Citation Nr: 1323462 Decision Date: 07/23/13 Archive Date: 08/01/13 DOCKET NO. 05-00 578 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to service connection for a genitourinary or prostate disorder, including enuresis, benign prostatic hypertrophy, nocturia, and urinary incontinence. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Bruce, Counsel INTRODUCTION The Veteran served on active duty from December 1975 to March 1976. This appeal to the Board of Veterans' Appeals (Board/BVA) is from June and November 2004 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In March 2007, the Board reopened the Veteran's previously denied claim of entitlement to service connection for enuresis, and then remanded this claim to the RO via the Appeals Management Center (AMC) for further development before readjudicating this claim on its underlying merits. The Board also remanded the remaining claims for an initial compensable rating for pseudofolliculitis barbae, for service connection for a psychiatric disorder, including depressive disorder, an adjustment reaction, and mixed emotional features, and for service connection for residuals of an excised lipoma of the right shoulder. The Board again remanded these claims in December 2008 for compliance with the prior remand directives, include obtaining the Veteran's Social Security Administration (SSA) records. In a December 2010 decision since issued, the Board denied the claim for service connection for residuals of an excised lipoma of the right shoulder. However, the Board again remanded the remaining claims for service connection for a urinary or prostate disability, including enuresis, benign prostatic hypertrophy, nocturia, and urinary incontinence, for an acquired psychiatric disorder, including depressive disorder, an adjustment reaction, and mixed emotional features, and for an initial compensable rating for the already service-connected pseudofolliculitis barbae. The Board subsequently, however, in a September 2011 decision, denied the claims for service connection for an acquired psychiatric disorder and for an initial, compensable, rating for the psuedofolliculitis barbae. Whereas the Board, instead, yet again remanded this remaining claim for service connection for a genitourinary or prostate disability, including enuresis, benign prostatic hypertrophy, nocturia, and urinary incontinence, for still further development and consideration. The Board again remanded this remaining claim in May 2012 for even further development, which since has been completed, so it is again before the Board. FINDING OF FACT There is competent and credible evidence indicating the Veteran's urinary incontinence or enuresis is at least partly related to his active duty service. CONCLUSION OF LAW Resolving all reasonable doubt in his favor, his urinary incontinence or enuresis was incurred in service. 38 U.S.C.A. §§ 1131, 1111, 1153, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist a claimant 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). But, here, given the favorable disposition of this claim, there is no need to discuss whether there has been compliance with these duty-to-notify-and-assist obligations. This is because even were the Board to assume for the sake of argument there has not been, this still would be inconsequential and therefore at most amount to nonprejudicial, i.e., harmless error. 38 C.F.R. § 20.1102. See also Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Analysis Service connection is granted if the evidence shows a current disability resulted from an injury or a disease that was incurred or aggravated during active military service in the line of duty. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for a disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). So establishing entitlement to direct service connection generally requires: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a nexus or link between the injury or disease in service and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002). See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999). If chronicity (permanency) of disease or injury in service is not shown, or legitimately questionable, then a showing of continuity of symptomatology following service is required to support the claim. 38 C.F.R. § 3.303(b). Under § 3.303(b), an alternative method of establishing the second and third Shedden elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); 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. see Hickson, 12 Vet. App. At 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection). In-service notation of a condition does not require medical evidence where the condition is of a type as to which a lay person's observation is competent. However, although prong (3) does not require medical nexus evidence, because it would not necessarily follow that there is a relationship between any present disability and the continuity of symptomatology demonstrated, medical evidence is required to demonstrate such a relationship unless such a relationship is one as to which a lay person's observation is competent. A recent decision of the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court) clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Court explicitly rejected the argument that a dictionary definition of "chronic" should be used instead, noting that continuity of symptomatology in § 3.303(b) had no other intent than to afford an alternative route to service connection for specific chronic diseases. Id. Notably, incontinence or enuresis is not a chronic disease per se listed in § 3.309(a), as such, not the type of condition that is subject to this continuity of symptomatology exception to the pleading requirements. Medical evidence is often, though not always, required to associate the claimed condition with service or a service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998); McQueen v. West, 13 Vet. App. 237 (1999) The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine whether the evidence is also "credible", or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007) (Observing that once evidence is determined to be competent, the Board additionally must determine whether the evidence also is credible). Only if evidence is both compete and credible does it ultimately have probative value. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"")). See also Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when 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); (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. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As held in Davidson, section 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. See also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ([T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence such as actual treatment records). 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). In ascertaining the competency of lay evidence, lay evidence has been found to be competent with regards to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Conversely, laypersons also have been found not to be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger VA's duty to seek a medical opinion on the issue). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value in relation to the other relevant evidence. Baldwin v. West, 13 Vet. App. 1, 8 (1999). In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza at 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons or bases for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). To this end, 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), citing its decision in Madden, the Federal Circuit Court recognized that that Board had inherent fact-finding ability. Id., at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the lower Veterans 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). See, too, Macarubbo v. Gober, 10 Vet. App. 388 (1997) (similarly holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). Every Veteran shall be taken to have been in sound condition when examined, accepted and enrolled in service, except for defects, diseases, or infirmities noted at the time of entrance, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto. See 38 U.S.C.A. § 1111 (West 2002). According to 38 C.F.R. § 3.304(b) (2012), the term "noted" denotes only such conditions that are recorded in examination reports. The existence of conditions prior to service reported by the Veteran as medical history does not constitute a notation of such conditions, but will be considered together with all other material evidence in determining the question of when a disease or disability began. See 38 C.F.R. § 3.304(b)(1) (2012). Determinations of whether a condition existed prior to service should be "based on thorough analysis of the evidentiary showing and careful correlation of all material facts, with due regard to ... manifestations, clinical course, and character of the particular injury or disease or residuals thereof." Id. Furthermore, a preexisting disease will be presumed to have been aggravated by military service when there is an increase in disability during such service, unless there is a specific finding that the increase is due to the natural progress of the disease. See 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306(a) (2012). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b) (2012); Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition itself, as contrasted with mere symptoms, has worsened. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The law further provides that the burden to show no aggravation of a preexisting disease or disorder during service is an onerous one that lies with the government. See Cotant v. Principi, 17 Vet. App. 116, 131 (2003); Kinnaman v. Principi, 4 Vet. App. 20, 27 (1993). Importantly, VA's Office of the General Counsel determined that VA must show by clear and unmistakable evidence (CUE) that there is a preexisting disease or disorder and that it was not aggravated during service. See VAOPGCPREC 3-03 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. Id. The Board must follow the precedent opinions of the General Counsel. 38 U.S.C.A. § 7104(c). Also pertinent is the decision of the Federal Circuit Court in Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004), issued on June 1, 2004, which summarized the effect of 38 U.S.C.A. § 1111 on claims for service-connected disability. In this regard Wagner stated when no preexisting condition is noted upon entry into service, the Veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any "increase in disability [was] due to the natural progress of the preexisting condition." 38 U.S.C.A. § 1153. If this burden is met, then the Veteran is not entitled to service-connected benefits. However, if the government fails to rebut the presumption of soundness under section 1111, the Veteran's claim is one for service connection. This means that no deduction for the degree of disability existing at the time of entrance will be made if a rating is awarded. See 38 C.F.R. § 3.322. See Wagner, 370 F. 3d at 1096. On the other hand, if a preexisting disorder is noted upon entry into service, the Veteran cannot bring a claim for service connection for that disorder, only instead a claim for service-connected aggravation of that disorder. In that case, however, section 1153 applies and the burden falls on him to establish aggravation. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If the presumption of aggravation under section 1153 arises, the burden shifts to the government to show a lack of aggravation by establishing "that the increase in disability is due to the natural progress of the disease." 38 U.S.C.A. § 1153; see also 38 C.F.R. § 3.306; Jensen, 19 F.3d at 1417. In deciding claims, it is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, this doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists that does not satisfactorily prove or disprove the claim. Reasonable doubt is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Turning now to the facts and circumstances of this particular case at hand. The Veteran's November 1975 service entrance examination did not note that he had any urinary incontinence or enuresis diagnoses or issues. Therefore, it must be presumed that he did not have these conditions when entering service. As for whether they clearly and unmistakably existed before his service, January 1976 service treatment records (STRs) indicate that he had had enuresis since age eleven, according to him. He acknowledged having no control over his urination, but also said the problem had become worse while serving in the military. The examiner explained that the etiology of the Veteran's enuresis was unknown and recommended psychiatric counseling. The Veteran resultantly was placed in a program to try and help him deal with his enuresis, but his problem was not corrected by the program, rather, persisted. He ultimately was found unsuitable for active duty in a February 1976 psychiatric evaluation as a result of both his enuresis and defective attitude. A February 1976 Aptitude Board Report concluded his condition had existed prior to his entry into Naval service and that it had not been aggravated by his service. He consequently was discharged from service in March 1976, so the following month. He had a VA compensation examination years later, in June 2008. The examiner observed the Veteran had obstructive symptoms of nocturia, frequency, urgency, and urgency incontinence. The examiner further noted the Veteran stated these symptoms did not exist prior to his military service and were not worsened beyond natural progression of prostatic disease. Ultimately, though, the examiner determined there was no correlation between the Veteran's time in service and symptoms beyond a natural progression of prostatic disease. Because the opinion of that June 2008 VA examiner was incomplete and had used an incorrect legal standard, in the Board's December 2010 remand another VA compensation examination and opinion were requested concerning whether there was the required clear and unmistakable evidence that the Veteran had a pre-existing genitourinary or prostate disability that was not aggravated during or by his active duty service. In the report of the January 2011 VA examination, the examiner opined that the Veteran's active duty service did not aggravate his urinary symptoms and did not cause any urological problems beyond natural progression. His symptoms of frequency and urgency incontinence would have occurred as a natural progression, according to this examiner. Still, in light of this additional VA examiner's response, and to avoid the potential application of an improper standard according to the law, the Board believed that further supplemental comment was needed applying the correct aggravation standard since clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that the "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than that of "clear and unmistakable evidence."). It is an "onerous" evidentiary standard, requiring that the pre-existence of a condition and the non-aggravation result be "undebatable." Cotant v. Principi, 17 Vet. App. 116, 131 (2003), citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993). The Board accordingly again remanded this claim in September 2011 for this additional development and consideration. The VA compensation examiner that had performed the January 2011 VA examination, and who previously had commented on his findings, provided this additionally requested comment in December 2011 as an ADDENDUM to that earlier evaluation. He wrote: After reviewing [the Veteran's] VA records and my statement, I do not belief [sic] there is clear and unmistakable evidence that his claimed disabilities of a urinary or prostate disability including enuresis, benign prostatic hypertrophy, nocturia, and urinary incontinence existed prior to his period of active military duty from December 1975 to March 1976, and further there is no clear and unmistakable evidence that these disabilities were not aggravated by his military service. Absent the required satisfaction of this two-pronged test, the presumption of soundness when entering service stands and the Board must next determine whether the Veteran's urinary incontinence or enuresis incepted during his military service or is otherwise related or attributable to his service. See Cotant, Wagner, supra. This as explained is because, if the government fails to rebut the presumption of soundness under 38 U.S.C.A. § 1111, the Veteran's claim is one for service connection, not instead premised on aggravation of a pre-existing condition. This means that no deduction for the degree of disability existing at the time of entrance will be made if a rating eventuality is awarded. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); see also 38 C.F.R. § 3.322. In this case, the Veteran contends that his urinary incontinence or enuresis is directly related to his service. Having determined that he was presumed sound when entering service, and after a careful review of the record, the Board also concludes there is competent and credible evidence of record establishing the required association between his incontinence or enuresis and his service. His claim of entitlement to service connection therefore must be granted, certainly when all reasonable doubt is resolved in his favor as § 3.102 requires. In this regard, an addendum opinion was requested in the Board's May 2012 remand to address whether the Veteran's incontinence or enuresis was related to his active duty service. An addendum opinion was provided by the examiner who had performed the January 2011 VA examination. This VA examiner opined, after reviewing the Veteran's claims file and in consideration of the presumption of soundness that "clear evidence of enuresis began in the military". An additional opinion was sought for clarification, and another VA examiner provided an additional addendum opinion in January 2013 noting that the previous examiner's rationale was that the enuresis was present in service and, as such, occurred in service according to the history and review of the records. This same examiner provided yet another addendum opinion in March 2013 stating that it was less than 50 percent probable that the Veteran's incontinence was incurred in the service, because reports from 1976 stated that he had incontinence prior to service and that it was not aggravated in service beyond its normal time. The Board realizes there have been several varying opinions concerning this claim, some favorable and others not. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive and providing reasons for rejecting any evidence favorable to the claimant. 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). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. The responsibility of weighing the probative value of evidence is especially difficult when, as here, opinions diverge so come to different conclusions. But it is entirely within the Board's province to give more probative weight to certain pieces of evidence than others, so long as the Board provides the required reasons or bases. See Schoolman v. West, 12 Vet. App. 307, 310-311 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). And, at the same time, the Board is mindful that it cannot make its own independent medical determination and there must be plausible reasons for favoring one medical opinion over another. Evans at 31; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). In weighing lay evidence, the Board must render a finding with regards to both competency and credibility. See Coburn v. Nicholson, 19 Vet.App. 427, 433 (2006). See also Dalton v. Nicholson, 21 Vet. App. 23 (2007). As the Court explained in Coburn, reliance on a Veteran's statements renders a medical report not credible only if the Board rejects the statements of the Veteran as lacking credibility. See, too, Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that it was based on history given by the Veteran). Generally, the degree of probative value that may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the Veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant however, and indeed what is most significant, is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually had examined the Veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim). So as the Court made clear in Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008), the probative value of a medical opinion comes from when there is factually accurate, fully articulated, and sound reasoning for the conclusion, not just from mere review of the claims file. 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"); Dennis v. Nicholson, 21 Vet. App. 18, 22 (2007) ("The Court has long held that merely listing evidence before stating a conclusion does not constitute an adequate statement of reasons and bases." (citing Abernathy v. Principi, 3 Vet. App. 461, 465 (1992)). The Board, then, may conversely reject a medical opinion that was based on an inaccurate factual premise. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). In this particular case at hand, there is no disputing the Veteran's STRs indicate he had ongoing problems with enuresis during his active duty service, indeed, so much so that he ultimately was determined unfit for further service. He stated in a January 1976 STR that he had had the same problem since he was eleven years old but that is was "becoming worse" during his service. While there is an Aptitude Board Report noting his condition pre-existed his entry into service and that it was not aggravated during or by his service beyond its natural progression, at least some of the other evidence in the file belies this point. The June 2008 and January 2011 VA examiners agreed that the Veteran's enuresis was not aggravated during or by his service beyond its natural progression, but this statement implies that his current incontinence issues were the same as those experienced in service and that they had progressed as they naturally would have. The December 2011 addendum opinion, however, determined there was no evidence that the Veteran's incontinence or enuresis was not clearly and unmistakably aggravated by his military service, so accepting that his enuresis may have been aggravated by his active duty service. While the question of whether his incontinence was aggravated by his service is not legally relevant with regards to the issue of his entitlement to direct service connection, that is, direct incurrence of this condition in service, the Board finds that noting that this disorder existed in service but was not aggravated serves to support the Veteran's claim that the disorder was related to his active duty service (especially since the presumption of soundness remains intact). Given this unrebutted presumption of soundness when entering service, the fact that the Veteran had this disorder in service - by all accounts, even according to those who concluded unfavorably - and that he continues to suffer from this same disorder tends to support the notion that his military service has something to do with this condition's continued existence. Certainly the evidence supporting this notion is just as probative as the evidence refuting it, and an "absolutely accurate" determination of etiology is not a condition precedent to granting service connection, nor is "definite" or "obvious" etiology. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). This need only be an "as likely as not" proposition, which in this instance it is. He therefore has established the required correlation between this condition and his military service so as to in turn warrant the granting of service connection. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). ORDER This claim of entitlement to service connection for incontinence or enuresis is granted. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs