Citation Nr: 1319023 Decision Date: 06/11/13 Archive Date: 06/21/13 DOCKET NO. 11-22 919 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Entitlement to service connection for heart disease, to include idiopathic dilated cardiomyopathy with pacemaker installation, including as secondary to a service-connected lung disability. 2. Entitlement to service connection for a bilateral knee disability, status post bilateral total knee replacement. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael Wilson, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1948 to August 1952. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) "Tiger Team" in Cleveland, Ohio, which, in relevant part, denied the Veteran's claims of entitlement to service connection for idiopathic dilated cardiomyopathy and bilateral total knee replacements. Jurisdiction over the Veteran's claims remains with the RO in Albuquerque, New Mexico. The Veteran testified at a hearing before the undersigned at the Albuquerque RO in July 2012. A transcript is of record. The Board remanded the Veteran's claims on appeal for additional evidentiary development in October 2012 and February 2013. The Board additionally granted service connection for a lung disability, originally claimed as asbestosis, in the February 2013 decision. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Service connection is in effect for a lung disability, asbestosis. 2. The Veteran's current heart disease, identified as idiopathic dilated cardiomyopathy, is not the result of a disease or injury during active service. 3. Idiopathic dilated cardiomyopathy is not proximately due to, or aggravated by, the service-connected lung disability. 4. A current bilateral knee disability is not the result of a disease or injury in active service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for idiopathic dilated cardiomyopathy, including as secondary to a service-connected lung disability, have not been met. 38 U.S.C.A. § 1110, 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 2. The criteria for entitlement to service connection for a bilateral knee disability have not been met. 38 U.S.C.A. §§ 1110, 1112(a), 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. 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. 2013); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b) (2012). This notice must be provided prior to an initial unfavorable decision on the claim by the Agency of Original Jurisdiction. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA requires notice of what information and evidence not previously provided, if any, that is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. November 2008 and May 2009 VCAA letters from the RO informed the Veteran of all elements required to substantiate his left knee disability claim in accordance with 38 C.F.R. § 3.159(b). Regarding the duty to assist, treatment records, including pertinent VA and private medical records have been obtained to the extent possible. The Veteran's service treatment records (STRs) could not be obtained, as they are unavailable because they were destroyed in a fire at the National Personnel Records Center (NPRC) in 1973. Destruction of service treatment records does not create a heightened benefit of the doubt, but only a heightened duty on the part of VA to consider the applicability of the benefit of the doubt, to assist the claimant in developing the claim, and to explain its decision. Cromer v. Nicholson, 19 Vet App 215 (2005); Russo v. Brown, 9 Vet. App. 46, 51 (1996). Where service medical records are missing, VA also has a duty to search alternate sources of service records. Washington v. Nicholson, 19 Vet. App. 362 (2005). Though further efforts were made to locate any available STRs, including by soliciting a NA Form 13055 from the Veteran and calling him with regard to his STRs, such efforts yielded no response. Accordingly, in proceeding with appellate review, the Board is mindful that when a claimant's records have been lost or are otherwise unavailable, the Board has a heightened duty to explain its findings and conclusions and to carefully consider the benefit-of-the-doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). In addition to obtaining relevant private and VA treatment records, the Veteran was afforded relevant VA examinations in December 2012, and addenda to those VA examination reports were obtained in April 2013. Collectively, these VA examination reports are responsive to the determinative questions regarding the etiology of the Veteran's claimed disabilities. Accordingly, VA's duty to provide an adequate VA examination has been met. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (rev'd on other grounds by Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). The RO/AMC substantially complied with the Board's October 2012 and February 2013 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). The Board remanded the Veteran's claims in an effort to obtain adequate medical opinions regarding the etiology of his claimed disabilities. He was afforded requested VA examinations in December 2012, following the Board's October 2012 remand; and addenda to those December 2010 VA examination reports were obtained in April 2013, following the Board's February 2013 remand. Collectively, these VA examination reports and addenda adequately addressed the queries put forth in the Board's remand directives. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that VA employees, including Board personnel, have two duties in conducting hearings. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. During the Veteran's July 2012 Board hearing, the issues were adequately identified, and the VLJ and the Veteran's representatives asked specific questions directed at identifying outstanding evidence that could substantiate his heart and knee disability claims. He was asked about treatment and was asked questions aimed at eliciting evidence that he had requisite symptoms meeting the criteria for service connection for his claimed disabilities. Information provided at his July 2012 hearing lead to the Boards remand to get schedule the Veteran for VA examinations to obtain opinions regarding the nature and etiology of his claimed disabilities. As such, the Bryant duties were met. The duty to assist has, therefore, been satisfied and there is no reasonable possibility that any further assistance to the Veteran by VA would be capable of substantiating these claims. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating his claims on appeal. II. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Establishing service connection requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Walker, 701 F.3d 133; Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Service connection may be granted for chronic diseases, including arthritis, when such disease is manifested to a degree of 10 percent or more within one year of discharge from service. See 38 U.S.C.A. §§ 1101, 1112(a) (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). When service connection for such chronic diseases is at issue, the second and third elements for service connection may be established by showing continuity of symptomatology. 38 C.F.R. § 3.303(b); see Walker, supra. Service connection will be conceded if a chronic disease is shown in service and at any time thereafter. 38 C.F.R. § 3.303(b). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2012). Additionally, service connection may be granted on a secondary basis for a disability that is proximately due to or the result of an established service-connected disorder. See 38 C.F.R. § 3.310(a) (2012). A claim for secondary service connection generally requires competent evidence of a causal relationship between the service-connected disability and the non-service-connected disease or injury. See Jones (Wayne L.) v. Brown, 7 Vet. App. 134 (1994). There must be competent evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Similarly, any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the non-service-connected disease, will be service connected. See 38 C.F.R. § 3.310(b) (2012); Allen v. Brown, 7 Vet. App. 439 (1995). In the latter instance, the non-service-connected disease or injury is said to have been aggravated by the service-connected disease or injury. See 38 C.F.R. § 3.310(b) (2012). In cases of aggravation of a non-service-connected disability by a service-connected disability, a claimant shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.322 (2012). VA will not concede aggravation unless there is medical evidence created prior to the aggravation or current level of disability that show a baseline of the disease prior to the aggravation. 38 C.F.R. § 3.310(b). In making all determinations, the Board must fully consider the lay evidence of record. Davidson, 581 F.3d 1313. A layperson is competent to report on the onset and continuity of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit, citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). The Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson, 2 Vet. App. at 618. As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. at 511. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. See 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. Idiopathic Dilated Cardiomyopathy The Veteran contends that he developed his claimed heart disease as a result of exposure to asbestos during service or as secondary to asbestosis. With respect to the current disability requirement for service connection for the Veteran's claimed heart disability, the Veteran's post-service private treatment records show frequent treatment for idiopathathic cardiomyopathy. His December 2012 VA examination report confirmed a diagnosis of idiopathic dilated cardiomyopathy. Accordingly, the current disability requirement is clearly met. See Walker, supra. The Veteran testified during his July 2012 Board hearing that he did not experience heart problems during service. His claim is based, rather, on a contention that he developed heart disease due to exposure to asbestos, and resulting asbestosis. See 38 C.F.R. §§ 3.303(d), 3.310 (2012). In the February 2013 decision, the Board found that the Veteran had been exposed to asbestos during service, and granted service connection for asbestosis. Accordingly, the second required element for service connection on a direct basis can be deemed to be satisfied with respect to this claim. See Walker, supra. The RO assigned an effective date of November 20, 2008 for the service-connected disability. Thus, service connection is in effect for a lung disability which incorporates his asbestosis. Based on the foregoing, the Board is left to consider the final required element for service connection, a nexus between the Veteran's current heart disability and his in-service exposure to asbestos, or his service-connected lung disability. The Veteran testified during his July 2012 Board hearing that he began having problems breathing in 1995. He reported being told at that time that he needed a heart replacement. The first evidence of record of treatment of a heart disability is found in private treatment records from Presbyterian Heart Group dated beginning in November 1997. At that time, he was noted to have been suffering from mild enlargement of the left ventricle. His diagnoses included a left bundle branch block, and a corresponding abnormal electrocardiogram. He was first diagnosed with idiopathic cardiomyopathy in August 2005. In January 2007, he was assessed with compensated congestive heart failure. In January 2008, he underwent a procedure to install an implantable cardioverter defibrillator (ICD). Later treatment records reveal that the Veteran was hospitalized in May 2012 with symptoms of acute hypercarbic respiratory failure. His discharge diagnoses included chronic obstructive pulmonary disease (COPD) exacerbation, acute on chronic systolic congestive heart failure exacerbation, and pneumonia. The physician's noted impression was that the Veteran's acute hypercapnic respiratory failure was most likely due to COPD exacerbation with likely underlying infectious etiology. She also indicated that it was possible that congestive heart failure may have played a role as well. During his December 2012 VA examination, the VA examiner opined that the Veteran's claimed heart disability was less likely than not incurred in or caused by any claimed in-service injury, event, or illness. The examiner explained that his heart condition was idiopathic, meaning that no source for the disability had been found. The examiner additionally opined that the Veteran's heart disability was not at least as likely aggravated beyond its natural progression by a service-connected condition. Here, the examiner noted that the Veteran's heart condition primarily involved the left chamber of the heart, and that pulmonary conditions generally are more likely to affect the right side of the heart with sufficient severity. The Board remanded the Veteran's claim in order to obtain further medical comment with respect to whether his heart disability was caused, or aggravated, by his service-connected lung disability. In an April 2013 addendum, a new VA examiner provided the opinion that the Veteran's current heart disability was not likely to be secondary to his service-connected lung disability. The examiner noted again that the Veteran's diagnosis was idiopathic cardiomyopathy, which signified that his heart condition was not secondary to a known etiology. With respect to whether the Veteran's current heart disability was aggravated by his service-connected lung disability, the examiner cited to medical evidence noting the Veteran's heart diagnoses involved the left side of his heart, and his decreased left ventricular ejection fraction documented since 1994, approximately a decade before his asbestosis had been manifested. The examiner further noted that if asbestosis were to affect the heart, it might specifically cause cor pulmonale. The Veteran, however, had not been diagnosed with cor pulmonale. The examiner reiterated that the Veteran's heart disability was idiopathic, thus, of an unknown cause. The opinions provided within the December 2012 VA examination report and the April 2013 addendum are both fully informed, fully articulated, and well-reasoned. The examiner indicated that review of the record was completed as well as examination of the Veteran. After reviewing his medical history and current diagnoses, the examiner's have indicated that the Veteran's current heart disability was not at least as likely as not incurred during or as a result of his active service, or as secondary (caused or aggravated by) to his service-connected lung disability, specifically asbestosis. See Nieves-Rodriguez, 22 Vet. App. at 304. The examiner's opinion clearly separates the Veteran's current heart disability from his in-service asbestos exposure and resulting development of asbestosis. Based on this thorough VA examination report, the Board cannot make a finding that a nexus exists between the Veteran's current idiopathic dilated cardiomyopathy and his in-service asbestos exposure, or the later development of his service-connected lung disability. See Walker, supra; see also Wallin, supra. Although the Veteran indicated in his testimony that while hospitalized in May 2012, his treating physician may have noted a relationship between his asbestosis and his current heart disability, and had "written that down;" the records of the May 2012 hospitalization contain no indication that his lung disability played a role in the development of his heart disease. At his hearing the Veteran was asked to obtain a statement in this regard from his treating physicians, but no such statement has been received. The Veteran has expressed his opinion that the heart disease is related to asbestosis, but it would require medical expertise to provide such an opinion, especially where, as here, medical professionals have found the heart disease to be idiopathic. As the Veteran lacks the requisite medical expertise, his opinion does not constitute competent evidence regarding the etiology of his diagnosed heart disease. See Jandreau v, 492 F.3d at 1376-77. There is no other competent evidence linking the current heart disease to asbestosis or another disease or injury in service. Absent competent evidence linking current heart disease to service or a service connected disease or disability, the preponderance of the evidence is against the claim. Reasonable doubt does not arise and the claim is denied. 38 U.S.C.A. § 5107(b). B. Bilateral Knee Disability The Veteran contends that he developed a bilateral knee disability as a result of strenuous physical activity performed during active service. Specifically, he contends that knee disabilities developed because of excessive marching and repeatedly jumping into tanks during service. With respect to the current disability requirement for service connection, the Veteran was diagnosed with bilateral knee arthroplasty, secondary to degenerative joint disease, during his December 2012 VA examination. The evidence of record shows that he underwent a bilateral total knee replacement in September 2007. Thus the Veteran clearly has a current bilateral knee disability, thus satisfying the first requirement for service connection. See Walker, supra. With respect to any potential in-service disease, event, or injury related to the Veteran's claimed knee disability, again, the Veteran's STRs are unavailable for review. Nonetheless, the Board observes that the Veteran has credibly reported working with, and performing maintenance on, tanks during his service. During his July 2012 Board hearing, he testified that he did not receive medical treatment for his knees during service. He reported, rather, that he began having problems with his knees about 15 years ago. He indicated his belief that the later development of his bilateral knee disability could be attributed to frequently marched 20 miles per day and to his he repeatedly jumping into tanks during his service. He specifically noted that he was expected to man artillery guns very quickly which required frequently jumping down into tanks, a six-foot drop. The Board finds that the Veteran's reports of performing excessive marching and frequently jumping down into tanks during service are plausible and credible. Accordingly, the Board will afford the Veteran the benefit of the doubt and find that he was exposed to strenuous physical activity, specifically involving his knees, during service. Thus, the second required element for service connection is met. See Walker, supra. With respect to the final element for service connection, a nexus between the Veteran's in-service strenuous activity and his current bilateral knee disability, the December 2012 VA examiner provided the opinion that the Veteran's current bilateral knee disability was less likely than not incurred in or caused by any claimed in-service injury, event, or illness. The examiner noted that there was no evidence showing a condition of the knees during service, and that there was no evidence regarding a knee condition prior to 2007. In the February 2013 remand, the Board noted that the VA examiner appeared to have not considered the Veteran's contentions that he injured his knees as a result of strenuous activity, including marching and jumping from tanks, during service, and remanded the claim to obtain further medical comment. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007). In an April 2013 addendum opinion, a new VA examiner provided the opinion that the Veteran's current bilateral knee disability was not caused by or a result of any in-service disease, event, or injury. The examiner cited to a June 2007 letter to the Veteran's primary care provider from Paul M. Legant, M.D., an orthopedic surgeon, indicating that the Veteran presented at that time with bilateral knee pain that had been plaguing him for many years. Dr. Legant noted that the Veteran was a retired heating and air conditioning repairman who had spent a lot of time crawling, kneeling, and squatting, which led to his current knee problem. The examiner noted that there was no evidence to corroborate the Veteran's contention that his knee disability developed as a result of his service, but rather that the evidence indicated that his civilian occupation and his age were likely factors contributing to his bilateral knee degenerative joint disease. The examiner additionally cited to a medical treatise describing how osteoarthritis results from a complex interplay of multiple factors, including joint integrity, genetics, local inflammation, mechanical forces, and cellular and biochemical processes. The examiner specifically noted information pertaining to how age and occupation play a role in the development of osteoarthritis. The Board finds that with respect to the Veteran's claimed knee disability, the April 2013 VA examiner's addendum opinion is fully informed, fully articulated, and well-reasoned. Again, the VA examiner was thoroughly familiar with the Veteran's medical history and the claimed underlying cause of his bilateral knee disability, and the examiner provided a thorough opinion based on examination of the Veteran, review of the record, and review of relevant medical literature. See Nieves-Rodriguez, 22 Vet. App. at 304. Based on the examiner's opinion, the Board cannot make a finding that the Veteran's bilateral knee disability is etiologically related to his active service. It would require medical expertise to say that a knee disability developing some years after service was the result of events in service, as opposed to any intervening cause. As the Veteran is not shown to possess this medical expertise, his opinion, but itself is not competent evidence. See Jandreau v. Nicholson, 492 F.3d at 1376-77. Apart from the Veteran's contentions, there is simply no evidence relating his current bilateral knee disabilities to active service. While a continuity of symptomatology could serve to establish the link between arthritis of the Veteran's knees, and injuries in service; the Veteran has not reported continuity. Thus, there is no evidence suggesting that his arthritis began in service. In sum, the weight of the evidence is against a finding that service connection is warranted for the Veteran's diagnosed idiopathic dilated cardiomyopathy, either on a direct or secondary basis, as secondary to a service-connected lung disability, or for his diagnosed bilateral knee disability. Although he currently suffers from a current heart disability and bilateral knee disability, and although his exposure to asbestos and strenuous physical activity during service have been conceded, and service connection is in effect for a lung disability, the December 2012 and April 2013 VA examiner's opinions weigh heavily against his contention that his heart disability developed because of asbestos exposure or asbestosis, or that his bilateral knee disability developed as a result of strenuous in-service physical activity. Based on the foregoing, the Board concludes that a preponderance of the evidence is against the Veteran's claims of entitlement to service connection for idiopathic dilated cardiomyopathy and for a bilateral knee disability. Thus, the benefit of the doubt rule, enunciated in 38 U.S.C.A. § 5107(b), is not for application in the Veteran's appeal. Entitlement to service connection for idiopathic dilated cardiomyopathy and for a bilateral knee disability, therefore, must be denied. ORDER Entitlement to service connection for idiopathic dilated cardiomyopathy is denied. Entitlement to service connection for a bilateral knee disability is denied. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs