Citation Nr: 1325512 Decision Date: 08/12/13 Archive Date: 08/16/13 DOCKET NO. 07-16 972 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Robin M. Webb, Attorney ATTORNEY FOR THE BOARD T. Y. Hawkins, Counsel INTRODUCTION The Veteran served on active duty from June 1948 to May 1963. The appellant is the Veteran's surviving spouse. This matter comes before the Board of Veterans' Appeals ("Board") on appeal from a September 2004 rating decision issued by the Department of Veterans Affairs ("VA") Regional Office ("RO") in St. Petersburg, Florida, which denied service connection for the cause of the Veteran's death. The matter has since been transferred to the Nashville, Tennessee RO. The Board has previously considered this claim. In an April 2009 decision, the Board denied the appellant's claim. The appellant subsequently appealed the decision to the United States Court of Appeals for Veterans Claims ("Court"). Thereafter, while the case was pending before the Court, the VA Office of General Counsel and the appellant's attorney (hereinafter known as "the parties") filed a Joint Motion for Remand ("Joint Motion"), requesting that the Court vacate the decision. By an Order dated January 2010, the Court granted the parties' Joint Motion, vacated the decision, and remanded the claim to the Board for compliance with the directives specified by the Court. In April 2012, the Board remanded the claim for further evidentiary development, specifically to obtain to obtain information as to whether the Veteran was exposed to ionizing radiation and obtain an additional medical opinion regarding the cause of his death. As there has been substantial compliance with the Board's remand directives, the Board finds there is sufficient evidence to adjudicate the claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand). The Board notes that a portion of the Veteran's records are contained in the Virtual VA system. Instead of paper, a highly-secured electronic repository is used to store and review every document involved in the claims process. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran died in March 2004. The death certificate shows that the immediate cause of death was cardiopulmonary arrest, due to (or consequence of) cholangiocarcinoma. 2. At the time of the Veteran's death, he was service-connected for postoperative splenectomy; postoperative hiatal hernia, post-operative hernia repair, vagotomy, and pyloroplasty with mild esophagitis; hemorrhoidectomy; and malaria. 3. The Veteran worked on radar equipment. 4. The most probative medical evidence of record does not establish that a disability of service origin caused or contributed to the Veteran's death. 5. The most probative medical evidence of record establishes that the Veteran's cholangiocarcinoma manifested many years after service and was not related to any incident of active duty service. CONCLUSION OF LAW Neither a disability incurred in, or aggravated by service, nor a service-connected disability caused or contributed substantially or materially to the Veteran's death. 38 U.S.C.A. §§ 1110, 1101, 1112, 1116, 1131, 1310, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159. 3.303, 3.304, 3.307(a)(6), 3.309(e), 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Veterans Claims Assistance Act of 2000 ("VCAA") With respect to the appellant's claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). A.) Duty to Notify Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2011); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) ("Pelegrini II"), the Court held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his or her possession that pertains to the claim. Element (4), the requirement of requesting that the claimant provide any evidence in his or her possession that pertains to the claim, was eliminated by the VA Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini, effective May 30, 2008). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability and effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). In addition, the Court has held that, in general, 38 U.S.C.A. § 5103(a) notice for a claim of entitlement to dependency and indemnity compensation ("DIC") benefits must include: (1) a statement of the conditions, if any, for which a veteran was service-connected at the time of his death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service-connected. Hupp v. Nicholson, 21 Vet. App. 342 (2007). The Court also held that a DIC claim imposes upon VA no obligation to inform a DIC claimant, who submits a non-detailed application, of the specific reasons why any claim made during the deceased veteran's lifetime was not granted. Id. Notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction ("AOJ"). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice is provided after the initial decision, such a timing error can be cured by subsequent readjudication of the claim, as in a Statement of the Case ("SOC") or Supplemental Statement of the Case ("SSOC"). Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006). Here, a June 2004 pre-adjudication letter notified the appellant of the evidence and information necessary to substantiate a DIC claim based on service connection for the cause of the Veteran's death. Specifically, she was notified of the evidence that was needed to substantiate her claim, what information and evidence VA would provide, and what information and evidence she was expected to provide. She was further advised that VA would assist her in obtaining evidence, but that it was ultimately her responsibility to provide VA with any evidence pertaining to her claim. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004). The appellant was notified of her responsibility to submit evidence which showed that the Veteran died while on active duty or died from a service-related injury or disease, what evidence was necessary to establish service connection for the cause of the Veteran's death, and why the current evidence was insufficient to award the benefits sought. A subsequent letter, dated April 2005, provided the appellant with information pertaining to substantiating service connection for radiation-exposed veterans. Because the Board has concluded that the preponderance of the evidence is against the appellant's claims, any questions as to the appropriate disability ratings or effective dates to be assigned are rendered moot, and no further notice is needed. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). B.) Duty to Assist Under the VCAA, VA also has a duty to assist the appellant in the development of a claim. This includes assisting the appellant in procuring service treatment records, relevant post-service treatment records, and providing a VA examination or opinion when warranted. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). The Board concludes that VA's duty to assist has been satisfied in this case. Of record are the Veteran's service and post-service treatment reports, his terminal hospital treatment reports, several opinion statements from his private treating physician and his death certificate. The claims folder also contains the appellant's personal statements and testimony in support of her claim. Also of record are expert advisory opinions, one from a Veterans Health Administration physician and the other from a VA physician, who, after reviewing the complete evidence of record, concluded that it was less likely than not that the Veteran's cholangiocarcinoma was caused or aggravated by any incident or event of active service, to include an already service-connected disability. The Board finds these opinions are adequate, as they were predicated on a complete review of the aforementioned service and post-service treatment reports of record, assertions from the appellant, as well as the physicians' own expert knowledge. The reports also provide a complete rationale for the opinions stated. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). Accordingly, the Board finds that VA's duty to assist has been met and no further development is necessary. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. Moreover, all procedures to obtain records pertaining to the Veteran's claim have been correctly followed. As discussed above, in April 2012, the Board remanded the appellant's claim for additional development, including an attempt to ascertain whether the Veteran had been exposed to ionizing radiation as a result of working with NIKE launchers. In an October 2012 letter, the U.S. Army Dosimetry Center replied that it had researched its files for records of the Veteran's possible exposure to ionizing radiation, but was unable to locate any information on the Veteran. In short, the Board has carefully considered the provisions of the VCAA in light of the record on appeal, and for the reasons expressed above finds that the development of the claims has been consistent with the provisions of the VCAA. The appellant has been provided with every opportunity to submit evidence and argument in support of her claims, and to respond to the VCAA notice. The purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of her appealed claims. Accordingly, the Board will proceed to a decision on the merits. II. Discussion The Board has thoroughly reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Under 38 U.S.C.A. § 1154(a), VA is also required to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. In Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3), lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." (footnote omitted). However, the Court has held that "[t]he type of evidence that will suffice to demonstrate entitlement to service connection, and the determination of whether lay evidence may be competent to satisfy any necessary evidentiary hurdles, depends on the type of disability claimed." Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic disease during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity for those chronic diseases listed specifically at 38 C.F.R. § 3.303(b) (2012) such as malignant tumors. Walker v. Shinseki, 708 F.3d 1331, 1337-39 (Fed. Cir. 2013), aff'g Walker v. Shinseki, No. 10-2634, 2011 WL 2020827 (Vet. App. May 25, 2011). For disabilities that are not listed as chronic under 38 C.F.R. § 3.303(b), the only avenue for service connection is by a showing of in-service incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). In order to establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) the in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). The Court has construed this provision as entailing "any additional impairment of earning capacity resulting from an already service- connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition." Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Establishing service connection on a secondary basis essentially requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by, or (b) aggravated by a service-connected disability. Id.; see also Wallin v. West, 11 Vet. App. 509, 512 (1998). In order to establish service connection for the cause of a veteran's death, it must be shown that a service-connected disability caused the death, or substantially or materially contributed to it. A service-connected disability is one which was incurred in, or aggravated by active service, one which may be presumed to have been incurred during such service, or one which was proximately due to, or the result of a service-connected disability. 38 U.S.C.A. § 1310 (West 2002); 38 C.F.R. § 3.312(a) (2012). The death of a veteran will be considered as having been due to a service-connected disability when such disability was either the principal or contributory cause of death. 38 C.F.R. § 3.312(a). The issue involved will be determined by exercise of sound judgment, without recourse to speculation, after a careful analysis has been made of all the facts and circumstances surrounding the death of the veteran, including, particularly, autopsy reports. Id. The service-connected disability will be considered the principal (primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death, or was etiologically related thereto. 38 C.F.R. § 3.312(b) (2012). The service-connected disability will be considered a contributory cause of death if it is shown that it contributed substantially or materially to death, combined to cause death, or that it aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c) (2012). It is not sufficient to merely show that it casually shared in producing death, but rather it must be shown that there was a causal connection. Id. Medical evidence is required to establish a causal connection between service, or a disability of service origin, and the veteran's death. See Van Slack v. Brown, 5 Vet. App. 499, 502 (1993). The debilitating effects of a service-connected disability must have made the veteran materially less capable of resisting the fatal disease, or have had a material influence in accelerating death. See Lathan v. Brown, 7 Vet. App. 359 (1995). The appellant advances three separate theories regarding the cause of the Veteran's death. First, she contends that his death from cholangiocarcinoma was the result of liver flukes (parasitic worms) contracted while serving in Southeast Asia during service in the Korean War. Alternatively, she claims that he developed cholangiocarcinoma from exposure to ionizing radiation as a result of working on NIKE launchers radar equipment. Finally, she asserts that his cholangiocarcinoma was caused by his service-connected postoperative hiatal hernia, post-operative hernia repair, vagotomy, and pyloroplasty with mild esophagitis. As an initial matter, the Veteran's service treatment records show no evidence of treatment for, or a diagnosis of cholangiocarcinoma or any other type of carcinoma during service. There is also no evidence, including from the appellant, that he was diagnosed with any type of cancer within one year after separation from service. The Veteran's service personnel records, however, demonstrate that he served in Korea during the Korean War, and that his service transport made stops in Sasebo, Japan. Accordingly, the Board concedes the Veteran's service in Southeast Asia. The treatment reports of record demonstrate that the first evidence of treatment for any type of liver ailment was in March 2003, when the Veteran was seen by a private physician for jaundice and fatigue. Diagnostic testing revealed a finding of adenocarcinoma of the bile duct, diagnosed as cholangiocarcinoma, and the Veteran underwent surgery to remove a tumor from the common bile duct. Thereafter, he was treated with a combination of chemotherapy and radiation therapy, which proved unsuccessful. On March 12, 2004, the Veteran passed away. As mentioned above, the claims folder contains several written statements from one of the Veteran's private treating physicians, G. Palermo, M.D., who suggested a possible relationship between the Veteran's cholangiocarcinoma and his military service. In a treatment note dated August 2003, Dr. Palermo noted that the Veteran had a history of exposure to malaria in service and stated that, "[a]pparently there is a correlation between the infection and the development of a cholangiocarcinoma down the line." In letter dated February 2004, Dr. Palermo reported that the Veteran served in Southeast Asia during service and indicated that it was "documented" that certain biliary parasites endemic to Southeast Asia increased the risk of cholangiocarcinoma. In the third letter, dated March 2004, Dr. Palermo reiterated his assertion that certain biliary parasites endemic to Southeast Asia increased the risk of cholangiocarcinoma and that since other risk factors, such as, ulcerative colitis, primary sclerosing cholangitis, or congenital anomalies of the pancreoticobiliary tree did not apply to the Veteran's case, the parasite infection risk factor acquired a greater likelihood. In October 2003, prior to the Veteran's death, and in connection with his claim of entitlement to increased disability ratings for his service-connected postoperative hiatal hernia, post-operative hernia repair, vagotomy, and pyloroplasty with mild esophagitis, and hemorrhoidectomy, the Veteran underwent a VA compensation and pension examination. The examiner noted that the Veteran reported that he had been told by one of his treating clinicians that his bile duct cancer or one of its variants was a rare form of cancer and may have been caused by parasitic invasion of the bile duct resulting from his military service in Asia during the Korean War. Significantly, however, examiner noted that the claims folder was not available for review, thus, the examiner was unable to review any of the Veteran's service or post-service oncology treatment records and instead, appeared to rely upon the Veteran's self-reported lay statements as to what he had been told by other practitioners. After noting that he had reviewed an x-ray of the Veteran's upper gastrointestinal tract (citing an impression of defect in the distal esophagus with a shelf defect, rule out submucosal tumor) and discussing the occasional difficulty the Veteran experienced with foods and liquids becoming stuck in his lower esophagus, the examiner concluded "[b]ased on these findings, it is more likely than not that the patient's present difficulties are related to prior surgery and/or paracytic [sic] infection of the bile ducts as a result of his service in the Korean War." In addition, on the bottom of the printed examination report, there is a handwritten note of unknown origin, with the question "[d]oes the cancer relate to what was the hiatal hernia?" The handwritten response reads "[the VA examiner] states this is [with]in possible [and] is just as likely as not." In January 2009, the Veteran's claims folder was reviewed by a VHA physician, the Chief of Gastroenterology and Hepatology at a VA New York Health Care Center, for an expert medical opinion as to whether the Veteran's fatal cholangiocarcinoma was causally-related to a clinically-silent and undiagnosed parasitic infestation acquired in Southeast Asia. The physician noted that his review included the complete evidence of record, including the Veteran's service records, and included a brief but comprehensive restatement of the Veteran's medical history. Initially, he noted that although the Veteran was diagnosed with malaria in 1951 following service, and had a documented relapse in 1952, subsequent medical records revealed no further symptoms associated with the disease. He then discussed the nature and characteristics of cholangiocarcinoma, noting that the Veteran's tumor was a perihiliar cholangiocarcinoma involving the common hepatic duct and proximal common bile duct, and was considered an extrahepatic tumor, as opposed to an intrahepatic tumor, which arise above the right and left hepatic ducts. He noted that in the United States, even though there are well described conditions associated with this type of tumor, the majority of cases are without a clear cut cause, with liver fluke infestations being a much less common finding. For example, he noted a recent National Institutes of Health (NIH)/VA joint study that looked at the risk factors associated with cholangiocarcinoma in the United States from 1993 to 1999, which found the prevalence of liver fluke infestation to be zero among persons diagnosed with the disease. He also discussed a liver fluke endemic to Southeast Asia. After careful review of the Veteran's claims folder, however, the physician stated that he did not find any evidence to suggest the Veteran had a silent liver fluke infection. In this regard, he observed that even though he had chronic gastrointestinal complaints throughout his adult life, these complaints were very well evaluated and were consistent with chronic gastroesophageal reflux disease ("GERD") with hiatal hernia. He further noted that even after his gastropexy, vagotomy and pyloroplasty, the Veteran continued to be symptomatic with documented esophagitis as well as eventual development of Barrett's esophagus, all of which confirm his chronic diagnosis of GERD. The physician noted review of the Veteran's surgery report and surgical pathology did not reveal anything suspicious or suggestive of liver fluke infection, adding that he specifically looked at the description of the liver and found no abnormalities described in the liver suggestive of liver fluke related fibrosis, increased mucus secretion, calcium bilirubinate stones, etc. Again, he noted that, per the NIH/VA report, none of the over 1,000 cholangiocarcinoma patients had a liver fluke infestation, and most cases did not have a demonstrable etiology. He concluded that the medical evidence was against finding that the Veteran's carcinoma was related to a silent liver fluke infestation. Concerning the suggestion that the Veteran's cholangiocarcinoma was possibly related to malaria, the VA hospital physician pointed out that malaria is not associated with the development of cholangiocarcinoma, and that he could find no competent support in the medical literature relating malaria to cholangiocarcinoma. He acknowledged that one could theoretically make the case that, with repeated malarial episodes, there might be hemolysis which, over the years, might lead to bilirubin stones with constant irritation in the bile duct and become carcinogenic. However, in this case, he again noted that there was absolutely no evidence that the Veteran suffered from recurrent malaria attacks or any evidence of bilirubin stones. In August 2010, a VA gastroenterologist concluded that the Veteran's hiatal hernia in no way contributed to the development of the Veteran's cholangiocarcinoma. Risk factors were stated to include PSC, choedochal cysts, cholelithiasis/hepatolithiasis, certain parasitic infections, certain toxic exposures, and chronic hepatitis. There was reportedly no connection with hiatal hernia. In January 2013, the Veteran's complete claims folder was reviewed by a VA clinician in order to obtain another opinion concerning the etiology of his cholangiocarcinoma. As noted above, because the Board was unable to obtain any information from the Army concerning the Veteran's possible exposure to ionizing radiation, the Board concedes only that he was exposed to non-ionizing radiation by virtue of his work with NIKE launcher radar equipment. Regarding the issue of whether it is as likely as not that his cholangiocarcinoma was caused by his exposure to non-ionizing radiation, the VA clinician opined that his cholangiocarcinoma was less likely than not incurred in, or caused by non-ionizing radiation in service. In this respect, he noted that non-ionizing radiation is low-frequency radiation that does not have enough energy to remove electrons or directly damage DNA. Low-energy ultraviolet ("UV") rays, visible light, infrared rays, microwaves and radio waves are all forms of non-ionizing radiation. He noted that, aside from UV rays, these types of radiation are not known to increase cancer risk and therefore, the Veteran's cholangiocarcinoma was less likely than not caused by non-ionizing radiation. With regard to the appellant's contention that the Veteran's cholangiocarcinoma resulted from his service-connected postoperative hiatal hernia, post-operative hernia repair, vagotomy, and pyloroplasty with mild esophagitis, the clinician opined that his carcinoma was less likely than not due to this service-connected disability. In this regard, he noted that hiatal hernia, post-operative hernia repair, vagotomy, and pyloroplasty with mild esophagitis have not been shown to produce cancer in the bile ducts. He added that the Veteran's service-connected disability also was less likely than not to have contributed substantially or materially to his cause of death, as his death, according to the information of record, was more likely than not related to complications of his cholangiocarcinoma and not as a result of any of his service-connected disabilities. III. Conclusion It is the responsibility of the Board to weigh the evidence, including the medical evidence, to determine where to give credit and where to withhold the same, and in so doing, the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993); Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board must also make judgments as to the credibility of testimony, as well as of various medical opinions. In determining whether evidence submitted by a claimant is credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Having reviewed the complete evidence of record, the Board concludes that the most probative evidence fails to support the appellant's contention that the Veteran's death was related to service or a service-connected disability, to include as a result of liver flukes, being exposed to ionizing radiation, or as a result of his service-connected hiatal hernia, post-operative hernia repair, vagotomy, and pyloroplasty with mild esophagitis. In this regard, the Board finds the most probative evidence of record to be the January 2009 opinion from the VA Health Care Center physician and the January 2013 opinion from VA clinician, respectively. In this respect, the VA opinions were based on a comprehensive analysis of the complete evidence of record, including the Veteran's service treatment and personnel records, his post-service gastroenterology and oncology treatment records, and the private opinions from Dr. Palermo. The VHA hospital physician provided a very detailed report supported by a more than a dozen medical research studies on the subject of cholangiocarcinoma. Similarly, the January 2013 clinician's opinion was based on the exercise of sound judgment after a careful analysis of all the facts and circumstances surrounding the Veteran's death, to include the complete claims folder. See 38 C.F.R. § 3.312(a). As previously noted, VA regulations provide that the issue of entitlement to service connection for the cause of a veteran's death will be "determined by exercise of sound judgment, without recourse to speculation, after a careful analysis has been made of all the facts and circumstances surrounding the death of the veteran." 38 C.F.R. § 3.312(a) (emphasis added). Here, the Board finds the opinions from the Veteran's treating physician, Dr. Palermo, to be mainly speculative in nature, as he neither included any discussion or analysis of the facts surrounding the Veteran's death, nor provided any medical basis for his theory that the Veteran's cancer was the result of liver flukes. With regard to the medical opinion of the clinician who examined the Veteran in October 2003, the Board notes that, while professional medical opinions must be considered and the Board may not disregard a favorable medical opinion based solely on the rationale that it was based on a history given by the claimant (Kowalski v. Nicholson, 19 Vet. App. 171 (2005)), the Board is not bound to accept the opinions of physicians whose diagnoses or opinions are based on a medical history provided by a veteran or claimant. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (the mere transcription of a claimant's statements regarding medical history does not transform the information into competent medical evidence merely because the transcriber happens to be a medical professional). In this case, as noted above, this examiner specifically noted that his review did not include the Veteran's claims folder. Rather, his statements appear to have been based primarily on the Veteran's assertions concerning what another provider allegedly told him about the etiology of his cholangiocarcinoma. The examiner also did not provide an adequate rationale for the opinion. As such, the Board finds his opinion to be of little probative value. In addition to the medical evidence, the Board has also considered the statements of the appellant, as well as the evidence she presented in support of her claim. In this regard, the Board certainly finds that the appellant is competent to offer evidence as to facts within her personal knowledge, such as observable symptoms of the Veteran's illness prior to his death. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Moreover, the Board acknowledges that there are instances in which lay testimony can serve to establish an association between service and the claimed disability or death. See Charles v. Principi, 16 Vet. App. 370 (2002). For example, a lay person may be competent to offer testimony on certain medical matters, such as describing symptoms observable to the naked eye, or even diagnosing simple conditions such as a dislocated shoulder. However, the Board finds that a lay person is not competent to offer an opinion on a matter clearly requiring medical expertise, such as linking a death from a complex cancer of the bile ducts to an alleged exposure to ionizing radiation or parasites more than 50 years earlier. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Therefore, this is not a case in which the appellant's lay beliefs alone can serve to establish any association between the Veteran's death and military service or a service-connected disability. In contrast, the VA examiners used their comprehensive medical knowledge, along with the complete facts surrounding the Veteran's death, in formulating their respective conclusions that his death was not related to any aspect of active duty service. Finally, the Board notes that it has also considered the treatise information submitted by the appellant. In this regard, the Board notes that treatise evidence can, in some circumstances, constitute competent medical evidence. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). In addition, the Court has held that, while a medical article or treatise can provide support to a claim, it must be combined with an opinion from a medical professional and be reflective of the specific facts of a case as opposed to a discussion of generic relationships. Sacks v. West, 11 Vet. App. 314, 316-17 (1998); see Wallin v. West, 11 Vet. App. 509, 514 (1998) (medical treatise evidence discussed generic relationships with a degree of certainty to establish a plausible causality of nexus); see also Mattern v. West, 12 Vet. App. 222, 228 (1999). However, medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). In this case, while the article submitted by the appellant discusses the needs of so-called "atomic veterans" who were part of the 1945-1946 occupation of Hiroshima and Nagasaki, or participated in U.S. above-ground nuclear testing conducted between 1945 and 1962, there has been no competent evidence presented to suggest that the Veteran was part of either of those groups. As discussed above, although the Board attempted to ascertain whether the Veteran had been exposed to ionizing radiation, this claim could not be verified. Although the Board is genuinely sympathetic to the appellant's loss, the Board concludes that the preponderance of the evidence is against granting service connection for the cause of the Veteran's death. The "benefit-of-the-doubt" rule enunciated in 38 U.S.C.A. § 5107(b) is not for application, as there is not an approximate balance of evidence. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). ORDER Service connection for the cause of the Veteran's death is denied. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs