Citation Nr: 1326457 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 97-24 700 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to disability compensation under 38 U.S.C.A. § 1151 for coronary artery disease, status post aortofemoral bypass. 2. Entitlement to disability compensation under 38 U.S.C.A. § 1151 for peripheral vascular disease with impotence, claudication, and clots. REPRESENTATION Veteran represented by: Daniel G. Krasnegor, Attorney at Law WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Debbie A. Breitbeil, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from August 1956 to May 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal of rating decisions in April 2000 and December 2000 of a Department of Veterans Affairs (VA) Regional Office (RO) in Albuquerque, New Mexico. The Veteran subsequently relocated and the Phoenix, Arizona RO now has jurisdiction of the claims. In September 2001, the Veteran testified at a hearing before a Veterans Law Judge. A transcript of the hearing has been associated with the claims file. It is noted that the Veterans Law Judge who conducted the hearing has since retired, but the Veteran has indicated that he did not desire another hearing. In a November 2004 decision, the Board denied the Veteran's claims of VA disability compensation under 38 U.S.C.A. § 1151 for coronary artery disease and peripheral vascular disease. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a Memorandum Decision dated in April 2007, the Court vacated the Board's November 2004 decision as to the claims on appeal and remanded the case to the Board for further proceedings consistent with the Court's decision. Then, in July 2008, the Board requested an independent medical expert opinion concerning the claim, pursuant to 38 U.S.C.A. § 7109; 38 C.F.R. § 20.901(d). That opinion, dated in October 2008, was received, and the Veteran was provided a copy of the opinion and an opportunity to respond. In March 2009 decision, the Board denied the Veteran's claims of VA disability compensation under 38 U.S.C.A. § 1151 for coronary artery disease and peripheral vascular disease. The Veteran appealed the Board's decision to the Court. In September 2010, the Court granted a Joint Motion for Remand of the parties (the Secretary of VA and the Veteran), vacating the Board's decision and remanding the case to the Board for readjudication consistent with the Joint Motion. Then, in March 2012, the Board requested another independent medical expert opinion concerning the claim, pursuant to 38 U.S.C.A. § 7109; 38 C.F.R. § 20.901(d). That opinion, dated in July 2012, was received, and the Veteran was provided a copy of the opinion and an opportunity to respond. Given that the July 2012 medical opinion was deemed inadequate and at odds with the earlier medical opinion of October 2008, the Board sought a third independent medical expert opinion to reconcile the disparities in the record. That opinion, dated in April 2013, has been received, and the Board sent the Veteran a copy of the opinion for his review and any response; the Veteran's representative responded with a written statement in June 2013. FINDINGS OF FACT 1. In April 1996, September 1996, and on several subsequent occasions in regard to peripheral vascular disease, the Veteran received VA hospital and surgical treatment. 2. The Veteran's underlying coronary artery disease and peripheral vascular disease preexisted and were not aggravated by his VA medical treatment beginning in April 1996; claudication and clots were symptomatic of the progression of the underlying vascular disease, made worse primarily by the Veteran's smoking history. 3. Coronary artery disease, status post aortofemoral bypass, and his peripheral vascular disease with impotence, claudication, and clots, were not due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA; impotence, as a complication of aortic surgery, was a reasonably foreseeable event of the VA hospital and surgical treatment. CONCLUSIONS OF LAW 1. The criteria for VA disability compensation under 38 U.S.C. § 1151 for coronary artery disease, status post aortofemoral bypass, due to VA hospital and medical treatment have not been met. 38 U.S.C.A. §§ 1151, 5107(b) (West 2002); 38 C.F.R. § 3.361 (2012). 2. The criteria for VA disability compensation under 38 U.S.C. § 1151 for peripheral vascular disease with impotence, claudication, and clots due to VA hospital and medical treatment have not been met. 38 U.S.C.A. §§ 1151, 5107(b) (West 2002); 38 C.F.R. § 3.361 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The VCAA notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided post-adjudication VCAA notice by letter, dated in June 2004. The notice included the type of evidence needed to substantiate the claims under 38 U.S.C.A. § 1151, namely, evidence of additional disability as a result of VA hospitalization, medical or surgical treatment, examination, or training, and evidence that the disability was the direct result of VA fault or was not a reasonably expected result of complication of the VA care or treatment. The Veteran was notified that VA would obtain VA records and records of other Federal agencies and that he could submit other records not in the custody of a Federal agency, such as private medical records, or with his authorization VA would obtain any non-Federal records on his behalf. As for content of the VCAA notice, the documents complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370 (2002) (identifying the document that satisfies VCAA notice); and of Dingess v. Nicholson, 19 Vet. App. 473 (notice of the elements of the claim, except for the effective date of the claim and for the degree of disability assignable). To the extent that the VCAA notice came after the initial adjudication, the timing of the notice did not comply with the requirement that the notice must precede the adjudication. The procedural defect was cured as after the RO provided content-complying VCAA notice, the claims were readjudicated as evidenced by the supplemental statement of the case, dated in August 2004. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.). To the extent that the VCAA notice did not provide notice of the provisions regarding the effective date of the claim and the degree of disability assignable, such deficiency is not prejudicial to the Veteran. As the claims are denied, no effective date or disability rating can be assigned as a matter of law, so there can be no possibility of any prejudice to the Veteran with respect to the limited timing defect in the VCAA notice. Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The Veteran was afforded the opportunity to appear at a hearing in September 2001 before a Veterans Law Judge. The RO has obtained VA records of treatment of the Veteran. The Veteran has not identified any additionally available evidence for consideration in his appeal. Further, VA has conducted necessary medical inquiry in an effort to substantiate the claim. 38 U.S.C.A. § 5103A(d). The Veteran was afforded a VA examination in April 2003; however, as the examination report was deemed to be inadequate to decide the claim, the Board sought independent medical opinions, which were dated in October 2008, July 2012, and April 2013. The Veteran was provided a copy of the opinions, and afforded opportunity to respond. The Board, in contrast to the argument from the Veteran's representative in June 2013 that the April 2013 medical opinion was inadequate and an addendum opinion should be sought, finds that the medical opinion is sufficient to decide the claims; the expert accounted for the significant facts in the case and provided rationale to support the conclusion reached in the opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). It is noted that the Veteran's representative has argued that the April 2013 did not fully answer the questions posed by the Board. Specifically, it is contended that the expert did not opine as to whether the Veteran's peripheral vascular disease was aggravated by VA medical care, and that he only addressed impotence as a complication and failed to address whether claudication and clots were caused or aggravated by VA medical care or whether the claudication and clots were due to an event not reasonably foreseeable. As will be discussed in the decision herein below, the opinion of April 2013 answered each of the questions posed in the opinion request with a certain "yes" or "no" and there was no ambiguity over what the vascular surgeon concluded in terms of the determinative queries in this case, including whether coronary artery disease and peripheral vascular disease preexisted the VA medical treatment beginning in April 1996, whether the diseases (and the symptom manifestations of the diseases) were caused or aggravated by VA medical care, whether there was additional disability caused by VA medical care, and if such additional disability was due to an event not reasonably foreseeable. As for impotence, the surgeon discussed that disability as being the one identifiable disability that was a probable result of VA surgery, and in so doing a discussion of claudication and clots was not necessary. Further, as seen with the prior independent medical experts, claudication and clots were considered part of the underlying vascular disease progression during the period the Veteran was receiving VA treatment, which were also made worse by the Veteran's smoking and not VA care. It is noted that in reviewing the medical opinions for adequacy, the Board does not discount the findings of previous examiners, particularly if the conclusions are based on a review of the entire record and is consistent with each other. Oftentimes, another opinion is sought where a more full explanation of rationale is needed, so that the Board may decide how much probative weight to assign it. In this case, the independent medical opinions were consistent with one exception, which was explained in the decision below, and such consistency is probative in terms of deciding the claims. The totality of the evidence, including all medical opinions, has been considered, and the Board finds that the medical evidence is sufficient to proceed with deciding the claim. As there is no indication of the existence of additional evidence to substantiate the claim, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claim is required to comply with the duty to assist. II. Legal Criteria Compensation under 38 U.S.C.A. § 1151 is awarded for a qualifying additional disability of a veteran in the same manner as if such additional disability were service connected. A disability is a qualifying additional disability if the disability was caused by VA medical treatment, and the proximate cause of the disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the medical treatment; or the additional disability was not reasonably foreseeable. 38 U.S.C.A. § 1151. Under 38 C.F.R. § 3.361(c), a claim based on additional disability due to medical treatment must meet the causation requirements. To establish causation, the evidence must show that VA's medical treatment resulted in additional disability. Merely showing that a veteran received treatment and that the veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361(c)(1). The proximate cause of disability is the action or event that directly caused the disability, as distinguished from a remote contributing cause. Under 38 C.F.R. § 3.361(d), to establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing medical treatment, it must be shown that the treatment caused the veteran's additional disability; and VA failed to exercise the degree of care that would be expected of a reasonable health care provider. Whether the proximate cause of the additional disability was an event not reasonably foreseeable is to be determined based on what a reasonable health care provider would have foreseen. 38 C.F.R. § 3.361(d)(2). The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with informed consent. 38 C.F.R. § 3.361(d)(2). III. Facts The Veteran was admitted to a VA hospital in April 1996 for evaluation of complaints of an intermittent right blue toe. He had also been experiencing buttock claudication for six months after walking two blocks. An angiogram showed bilateral focal iliac stenoses near the orifices of the hypogastric arteries. A cervical procedure involving bilateral iliac angioplasty and stents was performed. The diagnosis was bilateral iliac stenoses with thrombus in the right iliac. The Veteran was readmitted to the hospital in September 1996 for continuing symptoms. During the hospitalization, he underwent an aorto-bifemoral bypass without complications. In December 1997, he underwent a left aorto-bifemoral loom thrombectomy with revision. Similar procedures were performed on several subsequent occasions. VA medical records dated from 1998 refer to diagnosis and treatment of coronary artery disease and peripheral vascular disease. A July 2002 VA examination report indicates that the Veteran reported noticing (around 1990) that his right leg was dragging. The examiner diagnosed him with peripheral vascular disease and indicated that his impotency was secondary to this diagnosis. There was no opinion as to whether this disability was due to VA treatment or surgical care. In April 2003, the Veteran underwent another VA examination. The examiner determined that the Veteran's coronary artery disease and peripheral vascular disease were not caused by or aggravated by the aorto-femoral bypass and treatment or any other treatment by the VA. The examiner did not provide a complete rationale for her opinion. Moreover, the evidence was not clear as to whether the Veteran's disabilities preceded the April 1996 VA hospitalization and, if so, whether they were aggravated by the VA surgeries and subsequent treatment. In October 2008, an independent medical expert opinion was obtained by the Board from a specialist in cardiology, R.M.S., M.D., from Wake Forest University School of Medicine. In his opinion, Dr. R.M.S. noted that the Veteran did not reveal a presentation consistent with coronary artery disease for many years after his 1996 VA hospitalization. He specifically noted that "as late as 4-09-02 a dipyridamole Sestamibi study revealed normal left ventricular ejection function, normal wall motion and no evidence of ischemia or infarction. In other words, prior to 4-09-02 we can safely say that there was no evidence of coronary artery disease." After reviewing the entire record, Dr. R.M.S. concluded that "there is no evidence that VA care caused [the Veteran's] coronary artery disease." Dr. R.M.S. further stated that with respect to the Veteran's peripheral vascular disease, he had presented with a six-month history of right buttock claudication in April 1996 and acute onset of blue toe syndrome in February 1996. It was further pointed out that when the Veteran presented with "blue toe syndrome" in April 1996 his "history and physical document[ed] ankle/brachial indices of 1.0 on the left and 0.83 on the right." After describing blue toe syndrome along with the Veteran's reported history and the significance of his ankle/brachial indices, Dr. R.M.S. concluded that the Veteran had peripheral vascular disease at the time of his presentation in April 1996 and perhaps as early as six months prior to his presentation in April. In sum, Dr. R.M.S. indicated that coronary artery disease did not exist before or during VA medical treatment and that its later onset was not caused by such treatment. Dr. R.M.S. further opined that based on the Veteran's symptoms, peripheral vascular disease had existed prior to VA medical treatment. Dr. R.M.S. noted that the Veteran had "multiple risk factors for peripheral vascular disease, in particular smoking, which is the most likely basis for causality of his peripheral vascular disease." In determining whether VA care aggravated the Veteran's pre-existing peripheral vascular disease, Dr. R.M.S. noted that the Veteran presented on several occasions with symptoms suggestive of claudication or other acute exacerbations of his peripheral vascular disease and that it appeared that he was appropriately attended to, evaluated, and treated. It was his opinion that the Veteran's peripheral vascular disease was not aggravated by VA medical care. A second independent medical expert opinion, dated in July 2012, was obtained by the Board from a specialist in vascular surgery, C.W.A., M.D., from the University of Wisconsin-Madison. This opinion was sought after considering arguments from the Veteran's representative to the effect that Dr. R.M.S. was an interventional cardiologist who had also stated in his report that he could not speak to the appropriateness or technical adequacy of the surgical procedures as it was beyond his medical expertise. In his opinion, Dr. C.W.A. opined that it was "certain" that the Veteran's coronary artery disease and vascular disease were present prior to his 1996 surgery, and that the aortic surgery in 1996 was due to preexisting, underlying vascular disease that progressed over time and was not aggravated by VA medical care. He found that "VA medical care was instituted to treat these conditions; it did not cause these conditions." He further asserted that there was no indication in the record that any additional disability was due to the carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing medical treatment. He felt that the Veteran's preexisting conditions resulted from his own "natural biology and environmental factors, the primary one of which was smoking." He found that there was nothing in the records, despite the VA surgeries, that VA medical treatment made his condition worse; rather, he found that the medical care was "required because of progression of his vascular disease made worse by environmental factors (smoking)." Then, contrary to his findings and evidently a typographical error on his part, Dr. C.W.A. responded to some questions asked of him by stating that there was a "higher than 50% degree of probability" in regard to whether the Veteran's claimed conditions were caused by or aggravated by VA medical care, whether such additional disability was due to carelessness/negligence/lack of proper skill/etc. on VA's part, and whether such additional disability was due to an event not reasonably foreseeable. Notably, Dr. C.W.A.'s conclusions lacked detailed rationale supported by particular reference to facts in the record, failed to address with any particularity one of the questions requested by the Board in regard to reasonable foreseeability, evidently made a typographical error (given the context of the whole opinion) in which he finds that there was a better than 50 percent probability that the Veteran's additional disability was due to VA carelessness/negligence/lack of proper skill/etc., and made a finding that the onset of the Veteran's coronary artery disease was prior to VA surgery in 1996 (which clearly contradicted the finding of Dr. R.M.S., who found that there was no evidence of coronary artery disease prior to 2002). In light of such deficiencies, the Board sought a third independent medical expert opinion. In April 2013, E.A., M.D., a Board-certified vascular surgeon from the University of Massachusetts Medical Center in Worcester reviewed the claims files and responded to the following set of questions: (1). Is it at least as likely as not (a 50 percent or higher degree of probability) that the Veteran's coronary artery disease and/or peripheral vascular disease existed prior to the April 1996 VA surgery? (2). Is it at least as likely as not (a 50 percent or higher degree of probability) that the Veteran's coronary artery disease and/or peripheral vascular disease with impotency, claudication and clots was caused by or aggravated by VA medical care? In other words, please determine whether the Veteran has any additional disability or disabilities as a result of the original April 1996 surgery and subsequent surgeries/treatment performed at the VA, and if so, please detail the nature of such disability or disabilities. If yes, please proceed to question numbers 3 and 4. (3). Is it at least as likely as not (a 50 percent or higher degree of probability) that any such additional disability or disabilities is due to carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on the part of VA in furnishing hospital care, medical or surgical treatment? (4). Is it at least as likely as not (a 50 percent or higher degree of probability) that any such additional disability or disabilities is due to an event not reasonably foreseeable? A "not reasonably foreseeable" event is one that would not be reasonably anticipated or expected by a health care provider who utilized the degree of care a prudent or competent person so engaged would exercise. Dr. E.A. indicated in his report that he reviewed all of the Veteran's medical records, including the prior independent medical expert opinions in the file. Regarding the first question, the physician's response was "yes." He explained that the Veteran presented with a months-long history of buttock claudication with subsequent blue toe syndrome as a result of his aortoiliac occlusive disease and "based on his concomitant risk factors (especially smoking) it is more likely than not that he had an associated coronary artery disease." He also explained why he felt that the negative dipyridamole Sestamibi scan in 2002 did not exclude the fact that the Veteran had an underlying coronary artery disease. As to the second question, Dr. E.A.'s response was "no." He indicated that peripheral vascular disease preexisted the April 1996 treatment as shown by the existence of claudicating symptoms and blue toe syndrome. He noted that the Veteran had impotence, but stated that such a condition "is a well known complication to aortic surgery" that is "well documented in the literature." As to the third question, his response was "no." He stated that the Veteran's disabilities were "directly related to his underlying disease" that he initially presented with and that they were "not related to any carelessness, negligence, lack of proper skills, or error in judgment." Regarding the fourth question, Dr. E.A.'s response was "no." He reiterated that impotence was a well recognized complication or outcome following aortic surgery and that coronary artery disease was often associated with peripheral vascular disease as part of the same disease, especially where the aorta is concerned. He stated that this was so even in cases where the patient might be asymptomatic for coronary artery disease (i.e., without such symptoms as angina and myocardial infarction) or have a negative non-invasive cardiac evaluation (i.e., dipyridamole Sestamibi scan), and the only way to detect his underlying coronary artery disease would have been cardiac catheterization (but this clearly was not indicated at the time). IV. Analysis The threshold question in this case is whether the Veteran had any additional disability as a consequence of VA surgery and medical treatment beginning in April 1996, when the Veteran was hospitalized and underwent surgery following vascular complaints. It appears the Veteran is asserting that his coronary artery disease and peripheral vascular disease were either caused or aggravated by the VA medical treatment. Such disabilities were not specifically diagnosed or documented in the record prior to the 1996 VA medical procedures. Various independent medical opinions have been obtained on the issue of whether or not coronary artery disease and/or peripheral vascular disease preexisted VA medical treatment in 1996, with varying results. For example, in October 2008, an interventional cardiologist believed that there was no coronary artery disease prior to April 2002 (he relied in part on a dipyridamole Sestamibi study in April 2002 that was negative for ischemia and infarction) but that the Veteran's symptoms and history in April 1996 was indicative of peripheral vascular disease at the time of his presentation to VA in April 1996, probably caused by smoking. Then, in July 2012, a specialist in vascular surgery concluded that both coronary artery disease and peripheral vascular disease existed prior to his 1996 VA treatment, primarily as a result of his smoking history. His final remarks unfortunately contained typographical errors that appeared to contradict his earlier conclusions (perhaps as a consequence of misunderstanding or misapplication of the legal standard of proof). Finally, in April 2013, another vascular surgeon concluded that it was likely the Veteran's coronary artery disease and peripheral vascular disease existed prior to the April 1996 VA treatment, with smoking as the particular causative risk factor. He explained his opinion with reference to the negative dipyridamole Sestamibi study in April 2002. Given the foregoing medical opinions, the Board finds that the weight of the evidence shows the Veteran's coronary artery disease and peripheral vascular disease preexisted his VA treatment that began in April 1996, despite there being no diagnoses of such disabilities at the time of his presentation to VA. In other words, it cannot be said that VA treatment caused the diseases, as they preexisted such treatment. All opinions were in agreement that peripheral vascular disease preexisted VA treatment, and only one opinion found coronary artery disease did not exist until after a negative April 2002 scan. As to that particular scan, one of the vascular surgeons explained that a negative scan, as relied upon by the interventional cardiologist, did not preclude the existence of an underlying coronary artery disease (even a coronary artery disease that was significant), and he gave reasons for why this was so. The cardiologist did not mention how such a scan could have a false-negative result, and for this reason his opinion has limited probative value that the Board can consider and weigh against the contrary opinion. In any case, the cardiologist found no evidence that coronary artery disease was caused by VA care (although without providing rationale for such opinion). Thus, in considering the medical opinions and the explanation of rationale provided, the Board believes that the opinions finding preexistence of the claimed diseases (i.e., the cause of the diseases are not linked to VA treatment) are more probative and entitled to greater weight than any opinion or belief asserted that the diseases arose out of or as a consequence of VA treatment from 1996 onward. In fact, the independent medical opinions pointed to the Veteran's smoking history as the likely, or most probable, cause of his coronary artery disease and peripheral vascular disease. With regard to medical opinions, it is emphasized that the probative value or evidentiary weight to be attached to a medical opinion is within the Board's province as finder of fact. The guiding factors in evaluating the probative value of a medical opinion include whether the opinion is based upon sufficient facts, whether the opinion is the product of reliable principles, and whether the opinion applied valid medical analysis to the significant facts of the case in order to reach the conclusion submitted in the opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). A mere conclusionary opinion is insufficient to allow the Board to make an informed decision as to the weight to assign to the opinion against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007). Greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). The probative value of a medical opinion is also generally based on the scope of the examination or review, as well as the relative merits of the analytical findings; the probative weight of a medical opinion may be reduced if the physician fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). Thoroughness and detail of the opinion are also among the factors for assessing the probative value of a medical opinion. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The Board proceeds to discuss whether the Veteran's coronary artery disease and peripheral vascular disease, having preexisted VA treatment beginning in 1996 and thus not caused by it, were aggravated by such treatment. As with the question of causality, the Board finds that the weight of the medical evidence is against the claim that coronary artery disease and peripheral vascular disease were aggravated by VA treatment beginning from April 1996. A VA examiner in April 2003 opined that VA treatment did not aggravate coronary artery disease or peripheral vascular disease; however, given the lack of rationale for the opinion, independent medical opinions were thereafter sought to clarify the matter. The interventional cardiologist in October 2008 believed that the Veteran's VA medical treatment was appropriate relative to his ongoing symptoms suggestive of peripheral vascular disease, and that there was no aggravation of peripheral vascular disease by VA care. He noted that his opinion was based on a review of documents of the Veteran's VA care in which the Veteran presented with symptoms suggestive of claudication or other acute exacerbations of peripheral vascular disease. The Board notes that although the cardiologist stated he was unable to opine directly on the "appropriateness or technical adequacy" of the surgical procedures themselves, there is no indication that he was without expertise to identify a worsening of the underlying vascular disease following surgery vis-a-vis the disease prior to surgery. The vascular surgeon in July 2012 found that the Veteran's preexisting coronary artery and vascular disease was not aggravated by VA care and that any additional disability was not due to the carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing medical treatment. He did not identify any specific additional disability except to note impotence, claudication, and clots as manifestations or recurrent symptoms of the progression of the Veteran's "advanced vascular disease." He found that smoking in particular, not VA medical care, worsened the Veteran's vascular disease. Lack of a detailed rationale and misapplication of the evidentiary standard of proof in concluding remarks of the July 2012 opinion led to the request for another opinion. The vascular surgeon in April 2013 likewise reviewed the pertinent records on file and found there not to be aggravation by VA medical care. He found the Veteran's vascular symptoms to be "directly related" to his underlying coronary artery and vascular disease. He noted that the Veteran already had such symptoms as claudication when he first presented to the VA in 1996. He singled out the Veteran's impotence, which arose during VA medical care, and stated that such an additional disability could be the result of aortic surgery, albeit a known complication of aortic surgery. In other words, it was not shown that the underlying vascular disease became worse beyond natural progression. In sum, this opinion, like the ones before it, is not supportive of the claim that the Veteran's coronary artery disease and peripheral vascular disease were aggravated by VA medical care. It is noted that the independent medical opinions of record were based on a review of the Veteran's entire record, and while there was some deficiency in providing a complete explanation of rationale for conclusions reached or in making specific reference to particular facts in the record (thus necessitating a request for a new opinion), the Board finds that as a whole the opinions were consistent on the significant questions presented in this case. The one notable exception is the issue of whether coronary artery disease preexisted VA medical care in 1996, but the April 2013 vascular surgeon furnished adequate rationale to decide this issue and reconcile the varying opinions on that matter. It is also observed that the Veteran has not presented any medical opinions that outweigh those of record in order to support his claim that coronary artery disease and peripheral vascular disease were caused or aggravated by VA medical care beginning in April 1996. The Board acknowledges that impotence, as a separately identified additional disability, has been found to have a possible association with the Veteran's vascular disease and VA medical care. The Veteran apparently also asserts that claudication and clots constitute "additional disability" due to VA medical treatment. The next questions to be addressed are whether any additional disability was due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing surgical and other treatment and whether VA failed to exercise the degree of care that would be expected of a reasonable health care provider. The opinion of the interventional cardiologist in October 2008, albeit given his lack of expertise in the area of surgical intervention, believed on his review of the Veteran's records that proper evaluation and treatment was rendered upon the Veteran's presentation of claudication or exacerbation of peripheral vascular disease. In a general statement, he did not find evidence of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA. The vascular surgeon in July 2012 proffered the same opinion relative to the degree of VA care to the Veteran. His review of the records demonstrated to him that the Veteran "received quite good care at the VA hospital in spite of his advanced vascular disease with recurrent symptoms and disease progression." This surgeon emphasized that it was the progression of the Veteran's vascular disease, essentially caused by a "combination of his smoking and genetic predisposition (cholesterol)" and "made worse by environmental factors (smoking)," that necessitated the surgeries at VA, and that the evidence did not show any additional disability from carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA through the years. In short, the surgeon did not identify any additional disability from VA treatment, but appeared to find that the Veteran had recurrent symptoms that were reflective of the progression of his underlying vascular disease. This opinion was echoed by the vascular surgeon in April 2013, but the surgeon also provided remarks identifying the Veteran's impotence as an additional disability as opposed to a sign of underlying disease progression. In that regard, he stated that impotence "could be" a result of the aortic surgery at VA but was a "well recognized complication or outcome following aortic surgery" and was therefore not related to any carelessness, negligence, lack of proper skill, or error in judgment. In sum, on the question of fault with regard to any additional disability, it appears that impotence stands as the only clear "additional disability" probably arising from VA medical care (as well as from underlying vascular disease), given that other exacerbations of the underlying vascular disease such as claudication and clots were universally viewed by the independent medical experts as symptomatic of the progression of the vascular disease and not due to some deficiency in VA medical care. The vascular surgeon in April 2013 felt that impotence was probably a complication of the aortic surgery that "happens" as a result of "interruption of some of the autonamic [sic] nerve fibers near the area of the aortic bifurcation" and was not the fault of VA. None of the medical opinions of record, VA or independent, has suggested that VA failed to exercise the degree of care that would be expected of a reasonable health care provider in relation to the Veteran's coronary artery disease, peripheral vascular disease, or impotence in particular. Furthermore, the Veteran has not furnished any evidence to the contrary. The Board notes that apart from additional disability, fault, and the degree of care that would be expected of a reasonable health care provider, a claim under 38 U.S.C.A. § 1151 may also be established by showing that an additional disability was an event not reasonably foreseeable, which is determined based on what a reasonable health care provider would have foreseen. On that question, given that impotence was the only clearly identifiable disability that probably arose from VA care, the Board addresses whether impotence was due to an event not reasonably foreseeable. The vascular surgeon in April 2013 found that the Veteran's impotence was not due to an event that was not reasonably foreseeable. In other words, he explained that impotence was a well known (i.e., well documented in the medical literature) complication of or outcome following aortic surgery. Thus, a reasonable health care provider would have foreseen the development of impotence in conjunction with VA medical care. In statements, the Veteran maintains that disability compensation is warranted under 38 U.S.C.A. § 1151 on the basis of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part for his coronary artery disease and peripheral vascular disease. To the extent the Veteran's statements are offered. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007)). Competency is a question of fact, which is to be addressed by the Board. Jandreau, 492 F.3d at 1377. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159; Layno v. Brown, 6 Vet. App. 465, 469 (1994) (A witness must have personal knowledge in order to be competent to testify to a matter; personal knowledge is that which comes to the witness through the use of the senses.) As a lay person, the veteran's statements or opinions are limited to inferences that are rationally based on the veteran's perception and do not require specialized education, training, or experience. In this case, while the Veteran is competent to describe his symptoms and the events surrounding the VA surgeries and treatment beginning in April 1996, the question of fault on the part of VA or the question of additional disability not reasonable foreseeable are not simple medical conditions that can be determined by the Veteran based on inferences gained by his own personal knowledge, that is, perceived through the use of his senses without specialized knowledge, education, or experience. Further, it is not argued or shown that the Veteran is otherwise qualified through specialized education, training, or experience to offer an opinion on the question of fault on the part of VA or the question of additional disability due to an event not reasonably foreseeable. For these reasons, the Board rejects the Veteran's lay statements and opinion as competent evidence to substantiate the claims. In short, there is no competent, independent medical evidence to support the Veteran's assertions regarding questions of fault on the part of VA or on an event not reasonably foreseeable. As there is no favorable competent evidence to support the claims as articulated above, the preponderance of the evidence is against the claims for VA disability compensation under 38 U.S.C.A. § 1151 for coronary artery disease and peripheral vascular disease as the result of VA treatment in 1996 and thereafter, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). ORDER VA disability compensation under 38 U.S.C.A. § 1151 for coronary artery disease, status post aortofemoral bypass, is denied. VA disability compensation under 38 U.S.C.A. § 1151 for peripheral vascular disease with impotence, claudication, and clots is denied. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs