Citation Nr: 1320797 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 09-03 667 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to an effective date earlier than October 17, 2002 for the grant of service connection for cardiomyopathy. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from October 1988 to August 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In a September 2007 rating decision, the Appeals Management Center (AMC) in Washington, D.C., in pertinent part, granted service connection and assigned an initial 60 percent rating for cardiomyopathy claimed as an enlarged heart, effective October 17, 2002. The Veteran disagreed with the effective date for the grant of service connection. In March 2012, the Board remanded the claim for an earlier effective date for the grant of service connection to the RO via the AMC in Washington, DC, for further development. After completing the additional development, the AMC continued to deny the claim (as reflected in a December 2012 supplemental statement of the case (SSOC)), and returned this matter to the Board. The Veteran's Virtual VA file includes the Veteran's representative's May 2013 Informal Hearing Presentation (IHP), but does not include any additional relevant documents. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim on appeal have been accomplished. 2. The Veteran filed a claim for service connection for an enlarged heart in September 1992, within one year of separation from service. 3. In a June 1994 rating decision, the RO denied service connection for an enlarged heart; the Veteran did not appeal this denial. 4. On October 17, 2002, the Veteran filed a request to reopen his claim for service connection for a heart disorder. 5. In a March 2003 rating decision, the RO determined that new and material evidence had not been submitted to reopen a claim for service connection for an enlarged heart. 6. The Veteran appealed the March 2003 denial and, based in part on the submission of relevant service treatment records which were not previously considered, the AMC determined in the September 2007 rating decision that service connection for cardiomyopathy, claimed as an enlarged heart, was warranted, effective October 17, 2002. 7. The Veteran's cardiomyopathy was first manifested on June 27, 2001. CONCLUSION OF LAW The criteria for an effective date of June 27, 2001, but no earlier, for the grant of service connection for cardiomyopathy have been met. 38 U.S.C.A. §§ 5107(b), 5110 (West 2002); 38 C.F.R. §§ 3.102, 3.156(c), 3.155, 3.400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The United States Court of Appeals for Veterans Claims (Court) in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), held that the VCAA notice requirements apply to all elements of a claim. The Board notes that the request for an earlier effective date is a downstream issue from the grant of the benefit sought, which was initiated by a notice of disagreement (NOD). The Court has held that, as in this case, once an NOD from a decision establishing service connection and assigning the rating and effective date has been filed, the notice requirements of 38 U.S.C.A. §§ 5104 and 7105 control as to the further communications with the appellant, including as to what "evidence [is] necessary to establish a more favorable decision with respect to downstream elements...." Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). The Veteran has been provided the required statement of the case (SOC) discussing the reasons and bases for not assigning an earlier effective date and citing the applicable statutes and regulations. The Board also finds that all necessary development of the downstream earlier effective date claim has been accomplished, and therefore appellate review of this claim may proceed without prejudicing the Veteran. The claim was remanded in March 2012 to obtain a medical opinion regarding whether the service treatment records obtained after June 1994 showed that the Veteran's cardiomyopathy originated in service, including as due to elevated blood pressure or his June 1989 treatment for viral pharyngitis. A medical opinion addressing the questions posed in the March 2012 remand was obtained in May 2012. There was substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). While the May 2012 VA examiner provided a negative opinion regarding the relationship between the Veteran's cardiomyopathy and his elevated blood pressure and viral pharyngitis in service, as will be discussed below, the resolution of this claim ultimately turns on when the Veteran filed his claim and when his cardiomyopathy had its onset. Each of these matters is adequately demonstrated by the evidence of record. The Veteran has been afforded several VA examinations to evaluate his cardiomyopathy, and an additional examination/opinion is not needed to fairly decide this claim for an earlier effective date. See 38 U.S.C.A. § 5103A(d)(2)(A)-(C); 38 C.F.R. § 3.159(c)(4)(A)-(C). See also Chotta v. Peake, 22 Vet. App. 80, 85-86 (2008). While the Veteran filed his claim for service connection in September 1992, within one year after separation from service, the pertinent question here is the date of onset of his cardiomyopathy. The evidence already of record demonstrates that this condition was first manifested on June 27, 2001; hence, remand to obtain additional evidence regarding this question is not necessary. The Veteran reported during an August 2004 VA examination that he presented for treatment at the Durham VA Medical Center (VAMC) in 2001. During a February 2005 videoconference hearing regarding his request to reopen the claim for service connection for an enlarged heart, the Veteran testified that he was evaluated for a fainting spell at some point in 2000 or 2001 at the Durham VAMC. The earliest treatment records from the Durham VAMC associated with the claims file are dated in September 2002. However, despite his August 2004 and February 2005 reports of earlier treatment at that facility, in his October 2002 request to reopen the claim for service connection for a heart problem, the Veteran reported that his treatment records, dated from May 2002 to the present, could be obtained from the Durham VAMC. In an April 2005 VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), the Veteran reported that he had received treatment at the Durham VAMC from September 2002 to the present. The Veteran more recently reported in October and December 2008 VA Form 21-4142s and in his December 2008 VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, that he received treatment at the Durham VAMC from September 2002 to the present. In September 2002, the Veteran presented to the Durham VAMC for treatment of hypertension and an "enlarged heart" found on separation examination. He was referred to a primary care provider. Significantly, a November 2002 VA primary care provider note reflects that the Veteran was a new patient, although he had previously been followed for hypertension at the Richmond VAMC. This November 2002 primary care note supports the conclusion that the Veteran had not received treatment earlier than September 2002 at that facility. The Veteran himself reported during his September 2006 VA examination that he presented to the Durham VAMC in 2002 for work-up of his enlarged heart. While a March 2009 VA examination report indicates that the Veteran's cardiomyopathy had a date of onset in 2000 and describes the initial manifestation of this disorder as when the Veteran was admitted to the Durham VAMC for syncope and an irregular heartbeat was identified, records from the Durham VAMC, printed in November 2002, reflect that there was no data regarding admissions or discharges. In light of this evidence indicating that the Veteran did not receive treatment at the Durham VAMC prior to September 2002, remand to attempt to obtain any earlier treatment records from this facility is not necessary. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to the requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). Regarding the Veteran's reported treatment at the Richmond VAMC, in March 2005, the AMC requested treatment records dated from August 1992 to September 2002 from this facility; however, the Richmond VAMC responded that there were no records other than a February 1995 VA joints examination. In an April 2005 VA Form 21-4142, the Veteran reported treatment from a private physician, Dr. S.K., from 1997 through 1998. No records from this physician have been associated with the claims file; however, an August 2006 letter from this physician to the Veteran indicates that no medical records could be provided because records were only retained for seven years and the Veteran had last been seen in 1998. Similarly, in a July 2005 VA Form 21-4142, the Veteran reported treatment at Nash General Hospital in 2000, for disorders including an enlarged heart. However, this hospital responded the following month that there were no records for the Veteran. No further action in regard to obtaining these private treatment records is necessary. In an April 2005 VA Form 21-4142, the Veteran reported that he had filed a claim for disability benefits with the Social Security Administration (SSA) in 1996 which had been denied. SSA records have not been associated with the claims file; however, the SSA advised the Veteran in May 2006 that his medical file had been destroyed. Accordingly, no further action to attempt to obtain SSA records is warranted. The claims file does reflect that there are additional VA and private treatment records, dated since the grant of service connection for cardiomyopathy, which have not been obtained. The Veteran underwent a biventricular implantable cardioverter-defibrillator implantation for sarcoid cardiomyopathy in September 2008 at the Durham VAMC. The procedure note and discharge instructions from his period of hospitalization are of record; however, complete records from this hospitalization have not been obtained. Rather, a handwritten note states that while the discharge notes were printed, printing all of the Compensation and Pension Record Interchange (CAPRI) notes would be excessive due to the amount of notes. The claims file also includes after care instructions from Maria Parham Hospital dated in August 2008 which reflect that the Veteran received treatment for congestive heart failure; however the actual records of this treatment have not been obtained. The present case turns on the date of onset of the Veteran's cardiomyopathy, prior to October 17, 2002, and the Board has determined that the evidence of record indicates that this condition was first manifested on June 27, 2001. These VA and private treatment records, dated since September 2008, would not demonstrate that the current cardiomyopathy first manifested on a date prior to June 27, 2001. Therefore, remand to attempt to obtain these additional medical records is not warranted. See Soyini, 1 Vet. App. at 546; see also Sabonis, 6 Vet. App. at 430. A VA primary care note from December 2008 includes on the Veteran's problem list cardiomyopathy with an onset date in 1992, apparently added to the problem list by the Veteran's primary care provider in September 2008 on the date of his heart surgery. A treatment note from this primary care provider on this date is not included in the VA treatment records currently associated with the claims file. However, there is no indication that simply because such an onset date was added to the problem list (which also includes onset dates for several other conditions), any treatment record from such date would include an explanation as to the reason for assigning such onset date. Moreover, as will be discussed below, even if this record were to include an explanation as to why an onset date of 1992 was indicated, the evidence of record weighs against a finding that the Veteran's current cardiomyopathy had its onset in 1992, based on testing performed at that time. Therefore, remand to obtain any additional medical records is not warranted. The Veteran has not identified any additional, relevant evidence that has not been requested or obtained. Accordingly, the Board finds that no further notice or assistance is needed to meet the requirements of the VCAA. The Merits of the Claim Except as otherwise provided, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a) (West 2002); 38 C.F.R. § 3.400 (2012). If a claim for service connection is received within a year following separation from service, the effective date will be the day following separation; otherwise, the effective date is the date of the claim. 38 U.S.C.A. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). A specific claim in the form prescribed by VA must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. 38 U.S.C.A. § 5101(a); 38 C.F.R. § 3.151(a). Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant, his duly-authorized representative, or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a 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 as filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155(a). Revisions were made to 38 C.F.R. §§ 3.156(c) and 3.400(q), effective on October 6, 2006. 38 C.F.R. § 3.156(c) was revised to establish clearer rules regarding reconsideration of decisions on the basis of newly discovered service department records. The substance of 38 C.F.R. § 3.400(q)(2) is now included in the revised § 3.156(c). Prior to the revision, § 3.400(q)(2) governed the effective date of benefits awarded when VA reconsidered a claim based on newly discovered service department records. The prior 3.400(q)(1) is redesignated as new § 3.400(q)(1) and (2) without substantive change. See 70 Fed. Reg. 35388 (2005). As in effect prior to October 6, 2006, 38 C.F.R. § 3.156(c) and § 3.400(q)(2), together establish an exception to the general effective date rule in § 3.400 which provides that the effective date of an award of benefits will be the date of claim or the date entitlement arose, whichever is later. The exception applies when VA receives official service department records that were unavailable at the time that VA previously decided a claim for a benefit and those records lead VA to award a benefit that was not granted in the previous decision. Under this exception, the effective date of such an award may relate back to the decision of the original claim or date entitlement arose, whichever is later, even though the decision on that claim may be final under § 3.104. As noted above, § 3.156(c) was revised to clarify VA's current practice that when VA receives service department records that were unavailable at the time of the prior decision, VA may reconsider the prior decision, and the effective date assigned will relate back to the date of the original claim, or the date entitlement arose, whichever is later. The pertinent revisions include removal of the "new and material" requirement in § 3.156(c). Because the rule regarding the effective date of an award of benefits based all or in part on newly-discovered service department records is now included in § 3.156(c), the effective date provision was removed from § 3.400(q). Effective on or after October 6, 2006, 38 C.F.R. § 3.156(c) provides that notwithstanding any other section in this part, 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 paragraph (a) of this section. 38 C.F.R. § 3.156(c)(1). An award made based all or in part on the records identified by paragraph (c)(1) is effective on the date entitlement arose or the date VA received the previously decided claim, whichever is later, or such other date as may be authorized by the provisions of this part applicable to the previously decided claim. 38 C.F.R. § 3.156(c)(3). Service connection may be established for disability resulting from personal injury or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A three-element test must be satisfied in order to establish entitlement to service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran filed an initial claim for service connection for an enlarged heart in September 1992, less than one month after separation from service. His claim was denied in a June 1994 rating decision. Only limited service treatment records were available at the time of the June 1994 rating decision. Specifically, the Veteran's March 1992 separation exam revealed a possibly enlarged right atrium on chest X-ray. However, echocardiogram and clinical evaluation of the heart were normal. The chest X-ray report itself includes an impression of enlargement of the cardiac silhouette with prominence of the right cardiac margin highly suspicious for enlargement of the right atrium. Correlation with echocardiography was suggested. Blood pressure on separation examination was 136/88. The physician noted "rule out" for right atrial enlargement but echocardiogram and bubble study were normal. The Veteran denied any heart trouble in his Report of Medical History at the time of his March 1992 separation examination. An April 1992 cardiology consultation request reflects that the Veteran was noted to have increased flow in the right atrium on an April 1992 echocardiogram. A contrast echocardiogram with subcostal view to rule out atrial septal defect was requested. This consultation request reflects that, in May 1992, the Veteran had a normal bubble study with normal subcostal views and no evidence of an atrial septal defect. The RO denied service connection in the June 1994 rating decision because, while chest X-ray at discharge examination was suspicious for an enlarged atrium, subsequent study by cardiology showed no abnormality. Private treatment records dated from November 1997 to August 1998 make no mention of a heart disorder other than hypertension. On June 27, 2001, the Veteran presented to the emergency department at Maria Parham Hospital with a complaint of near syncope. He stated that he had a prior similar episode in the remote past. Electrocardiogram (EKG) revealed a normal sinus rhythm, tachycardia, and a left bundle branch block. The impression from a chest X-ray report was: Cardiomegaly with findings consistent with mild pulmonary edema. Alternatively, marked enlarged cardiac silhouette may represent pericardial effusion. Correlate clinically. The impression was near-syncope, vasovagal episode, cardiomegaly, and untreated hypertension. He returned in July 2001 (less than a week later) with complaints of shortness of breath, weakness, and chest pressure. EKG at that time revealed normal sinus rhythm, possible left atrial enlargement, and left bundle branch block. In a March 2003 rating decision, the RO found that new and material evidence had not been submitted sufficient to reopen the claim for service connection for an enlarged heart. An October 2003 VA chest X-ray was obtained because the Veteran had hypertension and diabetes and an unusual systolic murmur with a pericardial sound. The X-ray revealed mild cardiomegaly without stigmata of congestive heart failure or other acute cardiopulmonary disease. Due to the Veteran's young age, an echocardiogram was recommended to evaluate for possible valvular heart disease, developing cardiomyopathy, or possible anomalies of the cardiovascular system. The Veteran had an echocardiogram in October 2003 which revealed moderate left ventricle dysfunction with mild left ventricular hypertrophy, trivial mitral regurgitation, and no valvular stenosis. The left ventricle was mildly enlarged. The Veteran's VA primary care physician called him after this study to review his cardiac history and the Veteran reported one episode two years earlier when he passed out and went to Maria Parham Hospital. In November 2003, the Veteran presented to his VA primary care provider for evaluation of his cardiomyopathy. He reported that he had a bubble study in 1992 at discharge from service for an enlarged heart seen on X-ray and had noticed exercise intolerance at that time. He reported two fainting spells two years earlier, one while urinating and the other when getting up. He denied any prolonged illness during childhood, but reported that he was hospitalized for a week with a flu-like illness during service. The physician opined that the most likely etiology of the Veteran's cardiomyopathy was viral, commenting that, by history, the Veteran's enlarged heart was first noticed in 1992. The physician added that it was possible that the Veteran's cardiomyopathy was due to alcohol use, but that the Veteran only reported drinking during weekends while in service. In December 2003, the Veteran's cardiomyopathy was evaluated by a VA cardiologist. The Veteran reported being told that his heart was abnormal on separation from service. He added that he had been hospitalized for about a week for a flu-like illness in service. The Veteran gave a history of two syncopal episodes about two years earlier, for which he went to Maria Parham Hospital. The assessment was cardiomyopathy and the cardiologist stated that there were several possible causes, including viral illness, alcohol abuse, and long-standing untreated hypertension, but that viral cardiomyopathy was most likely. In July 2004, the Veteran submitted additional service treatment records in support of his claim for service connection. These records show that the Veteran was hospitalized for four days for viral pharyngitis in service. Additional service treatment records were obtained from the National Personnel Records Center (NPRC) in May 2005. The additional service treatment records associated with the claims file since the June 1994 rating decision reveal blood pressure readings ranging from 100/60 to 135/79. The Veteran was afforded a VA heart examination in August 2004. He gave a history of intermittent variable elevations of blood pressure in service, although the examiner commented that the Veteran's blood pressure was 136/88 on separation examination and no mention was made of hypertension or heart disease. The Veteran reported that he had an enlarged heart silhouette on chest X-ray on separation examination in March 1992, which prompted a cardiology evaluation and echocardiogram. It was noted that this echocardiogram suggested a possible right atrial enlargement, but it was not documented as a certain diagnosis in the claims file. The examiner added that the echocardiogram done in April 1992 was a limited study and the part that was done was essentially normal. The Veteran also reported that he had been hospitalized in service for a viral syndrome. He reported that, after 1989, he received no medication or treatment until 1997 when he saw a physician who put him on a water pill and cholesterol medication, although he was not having symptoms at that time. He added that he next presented for treatment at the Durham VAMC in 2001. The examiner acknowledged the December 2003 VA cardiologist's opinion that the Veteran's cardiomyopathy was most likely viral, but opined that this was purely conjectural. The VA examiner's diagnosis was cardiomyopathy thought to be secondary to viral etiology. The examiner stated that he could not connect the cardiomyopathy to the abnormal in-service chest X-ray or the diagnosis of viral pharyngitis without resorting to speculation. During a February 2005 videoconference hearing regarding his request to reopen the claim for service connection for an enlarged heart, the Veteran discussed having an enlarged heart on separation examination, and that he was referred to cardiology where he had a bubble study. He reported that the study showed that his heart was enlarged, but that flow was normal. He testified that he first started having problems with his heart after separation from service when he had a fainting spell at some point around 2000 or 2001. The Veteran underwent another VA heart examination in September 2006. The examiner noted that the March 1992 chest X-ray revealed right atrial enlargement and follow-up echocardiogram from May 1992 showed normal findings. The examiner also noted the January 1989 hospitalization for viral illness/pharyngitis. The Veteran reported that he presented to Maria Parham Hospital approximately four to five years earlier after experiencing syncopal episodes. The assessment following examination was cardiomyopathy, and the examiner opined that there were several possible causes for the Veteran's cardiomyopathy, including a viral illness, alcohol abuse, and long-standing untreated hypertension. He opined that viral cardiomyopathy was most likely, as previously stated by the cardiologist in December 2003, citing to medical literature identifying the history of viral illness as an etiology for cardiomyopathy. The September 2006 examiner was subsequently asked to provide an addendum as to whether the Veteran's enlarged heart is due to service. In his February 2007 addendum he stated that, given the Veteran's reported history, review of the claims file, and from the time course and given the Veteran's age, "there is no clinical means to establish that his cardiomyopathy was caused by his prior viral illness. There is no compelling evidence or scientific means to establish the relationship. The issue cannot be resolved without resort to mere speculation." The AMC then obtained another medical opinion in September 2007. The September 2007 VA examiner noted a history of cardiomyopathy with an official diagnosis in 2001. She acknowledged the in-service chest X-ray and echocardiogram, but noted that the echocardiogram was a limited study for an atrial septal defect which did not evaluate the Veteran's enlargement adequately and he was never told to have his enlargement monitored. Confusingly, the examiner stated that an EKG on March 20, 1972 revealed a large QRS complex, suggesting an electrical delay also suggesting a heart condition (perhaps a bundle branch block). [No EKG dated in March 1972 or in service is of record, and the Veteran reported in a November 2004 statement that the Army did not run an EKG on him.] She stated that, at the least, a repeat EKG and blood pressure monitoring should have been recommended to the Veteran on discharge from service. The Veteran reported to the September 2007 VA examiner that he had passed out twice at home and his wife insisted that he seek care at Maria Parham Hospital, where evaluation revealed an enlarged heart and he was referred to the VAMC. The examiner noted that the Veteran's October 2003 echocardiogram showed an ejection fraction of only 30 percent, but the Veteran was still asymptomatic for symptoms of cardiomyopathy in 2003 other than the syncopal episode in 2001. She added that the Veteran was probably experiencing dyspnea on exertion but was unaware it was an issue even in 2003 except that he had been diagnosed with cardiomyopathy and knew that his heart was not working as it should. The Veteran gave a history of being treated at Maria Parham Hospital for syncopal episodes in 2000 and 2001; being treated for syncope and sent home after the first episode and having cardiomyopathy found and being referred to the VAMC after the second episode. The examiner stated that there was a history of trauma to the heart, specifically, possible viral trauma. She commented that EKG on exit showed a widened QRS, which was at least likely to suggest an enlarged heart (which was not confirmed until a 2003 echocardiogram). She commented that a change of healthcare providers led to further evaluation and the Veteran was beginning to complain of more overt symptoms of cardiomyopathy. The examiner discussed the Veteran's service treatment records, noting the findings on chest X-ray in March 1992, with the recommendation for correlation with echocardiography. She observed that the Veteran had mild increased flow in the right atrium on echocardiogram on April 14, 1992, with a request for a contrast echocardiogram and subcostal view. She emphasized that this report was not in the claims file and, if it were, it would help to clarify the Veteran's condition. She stated that she had been unable to determine why a bubble study had been performed, and it was only with close attention that she found notice of the first echocardiogram, performed in April 1992. She added that the bubble study, which was normal, was performed on April 20, 1992. [However, from the Board's review, it appears that the bubble study was requested on April 20, 1992, but performed in May 1992.] The VA examiner's diagnosis was cardiomyopathy with delayed diagnosis. She opined that, while the Veteran may have had early cardiomyopathy (which was a likely reality in light of his relative youth and hypertensive history) she had no conclusive evidence that he developed cardiomyopathy secondary to his military service, whether related to a viral etiology or hypertensive issue. She added that the in-service chest X-ray and echocardiogram and his report of intermittent hypertension (with a borderline reading at discharge) made this a reasonable scenario. She commented that she was very surprised at the lack of documentation of a cardiac evaluation (to include history, physical examination, and EKG) which would have been the expected standard of care in a case of questionable heart enlargement, yet there was not even any documentation for recommendations to the Veteran, such as routine monitoring with primary care. The examiner added that the Veteran's later history, exams, EKGs, and echocardiogram suggested that his present cardiomyopathy could have been hypertensive or viral in etiology and may have started while in the military, but this onset was inconclusive as a full evaluation did not occur until early 2000. She concluded by stating that, due to a lack of records, she would have to speculate to the origin of the cardiomyopathy and its onset. Based on the evidence of record, in the September 2007 rating decision, the AMC granted service connection for cardiomyopathy, claimed as an enlarged heart, and assigned an initial 60 percent rating, effective October 17, 2002, the date of the Veteran's request to reopen his claim for service connection. The grant of service connection was based in part on the service treatment records reflecting elevated and normal blood pressure readings and a diagnosis of a viral syndrome. The AMC resolved reasonable doubt in the Veteran's favor and granted service connection, stating, "Based on the evidence of record, the statement by the examiners, to include the lack of evidence due to military medical members not performing standard evaluations when required, the service evidence that there was a possible enlargement of the heart, a definite diagnosis of a viral syndrome, and erratic blood pressure readings which were also not followed up on with evaluations, all of which were subsequently confirmed in 1997 and 2000, post service discharge in 1992 there is a reasonable doubt in existence because of a balance of both positive and negative evidence." The Veteran was afforded a VA heart examination in March 2009 in conjunction with a claim for an increased rating. The claims file was not requested, although medical records were reviewed. The examination report indicates that the Veteran's cardiomyopathy had a date of onset in 2000. The circumstances and initial manifestation of the condition was described as the Veteran being admitted to the Durham VAMC for syncope and an irregular heartbeat was identified. In May 2012 a VA physician, Board certified in internal medicine and cardiology, reviewed the Veteran's complete claims file and noted that the Veteran had a blood pressure reading of 135/79 in January 1989 during an emergency room visit for a fever of 102.8/possible viral pharyngitis, with normal blood pressure readings on subsequent days. The examiner commented that the Veteran's March 1992 separation examination did not note an enlarged heart, but the heart was specifically described as "normal" on examination. The examiner included the findings from the March 1992 chest X-ray, including enlargement of the cardiac silhouette highly suspicious for enlargement of the right atrium. He noted that correlation with echocardiography was suggested and an echocardiogram performed on April 14, 1992 indicated increased flow to the right atrium and a follow-up study was requested. The VA examiner commented that the report of the April 14, 1992 echocardiogram was not in the claims file, but that it was referenced on the follow-up echocardiogram request, and was reported as "normal" by the physician performing the separation examination. The VA examiner included the findings from the May 1992 echocardiogram, requested in light of the April 14, 1992 study, specifically, a normal bubble study and subcostal views with no evidence of atrial septal defect. The VA examiner responded to the request for an opinion as to whether the Veteran's elevated blood pressures in June 1988 and June 1989 and/or his June 1989 case of viral pharyngitis caused his cardiomyopathy. He stated that the Veteran did not have viral pharyngitis in June 1989, but was treated for viral pharyngitis in January 1989. He added that the only blood pressure reading that was elevated was the January 15, 1989 blood pressure reading of 135/79, in the setting of an acute febrile illness, which would not constitute a diagnosis of hypertension. The examiner observed that the Veteran's blood pressure readings returned to much lower levels the following day, after his fever lessened. He opined that a single elevated blood pressure would not constitute a cause of cardiomyopathy, and the Veteran's echocardiogram performed at discharge, in follow-up of the prominence of the right cardiac margin highly suspicious for enlargement of the right atrium as seen on chest X-ray, did not find any cardiomyopathy. The examiner noted that the full echocardiogram performed on April 14, 1992 revealed increased right atrial flow but the subsequent bubble study and subcostal view echocardiogram performed in May 1992 was normal. The examiner stated that there was no indication by review of the Veteran's echocardiogram results that he had any echocardiographic features which would be necessary to have a diagnosis of cardiomyopathy. In providing a rationale for his opinion, the examiner stated that there was no ventricular hypertrophy, ventrical chamber dilatation, or ventricular dysfunction noted on echocardiogram at discharge. Rather, echocardiogram was described as normal on discharge examination and the echocardiogram report from May 1992 was normal (i.e., no cardiomyopathy was found). The examiner included the definition of cardiomyopathy according to the American Heart Association, that cardiomyopathies are a heterogeneous group of diseases of the myocardium associated with mechanical and/or electrical dysfunction that usually (but not invariably) exhibit inappropriate ventricular hypertrophy or dilatation and are due to a variety of causes that frequently are genetic. The examiner concluded by stating that no cardiomyopathy was seen on review of echocardiogram results from April and May 1992. Considering the evidence of record in light of the law, the Board finds that an effective date of June 27, 2001, and no earlier, for the grant of service connection for cardiomyopathy is warranted. The Veteran has asserted that he is entitled to an effective date of September 1, 1992 for the grant of service connection for cardiomyopathy, as that is when he filed his original claim for service connection for an enlarged heart. The Veteran did file an original claim for service connection for an enlarged heart on September 1, 1992. This claim was denied in the June 1994 rating decision. Although notified of the June 1994 rating decision by letter in June 1994, the Veteran did not initiate an appeal; hence, that decision became final. See 38 U.S.C.A. § 7105(b); 38 C.F.R. §§ 3.104, 20.302, 20.1103. The law provides that generally, when a claim has been denied, as in the case of the June 1994 denial here, new and material evidence is required to reopen the claim. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). However, in this case, the AMC later determined, based in part on additional service treatment records which existed but had not been considered at the time of the June 1994 decision, that the Veteran's cardiomyopathy is related to service, including his in-service viral pharyngitis. The governing regulation makes clear that, in a case such as this, where the grant of service connection was based on additional service records which were in existence but not of record at the time of the prior denial, the grant of service connection should be effective on the date entitlement arose or on the date VA received the previously decided claim, whichever is later. 38 C.F.R. § 3.156(c). Thus, because the claim was filed within one year of separation from service, the proper effective date for the grant of service connection is the day after separation from service or the date entitlement arose. See 38 C.F.R. § 3.400(b)(2)(i). However, if the Veteran filed his September 1992 claim for service connection before he actually had the disability of cardiomyopathy, the effective date for the grant of service connection can be no earlier than the date the disability first manifested. See McGrath v. Gober, 14 Vet. App. 28, 35 (2000). After careful review of the evidence of record, the Board finds that the evidence indicates that the Veteran's cardiomyopathy was first manifested on June 27, 2001. Despite the finding of a possibly enlarged right atrium on chest X-ray obtained in conjunction with the Veteran's March 1992 separation examination, follow-up echocardiogram and clinical evaluation of the heart were each normal. Although the Veteran was noted to have increased flow in the right atrium on an April 1992 echocardiogram, the May 1992 echocardiogram revealed a normal bubble study, normal subcostal views, and no evidence of an atrial septal defect. The evidence does not demonstrate that the Veteran had cardiomyopathy at the time of separation from service. Significantly, the May 2012 VA examiner, a cardiologist, reviewed all the evidence of record, including specifically reviewing and discussing the service treatment records (including the March 1992 chest X-ray and April and May 1992 echocardiograms), and clearly stated that there was no indication by review of the Veteran's echocardiogram results that he had any echocardiographic features which would be necessary to have a diagnosis of cardiomyopathy. He concluded by clearly stating that no cardiomyopathy was seen on review of echocardiogram results from April and May 1992. The May 2012 VA examiner's opinion as to the matter of whether the Veteran had cardiomyopathy at separation from service is highly probative - it is factually informed, medically qualified, and fully explained. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri, 4 Vet. App. at 470- 71 (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). Significantly, this VA examiner rendered his opinion after review of the claims file, summarized pertinent in-service findings, and provided a rationale for his opinion, specifically, there was no ventricular hypertrophy, ventrical chamber dilatation, or ventricular dysfunction noted on echocardiogram at discharge; rather, echocardiogram was described as normal on discharge examination and the echocardiogram report from May 1992 was normal (i.e., no cardiomyopathy was found). The first evidence indicating cardiomyopathy after separation from service is dated on June 27, 2001, when the Veteran presented to Maria Parham Hospital with a complaint of near syncope. X-ray at that time revealed cardiomegaly. Subsequently, the October 2003 echocardiogram revealed moderate left ventricle dysfunction with mild left ventricular hypertrophy, trivial mitral regurgitation, and no valvular stenosis. The Board has considered the fact that the Veteran reported to the September 2007 VA examiner that he had been treated at Maria Parham Hospital for syncopal episodes in 2000 and 2001; however, the earliest treatment record from this facility is the June 27, 2001 record. The conclusion that the Veteran's cardiomyopathy first manifested on June 27, 2001, and not earlier, is supported by the Veteran's own report, made to his primary care physician in October 2003, that his cardiac history included one episode two years earlier when he passed out and went to Maria Parham Hospital as well as his report, during treatment the following month, that he had two fainting spells two years earlier, one while urinating and the other when getting up to go to the refrigerator. Significantly, the Veteran testified during the February 2005 hearing that he first started having problems with his heart after separation from service when he had a fainting spell while using the bathroom around 2000 or 2001, consistent with his presentation for treatment on June 27, 2001. He also stated during his September 2006 VA examination that he did not "think much" of his heart condition until he presented to Maria Parham Hospital approximately four to five years earlier after experiencing syncopal episodes. The finding that the Veteran's cardiomyopathy did not manifest prior to June 27, 2001 is also supported by the Veteran's report, on VA examination in August 2004, that he received no medication or treatment after 1989 until 1997 when he saw a physician who put him on a water pill and cholesterol medication, and he next presented for treatment at the Durham VAMC in 2001. [However, as discussed above, other evidence of record indicates that the Veteran did not receive treatment at the Durham VAMC until September 2002.] As the Veteran's current cardiomyopathy was not manifested in service, based on the results of echocardiograms performed at that time, and the first post-service evidence relating to the current cardiomyopathy is the June 27, 2001 private treatment record, the Board finds that the earliest effective date available for the award of service connection for this disability is June 27, 2001, the date the condition first manifested. In reaching the decision that the Veteran's cardiomyopathy first manifested on June 27, 2001, the Board has considered the September 2007 VA examiner's diagnosis of cardiomyopathy with delayed diagnosis and her opinion that the Veteran may have had early cardiomyopathy and that his cardiomyopathy may have started while in the military, but that such onset was inconclusive as a full evaluation did not occur until early 2000. Significantly, the examiner concluded her opinion by stating that, due to a lack of records, she would have to speculate as to the origin of the cardiomyopathy and its onset. The Court has held that an examiner's conclusion that a diagnosis or etiology opinion is not possible without resort to speculation may be relied upon as long as well-supported by the facts and data of the case. See Jones v. Shinseki, 23 Vet. App. 382 (2010). The September 2007 VA examiner did provide discussion regarding the basis of her opinion; however, the Board finds the May 2012 VA examiner's opinion, which is not speculative, but rather clearly states that the Veteran did not have cardiomyopathy on his echocardiograms at separation from service, and is also supported by a rationale, to be more probative of the question of whether the Veteran's current cardiomyopathy was first manifested in service. See Hayes, 5 Vet. App. at 69-70. See also Guerrieri, 4 Vet. App. at 470- 71. Regarding the September 2007 VA examiner's reference to a full evaluation in early 2000, no such evaluation is of record and, as previously discussed, the Veteran has reported a history of first experiencing problems in 2001, consistent with his June 2001 presentation at Maria Parham Hospital. The September 2007 VA examiner did note elsewhere in the examination report that the Veteran had a history of cardiomyopathy with an official diagnosis in 2001. While the March 2009 VA examination report indicates that the Veteran's cardiomyopathy had a date of onset in 2000, there is no explanation for this statement, thus, is not probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (noting that most of the probative value of a medical opinion comes from its reasoning); Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (holding that "the mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor's opinion"). The Board has also considered the fact that a December 2008 VA nephrology note includes on the Veteran's problem list that he had dilated cardiomyopathy, presumed viral in 1991-2. A primary care note from the same day includes on the Veteran's problem list cardiomyopathy with an onset date in 1992, apparently added to the problem list by the Veteran's primary care provider in September 2008 on the date of his heart surgery. A treatment note from this primary care provider on this date is not included in the VA treatment records currently associated with the claims file. However, the mere inclusion of an onset date in 1992 for cardiomyopathy in the Veteran's problem list, without a rationale for the conclusion that the current cardiomyopathy had its onset at that time, is not probative. The courts have repeated ruled that medical evidence must be evaluated for both factual bases and their sources of information. See Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 125. The primary care provider's September 2008 notation of an onset of cardiomyopathy in 1992 is clearly based on the Veteran's reported history, as the November 2003 record of treatment with this physician includes the Veteran's report that, in 1992, at discharge from service, he had a bubble study for an enlarged heart seen on X-ray and the physician stated in his assessment that, by history, the Veteran had an enlarged heart first noticed in 1992. Notably, the computerized problem list included in that treatment record includes cardiomyopathy with an onset date in 2003, as indicated by the same primary care provider on October 24, 2003, the date of an echocardiogram revealing left ventricular ejection fraction of 30 percent. Even assuming that there is a September 2008 treatment record in which the Veteran's primary care provider did give a rationale for assigning such an onset date, there is no indication that this physician would have reviewed the entire claims file prior to rendering such opinion. The Veteran did testify during the February 2005 hearing that he showed his physician the service treatment records he had obtained regarding his in-service treatment for a viral illness; however, there is no indication that his primary care physician reviewed the remainder of the claims file. A review of the claims file is not a mandatory prerequisite for providing an adequate opinion; however, the physician must be fully informed of the pertinent factual premises (i.e., medical history) of the case. See Nieves-Rodriguez, 22 Vet. App. at 304. The Board finds that claims file review is relevant in this case, where the evaluation of the Veteran's heart condition from March to May 1992 is relevant as to whether or not he had cardiomyopathy at that time and where the Veteran has, as discussed above, reported that he first experienced heart problems after service around 2001. Further, any outstanding September 2008 treatment record from the Veteran's primary care provider could not change the results of the in-service chest X-ray and echocardiograms performed in 1992. The May 2012 VA examiner, who is board certified in cardiology, reviewed these pertinent tests and definitively stated that there was no indication by review of the Veteran's echocardiogram results that he had any echocardiographic features which would be necessary to have a diagnosis of cardiomyopathy. Therefore, to the extent that the Veteran's VA primary care provider has opined that the Veteran's cardiomyopathy had its onset in 1992, the Board finds more probative the May 2012 VA examiner's opinion, that no cardiomyopathy was seen on review of echocardiogram results from April and May 1992, and therefore, the Veteran did not have cardiomyopathy at that time. See Hayes, 5 Vet. App. at 69-70. See also Guerrieri, 4 Vet. App. at 470- 71. The weight of the competent evidence indicates that the Veteran's cardiomyopathy was first manifested on June 27, 2001, and not before. Based on this finding, an effective date of June 27, 2001 is warranted; however, as the effective date for the grant of service connection cannot be earlier than the date entitlement arose, no earlier effective date can be assigned. See 38 C.F.R. § 3.156(c). The Board has resolved reasonable doubt in the Veteran's favor in determining that an effective date of June 27, 2001 for the grant of service connection for cardiomyopathy is warranted, but finds that the preponderance of the evidence is against assignment of an earlier effective date. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER An effective date of June 27, 2001 for the grant of service connection for cardiomyopathy is granted. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs