Citation Nr: 1325327 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 07-07 057 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a left lung disorder, to include as secondary to service-connected history of rheumatic fever with myocarditis. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected history of rheumatic fever with myocarditis. 3. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected major depressive disorder. 4. Entitlement to service connection for a gastrointestinal disorder, including gastroesophageal reflux disease, to include as secondary to service-connected major depressive disorder. 5. Entitlement to an effective date prior to June 12, 2008 for a 100 percent rating for service-connected residuals of rheumatic fever with myocarditis, to include coronary artery disease, status post coronary artery bypass, status post AICD implantation with congestive heart failure. 6. Entitlement to an effective date prior to January 3, 2012, for special monthly compensation based on the need for aid and attendance. REPRESENTATION Appellant represented by: John S. Berry, attorney ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran served on active duty from January 1959 to March 1962. This matter comes before the Board of Veterans' Appeals (Board) on appeal from decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In October 2006, the RO granted the Veteran's claim for a compensable rating for his service-connected residuals, rheumatic fever, to the extent that it assigned a 60 percent rating, with an effective date of May 5, 2006. The Veteran filed a notice of disagreement as to the issue of entitlement to an earlier effective date for the 60 percent rating. In February 2007, the RO granted the earlier effective date claim, to the extent that it assigned an effective date of July 11, 2005 for the 60 percent rating. Since this grant did not constitute a full grant of the benefits sought, the earlier effective date issue remained in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). In January 2006 and October 2007, the RO denied claims for service connection for history of left lung granuloma with partial lobectomy, and hypertension. The Veteran appealed. In February 2010, the RO denied claims for service connection for erectile dysfunction, and "gastroesophageal reflux (GERD), to include acid reflux, hiatal hernia, and other intestinal problems." The Veteran appealed. In April 2010, the RO granted a 100 percent rating with an effective date of June 12, 2008, for the Veteran's service-connected heart problem, which it recharacterized as "residuals of rheumatic fever with myocarditis, to include coronary artery disease, status post coronary artery bypass, status post AICD implantation with congestive heart failure." In November 2010, the Board inter alia denied the claim for service connection for a gastrointestinal disorder, denied a rating in excess of 60 percent for history of rheumatic fever with myocarditis prior to June 12, 2008, and granted the claim for an earlier effective date for the 60 percent rating for history of rheumatic fever with myocarditis, to the extent that it assigned an effective date of May 29, 2005. The Board also remanded the claims for service connection for a left lung disorder, hypertension, and erectile dysfunction. The appellant appealed the Board's denials, to include the earlier effective date issue to the extent that it was denied, to the U.S. Court of Appeals for Veterans Claims (Court). In April 2011, while his case was pending at the Court, the VA's Office of General Counsel and appellant's representative filed a Joint Motion requesting that the Court vacate the Board's November 2010 decision with regard to the issues of entitlement to service connection for a gastrointestinal disorder, and entitlement to a rating in excess of 60 percent for history of rheumatic fever with myocarditis prior to June 12, 2008. That same month, the Court issued an Order vacating those November 2010 Board decisions. In January 2012, the Board remanded all of the claims for additional development. Apart from those claims, in September 2011, the RO granted special monthly compensation at the housebound rate. In July 2013, the Veteran's representative raised the issue of entitlement to an effective date prior to June 12, 2008, for special monthly compensation at the housebound rate. This issue has not been adjudicated by the RO, and is referred to the RO for appropriate action. The issue of entitlement to special monthly compensation based on the need for aid and attendance is addressed in the REMAND portion of the decision below and is REMANDED to the RO. FINDINGS OF FACT 1. The Veteran does not have a left lung disorder, hypertension, erectile dysfunction, or a gastrointestinal disability, that was caused his service, or that was caused or aggravated by a service-connected disability. 2. As of April 11, 2006, and no earlier, the Veteran's service-connected residuals of rheumatic fever with myocarditis, to include coronary artery disease, status post coronary artery bypass, status post AICD implantation with congestive heart failure, is shown to have been productive of chronic congestive heart failure. CONCLUSIONS OF LAW 1. A left lung disorder, hypertension, erectile dysfunction, and a gastrointestinal disability, were not caused by service, and were not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for an effective date of April 11, 2006, and no earlier, for a 100 percent rating for service-connected connected residuals of rheumatic fever with myocarditis, to include coronary artery disease, status post coronary artery bypass, status post AICD implantation with congestive heart failure, have been met. 38 U.S.C.A. §§ 5107, 5110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection The Veteran asserts that he is entitled to service connection for a left lung disorder, hypertension, erectile dysfunction, and a gastrointestinal disability. He argues that the claimed conditions should be service-connected because they were caused or aggravated by his service-connected residuals of rheumatic fever with myocarditis, to include coronary artery disease, status post coronary artery bypass, status post AICD implantation with congestive heart failure, and/or his service-connected major depression. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Service connection may also be granted for hypertension, when it is manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. Feb. 21, 2013) (holding that the term "chronic disease in 38 C.F.R. § 3.303(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). A grant of service connection under 38 C.F.R. § 3.303(b) does not require proof of the nexus element; it is presumed. Id. Service connection may be granted, on a secondary basis, for a disability, which is proximately due to, or the result of an established service-connected disorder. 38 C.F.R. § 3.310 (2012). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). Service connection is currently in effect for residuals of rheumatic fever with myocarditis, to include coronary artery disease, status post coronary artery bypass, status post AICD implantation with congestive heart failure," major depressive disorder, bilateral hearing loss, and bilateral tinnitus. Special monthly compensation has been awarded under 38 U.S.C.A. § 1114(s) (at the housebound rate. Finally, a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is in effect as of November 7, 2006. The Veteran's service treatment reports show that in 1959, he was hospitalized for complaints of bilateral foot pain. He was noted to have a spiking low-grade fever over the course of two weeks, and to have inflammation and pain in his feet during this time. An EKG (electrocardiogram) revealed T-wave abnormalities suggestive of diffuse myocardial involvement. In April 1959, he was afforded a diagnosis of rheumatic fever, active, with heart involvement (myocarditis). A July 1959 report shows that service physicians concluded that the Veteran had an episode of rheumatic fever with heart involvement as manifested by EKG changes. It was further concluded that he had recovered from his initial, acute disease without sequalae. He was discharged to duty. The Veteran's separation examination report, dated in March 1962, shows that his lungs, heart, abdomen and viscera, and G-U (genitourinary) system, were clinically evaluated as normal, and that his blood pressure was 142/82. The report notes a history of rheumatic fever with heart involvement (myocarditis), April 1959 NCD (not considered disabling), and that the Veteran was overweight NCD. As for the post-service medical evidence, it consists of VA and non-VA reports, dated between 1967 and 2012. This evidence shows that in October 1967, the Veteran was hospitalized for complaints of joint symptoms, and difficulty breathing. The report states that two days after being admitted, the Veteran was given a pass for the weekend, from which he failed to return. The diagnoses were obesity, and possible rheumatoid arthritis, early. There is no subsequently-dated relevant medical evidence for the next 37 years, until 2005. Specifically, private treatment reports show that in 2005, the Veteran was noted to have a 2.5 centimeter (cm.) nodule in the mid-left lung suggestive of a long tumor, slight cardiomegaly and arteriosclerosis of the aorta. He was noted to have a history of hypertension, and NIDDM (non-insulin-dependent diabetes mellitus). The clinical impressions were hypertension, CHF (congestive heart failure), pedal edema, and NIDDM. A VA examination report, dated in December 2005, notes that the Veteran reported a history of diabetes dating to the mid-1980s, and a history of hypertension dating to the 1980s. He complained of occasional dyspnea on exertion which he stated was related to "fluid build-up." He reported using Lasix since 2005, and that he had rare episodes of anterior chest pain lasting a few seconds. He stated that he was unaware of a diagnosis of CHF, but that a doctor "in recent years" had told him that he had an enlarged heart. The diagnosis notes rheumatic fever with myocarditis, 1959, per chart review, and that the Veteran has no clinical symptoms of active congestive heart failure, but he has a soft murmur on auscultation, and that he was to follow up with his local physician regarding his atypical chest pain, which was longstanding and stable. An associated VA echocardiogram, dated in December 2005, notes diastolic dysfunction, systolic dysfunction, pulmonary artery hypertension, and mild to moderate valve abnormalities. The examiner stated, "The question as to whether these findings are related to rheumatic fever or myocarditis is a matter of conjecture in my medical opinion." Private treatment reports from M.L.D., M.D., dated in April 2006, note that the Veteran has uncontrolled high blood pressure, overall decreased LV (left ventricle) function (by echocardiogram), Dr. D states: He has severe pulmonary hypertension which most likely relates to his underlying lung problems, although I do not have any pulmonary function tests to indicate the degree of severity of this. The mild mitral insufficiency and aortic stenosis are likely not contributors to the pulmonary hypertension. Both of these findings could relate to his prior history of rheumatic fever, although additional contributor to his mitral insufficiency is his systemic hypertension. He certainly does have diastolic dysfunction, which also indicates component of hypertensive heart disease. A private examination report, apparently taken in association with employment as a commercial driver, dated in November 2006, shows that the Veteran denied having shortness of breath, lung disease, or digestive problems. He indicated that he had a history of heart surgery and high blood pressure. The report notes a history of an ejection fraction of 30 to 35 percent in September 2006, and a history of bypass surgery in August 2006. On examination, no relevant abnormalities were noted. Blood pressure was 180/86. Reports from physicians associated with the University of Missouri's University Hospital (UMUH), include a report, dated in December 2006, which notes moderate to severe pulmonary hypertension that is most likely related to coronary artery disease with poor left ventricular function. The report further states that pulmonary hypertension was also possibly related to sleep apnea. A January 2007 report shows that the Veteran underwent of left muscle-sparing thoracotomy, evacuation of left pleural effusion, decortication of left lung, wedge resection of left upper lobe mass, multiple level intercostal nerve blocks. Another report notes pulmonary hypertension secondary to cardiovascular etiology, and a lung mass. A chest X-ray report contains an impression noting unimproved left lung volume loss, opacity, scarring, effusion, and pleural thickening. A November 2007 report notes a history of smoking from one to five packs of cigarettes per day, ending in 1966. A March 2008 report from Pershing Hospital notes that the Veteran has a history that included chronic obstructive pulmonary disease (COPD), and pneumonia. The dismissal diagnoses included acute bronchitis with recent history of pneumonia, uncontrolled NIDDM, lung cancer per history with left pulmonectomy, COPD, and hypertension. A VA mental disorders examination report, dated in August 2009, shows that, in response to the question of whether the Veteran had erectile dysfunction related to his service-connected depression, the health care provider stated, "This provider cannot provide an opinion without resorting to speculation. Specifically, as erectile dysfunction is a medical condition that can have several etiologies, the claim would need to be examined by a medical physician to provide a reliable opinion." A VA genitourinary examination report, dated in August 2009, shows that the examiner stated that the Veteran's claims file was not available for review, but that the Veteran's VA records had been reviewed. The examiner noted a history of erectile dysfunction beginning in 2005, hypertension since the 1970s (with medication since about 1980), diabetes since 1984, hyperlipidemia, and obesity. The report also notes a history of depression that was diagnosed soon after heart surgery in 2006. The Veteran reported that following his lung surgery in January 2007, it was determined that he did not have lung cancer. The examiner concluded that the Veteran's erectile dysfunction is less likely as not (less than 50/50 probability) caused by or a result of his service-connected major depressive disorder. The examiner explained that the Veteran has had depression since his 2006 heart surgery, that his erectile dysfunction started in 2005, and that it did not worsen after the diagnosis of depression. The examiner further stated that while the Veteran may have had undiagnosed depression prior to 2006, he has had other very significant conditions that are well-known to cause erectile dysfunction for many years. These include hypertension for approximately 30 years before developing erectile dysfunction, and diabetes for over 20 years before the onset of erectile dysfunction. A September 2009 VA progress note contains an impression noting a history of a lung biopsy found to be granulomatous disease. Another report dated that same month shows complaints of dyspnea on exertion, and it contains a notation that the Veteran did not have GERD. An October 2009 addendum to an October 2008 VA heart examination report shows that the physician concluded that the Veteran's dyspnea was not related to cardiac disease. A December 2009 VA progress note shows treatment for complaints of dyspnea. A VA general medical examination report, dated in May 2011, shows that the Veteran reported a history of elevated blood pressure in 1972, diabetes mellitus in 1984, and COPD and emphysema dating to 2006. The diagnoses included COPD, emphysema, and hypertension. In August 2012, the Veteran was afforded VA heart, esophageal, and intestinal examinations. The examiner indicated that the Veteran's claims file had been reviewed, and provided the following comments, diagnoses, and etiological opinions: With regard to the claim for a left lung disorder, the diagnosis was pulmonary granuloma, status post excision. The examiner noted that the Veteran has longstanding dyspnea on exertion that is due to non-lung conditions according to his records and history. The Veteran's condition is less likely than not (less than 50 percent probability) incurred in or caused by service. The examiner explained: The Veteran's pulmonary granuloma was first detected on imaging as an incidental finding in the mid-2000s. A pulmonary granuloma such as the Veteran had is an indicator of a previous infectious process of the lungs. It is in no way associated with heart disease of any kind. Rather, it is caused by an inhaled organism usually many years prior although the exact timing is not possible to determine. There is no evidence regarding whether the granuloma was present before or during military service. All that is known based upon the history and a review of the records is that it occurred sometime in his life. It is known that he traveled through states in the southwest that are more likely as sites of exposure for the condition that caused the granuloma. It is much more likely that this was when he was exposed and developed the granuloma as compared to the three years he spent on active duty service. For these reasons, in my opinion it is less likely than not due to active duty service, and it is less likely than not aggravated by or due to his service-connected heart disability. With regard to the claim for hypertension, the diagnosis was hypertension. The examiner noted that the Veteran reported that he was diagnosed with hypertension in about 1971 or 1972 during a Department of Transportation physical, and that he has been taking medication for it ever since then. The report notes that no particular cause was found for his hypertension at the time and it was determined to be essential hypertension. It has been well-controlled in recent years and he has had to have his medication decreased due to the blood pressure being too low at times. The Veteran's condition is less likely than not (less than 50 percent probability) incurred in or caused by service. The examiner explained: There is no evidence in the service medical records that the Veteran had hypertension during military service. He was a truck driver after military service and his blood pressure was checked regularly at his periodic DOT physicals. It was not until 1971 or 1972 that he was found to have hypertension. There is no evidence of any condition during military service that would lead to hypertension 9-10 years later. The Veteran had common risk factors for developing hypertension including smoking at the time (although [he] quit several years later after 15 years of heavy smoking according to pulmonologist Dr. K's note of 12/11/06) and being overweight (the C-file records indicated a diagnosis of obesity in 1967). For these reasons, the Veteran's hypertension is less likely than not related to his active military service or to any incident therein. In response to the question of whether the Veteran's hypertension had been caused or aggravated by a service-connected disability, the examiner indicated that it had not. The examiner explained: The Veteran's hypertension has actually improved and has been easier to control in recent years. The natural progression of hypertension is that is worsens with aging. Since there has been no evidence of worsening of his hypertension condition, and it would naturally be expected to worsen over 40 years since it was diagnosed, it is less likely as not that it has been aggravated by any heart condition. The Veteran's heart condition is not one that would be expected to worsen hypertension. (if anything , the reverse is likely in that hypertension for 40 years typically aggravates most heart conditions). With regard to the claim for a gastrointestinal disorder, including GERD, the diagnosis was GERD. The examiner indicated that this condition was less likely as not (less than 50 percent probability) incurred in or caused by service, or proximately due to or the result of a service-connected condition. The examiner explained: The Veteran's gastrointestinal condition of gastroesophageal reflux is caused by reflux of acid and food into the esophagus. As described in Up to Date (12/8/11), "The integrity of the esophageal mucosa in normal individuals reflects the balance between injurious forces (acid reflux, potency of refluxate) and defensive forces (esophageal acid clearance, mucosal integrity). This balance is impaired in patients who develop GERD. The three dominant pathophysiological mechanisms causing gastroesophageal junction incompetence are: transient lower esophageal sphincter relaxations, a hypotensive lower esophageal sphincter, and anatomic disruption of the gastroesophageal junction, often associated with a hiatal hernia." In the case of this Veteran, his GERD is easily and fully controlled with mediation that he takes (pantoprazole). The timing of the onset of his GERD in recent years would rule against it being due to his active military service of over 50 years ago, or service-connected depression, which began years after the onset of his GERD symptoms. Also, upon review of his C-file and VA records, there does not appear to be any correlation between the severity of his GERD symptoms (currently improved) and his service-connected conditions. For these reasons, in my opinion his GERD is less likely than not due to his military service or any service-connected disability. In response to the question of whether the Veteran's GERD had been caused or aggravated by a service-connected disability, the examiner indicated that it had not. The examiner explained: Upon review of his C-file and VA records, there does not appear to be any correlation between the severity of his GERD symptoms and his service-connected conditions including depression. This is confirmed on history given by the Veteran at this time. His symptoms are fully controlled with medication currently, and his condition is of a mild enough severity that there would be no other indicator of severity other than symptoms that are present. There is no test that would be indicated at this time to try to determine severity other than symptoms of reflux, which are absent as long as he takes his prescribed medication. The Board finds that the claims must be denied. As an initial matter, the Veteran has not asserted that he has any of the claimed conditions due to his service; he argues that service connection is warranted because these conditions were caused or aggravated by service-connected disability. However, the Board will also examine the possibility of service connection on a direct and presumptive basis. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004) (when determining service connection, all theories of entitlement, direct and secondary, must be considered). Here, the Veteran was not shown to have any of the claimed conditions during service. Rather, the earliest post-service medical evidence containing any relevant findings is dated in 2005. This is about 42 years after separation from active duty service. There is also no evidence to show that the Veteran has been experiencing chronic symptoms of hypertension since service, to include no evidence to show that hypertension was manifest to a compensable degree within one year of separation from service. By the Veteran's own reports, his hypertension was diagnosed in 1971 or 1972, approximately 10 years after separation from active duty service. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of his low back condition). Furthermore, the preponderance of the competent evidence of record shows that the Veteran's GERD, respiratory disorder, and hypertension are not related to his service. The August 2012 VA examination reports found that the Veteran's GERD, respiratory disorder, and hypertension, were not related to his service. These opinions are considered to be highly probative, as they are shown to have been based on a thorough review of the Veteran's claims files, and they are accompanied by sufficient explanations. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion); Neives- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board has also considered the April 2006 opinion of Dr. M.L.D., who asserts that the Veteran has a lung disorder, and (read broadly), hypertension, that are related to his service. However, this opinion warrants low probative value, as it is not shown to have been based on a review of the Veteran's claims files, or any other detailed and reliable medical history, and as the examiner's conclusion were not accompanied by any sort of explanation, or citation to clinical findings during service. See Prejean, 13 Vet. App. at 448-9; Neives- Rodriguez, 22 Vet. App. at 304. With regard to the Veteran's claim for erectile dysfunction, this is first shown no earlier than 2005. Such a finding is over 40 years after separation from service. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000); Mense v. Derwinski, 1 Vet. App. 354 (1991). The August 2009 VA examiner noted that the Veteran has other "very significant conditions" for many years that are well-known to cause erectile dysfunction, to include hypertension for approximately 30 years before developing erectile dysfunction, and diabetes for over 20 years before the onset of erectile dysfunction. Given the foregoing, service connection on the theories of direct onset (38 C.F.R. § 3.303(a)), a presumption of service connection (38 C.F.R. § 3.307, 3.309), or continuity of symptomatology (38 C.F.R. § 3.303(b)) is not warranted. However, the Veteran's primary argument is that service connection is warranted for the claimed conditions because they were either caused or aggravated by service-connected disability. See 38 C.F.R. § 3.310. The Board finds that service connection is not warranted on this basis. Specifically, the the August 2009 and August 2012 VA examination reports weigh heavily against the claims. As previously stated, these opinions are considered to be highly probative, as they are shown to have been based on a review of the Veteran's claims files, and they are accompanied by sufficient explanations. See Prejean, 13 Vet. App. at 448-9; Neives- Rodriguez, 22 Vet. App. at 304. Board has also considered the April 2006 opinion of Dr. M.L.D. with respect to this aspect of that claim. That report states that some of the findings noted therein "could relate to his prior history of rheumatic fever." Such a statement is speculative in nature and warrants low probative weight. See Bloom v. West, 12 Vet. App. 185, 186-87 (1999); McLendon v. Nicholson, 20 Vet.App. 79, 85 (2006). Furthermore, the Board notes that the April 2006 opinion as a whole warrants low probative weight for the reasons already discussed above. As a final matter, to the extent that the August 2009 VA mental health examiner was unable to state whether the Veteran's erectile dysfunction was related to his service-connected depression, current regulations provide that service connection may not be based on a resort to speculation, or even a remote possibility. See 38 C.F.R. § 3.102 (2012); see also Jones v. Shinseki, 23 Vet. App. 382 (2010); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Goss v. Brown, 9 Vet. App. 109, 114 (1996). Under certain circumstance, lay evidence can be competent and sufficient to establish the etiology or diagnosis of a condition. Davidson v. Shinseki, 581 F.3d 1313 (2009). However, such etiological evidence is only competent to the extent that it relies on observable symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). In this case, the Veteran is competent to report that he experiences various respiratory, gastrointestinal, and erectile dysfunction symptoms. However, the Veteran is not competent to report that any such reported symptoms are related to a specific diagnosis, or that any such diagnosis is itself related to service or to a service-connected disability. The Veteran is not shown to possess the requisite medical training, expertise, or credentials needed to render diagnoses of these disorders, or competent opinions as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating any of the disorders in issue. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Given the foregoing, the Board finds that the service treatment reports, and the post-service medical evidence, outweigh the Veteran's contentions to the effect that the claimed conditions were caused or aggravated by service or a service-connected disability. Accordingly, the Board finds that the preponderance of the evidence is against the claims, and that the claims must be denied. As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). II. Earlier Effective Date, 100 Percent Rating, Rheumatic Fever with Myocarditis The Veteran argues that he is entitled to an effective date prior to June 12, 2008, for his 100 percent rating for service-connected residuals of rheumatic fever with myocarditis, to include coronary artery disease, status post coronary artery bypass, status post AICD implantation with congestive heart failure (hereinafter "heart disability"). The administrative history of this claim shows that in November 1966, the RO granted service connection for history of rheumatic fever with myocarditis, and assigned a noncompensable rating, effective August 16, 1966. There was no appeal, and the RO's decision became final. See 38 U.S.C.A. § 7105(c) (West 2002 & Supp. 2012). In July 2005, the Veteran submitted medical evidence that was construed as an informal claim for a compensable rating. In January 2006, the RO denied the claim. However, in October 2006, following the receipt of additional relevant medical evidence, the RO assigned a 60 percent rating, with an effective date of May 5, 2006. The Veteran appealed the issue of entitlement to a rating in excess of 60 percent, and the issue of entitlement to an earlier effective date for the 60 percent rating. In February 2007, the RO assigned an effective date of July 11, 2005 for the 60 percent rating. In April 2010, the RO recharacterized the Veteran's service-connected disability to include coronary artery disease, status post-coronary artery bypass, status post-implantation of an automatic implanted cardioverter/defibrillator (AICD), with congestive heart failure, and assigned a 100 percent rating, effective from June 12, 2008. The Board notes that the Joint Motion states that, to the extent that the Board denied an effective date prior to May 29, 2005 for the 60 percent rating for the Veteran's service-connected heart disability, the issue of entitlement to an earlier effective date for the 60 percent rating is no longer on appeal. The issue which remains on appeal is whether the Veteran is entitled to an effective date prior to June 12, 2008 for his 100 percent rating for his service-connected heart disability. In this regard, the Joint Motion states that the Board had omitted the disjunctive connector "or" when it listed the criteria at DC 7000, and, in essence, it notes that the criteria for a 100 percent rating are met under DC 7000 inter alia when chronic congestive heart failure is shown. The assignment of effective dates of awards is generally governed by 38 U.S.C.A. § 5110 and 38 C.F.R. § 3.400. In general, the effective date of an award of increased compensation shall be the earliest as of which it is factually ascertainable that an increase in disability had occurred, if an application is received within one year from such date; otherwise, the effective date will be the date of VA receipt of the claim for increase, or date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a), (b)(2) (West 2002 & Supp. 2012); 38 C.F.R. § 3.400(o) (2012); Harper v. Brown, 10 Vet. App. 125 (1997). For an increase in disability compensation, the effective date will be the earliest date as of which it is factually ascertainable that an increase in disability had occurred if claim is received within one year from such date otherwise, date of receipt of claim. 38 U.S.C.A. § 5110; 38 C.F.R. § 3.400(o)(2); see also Hazan v. Gober, 10 Vet. App. 511 (1997); Servello v. Derwinski, 3 Vet. App. 196 (1992). The effective date of an award of disability compensation based on a claim to reopen after a final disallowance shall be the date of receipt of the new claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a) ; 38 C.F.R. § 3.400(q)(ii), (r) (2012). The Court has held that the term "new claim," as it appears in 38 C.F.R. § 3.400(q)(1)(ii), means a claim to reopen a previously and finally denied claim. Sears v. Principi, 16 Vet. App. 244 (2002). A claim is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). Under 38 C.F.R. § 4.88b, Diagnostic Code (DC) 6309 (rheumatic fever), a 100 percent rating is warranted during active disease. Thereafter, the disability is to be rated based on residuals under the appropriate system. Under 38 C.F.R. § 4.104, Diagnostic Code 7000, a 60 percent rating is warranted where there has been more than one episode of congestive heart failure in the past year, where a workload of greater than three METs but not greater than five METs results in dyspnea, fatigue, angina, dizziness, or syncope, or where there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure, or where a workload of three METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or where there is left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. 1 MET is the energy cost of standing quietly at rest, and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). Diagnostic Code 7011 is used for evaluating ventricular arrhythmias and provides that a 100 percent rating is to be assigned for an indefinite period from the date of hospitalization for initial evaluation and medical treatment for sustained ventricular arrhythmias, or following ventricular aneurysmectomy, or following insertion of an automatic implantable cardioverter/defibrillator (AICD). The record shows that the rating for the Veteran's heart disability was increased to 100 percent, effective June 12, 2008, based primarily on the implantation of an AICD. The Board finds that the criteria for a 100 percent rating are met as of April 11, 2006. Specifically, a report from Dr. D, dated April 24, 2006, notes that the Veteran was examined on April 11, 2006. See also November 2006 UMUH report (noting that the Veteran was first seen on April 11, 2006). Dr. D notes that the Veteran has New York Heart Association functional class II-III symptoms of heart failure with exertional limiting shortness of breath, that he can walk less than one block, and that he has symptoms at rest when recumbent at night. The causes of his shortness of breath were noted to be mulitfactorial, and to include heart failure, systemic and pulmonary hypertension, and lung disease. The Board finds that this report, when considered in conjunction with the subsequently dated medical evidence discussed infra, is sufficient to show that the Veteran had chronic congestive heart failure as of the date of his initial examination with Dr. D (i.e., April 11, 2006). The subsequently dated medical evidence includes the following: A UMUH report, dated in November 2006, indicates that it was signed by Dr. D. The report notes that the Veteran was initially seen on April 11, 2006. The report notes an ejection fraction of between 35 and 40 percent in December 2005, and an ejection fraction of between 20 and 25 percent prior to three-vessel coronary artery bypass grafting surgery (in August 2006). In this regard, the Board notes that under DC 7000, a 100 percent rating is warranted for symptoms that include an ejection fraction of less than 30 percent. An examination undertaken in association with a commercial driver's license, dated in November 2006, notes a history of bypass surgery in August 2006, and that the Veteran's ejection fraction was between 30 and 35 percent in September 2006. The claims files include several reports from a private physician, J.J., M.D., dated between 2006 and 2007. These reports contain a number of notations of congestive heart failure, dated as early as January 2007. A July 2007 report notes an ejection fraction of between 30 to 35 percent, and a history of congestive heart failure. Thereafter, several reports note a history of congestive heart failure. See, reports, dated in September, October, and November of 2007. Records from the Pershing Hospital, dated between March and May of 2008, show that in March 2008, the Veteran was hospitalized for acute respiratory distress. A report dated upon admission (i.e., on March 21, 2008) contains diagnoses that included "acute congestive heart failure." The discharge summary (March 25, 2008) contains diagnoses that include congestive heart failure. The summary states that important diagnostic findings prior to admission included a chest X-ray which "revealed the presence of congestive heart failure." Another March 2008 report contains final diagnoses that included mild congestive heart failure with elevated PRO BNP without atrial insufficiency. A May 2008 report indicates treatment for cough and chest discomfort. An associated X-ray report contains diagnoses of fluid retention, and congestive heart failure. A UMUH report, dated in May 2008, notes an estimated ejection fraction between 30 and 35 percent. A VA examination report, dated in November 2008, notes a history of chronic congestive heart failure with onset in 2006. The diagnosis was congestive heart failure. In summary, the medical evidence shows that since April 11, 2006, the Veteran has repeatedly been noted to have congestive heart failure. While the reports do not characterize the Veteran's congestive heart failure as either "acute" or "chronic" (with one exception, as noted) and while some of the findings of congestive heart failure could be read to merely indicate that they are "by history" only, there are no clear findings on this point. In September 2006, July 2007, and May 2008, the Veteran was also shown to have an ejection fraction on the borderline (30 percent) of that required for a 100 percent rating; it appears that he had an ejection fraction of between 20 and 25 percent in August 2006. These reports indicate that the Veteran's ejection fraction was at, or on the borderline of, the criteria for a 100 percent rating under DC 7000 (there are also a number of reports indicating an ejection fraction over 30 percent during the time period in issue). The records from Pershing Hospital, dated in 2008, clearly indicate the current presence of congestive heart failure. While these records show that there was a notation upon admission that the Veteran's congestive heart failure was "acute," the discharge diagnoses do not repeat that characterization. The Board therefore finds that, affording the Veteran the benefit of all doubt, that the evidence is at least in equipoise, and that the criteria for a 100 percent rating are shown to have been met as of April 11, 2006. An effective date for the 100 percent rating is not warranted prior to April 11, 2006. In this regard, private treatment reports, dated in May and July of 2005, show that the Veteran had pedal edema and shortness of breath. A May 2005 pathology report notes a BNP (nucleo-peptide) value that was consistent with the diagnosis of congestive heart failure "in the appropriate clinical setting." The July 2005 report contains impressions that include congestive heart failure, with no other relevant findings. A VA examination report, dated in December 2005, contains diagnoses that include "Veteran has no clinical signs of active congestive heart failure but he has a soft murmur on auscultation. Echocardiogram is pending. Defer opinion until further exam." An associated echocardiogram report notes an ejection fraction of between 35 and 40 percent; the report does not note congestive heart failure. In summary, although there was a May 2005 BNP (nucleo-peptide) value that was "consistent with" a diagnosis of congestive heart failure "in the appropriate clinical setting," this was equivocal in its terms and there is no contemporaneous diagnosis of congestive heart failure. Although congestive heart failure was noted in July 2005, this report did not characterize the Veteran's congestive heart failure as chronic, and it is unaccompanied by any findings to show that this condition was chronic. Seven months later, in December 2005, a VA examiner stated that the Veteran has no clinical signs of active congestive heart failure. An associated echocardiogram did not note the presence of congestive heart failure. To the extent that the November 2008 VA examination report indicates a history of chronic congestive heart failure since "2006," the examiner did not state what month, and the aforementioned evidence does not warrant the conclusion that the Veteran had chronic congestive heart failure prior to April 11, 2006. In summary, there are no findings dated prior to April 11, 2006 which show that the criteria for a 100 percent rating have been met, to include on the basis of METS findings (of 3 METS or less), or ejection fraction findings (of 30 percent or less). DC 7000. Given the foregoing, the Board finds that the evidence is insufficient to show that the criteria for a 100 percent rating are met prior to April 11, 2006. The Board notes that the criteria for a 100 percent rating under DC 7000 and DC 7005 (arteriosclerotic heart disease/coronary artery disease) are identical, so an earlier effective date is not warranted under DC 7005. In light of the June 2008 implantation of an AICD, the Board has also considered rating the disability under DC 7016 (sustained ventricular arrhythmias). However, prior to April 11, 2006, the evidence does not show that the Veteran was hospitalized for evaluation and treatment of sustained ventricular arrhythmias, as required for a 100 percent rating under this diagnostic code. Therefore, an earlier effective date is not warranted on this basis. To the extent that the claim has been denied, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). III. Veterans Claims Assistance Act of 2000 (VCAA) The Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The notification obligation in this case was accomplished by way of letters from the RO to the Veteran dated in February and March of 2007, September 2008, and April 2009. Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). With regard to the claim for an earlier effective date for a 100 percent rating for the Veteran's service-connected heart disability, to the extent that this claim has been denied, the VCAA is no longer applicable. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 491 (2006). The RO also provided assistance to the appellant as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. It appears that all known and available service and post-service records relevant to the issues on appeal have been obtained and are associated with the Veteran's claims file. The RO has obtained the Veteran's VA and non-VA medical records. The Veteran has been afforded VA examinations, and etiological opinions have been obtained, except as discussed infra. Simply stated, the Board finds that the post-service medical record provides evidence against these claims. With regard to the claim for service connection for erectile dysfunction, an etiological opinion has been obtained only with regard to the possibility of causation or aggravation by the Veteran's service-connected major depressive disorder. Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in disability compensation (service connection) claims, the VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifest during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. The Veteran's service treatment reports do not show any relevant complaints, treatment, or findings, providing evidence against the claim on a direct basis. Therefore, the second McLendon criterion is not satisfied. With regard to the third McLendon criterion, the earliest medical evidence of erectile dysfunction is dated no earlier than 2005. There is no competent evidence to show that erectile dysfunction is related to service, which ended in 1962, or that it was caused or aggravated by a service-connected disability. Therefore, additional etiological opinions need not be obtained. McLendon; see also 38 C.F.R. § 3.159(c)(4) (2012); Wells v. Principi, 327 F. 3d 1339, 1341 (Fed. Cir. 2002). Finally, in January 2012, the Board remanded these claims. The Board directed that an attempt be made to obtain the Veteran's VA treatment records from the Columbia VAMC and the COPC in Kirksville dated from June 2010, as well as any other records of treatment identified by the Veteran. Records from the Columbia VAMC and the COPC in Kirksville, dated through May 2012, were subsequently obtained and have been associated with the Veteran's claims file. See Veteran's Virtual VA (VVA) file. The Board further directed that the Veteran be afforded examinations for his claims for service connection for a left lung disorder, hypertension, and a gastrointestinal disability, and that etiological opinions be obtained. In August 2012, this was done. With regard to the claim for service connection for erectile dysfunction, an August 2009 VA examiner concluded that this was not related to his service-connected major depression. The examiner further stated that the Veteran has other very significant conditions that are well-known to cause erectile dysfunction for many years, to include hypertension for approximately 30 years before developing erectile dysfunction, and diabetes for over 20 years before the onset of erectile dysfunction. Therefore, in its remand, the Board conditioned an examination for the Veteran's claim for erectile dysfunction upon a favorable etiological opinion for hypertension. However, the August 2012 etiological opinion as to hypertension was unfavorable. Given the foregoing, the Board finds that there has been substantial compliance with its remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with); 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 a veteran are to be avoided). Simply stated, the Board finds that the service and post-service medical record provides evidence against these claims. The Board concludes, therefore, that decisions on the merits at this time do not violate the VCAA, nor prejudice the appellant under Bernard v. Brown, 4 Vet. App. 384 (1993). Based on the foregoing, the Board finds that the Veteran has not been prejudiced by a failure of VA in its duty to assist, and that any violation of the duty to assist could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). ORDER Service connection for a left lung disorder, hypertension, erectile dysfunction, and a gastrointestinal disability, is denied. An effective date of April 11, 2006, and no earlier, for the 100 percent rating for service-connected residuals of rheumatic fever with myocarditis, to include coronary artery disease, status post coronary artery bypass, status post AICD implantation with congestive heart failure, is granted, subject to the laws and regulations governing the award of monetary benefits. REMAND In November 2012, the RO granted special monthly compensation based on the need for aid and attendance, with an effective date of January 3, 2012. See 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350(b). In July 2013, the Veteran's representative filed a timely notice of disagreement on the issue of entitlement to an effective date prior to January 3, 2012, for special monthly compensation based on the need for aid and attendance. See 38 C.F.R. §§ 20.201, 20.302 (2012). A statement of the case has not yet been issued as to this claim. Because a timely NOD was filed to the November 2012 rating decision, the RO must now provide the Veteran with a statement of the case on the issue of entitlement to an effective date prior to January 3, 2012, for special monthly compensation based on the need for aid and attendance. See Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: Issue a statement of the case with respect to the issue of entitlement to an effective date prior to January 3, 2012, for special monthly compensation based on the need for aid and attendance. The Veteran should be advised that he may perfect his appeal of this issue by filing a Substantive Appeal within 60 days of the issuance of the Statement of the Case. See 38 C.F.R. § 20.302(b). The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). ______________________________________________ DAVID S. AMES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs