Citation Nr: 1320319 Decision Date: 06/24/13 Archive Date: 07/02/13 DOCKET NO. 06-37 090A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for a heart disability, to include as secondary to a service-connected respiratory disorder. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD Sarah Richmond, Counsel INTRODUCTION 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). The claimant is a Veteran of both World War II and the Korean War, having served on active duty from November 1944 to October 1947, and from August 1950 to May 1954. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision of the RO in Cleveland, Ohio, which denied service connection for a heart disability. In his November 2006 VA Form 9, the Veteran requested a hearing before the Board at his local RO. Accordingly, the Veteran was scheduled for a hearing to be held on September 3, 2009. The Veteran cancelled this hearing in August 2009, stating that his wife had Alzheimer's disease and he was unable to leave her for any length of time. The Veteran's hearing was re-scheduled for October 29, 2009. The Veteran cancelled this hearing in October 2009, again stating that he was not able to attend due to his wife's condition. The Veteran's hearing date was again re-scheduled for March 2010. In a February 2010 letter, the Veteran stated that he was unable to leave his wife's side and thus could not attend the hearing. The Veteran requested that his case be held in reserve until he was able to attend a hearing. However, in March 2010, the Veteran submitted a motion to have his case advanced on docket pursuant to 38 U.S.C.A. § 7107(a)(2)(B) (2012). This motion has been granted. The Board finds it would be at odds with the Veteran's motion to advance this case on docket, which is essentially a request for expedited review, to indefinitely delay adjudication of the claims at issue until such time as the Veteran is able to attend a hearing. Thus, given the fact that the Veteran has cancelled three scheduled Board hearings, has indicated that he would not be able to attend a Board hearing for an indefinite time period, and has requested that this case be advanced on docket, the Board deems his request for a hearing to be withdrawn. See 38 C.F.R. § 20.704(c)(e). This case has been before the Board twice before, in April 2010 and August 2011, at which times the Board remanded the case for additional development. Specifically, the RO was to provide the Veteran with a VA examination with an examiner with the requisite qualifications to address the issue on appeal; also a VCAA letter was to be provided. The directives of the Board's remands have been substantially complied with, as the requested opinions were provided in August 2011 and January 2013, and the VCAA letter was provided in August 2011. FINDING OF FACT The competent and probative evidence of record shows that the Veteran does not have a current heart disability related to his service-connected asbestosis, or any event or injury in service, or that any heart disability had its onset in service. CONCLUSION OF LAW The criteria for service connection for a heart disability have not been met. 38 U.S.C.A. §§ 1110, 1137, 5103, 5103A, 5107, (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. The Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that 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; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. The requirement of requesting that the claimant provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Any error related to this element is harmless. Prior to and following the initial adjudication of the Veteran's claim, letters dated in March 2005 and August 2011 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. at 187; Pelegrini II, 18 Vet. App. at 120-21. The letters advised the Veteran of the information necessary to substantiate the claim, and of his and VA's respective obligations for obtaining specified different types of evidence. The Veteran was informed of the specific types of evidence he could submit, which would be pertinent to his claim. He was also told that it was still his responsibility to support the claim with appropriate evidence. Since the Board has concluded that the preponderance of the evidence is against the claim for service connection, any questions as to the appropriate disability ratings or effective dates to be assigned are rendered moot, and no further notice is needed. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). In any event, it is noted that the Veteran was given proper notice in the August 2011 letter and was given ample opportunity to respond. No response was received, and the claim was readjudicated in supplemental statements of the case dated from June 2012 to February 2013. Thus, there was no deficiency in notice and a harmless error analysis is not necessary. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). The Board also concludes that VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. Neither the Veteran, nor his representative, has at any time referenced outstanding records that they wanted VA to obtain or that they felt were relevant to the claim. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The Veteran was afforded a VA examination in May 2006, with an addendum opinion in July 2006. He also was provided additional VA opinions in April 2008, May and July 2010, August 2011, and January 2013 in order to determine whether his heart disability can be secondarily attributed to his service-connected asbestosis on the basis of causation or aggravation. The Board finds that the August 2011 and January 2013 examinations and medical opinions and reports are sufficient in addressing the matter of nexus. In this regard, it is noted that the VA clinicians reviewed the Veteran's claims file and medical records prior to providing the opinion, and the reports themselves are thoroughly supported by objective and clinical findings. The VA clinicians also considered all relevant information of record, including the Veteran's reports, previous opinions of record, and the pertinent medical evidence of record. In June 2012, the RO acknowledged in an internal memorandum that the examination in August 2011 had not been provided by a cardiologist, pulmonologist, or doctor with an adequate background in cardiology or pulmonology, as requested in the Board remand. It was noted that the pulmonary function test was provided by a Certified Respiratory Therapist but that the mid-level provider with a background in cardiology that was referenced by the physician's assistant was actually a program consultant/ Compensation and Pension reviewer. The RO determined that this did not fulfill the directive of the Board's remand. However, the Board notes that because the physician's assistant indicated that she had reviewed the opinion with a physician with a background in cardiology and a Respiratory Therapist also provided the pulmonary function test and signed the report, the opinion would not have been inadequate solely on the basis of the opinion being provided by a physician's assistant. VA satisfies its duty to assist when it provides a medical examination performed by a person who is qualified through education, training, or experience to offer medical diagnosis, statements, or opinions able to provide competent medical evidence, whether that is a doctor, nurse practitioner or physician's assistant. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (physician's assistant was competent to perform examination). Although VA has no obligation to present affirmative evidence of a VA physician's qualifications during Board proceedings, in this case the Veteran has challenged the qualifications of his VA clinicians. See Hilkert v. West, 12 Vet. App. 145, 151 (1999). Specifically he has stated that the physician who provided the opinion in September 2007 was a heart specialist and that the opinions provided in 2010 were from a nurse. Nonetheless, the Veteran bears the burden of persuasion to show that the Board's reliance on an examiner's opinion was in error and in the case of the August 2011 VA opinion, the Veteran has not done so. Id. In spite of this, to be sure the directives of the Board's remand were met, the Veteran was provided with another examination in January 2013 by a physician who was noted as having a background in cardiology and internal medicine. The Board, therefore, concludes that the August 2011 and January 2013 opinions are adequate upon which to base a decision in this case. There is no need for further development, as the medical evidence in this case is sufficient to make a decision. The duty to assist has therefore been satisfied and there is no reasonable possibility that any further assistance to the appellant by VA would be capable of substantiating her claim. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); 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 appellant in adjudicating this appeal. II. Service Connection The Veteran seeks service connection for a heart disability, which he relates to his service-connected asbestosis. 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. § 1131; 38 C.F.R. § 3.303(a). Service connection can be demonstrated for a disease diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (holding that proof of direct service connection may entail proof that exposure during service caused the malady that appeared many years later); Cosman v. Principi, 3 Vet. App. 503, 505 (1992) (holding that service connection can still be established even when a Veteran did not have a particular condition diagnosed during service or for many years thereafter). In order to establish service connection, the evidence must generally show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); see generally 38 C.F.R. § 3.303. Alternatively, under 38 C.F.R. § 3.303(b), the second and third Shedden/Caluza elements can be established through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr, 21 Vet. App. at 307. Symptoms, and not treatment, are the essence of any evidence of continuity of symptomatology The U.S. Court of Appeals for the Federal Circuit has recently held that for purposes of 3.303(b), where the veteran asserts entitlement to a chronic condition but there is insufficient evidence of a diagnosis in service, the veteran can establish service connection by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), affirming Walker v. Shinseki, No. 10-2634, 2011 WL 2020827 (Vet. App. May 25, 2011). [emphasis added]. For disabilities that are not listed as chronic under 38 C.F.R. § 3.303(b), the only avenue for service connection is by showing inservice incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). Certain chronic disabilities, including cardiovascular-renal disease, may be presumed to have been incurred in service if they become manifest to a degree of 10 percent or more within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for a disability proximately due to or the result of a service-connected disability and where aggravation of a nonservice-connected disorder is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Further, effective October 10, 2006, 38 C.F.R. § 3.310 was amended to codify the Court's holding in Allen, which relates to secondary service connection on the basis of aggravation of a nonservice-connected disorder by a service-connected disability. See 38 C.F.R. § 3.310(b). The amendment essentially requires that a baseline level of severity of the nonservice-connected disease or injury must be established by medical evidence created before the onset of aggravation. 38 U.S.C.A. § 1154(a) requires VA to give "due consideration" to "all pertinent medical and lay evidence" when evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Generally, the Board should determine whether the Veteran's particular disability is the type of disability for which lay evidence is competent, and, if so, weigh that evidence against the other evidence of record in making its determinations. Kahana v. Shinseki, 24 Vet. App. 428, 433 n.4 (2011). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). "Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer." Jandreau, 492 F.3d at 1377, n4. A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Lastly, a layperson may also be competent to testify to the manifestations of a chronic condition during service or a presumptive period or to continuity of symptomatology. Hickson, 12 Vet. App. at 253. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). 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. Nicholson, 492 F.3d 1372, 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 (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). 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 v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). 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."). Turning now to the facts of this case, the Board has reviewed the service treatment records and finds that they are negative for any signs or symptoms of a heart disability. The first finding of a heart disability of record is when the Veteran was admitted to the hospital in April 1999 with complaints of chest pain. He was diagnosed with acute inferior wall myocardial infarction. A November 2003 private treatment record also reflects diagnoses of atherosclerotic heart disease, systolic hypertension, hypercholesteremia, and asymptomatic bradycardia. As the first finding of a heart disability is not until 45 years after service, with no evidence linking this disability to service, there is no medical evidence that the Veteran's heart disability was incurred in service or was diagnosed within one year after service. See 38 C.F.R. §§ 3.303, 3.307, 3.309. However, the Veteran is not claiming that his heart disability was incurred in service. The Veteran contends that his heart disability is the result of his asbestos-related pleural disease, as the heart attack happened shortly after he was diagnosed with asbestosis. The record shows a November 1999 chest x-ray, which was found to demonstrate asbestos pleural disease. In December 2005, the Veteran was granted service connection for asbestosis with shortness of breath and pleural thickening and assigned a 0 percent rating. In an April 2010 rating decision, the Veteran's disability rating for asbestosis was increased to 30 percent, pursuant to an April 2010 Board decision. Given that the Veteran has a heart disability and is service-connected for asbestosis, the determinative issue in this case is whether the service-connected asbestosis caused or aggravated the Veteran's heart disability. A September 2007 letter from a private physician reflects a diagnosis of atrial fibrillation. This letter states that although asbestosis is not directly tied to cardiac disease, it can indirectly affect the pulmonary bed and pulmonary circulation resulting in distention of the left and right atrial chambers over time, which can precipitate atrial fibrillation. Although this opinion is favorable to the Veteran's claim the Board cannot rely on this opinion solely to grant the claim, as it is a speculative opinion without any supporting rationale. While the physician determined that asbestosis can affect pulmonary circulation resulting in distention of the left and right atrial chambers over time, the physician did not definitively state whether it was at least as likely as not that the Veteran's heart disability was caused or aggravated by his asbestosis. A medical opinion must support its conclusions with analysis. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). "Neither a VA medical examination report nor a private medical opinion is entitled to any weight in a service-connection or rating context if it contains only data and conclusions [without reasoning or rationale]." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Thus, another medical opinion addressing all the relevant factors of the Veteran's claim was deemed necessary. The Veteran was provided a VA examination in May 2006. In the May 2006 VA examination report, the examiner determined that the Veteran's coronary artery disease was not caused by or a result of his restrictive lung disease due to asbestosis. In a July 2006 addendum to this opinion, the examiner explained that restrictive lung disease due to asbestosis is not a cardiac risk factor and a causal relationship with coronary artery disease has never been reported in the medical literature. In its April 2010 remand, Board noted that the rating criteria under DC 6845 for chronic pleural effusion or fibrosis, which is classified under restrictive lung disease, provide for cardiac involvement to include right heart failure and right ventricular hypertrophy. See 38 C.F.R. § 4.97. The Board also noted that the September 2007 letter from the Veteran's private physician states that he believed there was a relationship between the Veteran's asbestosis and his atrial fibrillation. The physician explained that although asbestosis has not been implicated directly with cardiac disease, it can indirectly affect the pulmonary bed and pulmonary circulation resulting in distention of the left and right atrial chambers over time, which can precipitate atrial fibrillation. In light of DC 6845 and the September 2007 letter from the Veteran's private physician, the Board found that the explanation provided in the VA examination report and its addendum was insufficient for the purpose of rendering a decision on this claim. Therefore, the Board remanded the claim for the RO to obtain a new opinion from a specialist in cardiology or other appropriate specialist to determine whether it is at least as likely as not that the Veteran's heart conditions were caused or aggravated by his service-connected respiratory disorder due to asbestosis. It was noted that the Veteran should not be scheduled for an examination. Rather, the opinion should be based on a thorough review of the Veteran's claims file and the medical records contained therein. Thereafter, the Veteran was provided with VA medical opinions in May 2010 and July 2010. The May 2010 opinion was provided by a nurse practitioner and signed by a physician. The report notes that it was the nurse practitioner's opinion that the Veteran's heart disability was at least as likely as not caused or aggravated by his respiratory disorder. The rationale was that heart problems resulting from pulmonary hypertension take place because the heart has to work harder to pump blood through your lungs, and will try to compensate by thickening the walls of the right ventricle so that it could hold more blood. In time the heart would wear out from working so hard. The nurse practitioner further noted that people with asbestosis might develop dangerous complications that occur as a result of reduced lung function. These include high blood pressure, heart disease, and buildup of fluid in the lungs. A July 2010 addendum to this report signed by the same nurse practitioner notes, however, that the nurse practitioner's opinion was that the Veteran's heart disease was less likely than not related to or caused by the Veteran's respiratory condition. The rationale was that restrictive lung disease due to asbestosis was not a cardiac risk factor and a causal relationship with coronary artery disease had never been reported in the medical literature. It was noted that asbestosis might lead to high blood pressure in the lungs but that the Veteran had not been diagnosed with pulmonary hypertension. In August 2011, the Board found that the May 2010 and July 2010 VA medical opinions obtained pursuant to the Board's remand instructions were not adequate for the purpose of making a decision on the claim. First, the opinions were issued by a nurse practitioner rather than a cardiologist or similar specialist as instructed in the Board's April 2010 remand directive. Although a physician did co-sign the report in accordance with the Adjudication Procedure Manual, M21-1MR, Part III, Subpart IV, Chapter 3, Section D 18 (a), there was no indication that the physician had the requisite background in cardiology or pulmonology. Second, the Board found that adequate rationales were not provided in either VA opinion. Specifically, the May 2010 opinion finding in favor of a relationship between restrictive lung disease and a heart disorder, and the July 2010 opinion finding against such a relationship, were both authored by the same nurse practitioner. Both opinions are devoid of any analysis of the evidence of record apart from noting the Veteran's diagnoses. Indeed, the first opinion had been returned by the Rating Officer as inadequate because the claims file had not been reviewed. However, the second opinion is still based almost exclusively on sources found on the Internet and without any analysis of the Veteran's medical history. The only difference is that in the second opinion the nurse practitioner noted that the Veteran did not have a diagnosis of pulmonary hypertension, without an explanation as to why this fact alone accounted for the switch from a positive to a negative nexus opinion. Finally, the opinion does not address the likelihood that the Veteran's heart disorder was aggravated by restrictive lung disease, even if it was found that it was not directly caused thereby. Because these opinions are not adequate for decision-making purposes, the Board found that there had not been substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to insure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The Board determined that on remand, a VA examination should be performed by a cardiologist, pulmonologist, or a VA doctor with an adequate background in cardiology or pulmonology. After reviewing the claims file and examining the Veteran, the examiner should render an opinion as to whether it is at least as likely as not that the Veteran's service-connected restrictive lung disease due to asbestosis caused or aggravated a heart disorder. The examiner should provide a complete rationale for his or her opinion. The examiner should note that the Veteran suffered a heart attack in April 1999, and that a November 2003 private treatment record reflects diagnoses of atherosclerotic heart disease, systolic hypertension, hypercholesteremia, and asymptomatic bradycardia. The examiner should further note the September 2007 letter from a private physician reflecting a diagnosis of atrial fibrillation, and the opinion that although asbestosis is not directly tied to cardiac disease, it can indirectly affect the pulmonary bed and pulmonary circulation resulting in distention of the left and right atrial chambers over time, which can precipitate atrial fibrillation. Thereafter a VA examination was provided in August 2011, which was signed by a physician's assistant. The diagnoses were acute, subacute, or old myocardial infarction, atherosclerotic cardiovascular disease, coronary artery disease, and supraventricular arrhythmia. It was noted that the Veteran had an implanted cardiac pacemaker. It was further noted that the Veteran had a diagnosis of asbestosis. The examiner noted a review of the claims file and determined that the claimed condition was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. The examiner noted that asbestosis in its early stages causes interstitial fibrosis, plaques, and restrictive respiratory disease. As it progresses the lungs become stiffer, less elastic, and atelectasis is noted. Worsening of restrictive disease is noted in the pulmonary function tests. In advanced stages of the disease honeycombing of the lungs appear on chest x-ray; and there is clubbing of the extremities (fingers and toes), as well as right ventricular hypertrophy (cor pulmonale). The right ventricular hypertrophy is the cause for cardiac complications in the asbestosis patient. Common complications include right-sided heart failure, and atrial fibrillation heart arrhythmia. The examiner noted that the Veteran's chart showed no symptoms of moderate or severe restrictive respiratory disease prior to his atrial fibrillation diagnosis. He had no current symptoms of advanced asbestosis, clubbing of the fingers/toes, or crackles in the lungs. The chest x-ray also did not show honeycombing. This was less than five years after the diagnosis of his atrial fibrillation. Thus, in the examiner's opinion the Veteran's heart diseases were not caused by or related to his asbestosis. As far as worsening of the heart disease beyond the normal progression it was the examiner's opinion that the Veteran's baseline of cardiac disease had been less likely than not worsened by the asbestosis. The Veteran's asbestosis appeared to be stable. To cause cardiac-related symptoms or complications the progression of the asbestosis would have to be moderate to severe. The Veteran's current chest x-ray as compared to the one in 2005 was stable, with the exception of the addition of the pacemaker. After reviewing pulmonary function tests and an echocardiogram that was pending, the examiner noted that she had reviewed this report with a mid-level provider in cardiology and after reviewing the notes in the claims file stood by her opinion in the report. As previously mentioned, in June 2012, the RO determined that the August 2011 opinion did not fulfill the Board's remand directive, because the opinion in August 2011 had not been provided by a cardiologist, pulmonologist, or doctor with an adequate background in cardiology or pulmonology, as requested in the Board remand. It was noted that the pulmonary function test was provided by a Certified Respiratory Therapist but that the mid-level provider with a background in cardiologist that was referenced by the physician's assistant was actually a program consultant/ Compensation and Pension reviewer. The Board has determined that because the physician's assistant indicated that she had reviewed the opinion with a physician with a background in cardiology and a Respiratory Therapist also provided the pulmonary function test and signed the report, the opinion would not have been inadequate solely on the basis of the opinion being provided by a physician's assistant. See Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (physician's assistant was competent to perform examination). Also, the Veteran did not specifically challenge the qualifications of the physician's assistant. See Hilkert v. West, 12 Vet. App. 145, 151 (1999). Nonetheless, to be sure the directives of the Board's remand were met, the Veteran was provided with another examination in January 2013 by a physician who was noted as having a background in cardiology and internal medicine. The VA physician in January 2013 determined that the Veteran's claimed condition was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. The physician also found that it was not at least as likely as not that the Veteran's claimed condition/ diagnosis was aggravated beyond the normal progression by his service-connected condition. In the rationale section, it was noted that the Veteran's claims file was reviewed as well as the private treatment records provided by the Veteran. It was further noted that the Veteran was presently service-connected for asbestosis and that pulmonary function tests performed in September 2011 revealed normal spirometry and normal lung volumes with minimal impairment of DLCO. The Veteran's chest x-ray revealed only pleural thickening at this time. The physician noted that there was currently no evidence in the medical literature that showed asbestosis causing coronary artery disease, atherosclerosis, or hypertension. There also was no evidence either clinically or in the medical literature of asbestosis worsening coronary artery disease, atherosclerosis, or hypertension. The VA physician reviewed the September 2007 opinion provided by the private physician who found that while asbestosis had not been implicated directly with cardiac disease, indirectly it was because of its effect on the pulmonary bed and pulmonary circulation. It was further noted that the private physician determined that this might result in distention in the left and right atrial chambers over time, which then could precipitate atrial fibrillation. The VA physician noted that the Veteran's pulmonary function tests in 2011 revealed normal spirometry and lung volumes. His echocardiogram in September 2012 also showed no evidence of pulmonary hypertension and mildly dilated left and right atrial chamber. The VA physician determined that although atrial fibrillation had been associated with chronic lung disease, the more likely etiology of the Veteran's atrial fibrillation was his prior history of hypertension and coronary artery disease. Likewise, the Veteran's atrial fibrillation was controlled with a permanent pacemaker and metoprolol and there was no evidence of aggravation at that time. Finally, the physician noted that medical literature was reviewed in rendering this opinion. Based on the foregoing, the Board finds that the preponderance of the evidence shows that the Veteran's heart disability is not related to his service-connected asbestosis or any event in service. The Board acknowledges that the Veteran is competent to report that he has experienced symptoms related to his heart disability since his diagnosis of a respiratory disorder. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (holding that lay testimony is competent to establish the presence of observable symptomatology); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). There is no reason to doubt the Veteran's credibility when he states that his heart disability began after his asbestosis diagnosis, although it is worth noting that the medical evidence shows that these two disabilities both arose in 1999 and the first record of asbestosis in December 1999 is actually after the Veteran's heart disability first manifested in April 1999. Nonetheless, the Veteran's opinions are insufficient to provide the requisite nexus between his heart disability and his asbestosis because, as a lay person, he is not competent to establish a medical etiology merely by his own assertions; such matters require medical expertise. See 38 C.F.R. § 3.159(a)(1); Duenas v. Principi, 18 Vet. App. 512, 520 (2004); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) (holding that a layperson is generally not capable of providing opinions on matters requiring medical knowledge, such as the condition causing or aggravating the symptoms); see also Bostain v. West, 11 Vet. App. 124, 127 (1998); Stadin v. Brown, 8 Vet. App. 280, 284 (1995); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). As such, his statements regarding the etiology of any heart disorder are merely speculation as to a possible cause as he is not medically qualified to prove a matter requiring medical expertise, such as an opinion as to medical causation. The Veteran also has not submitted any probative medical evidence to support his claim. As previously discussed the favorable September 2007 private medical opinion that he submitted is not entitled to any significant weight as it is a speculative opinion without supporting rationale provided. The favorable opinion provided by the nurse practitioner in May 2010 also is not entitled to any probative value, as the nurse did not provide any supporting rationale, and then a few months later proceeded to provide a conflicting negative medical opinion with no explanation or rationale. The Board finds the VA opinions provided in August 2011 and January 2013 to be more probative as to the etiology of his heart disability. The January 2013 VA examiner reviewed the claims file and examined the Veteran and found that his current heart disability was not caused or aggravated by his service-connected asbestosis, as there was currently no evidence in the medical literature that demonstrated that asbestosis caused coronary artery disease, atherosclerosis, or hypertension. The physician acknowledged the private opinion in September 2007 and found that although atrial fibrillation had been associated with chronic lung disease, the more likely etiology of the Veteran's atrial fibrillation was his prior history of hypertension and coronary artery disease. The physician further determined that there was no evidence of aggravation of the Veteran's heart disability as his atrial fibrillation was controlled with the pacemaker and medication. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. As the VA physician was fully informed of the pertinent medical history, the opinion was fully-articulated, and supported by reasoned analysis, it is entitled to high probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-04 (2008). Although the August 2011 VA opinion was provided by a physician's assistant and not a cardiologist, the physician's assistant indicated that she had reviewed he opinion with a mid-level provider in cardiology and the RO noted that a respiratory therapist also signed the report. Thus, it is also significant to note that the physician's assistant found that the Veteran's heart disease was not shown to have been worsened by the asbestosis; as the asbestosis appeared stable and to cause cardiac-related symptoms or complications the progression of the asbestosis would have to be moderate to severe. Thus, both VA clinicians acknowledged that while in some circumstances restrictive lung disease can be associated with heart disease and atrial fibrillation, in the Veteran's case his atrial fibrillation was more likely caused by his history of hypertension and coronary artery disease; moreover, his restrictive lung disease was not shown to be severe enough to warrant causation or aggravation of his heart disease. As such, after weighing and balancing the evidence of record, the Board finds that the preponderance of the evidence of record is against a finding that the Veteran's heart disability is related to his service-connected asbestosis, or any in-service disease, event, or injury. See 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.310. Accordingly, the Board finds that the criteria for service connection for a heart disability are not met and the Veteran's claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b). However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997) ORDER Entitlement to service connection for a heart disability, to include as secondary to a service-connected respiratory disorder, is denied. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs