Citation Nr: 1326715 Decision Date: 08/21/13 Archive Date: 08/29/13 DOCKET NO. 05-35 228 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected disability. 2. Entitlement to service connection for heart disease, to include as secondary to service-connected disability. 3. Entitlement to service connection for ventral hernia, to include as secondary to service-connected disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD S. M. Kreitlow INTRODUCTION The Veteran had active service from December 1965 to December 1967. This matter came before the Board of Veterans' Appeals (Board) on appeal from a decision August 2004 by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The Board notes that, in this rating decision, the RO denied reopening a previously denied claim for service connection for obstructive sleep apnea. In a December 2009 decision, the Board found that new and material evidence had been submitted and reopened this claim. Consequently, the issue currently before the Board is for a decision on the merits of the claim. In December 2009 and November 2011, the Board remanded the issues on appeal for additional development and due process concerns. At this time, the Board finds that the prior remands have been substantially complied with; therefore, the Board may proceed forward with adjudicating the Veteran's claims. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Finally, the Board notes that the Veteran had requested hearings before both the RO and the Board; however, he cancelled the hearing scheduled at the RO and withdrew his request for a hearing before the Board. Consequently, the Board finds that VA has met its obligation to provide the Veteran with a hearing and no further efforts need to be made to do so. In the Veteran's March 2004 claim, he stated that he has two hernias. The medical evidence shows that, in March 2004, the Veteran was diagnosed by his primary care physician to have a left inguinal hernia in addition to a previously diagnosed ventral hernia. The Board notes that only the issue of service connection for a ventral hernia has been adjudicated. The issue of service connection for a left inguinal hernia has, therefore, been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran's obstructive sleep apnea is neither related to his military service nor is it proximately due to, related to or been aggravated by any service-connected disability. 2. The Veteran has non-ischemic dilated cardiomyopathy that is neither related to his military service nor is it proximately due to, related to or been aggravated by any service-connected disability. 3. The Veteran's ventral hernia is neither related to his military service nor is it proximately due to, related to or been aggravated by any service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for obstructive sleep apnea , to include as secondary to service-connected disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116, 1131, 1137, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2012). 2. The criteria for service connection non-ischemic cardiomyopathy, to include as secondary to service-connected disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116, 1131, 1137, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2012). 3. The criteria for service connection for a ventral hernia, to include as secondary to service-connected disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116, 1131, 1137, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Requirements VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Appropriate notice was provided in June 2004 and March 2006. The claims were subsequently readjudicated, most recently in an October 2012 supplemental statement of the case. Mayfield, 444 F.3d at 1333. With respect to VA's duty to assist, VA is only required to make reasonable efforts to obtain relevant records that the veteran has adequately identified to VA. 38 U.S.C.A. § 5103A(b)(1). All efforts have been made to obtain relevant, identified and available evidence, and VA has notified the Veteran of any evidence that could not be obtained. The Board notes that the RO attempted to obtain Social Security Administration records; however, was advised that no records were available. In January 2009, a formal finding of unavailability of Social Security Administration records was made and the Veteran was notified of such finding. VA, therefore, has made every reasonable effort to obtain all records relevant to the Veteran's claims. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. The Veteran was afforded VA examination on his claims in February 2010. Additional medical opinions were obtained in December 2011 and March 2013. The Board finds, when taken as a whole, the reports of the examination and medical opinions reflect that the examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate physical examinations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board, therefore, concludes that these reports are adequate for purposes of rendering a decision in the instant appeal. See 38 C.F.R. § 4.2; see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran and his representative have not contended otherwise. Thus, the Board finds that VA has satisfied its duties to inform and assist the Veteran at every stage of this case. Additional efforts to assist or notify him would serve no useful purpose. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to establish direct service connection for a disorder, there must be (1) medical evidence of the current disability; (2) medical, or in certain circumstances, lay evidence of the in-service incurrence of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); See Walker v. Shinseki, 708 F.3d 1331, 1334 (Fed. Cir. 2013). Subsection (a) also refers to "each disabling condition...for which [a veteran] seeks a service connection" and states that "[d]eterminations as to service connection will be based on review of the entire evidence of record." Walker at 1334. A second way to establish direct service connection is set forth in § 3.303(b). In Walker, the Court of Appeals for the Federal Circuit (Federal Circuit) found that, unlike subsection (a), which is not limited to any specific condition, subsection (b) is restricted to chronic diseases. "If a veteran can prove a chronic disease 'shown in service,' and there are no intercurrent causes, the manifestations of the chronic disease present at the time the veteran seeks benefits establish service connection for the chronic disease. By treating all subsequent manifestations as service-connected, the veteran is relieved of the requirement to show a causal relationship between the condition in service and the condition for which disability compensation is sought. In short, there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. at 1335-36. In addition, the Federal Circuit found that subsection (b) provides a second route by which service connection can be established for a chronic disease, which is if "evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not 'shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,' i.e., 'when the fact of chronicity in service is not adequately supported,' then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Id. at 1336. Furthermore, the Federal Circuit held that that the term "chronic disease" as set forth in subsection (b) is properly interpreted as being constrained by § 3.309(a) in that the regulation is only available to establish service connection for the specific chronic diseases listed in § 3.309(a) regardless of the point in time when a veteran's chronic disease is either shown or noted. Id. at 1336-39. In addition, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc), reconciling, Leopoldo v. Brown, 4 Vet. App. 216 (1993), and Tobin v. Derwinski, 2 Vet. App. 34 (1991). Thus, service connection on a secondary basis may be granted under one of two conditions. The first is when the disorder is proximately due to or the result of a disorder of service origin. In that case, all symptomatology resulting from the secondary disorder will be considered in rating the disability. The second is when a service-connected disability aggravates a nonservice-connected disability. In those cases, VA may only consider the degree of disability over and above the degree of disability prior to the aggravation. During the course of this appeal, VA amended 38 C.F.R. § 3.310 effective October 10, 2006). See 71 Fed. Reg. 52,744 -47 (Sept. 7, 2006). The amended 38 C.F.R. § 3.310 (b) institutes additional evidentiary requirements and hurdles that must be satisfied before aggravation may be conceded and service connection granted. To whatever extent the revised regulation may be more restrictive than the previous one, the Board will afford the Veteran review under both the old and new versions. See VAOPGCPREC 7-2003 (Nov. 19, 2003). In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability benefits. Medical evidence of a current disability and nexus is not always required to establish service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Lay 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. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("Although interest may affect the credibility of testimony, it does not affect competency to testify."). Obstructive Sleep Apnea The Veteran claims that he was treated in service for breathing problems and underwent surgery on his nose while in service to clear his nasal passages. He also claims that his obstructive sleep apnea is secondary to his PTSD or medication he takes for it (Wellbutrin). The Veteran's pre-induction examination reports from September 1965 demonstrate that he reported he had surgery for a deviated septum in 1962; however, no defect of the nose was noted on examination. In January 1966, the Veteran was seen at the Fort Benning dispensary with complaints of difficulty breathing through his nose. It appears the Veteran reported having a deviated septum with constant post nasal drip and history of surgery four years before. Physical examination was noted to show a septum deviated to the left. He was seen again on July 20, 1966, and referred to the Ear, Nose and Throat Clinic for evaluation. The note of that evaluation indicates the Veteran reported nasal obstruction since having a SMR (submucous resection) four years before and that he desired revision. After examination, a SMR and rhinoplasty were recommended. On August 18, 1966, the Veteran underwent a septectomy and rhinoplasty for "deformity, nasal, with nasal obstruction." Follow up treatment notes through October 1966 indicate the Veteran did well post surgically. The final treatment note from October 24, 1966 states, "Doing well. Airway good. No problems." The Veteran's separation examination reports from December 1967 show that the surgery for deviated septum was noted but no abnormality was noted. Although there was treatment for a deviated septum with nasal obstruction in service, the service treatment records fail to demonstrate that there was a diagnosis of obstructive sleep apnea rendered at that time. Furthermore, if the Veteran's deviated septum was considered to have pre-existed prior to his entry into service, the surgery conducted in August 1966 was meant to ameliorate this problem and the subsequent treatment records appear to demonstrate that it did so as no further problems were noted and his airway was noted to be good. Consequently, the evidence does not show aggravation of any pre-existing deviated septum. As for the Veteran's obstructive sleep apnea, he reports that it was first diagnosed in 1984 by a sleep study done at the VA Medical Center in Long Beach, California. The RO, however, was unable to obtain any such records despite several efforts. The claims file does, however, contain a sleep study conducted in December 1998 that shows the Veteran was found to have severe obstructive sleep apnea with successful CPAP titration to 17 cms of water. Alternatives to the use of nasal CPAP suggested was use of a mandibular repositioning device or surgery aimed at the level of obstruction of the upper airway. VA treatment records since February 2002 also indicate the Veteran has a diagnosis of severe obstructive sleep apnea with poor CPAP compliance. These records do not, however, demonstrate that any of the Veteran's treating physicians have related the Veteran's obstructive sleep apnea to his prior surgery in service for a deviated septum with obstruction or to his service-connected PTSD as he has claimed. Furthermore, the Veteran underwent VA examination in February 2010. As a result of that examination, after examining the Veteran and reviewing the claims file, the examiner opined that the Veteran's obstructive sleep apnea was not incurred in service or aggravated by service related disorders, including PTSD. The examiner's rationale for this opinion was that the Veteran was diagnosed with obstructive sleep apnea in 1987, service treatment records did not show any evidence of snoring, disrupted sleep, and apnea episodes during service, evidence of record showed that he had deviated nasal septum status post surgery prior to entry into active duty but not sleep apnea. In its November 2011 remand, the Board found the rationale for this medical opinion to be inadequate and requested that the claims file be returned to the examiner (or to another appropriate VA reviewer) for clarification of the examiner's rationale and to address the effect of the in-service rhinoplasty. In December 2012, a different VA examiner provided a new medical opinion with rationale after review of the prior examination report and the claims file. This examiner opined that it was less likely than not that the Veteran's obstructive sleep apnea was incurred in or caused by the claimed in-service injury, event or illness. His rationale was that the single most common risk factor for obstructive sleep apnea is an obese body habitus, which results in an anatomical crowding of one's airway due to soft tissue from a large neck circumference. The Veteran's last measured body mass index (BMI) on September 21, 2011 was 32, whereas normal BMI is less than 25. A review of his records shows that he has consistently had a BMI in the low-mid 30s. The examiner stated that an obese body habitus is not related to service. Furthermore the examiner stated that the Veteran had a deviated nasal septum status post surgery in 1962 - three years prior to entering service. Despite this fact, his service treatment records did not show any evidence of snoring, disrupted sleep, or apneic episodes during service. He had a redo surgery (septectomy and rhinoplasty) in the service on August 18, 1966 because he felt he was still having nasal blockage. The examiner stated that this procedure, if anything, would have helped his symptoms - not made them worse. Additionally, rhinoplasty does not cause obesity, which this Veteran suffers from. Lastly, the examiner stated that the Veteran's obstructive sleep apnea was diagnosed by sleep test conducted in 1987 - 21 years after his rhinoplasty. The examiner concluded that there is no correlation whatsoever to any events in the service to his diagnosis of obstructive sleep apnea made more than two decades later. His obstructive sleep apnea, as is the case in most everyone, is due to his obesity (BMI 32) causing anatomical soft tissue crowding in his airway. The Veteran's claim was again denied and returned to the Board. In November 2012, the Board requested a VHA medical expert opinion because, although the December 2011 VA examiner explained why the Veteran's obstructive sleep apnea was not directly related to service, he failed to provide a rationale as to why it was not aggravated by the Veteran's PTSD or GERD. The Board notes that the initial medical opinion received in December 2012 was inadequate as the language used by the VHA medical expert was confusing. Consequently, the Board requested clarification in February 2013. It obtained a new report from the VHA medical expert in March 2013. In this report, the VHA medical expert opined that it is "very unlikely that the service-connected PTSD or GERD aggravated or caused the Veteran's obstructive sleep apnea. He explained that sleep apnea is commonly from obesity and in patients with a big neck circumference and from crowding of upper airways. GERD and PTSD have no role in aggravation or causality of sleep apnea. The Veteran has been obese, that is had a BMI of more than 30, during the time he was diagnosed with sleep apnea. Normal BMI is less than 25. The Veteran has submitted no opposing medical opinions except his own statements that his obstructive sleep apnea is related to or been aggravated by his PTSD, or is related to the deviated nasal septum and surgery he had in service. The Veteran is competent to provide testimony concerning factual matters of which he has firsthand knowledge. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Further, under certain circumstances, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although the Veteran is capable of observing that he had a deviated nasal septum and nasal blockage in service and that he has disrupted sleep, he is not capable of observing that he had snoring and apneic events during service as he would have been asleep during those events. The Board notes that the Veteran has not submitted any lay statements from others who would have witnessed such events in support of his claim, which would help to establish that he had symptoms of obstructive sleep apnea in service. Moreover, the presence of obstructive sleep apnea and its etiology is a determination "medical in nature" and not capable of lay observation. Since most symptoms occur while a person is asleep, although suspected by symptom reports and inspection by a doctor of one's body habitus, a diagnosis of obstructive sleep apnea is confirmed by the performance of a sleep study (otherwise known as a polysomnography). Since a layperson lacks medical knowledge, he or she is generally not deemed competent to opine on a matter that requires medical knowledge, such as the question of whether a chronic disability is currently present or a determination of etiology. See 38 C.F.R. § 3.159(a)(1) (Competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements or opinions. Therefore, the Board finds that, in so far as the Veteran's lay statements opine that his obstructive sleep apnea either had its onset in service or is related to a service-connected disability such as PTSD or GERD, his statements are not probative to establish a nexus relationship between his obstructive sleep apnea and his military service or the etiology of it as he lacks the medical knowledge to make such opinions. Consequently, after weighing all the evidence of record, the Board finds that the preponderance of the evidence is against finding that the Veteran's obstructive sleep apnea is either related to his military service or is proximately due to, the result of or been aggravated by service-connected disability because the overwhelming competent, credible and probative evidence of record is against the claim. The only competent and probative medical opinions of record establish that it is less likely than not that the Veteran's obstructive sleep apnea is either related to service (specifically to the surgery for a deviated nasal septum in service because such ameliorated this pre-existing condition) or is secondary to the service-connected disabilities of PTSD or GERD because neither would have a role in causing or aggravating the cause of the Veteran's obstructive sleep apnea, which is his obesity, large neck circumference and crowding of the upper airways. Furthermore, there is nothing in the service treatment records to indicate the Veteran had symptoms of obstructive sleep apnea at that time, and, at the earliest, he was diagnosed to have obstructive sleep apnea in the mid to late 1980s, approximately 20 years after his discharge. The absence of symptoms of obstructive sleep apnea in the service treatment records or of persistent symptoms at separation, along with the first evidence of obstructive sleep apnea being many years later, constitutes negative evidence tending to disprove the assertion that the Veteran's obstructive sleep apnea was present during service. See Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact); see also Maxson v. West, 12 Vet. App. 453 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint can be considered as a factor, along with other factors concerning the veteran's health and medical treatment during and after military service). Finally, with regard to the Veteran's claim that his obstructive sleep apnea is aggravated by his PTSD or GERD, the treatment records show that both conditions have been essentially stable since 2003. In fact, he reported in 2004 that, although he had nightmares of Vietnam on and off, his sleep is mostly disturbed by his medical problems. At this same time, the Board notes that the VA treatment records demonstrate that it had been recommended that the Veteran undergo surgery (an uvulopalatopharyngoplasty) for his obstructive sleep apnea since he had such difficulties using the CPAP machine; however, than his heart troubles began in October 2003 and his physicians recommended a tracheotomy instead. The Board notes, however, that the Veteran has not had either procedure and appears to continue trying to use the CPAP machine. Furthermore, the medical evidence shows his obstructive sleep apnea symptoms have consistently been reported on sleep study to be reduced by no more than 17 cms of water pressure, which is an indication that his obstructive sleep apnea has not worsened. Thus, the VA treatment records appear to demonstrate an improvement in the Veteran's PTSD symptoms while simultaneously a worsening (or, at the very least, a continuance of the same severity) of his obstructive sleep apnea. As for his GERD, the VA treatment records show that it has been stable on Aciphex since 2002. More importantly, there is nothing in the record to demonstrate that the Veteran's GERD has had any effect on his obstructive sleep apnea. Thus, the medical evidence of record fails to demonstrate that the Veteran's obstructive sleep apnea has been either caused or aggravated by his PTSD or GERD. In conclusion, the Board finds that the preponderance of the evidence is against the claim for service connection for obstructive sleep apnea. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Service connection for obstructive sleep apnea is, therefore, denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Heart Disease At first, the Veteran claimed that his congestive heart failure was the result of his obstructive sleep apnea. Later on, however, the Veteran claimed that his current heart disease is the result of either his service-connected PTSD (or medication taken therefor) or GERD. In so much as the Veteran has claimed and the evidence may show a relationship exists between the Veteran's obstructive sleep apnea and his current heart disease, service connection for obstructive sleep apnea has not been established and, consequently, service connection on a secondary basis for heart disease related to obstructive sleep apnea is not warranted. The record shows that, in October 2003, the Veteran presented to the VA Medical Center in Long Beach, California, with a history of fluid retention for 7 to 10 days. He had swelling of his feet and abdomen, shortness of breath, and orthopnea. He had not urinated for three days. He reported one prior episode of fluid retention about eight months before that resolved with the use of a diuretic. On physical examination, it was noted that the Veteran had gained 20 pounds since he was seen in Primary Care a month before. He had tachycardia at 102 beats per minute, 3+ lower extremity edema, and course rales in the posterior bases of his lungs. He was noted to be shortness of breath with conversation and mild activity but without cough. Electrocardiogram (EKG) showed normal sinus rhythm with first degree atrioventricular block with occasional premature ventricular contractions, left axis deviation, incomplete left bundle branch block and non-specific T wave abnormality. A chest X-ray showed a questionable prominence of the pulmonary vasculature, a tiny right pleural effusion versus pleural thickening, and no frank pulmonary edema. The Veteran was placed on Furosemide (a diuretic) 40 mg twice a day for three days, and then once a day in the morning thereafter. He was seen for follow up a week later (November 7, 2003) and was assessed to have congestive heart failure, resolving. In January 2004, the Veteran underwent consultation with VA Cardiology. Risk factors for heart disease were noted to include hypertension; tobacco use - quit in 1998 but used one pack per week for about 25 years; obesity; positive family history for coronary artery disease (father expired at 72 years of an acute myocardial infarction); and sleep apnea. Physical examination was essentially normal except for trace edema of the bilateral lower extremities. A two dimension echocardiogram conducted showed the following: (1) Dilated left ventricle with severe systolic dysfunction, ejection fraction of 20 percent; cardiac output of three liters per minute (normal sinus rhythm of 86); restrictive diastolic filling pattern with elevated end diastolic pressure; no obvious thrombi. (2) Mild right ventricular dilation with elevated end diastolic pressure ("B" on TV). Probable reduced right ventricle systolic function. (3) Biatrial enlargement. Dilated inferior vena cava (24mm) with poor respiratory variation. Right atrial pressure 10mmHg. Moderate pulmonary hypertension (RVSP 47mmHg). Normal appearing coronary sinus. (4) Normal mitral, aortic, tricuspid and pulmonic valves. Moderate mitral and tricuspid regurgitation. No other valvular insufficiency. (5) No pericardial effusion. No obvious intracardiac masses or shunts. After reviewing the echocardiogram with the prior EKG and chest X-rays performed in November 2003, the impression was ischemic heart disease versus hypertensive heart disease versus idiopathic cardiomyopathy. A nuclear stress test (MIBI) conducted in February 2004 was clinically negative for ischemia. An April 2004 Cardiology note indicates a diagnosis of cardiomyopathy. The service treatment records are silent for any complaints of, treatment for or diagnosis of any heart disease. Furthermore, post-service treatment records are silent for any diagnosis of heart disease until October 2003 when the Veteran had his first episode of congestive heart failure. On VA examination in February 2010, after reviewing the claims file (along with the diagnostic studies previously conducted at VA) and examining the Veteran, the examiner diagnosed him to have congestive heart failure due to non-ischemic cardiomyopathy, which is compensated. The examiner opined, however, that the Veteran's heart disease was not incurred in service or caused or aggravated by a service-connected disorder to include PTSD. His rationale was that the service treatment records are silent for evidence of heart disease in service and the evidence shows he developed symptoms of heart failure in October 2003. In its November 2011 remand, the Board found the rationale for this medical opinion to be inadequate and requested that the claims file be returned to the examiner (or to another appropriate VA reviewer) for clarification of the examiner's rationale. In December 2012, a different VA examiner provided a new medical opinion with rationale after review of the prior examination report and the claims file. This examiner opined that it was less likely than not that the Veteran's heart disease was proximately due to or the result of the Veteran's service-connected condition. His rationale was that the Veteran has non-ischemic dilated cardiomyopathy. He stated that dilated cardiomyopathy can be caused by a variety of disorders and, in many cases, no etiology can be found and that the cardiomyopathy is deemed idiopathic. Citing to a study excerpted from UpToDate (a medical treatise), he set forth that the relative frequency of the different causes in patients with initially unexplained cardiomyopathy was assessed in a review of 1,230 patients, the results as follows: Idiopathic - 50 percent Myocarditis - 9 percent Ischemic heart disease - 7 percent Infiltrative disease - 5 percent ` Peripartum cardiomyopathy - 4 percent Hypertension - 4 percent HIV infection - 4 percent Connective tissue disease - 3 percent Substance abuse - 3 percent Doxorubicin - 1 percent Other - 10 percent Consequently, the examiner stated that "GERD (which causes acid reflux in the lower esophagus) and PTSD (a mental health disorder) are NOT etiologies for non-ischemic dilated cardiomyopathy or any other heart condition." The Veteran's claim was again denied and returned to the Board. In November 2012, the Board requested a VHA medical expert opinion because, although the December 2011 VA examiner explained why the Veteran's heart disease was not proximately due to or the result of his PTSD or GERD, he failed to provide a rationale as to why it was not aggravated by these disabilities. The Board notes that the initial medical opinion received in December 2012 was inadequate as the language used by the VHA medical expert was confusing. Consequently, the Board requested clarification in February 2013. It obtained a new report from the VHA medical expert in March 2013. In this report, the VHA medical expert opined that it is "very unlikely that the PTSD or GERD aggravated or caused the Veteran's heart disease." He explained that the Veteran has dilated cardiomyopathy as seen on his echocardiogram, which is not an ischemic cardiomyopathy. He stated that dilated cardiomyopathy is caused by either chemotherapy drugs, alcohol or viruses. He noted that the Veteran's history documented in the medical records mentions heavy use of alcohol and drug use in the past. The Veteran has submitted no opposing medical opinions except his own statements that his heart disease is related to his PTSD (or medication taken therefor) or his GERD. The Veteran is competent to provide testimony concerning factual matters of which he has firsthand knowledge. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Further, under certain circumstances, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although the Veteran is capable of observing the various symptoms of his PTSD, GERD and heart disease, he is not capable of providing a medical opinion as to a relationship between his heart disease and either his PTSD, medication taken for his PTSD, or his GERD because the question of the etiology of his current heart disease is a determination "medical in nature" and not capable of lay observation. Since a layperson lacks medical knowledge, he or she is generally not deemed competent to opine on matters that require medical knowledge, such as the question of whether a chronic disability is currently present or a determination of etiology. See 38 C.F.R. § 3.159(a)(1) (Competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements or opinions. Therefore, the Board finds that, in so far as the Veteran's lay statements opine that his current heart disease is related to either his service-connected PTSD or GERD, his statements are not probative to establish a nexus relationship because, as a lay person, he lacks the medical knowledge to make such opinions. As for the medical articles that the Veteran submitted in support of his claim, a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998). The articles submitted by the Veteran were not accompanied by the opinion of any medical expert linking the Veteran's non-ischemic dilated heart disease to his PTSD, medication taken for his PTSD or his GERD. Thus, the medical articles submitted are insufficient alone to establish the required medical nexus. Consequently, after weighing all the evidence of record, the Board finds that the preponderance of the evidence is against finding that the Veteran's current heart disease (diagnosed as non-ischemic dilated cardiomyopathy) is either related to his military service or is proximately due to, the result of or been aggravated by service-connected disability because the overwhelming competent, credible and probative evidence of record is against the claim. The only competent and probative medical opinions of record establish that it is less likely than not that the Veteran's non-ischemic dilated cardiomyopathy is either related to service or is secondary to either of the service-connected disabilities of PTSD or GERD as neither one are recognized as a possible etiology for non-ischemic dilated cardiomyopathy. In fact, the VHA medical expert appears to opine that the most likely etiology would be the Veteran's past history of alcohol and drug use (which is fully documented in the record). Furthermore, there is nothing in the service treatment records to indicate the Veteran had any heart disease at that time, and, at the earliest, he had symptoms of heart disease in October 2003, approximately 36 years after his discharge. The absence of symptoms of heart disease in the service treatment records or of persistent symptoms at separation, along with the first evidence being many years later, constitutes negative evidence tending to disprove the assertion that the Veteran's non-ischemic dilated cardiomyopathy was present during service. See Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact); see also Maxson v. West, 12 Vet. App. 453 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint can be considered as a factor, along with other factors concerning the veteran's health and medical treatment during and after military service). Finally, with regard to the Veteran's claim that his heart disease is secondary to his PTSD or GERD, the treatment records show that both conditions have been essentially stable since approximately 2003. In fact, with regard to his PTSD, he reported in 2004 that, although he had nightmares of Vietnam on and off, his sleep was mostly disturbed by his medical problems (of which his heart problems was the major one reported). At this same time, the VA treatment records demonstrate that the initial onset of congestive heart failure was in October 2003 and, although most of his symptoms had resolved, he continued to undergo work up to determine the etiology of it, which turned out to be established in April 2004 as non-ischemic dilated cardiomyopathy. Thus, the VA treatment records appear to demonstrate an improvement in the Veteran's PTSD and GERD symptoms while simultaneously the onset of his heart disease. More importantly, there is nothing in the VA treatment records to demonstrate that the Veteran's PTSD or GERD was thought to be the cause of the Veteran's cardiomyopathy or that they had had any effect on his heart problems. Thus, the VA treatment records fail to demonstrate that the Veteran's current heart disease is proximately due to, the result of or been aggravated by either his PTSD or GERD. In conclusion, the Board finds that the preponderance of the evidence is against the claim for service connection for non-ischemic dilated cardiomyopathy. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Service connection for non-ischemic dilated cardiomyopathy is, therefore, denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Ventral Hernia The Veteran initially contended that his ventral hernia was the result of coughing caused or aggravated by his congestive heart failure. Subsequently, he claimed it was related to either his service-connected PTSD or GERD. In so much as the Veteran has claimed that a relationship exists between the Veteran's current heart disease and his ventral hernia, service connection for heart disease has not been established and, consequently, service connection on a secondary basis for a ventral hernia as related thereto would not be warranted. The first evidence of record that the Veteran had a ventral hernia is the report of a December 2002 VA examination that he had relating to his GERD. On physical examination of the abdomen, a ventral hernia was noted of approximately 14x8 cms. in size. It was without obstruction or incarceration. There was noted evidence of diastasis recti. Subsequently, the VA treatment records show the Veteran's first complaints relating to the ventral hernia were not until September 2003 when he was seen by his primary care physician for a follow up visit and complained it was getting bigger and requested surgical evaluation. In December 2003, the Veteran underwent surgical evaluation and it was noted he had an upper abdominal diastasis with no risk of incarceration. Since the Veteran was still dealing with his heart problems at that time, surgery was not recommended until his medical problems had improved. At a VA examination in February 2010, the Veteran reported that he developed protrusion of the abdomen in about 2000 and was noticed to have diastasis of the rectus muscle in 2003. He reported this worsened after he developed congestive heart failure and currently it would pop out when he tries to get up from lying down or sitting. He denied any pain or constipation. On physical examination, it was noted that a ventral hernia was present in the mid-line of about 4 cms. in size. It was operable but had not been repaired. In concluding, the examiner noted that the Veteran has a diastasis of the rectus muscles which is a weakening of the anterior abdominal wall muscles. He opined that this condition is not related to peptic ulcer disease or GERD. Therefore, it is not caused or aggravated by service or a service-connected disorder including PTSD. In its November 2011 remand, the Board found the rationale for this medical opinion to be inadequate and requested that the claims file be returned to the examiner (or to another appropriate VA reviewer) for clarification of the examiner's rationale. In December 2012, a different VA examiner provided a new medical opinion with rationale after review of the prior examination report and the claims file. This examiner opined that it was less likely than not that the Veteran's ventral hernia was proximately due to or the result of the Veteran's service-connected conditions. His rationale was that ventral hernias result from defects in the abdominal wall. They are typically classified by etiology and location. Ventral hernias can develop as a result of prior surgery (incisional) or spontaneously (umbilical, epigastric, Spigelian, or lumbar hernias). He concluded by saying that "GERD (which causes acid reflux in the lower esophagus) and PTSD (a mental health disorder) do not result in anatomical defects in one's abdominal wall, and therefore are NOT etiologies for ventral or any other type of hernia." The Veteran's claim was again denied and returned to the Board. In November 2012, the Board requested a VHA medical expert opinion because, although the December 2011 VA examiner explained why the Veteran's ventral hernia was not proximately due to or the result of his PTSD or GERD, he failed to provide a rationale as to why it was not aggravated by these disabilities. The initial medical opinion received in December 2012 was inadequate as the language used by the VHA medical expert was confusing. Consequently, the Board requested clarification in February 2013. It obtained a new report from the VHA medical expert in March 2013. In this report, the VHA medical expert opined that it is "unlikely that PTSD or GERD aggravated or caused his ventral hernia. Ventral hernia is caused by weakness of the anterior abdominal muscles. GERD and PTSD have no role in this anatomical disorder." The Veteran has submitted no opposing medical opinions except his own statements that his ventral hernia is related to his PTSD or GERD. The Veteran is competent to provide testimony concerning factual matters of which he has firsthand knowledge. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Further, under certain circumstances, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although the Veteran is capable of observing the various symptoms of his PTSD, GERD and ventral hernia, he is not capable of providing a medical opinion as to a relationship between his ventral hernia and either his PTSD or GERD because the question of the etiology of his ventral hernia is a determination "medical in nature" and not capable of lay observation. Since a layperson lacks medical knowledge, he or she is generally not deemed competent to opine on matters that require medical knowledge, such as the question of whether a chronic disability is currently present or a determination of etiology. See 38 C.F.R. § 3.159(a)(1) (Competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements or opinions. Therefore, the Board finds that, in so far as the Veteran's lay statements opine that his ventral hernia is related to either his service-connected PTSD or GERD, his statements are not probative to establish a nexus relationship because, as a lay person, he lacks the medical knowledge to make such opinion. Consequently, after weighing all the evidence of record, the Board finds that the preponderance of the evidence is against finding that the Veteran's ventral hernia is either related to his military service or is proximately due to, the result of or been aggravated by service-connected disability because the overwhelming competent, credible and probative evidence of record is against the claim. The only competent and probative medical opinions of record establish that it is less likely than not that the Veteran's ventral hernia is either related to service or is secondary to either of the service-connected disabilities of PTSD or GERD as neither one are recognized as a possible etiology or an aggravating factor. Furthermore, there is nothing in the service treatment records to indicate the Veteran had a ventral hernia at that time, and the earliest post-service evidence of the presence of the ventral hernia was the 2002 VA examination, which was approximately 35 years after his discharge. The absence of symptoms or finding of a ventral hernia in the service treatment records or of persistent symptoms at separation, along with the first evidence being many years later, constitutes negative evidence tending to disprove the assertion that the Veteran's ventral hernia was present during service. See Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact); see also Maxson v. West, 12 Vet. App. 453 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint can be considered as a factor, along with other factors concerning the veteran's health and medical treatment during and after military service). Finally, with regard to the Veteran's claim that his ventral hernia is secondary to his PTSD or GERD, the Board notes that the VA treatment records show that both conditions have been essentially stable since at least 2003. The Veteran has made statements that his congestive heart failure worsened his ventral hernia; however, the VA treatment records fail to show any worsening. In fact, the Veteran initially complained of the ventral hernia worsening to his VA physician in September 2003, a month before the initial onset of his congestive heart failure in October 2003. At the December 2003 surgical consult, there was no indication that there was any worsening in the ventral hernia as a result of the Veteran's episode of congestive heart failure in October. Furthermore, the Board notes that it appears that the ventral hernia has gotten smaller. At the 2002 VA examination when it was first noted, the examiner stated its size was 14x8 cms.; however, at the 2010 VA examination, it was noted to measure only 4 cms. Thus, the medical evidence appears to demonstrate an improvement in the Veteran's ventral hernia instead of a worsening. The Board further notes that, as of the February 2010 VA examination, the Veteran had not had this hernia repaired although he did have repair of a left inguinal hernia in February 2005. More importantly, there is nothing in the VA treatment records or other medical evidence of record to demonstrate that the Veteran's PTSD or GERD was thought to be the cause of the Veteran's ventral hernia or that they had had any effect on it. Thus, the medical evidence of record fails to demonstrate that the Veteran's ventral hernia is proximately due to, the result of or has been aggravated by either his PTSD or GERD. In conclusion, the Board finds that the preponderance of the evidence is against the claim for service connection for a ventral hernia. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Service connection for a ventral hernia is, therefore, denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected disability, is denied. Entitlement to service connection for heart disease, to include as secondary to service-connected disability, is denied. Entitlement to service connection for ventral hernia, to include as secondary to service-connected disability, is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs