, 2009 for the award of a 100 percent evaluation for service connected PTSD is denied ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs