Citation Nr: 1327330 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 09-13 666 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for systemic lupus erythematosus (lupus), to include as due to herbicide exposure and as secondary to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for seizure disorder as due to lupus. 3. Entitlement to service connection for sleep disorder, to include sleep apnea, as due to lupus. 4. Entitlement to service connection for loss of balance and loss of hand and eye coordination including fine finger movements as due to lupus. 5. Entitlement to service connection for mood disorder (claimed as personality change) as due to lupus. 6. Entitlement to service connection for amnestic disorder (claimed as short-term memory loss and the loss of ability to concentrate) as due to lupus. REPRESENTATION Appellant represented by: Vietnam Era Veterans Association ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from May 1968 to April 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, which, in pertinent part, denied the claims on appeal. In an April 2009 substantive appeal, via a VA Form 9, the Veteran requested a personal hearing before the Board in Washington, DC. In an October 2012 informal hearing presentation, the Veteran's representative noted the Veteran's request to withdraw the hearing request. The Board finds there is no hearing request pending at this time. 38 C.F.R. § 20.702(e) (2012). The issues on appeal were previously remanded by the Board in October 2012 for further evidentiary development to obtain VA examinations for the Veteran's lupus disability and to identify any residuals of lupus. This was accomplished, and the claims were readjudicated in an April 2013 supplemental statement of the case. For this reason, the Board concludes that the Board's remand orders have been substantially complied with, and it may proceed with a decision at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). FINDINGS OF FACT 1. The Veteran has currently diagnosed lupus. 2. The Veteran was exposed to herbicides (Agent Orange) while serving in the Republic of Vietnam. 3. Symptoms relating to lupus were not chronic in service and have not been continuous since service separation 4. Lupus did not manifest in service or to a compensable degree within one year of service separation. 5. Currently diagnosed lupus did not have its onset in service and is not otherwise etiologically related to service, to include in-service exposure to Agent Orange while serving in the Republic of Vietnam. 6. The Veteran's currently diagnosed lupus disability is not caused or aggravated (permanently worsened in severity) by service-connected PTSD. 7. The Veteran's seizure disorder, sleep disorder, loss of balance of hand and eye coordination, mood disorder, and amnestic disorder are not caused or permanently worsened by any service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for lupus, to include as due to herbicide exposure in service and as secondary to service-connected PTSD, have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for seizure disorder as due to lupus have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 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 sleep disorder, to include sleep apnea, as due to lupus have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2012). 4. The criteria for service connection for loss of balance and loss of hand and eye coordination including fine finger movements as due to lupus have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2012). 5. The criteria for service connection for mood disorder (claimed as personality change) as due to lupus have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2012). 6. The criteria for service connection for amnestic disorder (claimed as short-term memory loss and the loss of ability to concentrate) as due to lupus have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 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 Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA 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. The Board finds that the VCAA notice requirements have been satisfied by a March 2008 letter. In this letter, VA informed the Veteran that in order to substantiate a claim for service connection, the evidence needed to show he had a current disability, a disease or injury in service, and evidence of a nexus between the post-service disability and the disease or injury in service, which was usually shown by medical records and medical opinions. The VCAA notice letter did not include a discussion on establishing service connection on a secondary basis; however, as will be discussed more fully below, the Veteran is not service connected for lupus. For this reason, service connection cannot be established on a secondary basis as due to lupus. Accordingly, as there is no primary service-connected disability, there is legally no evidence that could possibly substantiate a claim under the theory of secondary service connection. For this reason, a secondary service connection theory is legally precluded, and there was no insufficiency in the notice letter with regard to the theory of secondary service connection. As to informing the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf, VA informed the Veteran it had to obtain any records held by any federal agency. This letter also informed the Veteran that on his behalf VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the letter told the Veteran that he could obtain private records himself and submit them to VA. The VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the March 2008 letter included the type of evidence necessary to establish a disability rating and effective date. Regarding the duty to assist, VA must make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the service connection claims currently on appeal, the evidence of record includes service treatment records, service personnel records, VA and private treatment records, and January 2013 and March 2013 VA examinations obtained pursuant to the October 2012 Board remand directives. The January 2013 and March 2013 VA examiners reviewed the Veteran's claims file and medical history, recorded pertinent examination findings, and provided conclusions with supporting rationale. The Board notes that the VA examination reports are probative with regard to the service connection claims on appeal. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board acknowledges the representative's July 2013 informal hearing presentation noting that the March 2013 VA psychiatric examination did not specifically state whether lupus was "aggravated" by the Veteran's service-connected PTSD; however, for reasons discussed in detail below, the Board finds that the January 2013 and March 2013 VA medical examinations sufficiently address both the question of proximate cause and aggravation. Additionally, as the weight of the evidence shows no factual worsening of lupus after the PTSD diagnosis, there is in fact no worsening, that is, no aggravation of lupus so as to require an opinion on the question of aggravation, as any such opinion would call for speculation or an inaccurate assumption of worsening that is inconsistent with the evidence of record so as to be of no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (stating that an opinion based upon an inaccurate factual premise has no probative value). Further, in this case, there is sufficient medical evidence to decide this claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (VA medical examination is required when there is insufficient competent medical evidence on file for VA to make a decision on the claim). For these reasons, a remand for an additional examination and/or opinion to decide the claim is not warranted. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination has been met. 38 C.F.R. § 3.159(c)(4). For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claims on appeal that are addressed on the merits in this decision. The evidence of record provides sufficient information to adequately evaluate the claims, all obtainable evidence identified by the Veteran relative to the claims has been obtained and associated with the claims file, and the Board is not aware of the existence of any additional relevant evidence which was not obtained; therefore, no further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may 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). The condition of systemic lupus erythematosus is a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) for "chronic" in-service symptoms and "continuous" post-service symptoms apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). On the other hand, seizure disorder, sleep disorder, sleep apnea, loss of balance and loss of hand and eye coordination including fine finger movements, mood disorder, and amnestic disorder are not chronic diseases under 38 C.F.R. § 3.309(a) and will be adjudicated using the general principles of service connection. Generally, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In the case of a veteran who engaged in combat with the enemy in a period of war, lay evidence of in-service incurrence or aggravation of a disease or injury shall be accepted if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the lack of official record of such incurrence or aggravation. See 38 U.S.C.A. § 1154(b); Libertine v. Brown, 9 Vet. App. 521, 524 (1996); Collette v. Brown, 82 F.3d 389, 392-94 (Fed. Cir. 1996). The standard used to determine whether a veteran engaged in combat with the enemy is reasonable doubt, which is to be resolved in a veteran's favor. See VAOPGCPREC 12-99. The provisions of 38 U.S.C.A. § 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See Libertine, 9 Vet. App. at 522-23. The provisions of 38 U.S.C.A. § 1154(b) do not establish service connection for a combat veteran; it aids a veteran by relaxing the adjudicative evidentiary requirements for determining what happened in service. Clyburn v. West, 12 Vet. App. 296, 303 (1999). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. " Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). The following diseases are deemed associated with herbicide exposure, under VA law: AL amyloidosis, Chloracne or other acneform disease consistent with chloracne, Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), Multiple myeloma, Non-Hodgkin's lymphoma, Parkinson's disease, Acute and subacute peripheral neuropathy, Porphyria cutanea tarda, Prostate cancer, Respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and Soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). In Combee v. Brown, the United States Court of Appeals for the Federal Circuit held that when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994), reversing in part Combee v. Principi, 4 Vet. App. 78 (1993). As such, the Board must not only determine whether the Veteran has a disability which is recognized by VA as being etiologically related to prior exposure to herbicide agents that were used in Vietnam, but must also determine whether his current disability is the result of active service under 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303(d). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert, 1 Vet. App. at 57. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). Service Connection for Lupus The Veteran contends that currently diagnosed lupus is related to his in-service exposure to herbicides (Agent Orange) while serving in the Republic of Vietnam. Alternatively, the Veteran maintains that lupus was caused or aggravated by his service-connected PTSD disability. At the outset, while it has been determined that the Veteran served in Vietnam during the Vietnam Era, and is presumed to have been exposed to herbicide agents during service, lupus is not among the diseases listed under 38 C.F.R. § 3.309(e), for which presumptive service connection based on herbicide exposure is available; therefore, there is no basis for a presumptive grant of service connection for lupus. Notwithstanding the inapplicability of the Agent Orange presumptive service connection regulations, the Board is obligated to fully consider the Veteran's service connection claim on a direct basis. See Combee, 34 F.3d at 1043-1044. In this regard, the Board finds that the Veteran has currently diagnosed lupus. See October 2004 statement from Dr. P.N (test results "highly suggestive" of lupus) and treatment records from Dr. P.N. in August 2005 diagnosing lupus; see also January 2013 VA examination report. Next, symptoms relating to lupus were not chronic in service. Service treatment records are absent for complaints, diagnosis, or treatment for lupus. Further, the April 1970 service separation medical examination reveals normal clinical evaluations and no defects or diagnoses were noted, to include lupus. For these reasons, the Board finds that symptoms of lupus were not chronic in service and lupus did not have its onset in service. Next, the Board finds that the weight of the probative evidence demonstrates that lupus did not manifest to a compensable degree within one year of service separation. The evidence demonstrates no symptoms relating to lupus during the one year period after service, and no diagnosis or findings of lupus during the one year post-service presumptive period. See 38 C.F.R. §§ 3.307, 3.309. As will be discussed in detail below, the evidence shows the first assessment of lupus, based on Dr. P.N.'s treatment notes, was in 2005, over 30 years after service separation. For these reasons, the Board finds that lupus did not manifest to a compensable degree within one year of service separation; therefore, the presumptive provisions for lupus are not applicable in this case. 38 C.F.R. §§ 3.307, 3.309. The Board next finds that the weight of the evidence demonstrates that symptoms associated with lupus have not been continuous since service separation to warrant presumptive service connection on the basis of continuous post-service symptoms under 38 C.F.R. § 3.303(b). Post-service VA and private treatment records reveal that the Veteran manifested lupus symptoms after service and was first diagnosed with lupus in August 2005, over 30 years after service separation. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006) (stating the Board may weigh the absence of contemporaneous medical evidence in service as a factor in determining credibility of lay evidence, but the Board cannot determine that lay evidence of onset of psychiatric symptoms in service lacks credibility merely because it is unaccompanied by contemporaneous service treatment/medical record evidence). Aside from statements made pursuant to his current claim for VA compensation, the Veteran has not reported to medical professionals that his lupus disability is due to service or that he experienced symptoms associated with lupus since service. See Cartright, 2 Vet. App. at 25; Pond v. West, 12 Vet. App. 341 (1991) (interest may affect the credibility of testimony). Further, the Board further finds that the weight of the competent and probative evidence demonstrates that the currently diagnosed lupus is not related to or caused by service. Although private treatment records reveal ongoing treatment for lupus, beginning years after service separation, they do not provide an opinion relating lupus to service. On the question of relationship of current lupus to service, pursuant to the October 2012 Board remand directives, the Veteran was afforded a VA examination in January 2013 to assist in determining whether the Veteran's lupus was related to service. The January 2013 VA examiner reviewed the claims file, interviewed the Veteran, conducted laboratory testing, and diagnosed the Veteran with systemic lupus erythematosus. Further, the VA examiner opined that lupus was less likely than not incurred in or caused by service. In support of this opinion, the January 2013 VA examiner reasoned that the Veteran was on active duty from May 1968 to April 1970 and the diagnosis of lupus was made in 2005. According to the VA examiner, lupus would not have smoldered for 30 years. The Board finds that the January 2013 VA examination report is further evidence weighing against a relationship between post-service lupus and service. For these reasons, the Board finds that a preponderance of the evidence is against the claim for service connection for lupus on a direct basis. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. That notwithstanding, as noted above, service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). In this case, the Veteran has asserted that his currently diagnosed lupus is caused or aggravated by service-connected PTSD. Although the evidence demonstrates that the Veteran has currently diagnosed lupus and was granted service connection for PTSD in a November 2010 RO rating decision, after a review of all the lay and medical evidence, the Board finds that the weight of the competent and probative evidence of record is against a finding of a nexus, either by causation or by aggravation, between the service-connected PTSD disability and lupus. See Wallin, 11 Vet. App. at 512. In support of a nexus between currently diagnosed lupus and service-connected PTSD, the Veteran points to a September 2008 statement from his treating physician, Dr. P.N. In the September 2008 written statement, Dr. P.N. noted that the Veteran had been under his care since October 2004 when there was evidence of systemic lupus and myositis. Dr. P.N., a Board certified rheumatologist, further noted that the Veteran was under the care of a neurologist and psychiatrist for chronic pain and other diagnoses. In summary, Dr. P.N. stated that "even [if] one cannot say the post traumatic stress disorder was the direct cause of these diagnoses, I can comfortably state that the stress from this could have easily brought out systemic lupus in this patient." The Board finds that the September 2008 statement from Dr. P.N. is not an opinion of any probative value. The statement, or purported aggravation opinion, is not supported by any rationale and provides no basis for the purported opinion. Accordingly, the statement is not an opinion of any probative value. See Miller, 11 Vet. App. at 348 (a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record); see also Bloom v. West, 12 Vet. App. 185, 187 (1999) (the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"); Hernandez-Toyens, 11 Vet. App. at 382 (stating that the failure of the physician to provide a basis for his/her opinion goes to the weight or credibility of the evidence); Claiborne, 19 Vet. App. at 186 (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The absence of any basis for the purported opinion is especially relevant given that Dr. P.N. is a rheumatologist, not a psychiatrist, and his opinions regarding the effects of PTSD on other disorders are not supported by a rationale. Also, the statement is not based on an accurate factual assumptions that PTSD was diagnosed after the diagnosis of lupus and that lupus did now undergo worsening following the PTSD findings. The statement does not reflect that Dr. P.N.'s statement was based on accurate facts or accurate history, whether by review of the claims file or obtained from the Veteran or other sources. A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal, 5 Vet. App. at 461 (holding that the Board may reject a medical opinion based on an inaccurate factual basis). The record does not indicate that Dr. P.N. had the opportunity to review the Veteran's claims file or that he was privy to the relevant and accurate facts of the case, to include the fact that PTSD was diagnosed after the diagnosis of lupus. The Court has held that a physician's review of the claims file is not the determinative factor is assigning probative value, see Nieves-Rodriguez, 22 Vet. App. at 300, but it noted that a physician should have information regarding relevant case facts. Further, part of Dr. P.N.'s statement weighs against secondary service causation in that Dr. P.N. did not opine that PTSD was the "direct cause" of currently diagnosed lupus. Specifically, Dr. P.N. stated that "one cannot say that post traumatic stress disorder was the direct cause of these diagnoses." Further, Dr. P.N.'s statement does not address the degree of disability resulting from any purported aggravation of lupus by the service-connected PTSD disability. See Allen, 7 Vet. App. at 448. In this regard, Dr. P.N. did not provide a rationale as to how or to what extent PTSD "brought out" systemic lupus in the Veteran. This assumption of worsening is especially relevant given that lupus was diagnosed as systemic by Dr. P.N. in August 2005 and PTSD was not diagnosed until three years later in 2008. Moreover, in regard to the portion of Dr. P.N.'s statement where it was noted that he could "comfortably state that the stress from this could have easily brought out systemic lupus in this patient," the Board finds that this is not an opinion of probative value because both language and context do not reflect an opinion of probability, but only possibility; therefore, the statement is speculative. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). Considering the language used by Dr. P.N., "brought out" is a nonmedical and ambiguous phrase that, at best, only suggests symptoms were evident, but does not state or suggest the underlying lupus was worsened in severity, and certainly provides no basis or explanation as to even how or which symptoms are referred to. Further, "could have" asserts only a possibility of relationship, not probability, qualifying the relationship as one that "could" have occurred. The September 2008 private medical statement by Dr. P.N. lacks probative value because it is an opinion of mere possibility and not probability. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (a letter from a physician indicating that the veteran's death "may or may not" have been averted if medical personnel could have effectively intubated the veteran was held to be speculative); Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992) (the Court found evidence favorable to the veteran's claim that does little more than suggest a possibility that his illnesses might have been caused by service radiation exposure is insufficient to establish service connection); Obert, 5 Vet. App. at 33 (a physician's statement that the veteran may have been having some symptoms of multiple sclerosis for many years prior to the date of diagnosis also implied "may or may not" and was deemed speculative); Bloom, supra (the Court held that a physician's opinion that the veteran's time as a prisoner of war "could have" precipitated the initial development of a lung condition, by itself and unsupported and unexplained, was "purely speculative"); and Bostain v. West, 11 Vet. App. 124, 128 (1998) (the Court held that a physician's opinion that an unspecified preexisting service-related condition "may have" contributed to the veteran's death was too speculative to be new and material). Further, the evidence of record does not show a worsening or aggravation of the Veteran's lupus that could serve as a factual predicate to show aggravation or to serve as the basis for an opinion of aggravation; instead, the evidence shows not only no worsening of lupus, but some improvement, which weighs against a finding and factual assumption of worsening after and due to the service-connected PTSD. The Board finds the more recent January 2013 and March 2013 VA medical opinions to be highly probative on the question of whether the currently diagnosed lupus was caused or aggravated by service-connected PTSD. As noted above, the Veteran underwent an examination in January 2013 to assist in determining the nature and etiology of his lupus disability. The January 2013 VA examiner opined that PTSD would not cause lupus and it was "doubtful" that PTSD could aggravate lupus. The January 2013 VA examiner reasoned that the diagnosis of PTSD occurred three years after the diagnosis of lupus, which the Board finds to be an accurate fact. In March 2013, the Veteran underwent a VA psychiatric examination where the VA examiner reviewed the claims file, interviewed the Veteran, performed a mental status examination, and diagnosed the Veteran with PTSD. Further, the March 2013 VA psychiatrist opined that the Veteran's lupus more likely than not caused his PTSD to worsen, and the emergence of it clinically shortly after contracting of lupus was temporally consistent. Moreover, the VA psychiatrist noted that the Veteran was probably doing better now that his lupus was under better control, which suggests to the Board that the Veteran's lupus was not "aggravated," but had actually improved. Further, the VA examiner opined that it was more likely than not that there was no cause of PTSD by lupus or vice versa. In this regard, the VA examiner reasoned that lupus is an autoimmune disease caused by complex antibody difficulties, whereas PTSD is a psychological disorder caused by response to severe traumas. The Board has also considered the Veteran's statements asserting a nexus between the currently-diagnosed lupus and service-connected PTSD. While the Veteran is competent to report symptoms as they come to him through his senses, lupus, which requires laboratory testing and is in itself difficult to diagnose and has overlapping symptoms with other diagnoses that would require an ability to differentiate such symptoms, so is not the type of disorder that a lay person can provide competent evidence on questions of etiology. See Layno, 6 Vet. App. at 465 (competent lay evidence is evidence not requiring that the proponent have specialized education, training, or experience, but is provided by a person who has knowledge of facts or circumstances and conveys matter that can be observed and described by a lay person); see also Rucker at 74 (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (stating a veteran is not competent to diagnose rheumatic fever). Here, the Board finds that the Veteran does not have the education, training, or experience to provide a competent opinion as to the etiology of his lupus disorder, especially in the context of absence of symptoms or treatment for decades after service or how it may relate to his service-connected PTSD disorder. Instead, the Board finds the January 2013 and March 2013 VA medical opinions, which were based on a review of accurate facts in the claims file, history by the Veteran, laboratory and clinical findings, to be the most probative evidence of record. For the reasons stated above, the only competent and probative evidence addressing whether lupus is etiologically related to service, or as secondary to service-connected PTSD are the January 2013 and March 2013 VA opinions. The Board, therefore, finds that a preponderance of the evidence is against the claim for service connection for lupus, to include as due to herbicide exposure and as secondary to service-connected PTSD, and the claim must be denied. 38 C.F.R. § 3.303. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for Other Claims on Appeal The Veteran has maintained that the above-mentioned disorders are specifically due to lupus. See Veteran's April 2009 and October 2012 statements. Further, in a June 2013 written statement, the Veteran's representative noted that each of the above listed claims was dependent on the decision regarding service connection for lupus as secondary to service-connected PTSD. Accordingly, the Board will only address the theory of secondary service connection when deciding these issues, as this is the only theory reasonably raised by the evidence of record. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009). As it pertains to service connection for seizure disorder, sleep disorder, sleep apnea, loss of balance and loss of hand and eye coordination including fine finger movements, mood disorder, and amnestic disorder, all claimed as due to lupus, the Board finds that service connection is not warranted. As discussed in detail in this decision, the Board has denied service connection for lupus, to include as due to herbicide exposure and as secondary to service-connected PTSD; therefore, the claims for service connection for seizure disorder, sleep disorder, sleep apnea, loss of balance and loss of hand and eye coordination including fine finger movements, mood disorder, and amnestic disorder, all claimed as due to nonservice-connected lupus, must be denied because there is no primary service-connected disability upon which secondary service connection may be granted. 38 C.F.R. § 3.310(a). ORDER Service connection for lupus, to include as due to herbicide exposure and as secondary to service-connected PTSD, is denied. Service connection for seizure disorder as due to lupus is denied. Service connection for sleep disorder, to include sleep apnea, as due to lupus, is denied. Service connection for loss of balance and loss of hand and eye coordination including fine finger movements as due to lupus is denied. Service connection for mood disorder (claimed as personality change) as due to lupus is denied. Service connection for amnestic disorder (claimed as short-term memory loss and the loss of ability to concentrate) as due to lupus is denied. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs