Citation Nr: 1327280 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 07-27 826 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability of hypertension claimed to be the result of being prescribed an improper dosage of thyroid medication at the Department of Veterans Affairs (VA) Community Based Outpatient Clinic (CBOC) in Logan, West Virginia. 2. Entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability of vision problems claimed to be the result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia. 3. Entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability of tinnitus claimed to be the result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD D. Whitehead, Counsel INTRODUCTION The Veteran served on active duty from June 1964 to June 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. In July 2008, the Veteran testified before a Decision Review Officer during a hearing held at the RO. The Veteran and his wife also testified during a Travel Board hearing at the RO conducted by Kathleen K. Gallagher, a Veterans Law Judge who was designated by the Chairman to conduct the hearing pursuant to 38 U.S.C.A. § 7107(c), (e)(2) and who is rendering a determination in this case. Transcripts of these hearings have been associated with the claims file. The case was most recently before the Board in October 2012, at which time the Board remanded the claims to the RO via the Appeals Management Center (AMC) for additional development and adjudicative action. The case has now been returned to the Board for appellate review. FINDINGS OF FACT 1. The probative and persuasive evidence of record does not show that the Veteran has an additional disability of hypertension as a result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia. 2. The probative and persuasive evidence of record does not show that the Veteran has an additional disability of vision problems as a result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia. 3. The probative and persuasive evidence of record does not show that the Veteran has an additional disability of tinnitus as a result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia. CONCLUSIONS OF LAW 1. The requirements for entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability of hypertension claimed to be the result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia have not been met. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. §§ 3.3102, 3.159, 3.361 (2012). 2. The requirements for entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability of vision problems claimed to be the result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia have not been met. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. §§ 3.3102, 3.159, 3.361 (2012). 3. The requirements for entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability of tinnitus claimed to be the result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia have not been met. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. §§ 3.3102, 3.159, 3.361 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Board finds that the VCAA duty to notify was satisfied by letters sent to the Veteran in December 2006 and June 2010. The letters addressed all of the notice elements. Although the June 2010 letter was sent after the initial unfavorable decision by the agency of original jurisdiction, the claims were later readjudicated, with the most recent adjudication occurring in the February 2013 supplemental statement of the case. Nothing more is required. The Board finds that VA's duty to assist the Veteran has also been satisfied. The Veteran's service treatment records and relevant post-service VA and private medical records are of record. There is no indication in the record that additional, existing evidence relevant to the issues decided herein is available. The Veteran has also been afforded VA examinations and medical opinions have been obtained with respect to his claims. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). With respect to the issues decided herein, the Board finds that the VA opinions obtained in this case are adequate, as they are predicated on a reading of relevant medical records in the Veteran's claims file. The opinions considered all of the pertinent evidence of record, to include the Veteran's medical records and statements, and provide complete rationales for the opinions stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the claims has been met. 38 C.F.R. § 3.159(c)(4). As noted above, the case was previously before the Board. The Board remanded the claims in October 2012 in order to obtain any outstanding medical records and to obtain additional medical opinions regarding whether the Veteran has the claimed additional disabilities as a result of the improper dosage of thyroid medication prescribed by the Logan CBOC. The Veteran's outstanding VA treatment records have been obtained. Additionally, in October and November of 2012, the RO obtained addendum opinions regarding the Veteran's claims. As previously noted, the Board finds the VA medical opinions of record to be adequate with which to decide the Veteran's claims. Thus, the Board finds that the agency of original jurisdiction has substantially complied with the prior remand directives such that no further action is necessary in this regard. See Stegall v. West, 11 Vet. App. 268 (1998). Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Legal Criteria Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Under certain circumstances 38 U.S.C.A. § 1151(a) grants compensation and DIC for a qualifying disability or death of a Veteran in the same manner as if such disability or death were service-connected. See also 38 C.F.R. § 3.361. For claims filed after October 1, 1997, the disability or death must be caused by hospital care, medical or surgical treatment, or examination furnished the veteran by VA, and the proximate cause of the disability or death was (a) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (b) an event that was not reasonably foreseeable. 38 U.S.C.A. § 1151(a)(1); 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 hospital care, medical or surgical treatment, or examination proximately caused a Veteran's additional disability or death, it must be shown that the hospital care or medical or surgical treatment caused the Veteran's additional disability or death; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care or medical or surgical treatment without the Veteran's informed consent. See 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a Veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. 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 the informed consent procedures of 38 C.F.R.§ 17.32. See 38 C.F.R. § 3.361(d)(2). Second, there must be evidence of additional disability, as shown by comparing the Veteran's condition before and after the VA medical care in question. 38 C.F.R. § 3.361(b). In determining whether disability or death resulted from disease or injury or aggravation of an existing disease or injury suffered as a result of VA care, the evidence must show actual causation rather than coincidental occurrence. 38 C.F.R. § 3.361(c)(1). Finally, the disability or death must not be the result of the Veteran's failure to follow properly given medical instructions. 38 U.S.C.A. § 1151(a); 38 C.F.R. § 3.301(c)(3). In adjudicating a claim, the Board determines whether (1) the weight of the evidence supports the claim or, (2) whether the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim. The appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. (1990). Factual Background The Veteran claims that he currently has hypertension, vision problems, and tinnitus because he was prescribed an improper dosage of the thyroid medication Levothyroxine by the VA CBOC in Logan, West Virginia. VA treatment records show that the Veteran was prescribed a dosage of 0.2 milligrams (mg) of the thyroid supplement Levothyroxine, in tablet form, on December 22, 2004. At that time, the Veteran was noted to have a prior medical history significant for hypertension. He also reported experiencing roaring in his ears that began two months prior. The physical examination revealed a blood pressure level of 130/86. Subsequent VA treatment records show that the Veteran's blood pressure was assessed on multiple occasions and was reported as follows: 163/85 (1/05); 140/85 (2/05); 160/90 (2/05);156/98 (2/05); and 131/81 (5/05). Treatment records dated on May 25, 2005, reveal that the Veteran was advised to discontinue his use of the 0.2 mg dosage of Levothyroxine. He was instead prescribed a dosage of 0.025 mg of the medication. A September 2005 private treatment record reflects the Veteran's report of increased "roaring" in his ears and that the Veteran was being seen by private physician for concerns regarding retinopathy. In June 2007, the Veteran underwent a VA examination for his hypertension claim. The physician reviewed the claims file and indicated that the Veteran's hypertension was first diagnosed in 2002. The physician noted that the Veteran was prescribed 0.2 mg of Levothyroid instead of 0.025 mg of the medication from December 2004 until May 2005. Following the clinical examination, the physician opined that the Veteran's hypertension was not caused by, the result of, or aggravated by the accidental treatment with excessive thyroid medication from December 2004 till May 2005. The physician highlighted that the Veteran had hypertension prior to his treatment with the excessive thyroid medication and that his blood pressure was not excessively elevated during the accidental overdose. The physician noted that the Veteran's blood pressure was higher during the present examination than at any time during the time period he was taking the excessive medication. According to the physician, the effects of the thyroid medication were only present while the excessive medication was in the Veteran's body. His thyroid secreting hormone at the time of the examination was normal, and the physician determined that there was no effect on the Veteran's blood pressure. Regarding the Veteran's report of blurry vision and tinnitus, the June 2007 physician noted that these conditions are not mentioned in the literature on hyperthyroidism. The physician noted that Grave disease can cause eye problems, but that would be due to an apparent autoimmune reaction and not due to the increased thyroid hormone. The physician determined that this could not happen in this case. The June 2007 physician further stated that there was no mention of tinnitus or roaring in the ears related to hyperthyroidism. The medical records showed that the Veteran reported experiencing roaring in his ears on the date that the thyroid medication was prescribed. Thus, the physician concluded that the roaring in the ears preexisted the excessive medication dosage and that tinnitus could not be due to the excessive thyroid medication. The June 2007 physician opined that there was no disability caused or aggravated by the accidental increase in the amount of thyroid medication prescribed for the Veteran. He stated that careless would be the only possible problem in this case, which would suggest that the prescribing physician had no regard for the Veteran's safety. The June 2007 physician did not find this to be the case, given that the Veteran's treating physician recognized the error in the prescription and contacted the Veteran to resolve the mistake. The June 2007 physician opined that there was no lack of skill or judgment, error in judgment, or negligence. He characterized the medication error as only a mistake. The physician reiterated that there was no disability that resulted from the medication error. A June 2007 VA eye examination report documents the Veteran's report of blurred vision or diplopia for near vision and intermittent ocular pain for the previous three to four months. The clinical examination revealed stage II hypertensive retinopathy bilaterally, described as arteriole thinning with mild artery/vein (A/V) crossing changes, and bilateral dry eye syndrome. The examiner reported that the Veteran had 20/20 central visual acuity and full visual fields in both eyes. He noted that the Veteran was on Levothyroxine. The examiner concluded that there was no evidence of extraocular muscle restriction, diplopia, or optic nerve compression that could arise from excessive thyroid medication which could induce hyperthyroidism. A June 2007 audiology examination report shows the Veteran's report of experiencing tinnitus for over a year. He also reported a history of military and post-military noise exposure. The Veteran did not report, nor did the examiner address, the Veteran's assertion that his tinnitus was caused or aggravated by the excessive dosage of thyroid medication. In a July 2008 statement, the Veteran's daughter-in-law M.W., a registered pharmacist, reported the possible adverse reactions due to an excessive dosage of a thyroid hormone replacement supplement. M.W. listed the manifestations of excessive dosage or hyperthyroidism, which included eye irritation or inflammation. She reported that excessive dosage causes thyrotoxicosis, which if untreated, could lead to cardiac problems, including angina, atrial fibrillation, heart failure, palpitations, peripheral edema, and sinus tachycardia. M.W. advised that patients receiving an excessive dosage of thyroid hormone needed to be evaluated and treated individually. She did not identify the name of any specific thyroid supplement medication or provide any comments about the facts of the Veteran's case. In statements submitted in support of his claims and during his hearing testimony, the Veteran reiterated his contention that his current hypertension, vision problems, and tinnitus were caused or aggravated by the improper dosage of thyroid medication he received from the Logan CBOC from December 2004 to May 2005. He reported that he experienced a rapid heartbeat while taking the medication, and he expressed his belief that this was evidence of increased blood pressure. The Veteran also stated that his vision was good prior to the excessive dosage of medication, but that following the increased dosage he experienced blurry vision and eye pain. He denied having any problems or ringing in his ears prior to his use of the medication. In October 2010, a VA examiner, Dr. F.U., reviewed the claims file and the Veteran's VA medical records for the purpose of providing an opinion with regards to the hypertension claim. Dr. F.U. noted that the Veteran's hypertension was diagnosed prior to December 22, 2004, based on a review of his medical records. After reviewing the medical literature, the physician stated that Levothyroxine does not cause or aggravate hypertension. Dr. F.U. then opined that it was not carelessness, negligence, a lack of proper skill, error in judgment, or similar instances of fault on behalf of the Logan CBOC in prescribing the Veteran Levothyroxine. The physician stated that the question of foreseeability did not arise because the Veteran was diagnosed with hypertension prior to taking the improper dose of Levothyroxine. An October 2010 VA audiology examination report shows that an additional VA examiner, T.B., reviewed claims file in order to provide an opinion as to the Veteran's tinnitus. The Veteran reported that his tinnitus began years prior and had become progressively worse over the years. He stated that his tinnitus increased in severity after he was prescribed the excessive dosage of Levothyroxine and that it remained constant even after the medication dosage was lowered. The examiner noted that tinnitus is a documented side effect of metabolic abnormalities, and she stated that the possible side effects of an overdose of Levothyroxine can possibly affect tinnitus. The Veteran underwent a VA eye examination in November 2010. The VA optometrist, Dr. D.H., noted that the claims file and the Veteran's medical records were reviewed. The Veteran's eye disorders included venous tortuosity bilaterally, with an A/V ratio of approximately 1/2, and trace macular drusen in both eyes. The optometrist noted that the Veteran was prescribed an excessive dosage of Levothyroxine for approximately six months. He stated that of the numerous bodily functions that may be affected by excessive thyroid dosing, blood pressure was the one that was most likely to have ocular effects. According to Dr. D.H., excessive doses of the hormone have resulted in hypertension, palpitations, stroke, heart attack, and death. He noted that the signs of hypertensive disease in the eye seen in the Veteran's case included sclerosis of the arterioles, demonstrated by the change in the Veteran's A/V ratio. However, Dr. D.H. noted that focal arteriole constriction, crossing defects in the vessels, vessel sheathing, and papilledema were not seen in this case. Based on the examination results, the optometrist determined that the Veteran had a mild amount of early hypertensive retinopathy in the form of vascular alteration. Dr. D.H. stated that it could not be said whether there was a link between the Veteran's thyroid overdosing and his development of vascular changes. The optometrist commented that an argument could be made that in the absence of prior hypertension, the excessive dosage created elevated blood pressure and therefore a narrowing of the retinal arterioles. He also recognized the argument that given the Veteran's age, hypertension was not unexpected and that his retinal vasculature was a result of the naturally occurring systemic hypertension. Dr. D.H. ultimately concluded that the change in the Veteran's eyes had no impact on his vision and did not represent a disability. The Veteran's form of hypertensive retinopathy was not sight threatening and was instead an indication of a systemic condition. The optometrist indicated that he referred to numerous sources when providing his opinion. In October 2012, Dr. D.H. reviewed the claims file and provided clarification for the his previous November 2010 opinion with regards to the Veteran's vision claim. He noted that the previous examinations in June 2007 and November 2010 revealed signs of hypertensive retinopathy, but no signs of a loss of vision or a loss of other visual function. A review of the medical evidence revealed that the Veteran began treatment for hypertension in 2002. Dr. D.H. noted that the mechanism to precipitate hypertensive retinopathy was in place prior to the Veteran receiving the excessive medication dosage from December 2004 to May 2005. He stated that it was conceivable that retinopathy may have existed prior to the date of the VA examinations, although no eye examinations were available at the time of the initiation of the Veteran's antihypertensive therapy and the Levothyroxine overdose. Dr. D.H. concluded that the Veteran's retinopathy did not constitute a disability as it did not cause any loss of vision, loss of other vision function, or suggest the possible future loss of vision provided that his hypertension remained controlled. Based on the time line of the Veteran's hypertension treatment and the subsequent examinations that failed to show that the Levothyroxine overdosing significantly elevated his hypertension, Dr. D.H. opined that it was less likely as not that the Veteran suffered an additional disability or increase in disability, identified as vision problems, as a result of the overdose of Levothyroxine from December 2004 to May 2005. He also opined that it was less likely as not that the Veteran suffered a disability, identified as vision problems, due to the VA's failure to properly prescribe Levothyroxine. The optometrist reiterated his previous conclusion that the Veteran's hypertensive retinopathy did not constitute a disability and was merely an effect of his underlying hypertensive condition. As reflected in a November 2012 addendum report, Dr. F.U. reviewed the claims file and provided an additional opinion as to the Veteran's hypertension claim. The physician reiterated that the review of the medical records showed a diagnosis of hypertension prior to December 22, 2004. Dr. F.U. again stated that the medical literature did not show that Levothyroxine causes or aggravates hypertension. Thus, the physician opined that it was not carelessness, negligence, a lack of proper skill, error in judgment, or similar instance of fault on the part of the Logan CBOC in prescribing the medication. Instead, Dr. F.U. reported the most common causes of essential hypertension, which includes obesity, and noted that the Veteran's body mass index was 30.1 and that he was moderately obese during the time in question. The physician concluded that the Veteran did not suffer a disability attributable to VA's failure to properly prescribe Levothyroxine. Dr. F.U. stated that the question of foreseeability did not arise in this case because the Veteran was diagnosed with hypertension before taking the dosage of Levothyroxine. The physician stated that the 0.2 mg dose of Levothyroxine was not toxic or a high does, and restated that the medication does not cause or aggravate his hypertension. Therefore, Dr. F.U. concluded that the physician who prescribed the medication exercised his proper skill and care in this case. Subsequently, in November 2012, VA physician Dr. S.S., who examined the Veteran in October 2010 for another condition, reviewed the claims file and provided opinions as to the Veteran's claims. Based on a review of the record, the physician stated that the Veteran's hypertension, vision problems, and tinnitus predated the 0.2 mg dosage of Levothyroxine from December 2004 to May 2005. Thus, Dr. S.S. concluded that these disorders were not caused by the medication error of the Logan CBOC and was not related to careless, negligence, a lack of proper skill, error in judgment, or other similar instance of fault on the part of the facility and were instead related to the Veteran's age. The physician also highlighted the previous findings that the Veteran's vascular vision issues were secondary to his hypertension. Regarding foreseeability, Dr. S.S. again highlighted that the Veteran's conditions had their onset prior to the higher dosage of medication that started in December 2004. Dr. S.S. concluded that the Veteran did not suffer a disability, to include hypertension, vision problems, or tinnitus, attributable to the VA's failure to properly prescribe Levothyroxine. The physician highlighted that the Veteran had problems with hypertension and tinnitus prior to when the medication was given in 2004. According to the physician, there would not have been much of a difference if the Veteran was prescribed 0.025 mg or 0.2 mg of Levothyroxine since both doses fall within the therapeutic range of a daily dosing, with 0.3 mg being the daily maximum dose. Thus, the physician concluded that the Veteran did not suffer toxicity relating to an overdose. Dr. S.S. ultimately determined that the additional disabilities claimed by the Veteran are more indicative of age related medical issues and past noise exposure and are less likely a result of the medication given between 2004 and 2005. Analysis In light of the above, the Board finds that entitlement to compensation benefits pursuant to the provisions of 38 U.S.C.A. § 1151 for hypertension, a vision disorder, and tinnitus is not warranted. The weight of the evidence does not show that dosage of Levothyroxine prescribed by the Logan CBOC from December 22, 2004, to May 25, 2005, resulted in any additional disabilities due to either carelessness, negligence, or lack of proper skill, error in judgment, or similar instance of fault on the part of VA or an event not reasonably foreseeable. The Veteran contends that his current hypertension, vision problems, and tinnitus were caused or aggravated the increased dosage of Levothyroxine he was prescribed by the Logan CBOC. The Board acknowledges that the Veteran's VA records confirm that he was prescribed 0.2 mg of the medication from December 22, 2004, until May 25, 2005, at which time the dosage of the medication was decreased to 0.025 mg. The medical evidence of record also shows that the Veteran has current diagnoses of hypertension, hypertensive retinopathy, and tinnitus. The Board highlights, however, that the medical evidence reflects a report of tinnitus and a hypertension diagnosis prior to the Veteran receiving the increased dosage of Levothyroxine beginning in December 2004. Thus, at issue is whether his hypertension and tinnitus are additional disabilities that were aggravated by his treatment with the increased dose of thyroid medication. As for the hypertensive retinopathy diagnosis, the question is whether the condition constitutes an additional disability that was caused or aggravated by the increased dosage of Levothyroxine from December 2004 to May 2005. The most probative evidence on these matters are the January 2007, October 2010, November 2010, October 2012, and November 2012 VA medication opinions discussed above. Collectively, these medical professionals rendered opinions that weigh against the Veteran's claims for benefits under 38 U.S.C.A. § 1151. All of the VA medical professionals who provided probative medical opinions in this case failed to identify an additional disability, to include the claimed disorders, due to the excessive dosage of Levothyroxine prescribed by the Logan CBOC. The June 2007 examiner, and Drs. F.U., D.H., and S.S. essentially opined that there was no additional hypertension, vision disorder, or tinnitus disabilities that were due to a lack of skill, error in judgment, negligence, or similar instances of fault on behalf of the CBOC in prescribing the Veteran the 0.2 mg dosage of the medication. Indeed, the Veteran's hypertension disorder was attributable to his age and/or weight. His vision problems have been attributed to his hypertension, and his tinnitus has been attributed to noise exposure. The Board finds the VA medical opinions to be highly probative and compelling evidence against the Veteran's claim that his hypertension, vision problems, and tinnitus were caused or aggravated by the improper dose of thyroid medication he received from December 2004 to May 2005. See Nieves-Rodriguez, 22 Vet. App. 295, 299-301 (2008) ( "The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches.") quoting Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). There is no competent medical evidence of record to rebut the opinions against the claims or otherwise diminish their probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). In this regard, the Board recognizes the October 2010 opinion provided by the VA audiologist essentially that an overdose of Levothyroxine can possibly affect tinnitus. The Board also points out that the audiologist's use of the words "can possibly" in discussing the possible relationship between the medication and tinnitus makes the statement speculative in nature. See Warren v. Brown, 6 Vet. App. 4, 6 (1993) (finding that a doctor's statement framed in terms such as "could have been" is not probative). Thus, the audiologist's October 2010 opinion is of a lesser probative value as compared to the other medical opinions of record. The Board also acknowledges the conflicting statements offered by Drs. F.U. and D.H. in October and November of 2010 regarding the effect, if any, of Levothyroxine or excessive thyroid dosing on hypertension. Nevertheless, the Board points out that neither physician identified any additional disabilities caused or aggravated by the Veteran's improper dose of the thyroid medication. Thus, any disagreement as to the effect of the thyroid medication does not support the Veteran's claims, as the probative medical evidence still fails to show that he currently has an additional hypertension, vision, or tinnitus disability. In reaching the above determination, the Board has considered the Veteran's statements that the increased dosage of thyroid medication caused or aggravated his hypertension, vision problems, and tinnitus. While the Veteran is competent to describe his experiences and his symptomatology, his statements are not competent evidence to establish that he has any additional disabilities caused by the increased dose of his thyroid medication. The question as to an additional disability and causation does not lie within the range of common experience or common knowledge, but requires special experience or special knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). It is not shown that the Veteran possesses the ability, knowledge, or experience to provide a competent etiological opinion regarding whether he has an additional disability attributable to the increased dosage of thyroid medication he received from December 2004 to May 2005. See Jandreau, 492 1372; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board finds that the Veteran's lay statements in this regard are not competent evidence with which to grant his claims. The Board has also considered the July 2008 statement submitted by the Veteran's daughter-in-law M.W. regarding the possible adverse reactions due to an excessive dosage of thyroid medication. However, her statement does not directly address the facts of the Veteran's case or provide an opinion regarding whether the Veteran has additional disabilities due to his use of an increased dosage of thyroid medication. Thus, M.W.'s statement does not constitute probative evidence and does not support the Veteran's claims for benefits. In summary, the preponderance of the evidence is against claims for entitlement to compensation benefits pursuant to the provisions of 38 U.S.C.A. § 1151 for hypertension, vision problems, and tinnitus. As such, the doctrine of reasonable doubt is not applicable, and the Veteran's claims are denied. ORDER Entitlement to compensation for hypertension under the provisions of 38 U.S.C.A. § 1151 is denied. Entitlement to compensation for vision problems under the provisions of 38 U.S.C.A. § 1151 is denied. Entitlement to compensation for tinnitus under the provisions of 38 U.S.C.A. § 1151 is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs