Citation Nr: 1323662 Decision Date: 07/24/13 Archive Date: 08/01/13 DOCKET NO. 07-01 532 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to service connection for narrowing of arteries, to include as secondary to the service-connected diabetes mellitus, type II. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD S. Keyvan, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1966 to April 1970, and from December 1970 to May 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the May 2006 rating decision of the Jackson, Mississippi Regional Office (RO) of the Department of Veterans Affairs (VA), which denied the Veteran's claim for entitlement to service connection for narrowing of arteries. The Veteran perfected a timely appeal. The Veteran also testified at a RO hearing in March 2007; the transcript is of record. In a March 2011 decision, the Board denied entitlement to service connection for narrowing of arteries and entitlement to an increased rating for diabetes mellitus, type II. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court) the portion of the Board's decision that had denied service connection for narrowing of arteries, to include as secondary to a service-connected disability. In a March 2012 Order, the Court vacated that portion of the March 2011 Board decision and remanded the matter to the Board for development consistent with the parties' Joint Motion for Partial Remand (Joint Motion). In June 2012, the Board remanded the case for further development pursuant to the Court's Joint Motion. The Board specifically instructed the Agency of Original Jurisdiction (AOJ) to obtain the Veteran's outstanding VA treatment records from the VA Medical Center (VAMC) in Tuscaloosa, Alabama for the period from July 11, 2009, and to obtain private treatment records from various medical treatment facilities and providers. Copies of the more recent VA treatment records, as well as the specified private treatment records were secured and associated with the Veteran's claims file, as well as the Virtual VA Claims Processing system. The Veteran's claims file was thereafter returned to the Board for further review. In March 2013, the Board remanded the Veteran's claim requesting that the AOJ to schedule him for another VA examination, to determine the nature and etiology of any cardiac disability present. The examination was completed in April 2013, and a copy of the examination report and June 2013 addendum opinion have since been obtained and associated with the claims file. The AMC subsequently readjudicated the claim in the June 2013 Supplemental Statement of the case (SSOC). Thus, the AOJ has complied with all of the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). FINDING OF FACT A disability manifested by narrowing of arteries, or any cardiac disability, was not manifested during service or within the first post service year; is not related to the Veteran's active service, including his presumed exposure to herbicides; and is not proximately due to or aggravated by the service-connected diabetes mellitus, type II. CONCLUSION OF LAW The Veteran does not have a disability manifested by narrowing of the arteries that is the result of disease or injury incurred in or aggravated during active military service, or caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist At the outset, the Board will address the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), enacted in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)(2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). In this case, the Board finds that all notification and development action needed to arrive at a decision has been accomplished. In this respect, through a March 2006 notice letter, the Veteran received notice of the information and evidence needed to substantiate his claim. Thereafter, he was afforded the opportunity to respond. Hence, the Board finds that the Veteran has been afforded ample opportunity to submit information and/or evidence needed to substantiate his claim. The Board finds that the March 2006 notice letter satisfies the statutory and regulatory requirement that VA notify a claimant what evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). In the letter, the RO also notified the Veteran that VA was required to make reasonable efforts to obtain medical records, employment records, or records from other Federal agencies. The RO also requested that the Veteran identify any medical providers from whom he wanted the RO to obtain and consider evidence. Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See Pelegrini v. Principi, 18 Vet. App. 112, 121 (2004). See also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (to be codified at 38 C.F.R. § 3.159) (removing the prior requirement that VA specifically ask the claimant to provide any pertinent evidence in his possession). These requirements were met by the aforementioned March 2006 letter. The Veteran was also informed of the regulations underlying, as well as the evidence required to establish, secondary service connection in the March 2006 letter. In separate March 2006 correspondence, a letter was issued to the Veteran which notified him of what evidence is necessary to support a disability rating and effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 472 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The Board finds that the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of any notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Nothing about the evidence or any response to the RO's notification suggests that the case must be re-adjudicated ab initio to satisfy the notice requirements of the VCAA. There is no indication that any additional action is needed to comply with the duty to assist in connection with the claim on appeal. The Veteran's service treatment records as well as all identified and available private and VA treatment records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the service connection claim adjudicated herein. In accordance with the June 2012 Remand, the Appeals Management Center (AMC) obtained the Veteran's private treatment records from Baptist Medical Center South for the period from December 2005; and from Cardiology Associates of North Mississippi for the period from January 2006. The Veteran's updated VA treatment records have also been retrieved and scanned them into the Virtual VA claims processing system. Significantly, neither the Veteran, nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. The duty to assist also includes obtaining a medical examination/opinion when such is necessary to make a decision on the claim, as defined by law. A VA examination with respect to the issue on appeal was conducted in April 2013, and a VA addendum opinion was issued in June 2013. 38 C.F.R. § 3.159(c)(4). In addition, a Veterans Health Administration (VHA) medical expert opinion was obtained in September 2010 and the Veteran was given an opportunity to respond. The Board finds that collectively, these medical reports are adequate for purposes of rendering a decision in the instant appeal. 38 C.F.R. §4.2 (2012); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). They reflect that the physicians reviewed the Veteran's past medical history, his current complaints, conducted/reviewed necessary testing and examination findings, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Veteran and his representative have not contended otherwise. For this reason, the Board finds that no further efforts to provide the Veteran with a VA examination or to obtain a medical opinion are necessary. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome here, the Board finds that any such failure is harmless. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Analysis Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to establish direct service connection for a disorder, there must be (1) evidence of the current disability; (2) evidence of the in-service incurrence of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a). Subsection (a) also refers to "each disabling condition . . . for which [a veteran] seeks a service connection" and states that "[d]eterminations as to service connection will be based on review of the entire evidence of record." See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Certain chronic diseases, including arteriosclerosis, may be presumed to have been incurred during service if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307(a)(3); 3.309(a) (2012). Under section 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). For purposes of establishing service connection for a disability resulting from exposure to a herbicide agent, a veteran who, during active military, navel, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during service. 38 U.S.C.A. § 1116(f). Moreover, it is provided that the diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, with an exception not applicable to this case. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.308(a)(6)(ii). These diseases include chloracne or other acneform disease consistent with chloracne, Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 U.S.C.A. § 1116(a)(2); 38 C.F.R. §§ 3.307(a)(6), 3.309(e). As noted in the December 2001 rating action, the Veteran was treated at Tan Son Nhut Air Base in the Republic of Vietnam in 1969-1970; it is presumed that he was exposed to herbicides during his period of active service. 38 U.S.C.A. § 1116(f). As will be discussed in detail below, however, the preponderance of the evidence does not reflect that the Veteran has ischemic heart disease. Thus, service connection under the presumptive conditions is not warranted. The Veteran contends that his current heart problems arose as a result of his service-connected diabetes mellitus, type II. Initially, the Board notes that a cardiac disability was not shown during service, and the Veteran has not asserted that any such disability manifested during service. Review of the service treatment records reflect that the Veteran occasionally presented at the military clinic with complaints of chest pain. These records further reflect that the Veteran presented at his physician's office at the U.S. Air Force Medical Center Keesler at the Keesler Air Force Base, Mississippi, in March 1984 with complaints of atypical chest pain and chronic headaches. He relayed a recurring history of "chest pain syndrome that occurs with exertion, [and] is relieved by Nitroglycerin. . . ." He subsequently underwent a cardiac catheterization procedure, the results of which revealed a normal coronary anatomy with no signs of coronary vasospasm or fixed obstructive disease. The cardiologist recommended further work-up of the Veteran's chest pain syndrome, but noted that the coronary anatomy findings showed that the Veteran's chest pain syndrome was neither cardiac nor coronary occlusive in nature. The post-service record on appeal includes voluminous VA and private clinical records, dated from 1987 to 2013. In pertinent part, these records show that the Veteran presented at the Emergency Room at Cardiology Associates of North Mississippi PA-Columbus in May 2001 with complaints of chest pain. He underwent another cardiac catheterization procedure, as well as a selective coronary angiography and left ventriculogram. Findings from the coronary angiography revealed a 40 percent proximal stenoses in the left main artery and mild irregularities in the left anterior descending artery. The left circumflex artery also revealed mild wall irregularities while the right coronary artery was described as "large and dominant...[with] mild irregularities." The Veteran was assessed with moderate disease in the proximal portion of the left main artery of unknown hemodynamic significance. In a May 2001 letter, the Veteran's cardiologist, B.S., M.D., wrote that the "30-40 [percent] proximal left main stenosis" did not appear to be "hemodynamically significant" and results from the stress Cardiolite test were clear for any evidence of ischemia. The Veteran underwent another left heart catheterization procedure in July 2001, the findings of which revealed an estimated 20 percent stenosis in the left main artery, and minor irregularities in the left anterior descending artery and left circumflex artery. It was noted that the right coronary artery "was large and had no significant disease." Findings from the intracoronary ultrasound revealed the presence of "mild plaquing" in the left main artery, and the impression derived from the diagnostic tests was that of nonobstructive CAD. A subsequent left heart catheterization procedure, selective coronary angiography and left ventriculogram were performed in December 2001, the findings of which revealed minimal nonobstructive coronary artery disease, normal left ventricular systolic function and normal hemodynamics. A subsequent left heart catheterization procedure, selective coronary angiography and left ventriculogram were performed in December 2001, the findings of which revealed minimal nonobstructive coronary artery disease, normal left ventricular systolic function and normal hemodynamics. A December 2005 treatment report reflects that the Veteran presented at Baptist Medical Center South with complaints of sudden chest pain. According to the Veteran, he began to experience shortness of breath, pain and tightness in his chest during the afternoon while at rest. On a scale of one to ten (with one being the least level of pain and ten being the highest), he rated his pain level at an eight. Initially, the Veteran went to Maxwell Air Force Base Hospital where he reported his concerns of chest pain, and was provided with four doses of nitroglycerin. Despite the medication he received, he continued to experience chest pain and was subsequently brought to Baptist Medical Center South. The physician assessed the Veteran with unstable angina and referred him to a cardiologist. After his consultation with the cardiologist, the Veteran underwent a left heart catheterization, a coronary angiography, a left ventriculography, bilateral carotid angiograms, and a right iliac angiogram. Upon reviewing the diagnostic results, the physician observed no evidence of "extracranial carotid artery disease," but did make a notation of "[c]oronary spasm involving the distal left anterior descending, responded very well to intracoronary nitroglycerin." The Veteran presented at Cardiology Associates of North Mississippi in January 2006 with complaints of on-going chest pain, which he reported to experience one to two times a week. His cardiologist, J.F., M.D., noted that the Veteran had undergone five heart catheterizations, and results from the most recent one in December 2005 revealed no evidence of coronary artery disease. According to Dr. F., the Veteran was being treated with nitrates, and further cardiac testing was not necessary. In June 2010, the Board requested a medical advisory opinion from a cardiologist, and specifically asked the designated cardiologist to discuss whether the Veteran had a cardiac disability manifested by narrowing of the arteries and/or atherosclerosis, and if so, the likelihood that any cardiac disability manifested by narrowing of arteries and/or atherosclerosis, was either proximately due to, and/or aggravated by, the Veteran's service-connected diabetes mellitus, type II. In a September 2010 medical opinion, S.A., M.D., reviewed the claims file and determined that the Veteran did not suffer from significant coronary artery disease. In support of his conclusion, Dr. A. determined that the diagnosis of CAD had been applied "casually, without documentation and often based on hearsay." Based on his review of the diagnostic records, and the description of the catheterization reports, Dr. A. found that "the concept of coronary artery disease due to 'small vessel disease' was one that was reported to various physicians by the patient himself, and not necessary substantiated by definitive reports." Pursuant to the March 2013 remand, the Veteran underwent another VA examination in April 2013, at which time, the examiner reviewed the Veteran's claims file, to include the above-referenced catheterization reports, in detail, and noted that the Veteran's medical history reflected previous diagnoses of CAD and atypical chest pain. The examiner also reviewed the more recent treatment records generated at Cardiology Associates of North Mississippi, and noted that the Veteran underwent a nuclear perfusion imaging study in February 2011, the results of which revealed no evidence of myocardial infarction or stress inducted myocardial ischemia. She also noted that the Veteran underwent an EKG and a gated SPECT cardiac study in February 2011, the results of which were shown to be normal and reflective of normal left ventricular ejection fraction and normal wall motion, respectively. Based on the examiner's interpretation of these results, as well as her physical examination of the Veteran, it was determined that the Veteran did not have heart disease. According to the examiner, despite the fact that physicians over time have quoted heart disease and listed CAD on the Veteran's problem list, and notwithstanding the Veteran's reported claim that he has experienced heart disease based on the cardiac catheterization results, she was unable to "clearly and unmistakably" verify heart disease based on available test results and her review of the Veteran's claims file. The examiner noted that other than mere statements in the record taken from the Veteran's self-reported history there was no indication to support heart disease/small vessel disease. She further noted that the Veteran was not currently on any medication for heart disease, although he had been prescribed medication for chest pain, which the she felt was atypical chest pain based on the evidence of record. The examiner concluded that the an evaluation of the Veteran was negative for signs of heart disease. In a June 2013 addendum opinion, a VA physician reviewed the Veteran's claims file as well as the April 2013 examination report, and determined that the Veteran "[did] not presently have evidence of ischemic heart disease due to hemodynamically significant coronary artery disease/coronary atherosclerotic vessel disease." The VA physician noted that the Veteran's earliest heart catheterization for angina pectoris occurred in March 1984 "with an ejection fraction of 56 [percent] and [was] negative for significant coronary artery disease, such that [the] Veteran was discharged with diagnosis of non-cardiac origin chest pain." The VA physician also acknowledged that the Veteran underwent multiple heart catheterizations with coronary artery angiography beginning in May 2001, with the most recent one occurring in December 2005. It was further noted that diagnostic testing included the February 2011 nuclear stress test, the results of which were shown to be normal. Based on his review of medical records, although all of the Veteran's heart catheterizations with coronary artery angiography showed evidence of atherosclerotic coronary artery disease, the degree of stenosis was not assessed to be significant and left ventricular ejection fractions were shown to be in the normal range. According to the VA physician, it was difficult to argue that the Veteran's diabetes mellitus was the cause of his claimed cardiac disability, given that the Veteran's symptoms of chest pain, and evaluations for coronary artery disease began so far before the onset of his diabetes mellitus in 2001. Based on his training, as well as his review of pertinent medical literature, the VA physician noted that the Veteran's diabetes mellitus type II makes him at an increased risk that "atherosclerosis and occult macrovascular disease may follow an accelerated course," but at the present time, "based upon multiple invasive cardiac catheterizations with coronary artery angiography and a nuclear stress test...the Veteran does not have ischemic heart disease due to hemodynamically significant coronary artery disease/coronary atherosclerotic vessel disease." The VA physician concluded that it is less likely than not that the Veteran has any cardiac disability (ischemic heart disease due to hemodynamically significant coronary artery disease/coronary atherosclerotic vessel disease) that is proximately due to, or that has been permanently worsened, as a result of his service-connected diabetes mellitus type II. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for narrowing of the arteries. With regard to this claim, the Board notes that the existence of a current diagnosed disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. Here, the greater weight of the evidence points to the Veteran not having any form of heart disease. The Board notes that the more recent private treatment providers, the September 2010 VA physician, and the April 2013 and June 2013 VA examiners have not identified a current heart disability. Indeed, the more recent records issued at Cardiology Associates of North Mississippi, and dated from January 2006 to March 2011, reflect that the Veteran regularly underwent EKGs, all of which were shown to be normal and negative for ischemia. In a July 2007 treatment report, Dr. F. acknowledged Veteran was difficult to evaluate as he had "chronic atypical chest pain" and had undergone five catheterizations over the years, the findings of which have ranged from mild atherosclerotic plaquing, to normal coronaries to small vessel disease consistent with diabetes. Dr. F. further noted that ischemia had never been documented by noninvasive functional testing, and recommended functional testing of the Veteran's coronary circulation with an exercise Cardiolite study. An August 2007 treatment report reflects that the Veteran underwent a pharmacologic stress study and a resting/stress nuclear perfusion scan, the results of which were shown to be normal, with an unremarkable response to adenosine; no scintigraphic evidence of ischemia or infarction; and normal wall motion with an ejection fracture of 63 percent. Subsequent nuclear perfusion images were clear for evidence of a myocardial infarction or ongoing ischemia. Additionally, the Veteran underwent a computed tomography angiogram (CTA) of his heart at Baptist Memorial Hospital in August 2007, the findings of which revealed "some calcified plaque in the LAD [left anterior descending artery] beginning just distal to the origin of the first diagonal and proximal to the first septal perforator." According to the attending physician, J.H., M.D., "[t]his segment is degraded by motion, but...contrast flows around the calcification suggesting that there is not a significant lesion" and "the proximal coronary arteries otherwise appear unremarkable. . . ." In reaching his negative conclusion, Dr. A. (the September 2010 VHA physician) referenced these medical records and numerous treatment records within the claims file which were clear for clinical findings of coronary artery disease. The April 2013 VA examiner had an opportunity to evaluate the Veteran and review his claims file, to include the above-referenced catheterization reports and the more recent diagnostic test results, and still determined that clinical findings reflective of a cardiac disability were not shown. While the June 2013 VA physician noted that the Veteran's heart catheterizations with coronary artery angiography showed evidence of atherosclerotic coronary artery disease, he added that the left ventricular ejection fractions were in the normal range, and the degree of stenosis was not assessed to be significant, such that it could cause obstruction of blood flow sufficient to cause angina pectoris. Moreover, while the July 2001 and December 2001 left heart catheterization procedures revealed signs of nonobstructive coronary artery disease, the evidence must show that the Veteran has had the disability for which benefits are being claimed at some point during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (noting that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim). Indeed, the most recent catheterization report of record, dated in December 2005, is clear for evidence of extracranial carotid artery disease. The Board accepts the April 2013 VA examination report, in conjunction with the June 2013 medical opinion, as being the most probative medical evidence on the subject, as these opinions were based on a physical evaluation of the Veteran, as well as a thorough review of the entire record, and contain a detailed rationale for the medical conclusions based on sound medical principles. See Boggs v. West, 11 Vet. App. 334. As detailed, while records do reflect complaints and assessments of atypical chest pain for many years with multiple emergency and clinical visits, mere pain alone, without a diagnosed or identifiable underlying malady or condition, is not generally considered a disability and cannot substantiate a claim for service connection. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). The Board has also given consideration to the March 2008 and May 2008 VA examination reports. The probative value of a medical opinion, including, a private medical opinion, is generally based on the scope of the examination, as well as the relative merits of the expert's qualifications and analytical assessments. Guerrieri v. Brown, 4 Vet. App. 467 at 470-71 (1993). The adjudicator may favor one expert's opinion over another as long as an adequate statement of reasons and bases is given. Owens v. Brown, 7 Vet. App. 429 at 434 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The Court has held that claims file review, as it pertains to obtaining an overview of a claimant's medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further, a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2009). The March 2008 VA examination report was requested to assess the severity of the Veteran's service-connected diabetes mellitus, and to assess any related medical conditions. When asked whether the Veteran had cardiac symptoms related to his diabetes, the examiner answered in the affirmative and characterized these symptoms as "angina, shortness of breath, fatigue, peripheral edema, weakness and dizziness." When asked whether the Veteran had a cardiovascular disease, the examiner once again answered in the affirmative. In another part of the report, the boilerplate examination report requested "possible diabetes related condition" and the examiner stated "cardiac disease." According to the examiner, hypertension and coronary artery disease were potentially related conditions and although hypertension was diagnosed prior to the onset of diabetes, "it is a condition that is worsened or increased by the Veteran's [diabetes mellitus]." The examiner further stated that "[diabetes mellitus, type II] can worsen vascular disease and cause end organ damage, including the heart." At the May 2008 VA examination, the Veteran provided his medical history and reported a history of hypertensive heart disease, to include coronary artery disease and small vessel disease. On physical examination, the Veteran's cardiac and pulmonary examination findings were shown to be normal. Based on his discussion with, and physical evaluation of the Veteran, the examiner diagnosed the Veteran with CAD and small vessel disease Initially, the Board notes that while the VA examiner noted review of medical records, it does not appear that the examiner had access to the claims folder for either examination, as such had not been requested by the RO upon scheduling such examination. Thus, it is not clear which medical records were reviewed by the examiner, although the Board will assume that the examiner likely reviewed electronic medical records from the VA Medical Center. While a review of the claims file may not have been required, it is clear that in a case such as this, the VA examiner would likely have benefited from a review of the entirety of the VA and private medical records in formulating an opinion as to whether the Veteran has a cardiac disability. The Board places limited probative value on the VA examiner's opinion that the Veteran has a cardiac disability, specifically coronary artery disease, as such diagnosis was not based on any specific objective findings. In fact, the basis for this conclusion is unknown. Indeed, cardiovascular examinations were conducted at both examinations, however, the findings appeared to be normal and clear for signs of a cardiac disability. As such, the VA examiner's diagnosis of coronary artery disease does not appear to be based on independent findings using appropriate testing, but rather on unsubstantiated reports in the record. The source of a medical expert's information goes to the credibility of the medical evidence. A transcription of lay history unenhanced by any additional medical comment by the examiner does not constitute competent medical evidence. Moreover, a veteran's subjective complaint is not considered competent medical evidence. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). As such, these medical opinions are of little probative value because they are not predicated on an accurate and complete factual history. See Nieves-Rodriguez v. Peake. (It is what an examiner learns from the claims file for use in forming the expert opinion that matters. When the Board uses facts obtained from one opinion over another, it is incumbent upon the Board to point out those facts and explain why they were necessary or important in forming the appropriate medical judgment.) The Board has also given consideration to January 2008 correspondence from M.S., M.D., a specialist of endocrinology, diabetes, and metabolism. In the letter. Dr. S. noted that he had treated the Veteran for diabetes mellitus, type II, and its related complications and comorbidities since April 2005. According to Dr. S., after reviewing the Veteran's medical records dating back to that time and evaluating the Veteran, "[i]t is highly probable that all of the listed conditions are linked to his service-connected diabetes mellitus, type II. Such opinion, however, is entitled to no probative weight as Dr. S. did not clarify the 'listed conditions' that are being referenced nor did he provide a rationale for such opinion. An opinion that does not contain a rationale, i.e., the examiner merely states his conclusion, but does not explain how he reached this conclusion lacks probative value. See Prejean v. West, 13 Vet. Ap. 444, 448-49 (2000). Thus, such opinion cannot provide the basis for a finding that the Veteran has a narrowing of the arteries or any cardiac disability due to his diabetes mellitus, type II. To the extent that the March 2008 and May 2008 diagnoses of CAD and small vessel disease may have been reflective of a definite cardiac disability, the Board still concludes that the Veteran is not entitled to service connection for a cardiac disability manifested by narrowing of the arteries. As previously discussed above, the Board finds these opinions to be of limited probative value and insufficient to grant the Veteran's claim. Furthermore, in the September 2010 VHA opinion, Dr. A. wrote that even if a cardiac disability existed, he would conclude that it would not likely be attributable to the Veteran's service-connected diabetes since the initial angiographic findings occurred at or before the initial diagnosis of diabetes in 2001. According to Dr. A., "[a]though it is well established that, particularly in type 2 diabetes, target organ damage (particularly renal microvascular disease) can occasionally antecede the appearance or recognition of frank diabetes, this is probably due to low-grade vascular damage occurring during a prolonged period of impaired glucose tolerance or pre-diabetes. In this particular case, where even the patient's overt diabetes is not yet associated with evidence of retinal or renal microvascular damage, it would be untenable to argue that small vessel disease of the heart had its onset during a pre-diabetic phase." This opinion was reiterated in the June 2013 medical opinion. According to the June 2013 VA physician, with the Veteran's symptoms of chest pain, and evaluations for coronary artery disease beginning so far before the onset of his diabetes mellitus, it was difficult to find that his diabetes mellitus was the cause of his claimed cardiac disability. The Board has considered the Veteran's assertions that he has a cardiac disability manifested by narrowing of the arteries that is related to his service-connected diabetes. However, as a layperson, the Veteran is not competent to give a medical opinion on the diagnosis of this claimed disorder. He is competent to report on symptoms he experienced either during or following service, but not to say what any diagnosis is. Thus, while the Veteran is competent to report symptoms observable to a layperson, such as shortness of breath or chest pain, a diagnosis that is later confirmed by clinical findings, or a contemporary diagnosis, he is not competent to independently provide a medical diagnosis or opine as to the specific etiology of a condition. See Davidson v. Shinseki, 581 F.3d 1313 (2009). Further, the April 2013 and June 2013 VA examiners considered the Veteran's report of post-service symptoms in reaching their medical conclusions. Consequently, in this case, lay assertions of medical diagnosis or etiology cannot constitute evidence upon which to grant a claim for service connection. Lathan v. Brown, 7 Vet. App. 359, 365 (1995). Therefore, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for narrowing of arteries. See 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303. Because the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt provision does not apply. See Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, the Board concludes that service connection for narrowing of the arteries is not warranted. ORDER Entitlement to service connection for narrowing of the arteries is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs