Citation Nr: 1327342 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 12-14 608 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for diabetes mellitus, type II (diabetes) to include as secondary to herbicide exposure. 2. Entitlement to service connection for nephropathy with voiding dysfunction. 3. Entitlement to service connection for neuropathy of the lower and upper extremities as secondary to diabetes and/or a lumbar spine disorder. 4. Entitlement to service connection for retinopathy. 5. Entitlement to service connection for erectile dysfunction as secondary to diabetes. 6. Entitlement to service connection for hypertension, to include as secondary to diabetes. 7. Entitlement to service connection for coronary artery disease, to include as secondary to herbicide exposure and diabetes. 8. Entitlement to service connection for an asbestos-related lung disease, claimed as chronic obstructive pulmonary disease (COPD). 9. Entitlement to service connection for a lumbar spine disorder. REPRESENTATION Appellant represented by: Arkansas Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD N. Snyder, Counsel INTRODUCTION The Veteran served in the Army Reserve from January 1957 to June 1959 and on active duty with the U.S. Navy from June 1959 to May 1963. This appeal comes before the Board of Veterans' Appeals (Board) from an August 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The appeal is now under the jurisdiction of the RO in North Little Rock, Arkansas. In November 2012, the Board remanded the present matter for additional development and due process concerns. The Board is satisfied that there has been substantial compliance with the remand directives, and the Board may proceed with review. Stegall v. West, 11 Vet. App. 268 (1998). The issue of entitlement to service connection for a lumbar spine disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. In August 2012, the Veteran testified at a personal hearing before the undersigned, via videoconference. A transcript of the hearing is associated with the claims file. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran was not in Vietnam. 2. Diabetes did not have its onset in active service and is not the result of a disease or injury incurred in active service. 3. The Veteran does not have nephropathy, retinopathy, or neuropathy. 4. Erectile dysfunction did not have its onset in active service and is not the result of a disease or injury incurred in active service. 5. Hypertension did not have its onset in active service and is not the result of a disease or injury incurred in active service. 6. Coronary artery disease did not have its onset in active service and is not the result of a disease or injury incurred in active service. 7. The Veteran does not have an asbestos-related lung disease. CONCLUSIONS OF LAW 1. The criteria for service connection of diabetes have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. The criteria for service connection of nephropathy have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). 3. The criteria for service connection of neuropathy have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). 4. The criteria for service connection of retinopathy have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). 5. The criteria for service connection of erectile dysfunction have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). 6. The criteria for service connection of hypertension have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). 7. The criteria for service connection of coronary artery disease have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 8. The criteria for service connection of asbestos-related lung disease have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in 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). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent." However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). VA regulations provide presumptive service connection for diabetes and coronary artery disease for veterans shown to be exposed to an herbicide agent during active military service. 38 C.F.R. § 3.309(e). The regulations also provide that veterans who 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 to an herbicide agent, to include Agent Orange, unless there is affirmative evidence of non-exposure. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307. Service in Vietnam includes service in the waters offshore or service in other locations if the conditions of service involved duty or visitation in Vietnam. 38 C.F.R. § 3.313; see also Haas v. Peake, 544 F.3d 1306 (Fed. Cir. 2008) (upholding VA's interpretation that service in Vietnam requires that a claimant have set "foot-on-land" in Vietnam). Service connection may be established on a secondary basis for a disability which is proximately due to, or aggravated by, service connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). 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. 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. 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). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). Diabetes The Veteran has been diagnosed with diabetes. The Veteran contends that his diabetes is secondary to in-service herbicide exposure. The Veteran has reported that he was exposed to herbicides while doing a temporary duty assignment (TDY) in Vietnam while he was serving with the Atlantic Fleet Mobile Photo Group. The Veteran has explained that there is no documentation of the TDY because it was a classified mission. He has provided varying accounts of the reported TDY. On his initial claim in May 2009, the Veteran indicated that he served in Pleiku, which is in the Republic of Vietnam, from December 1962 to May 1963. He repeated the same history in a "letter of disagreement" dated in March 2011. In a letter dated in February 2010, the Veteran reported that he performed a TDY on the USS Thomas Jefferson between February and May 1963, at which time the USS Thomas Jefferson was conducting initial shakedown training off the coastal waters of the Republic of South Vietnam. He added that prior to arriving on the USS Thomas Jefferson, he spent two weeks on TDY with a Navy helicopter unit at Pleiku Air Base. The Veteran's former spouse has submitted a letter reporting that she remembers the Veteran mentioning orders and assignments off the coast of Vietnam and reporting that he departed a ship and served on the ground in Vietnam. In letters dated in July 2011 and August 2012, the Veteran indicated that he performed a TDY in Vietnam after serving onboard the USS Thomas Jefferson while it was performing classified training exercises in the waters off Vietnam. At the Board hearing in August 2012, the Veteran testified that he went to Vietnam on TDY in December 1962. He explained that he flew from Norfolk to a Vietnam airbase to take photos and that he only stayed in Vietnam for one night. After review of the record, to include the Wikipedia article on the USS Thomas Jefferson, the Board finds the Veteran did not serve within Vietnam. Initially, the Board notes that the available service records do not indicate that the Veteran ever set foot within Vietnam: the service records contain no notations from medical clinics in Vietnam and no histories or administrative remarks suggestive of being within Vietnam, and the National Personnel Research Center has indicated that there was no evidence in the Veteran's file to substantiate any service in Vietnam. The article on the USS Thomas Jefferson, which was a nuclear-powered submarine, also does not suggest that it served within, or even near, the waters of Vietnam. The Board acknowledges that the Veteran is competent to report that he performed a TDY within Vietnam. The Veteran has provided contradictory details about the nature of that TDY, however. He has provided conflicting information as to the length of the TDY - alternately reporting that the TDY lasted two days, three weeks, and five months - and conflicting information as to how he travelled to and from the TDY - alternately reporting that he went from the USS Jefferson, which was doing exercises in the waters off Vietnam, to Pleiku Air base; that he went from Pleiku to the USS Thomas Jefferson; and that he flew roundtrip from Norfolk. Furthermore, the medical evidence indicates that the Veteran was in Virginia in March 1963, contrary to the reported service in Vietnam from December 1962 until May 1963: a March 1963 treatment record documents treatment provided at a facility in Virginia. Based on the contradictory information provided by the Veteran and the evidence that he was in Norfolk in March 1962, the Board finds the Veteran's account of a TDY in Vietnam is not credible and thus not probative. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing competency from weight and credibility and noting that only competency involves a question of admissibility); 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."). Thus, service connection is not warranted on a presumptive basis. Service connection may still be established if the condition began during or is otherwise related to service. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Board finds service connection is not warranted, however, because the evidence does not indicate that diabetes manifest in service or is causally related to service. The Veteran's service treatment and examination records, to include the May 1963 separation examination record, do not report any diagnoses of diabetes or any symptoms indicative of diabetes, such as sugar in the urine, and post-service records indicate that the Veteran was "discovered" to have diabetes in July 1998, approximately 35 years after separation. See May 1959 and May 1963 examination records (urinalysis negative for sugar); January 2001 J.P. Hospital record. See also Maxson v. Gober, 230 F.3rd. 1330, 1333 (Fed. Cir. 2000) (time elapsed prior to initial complaint can be considered as evidence against the claim.). Additionally, the evidence of record also does not contain any competent evidence linking the Veteran's diabetes to service. The Veteran has contended that his diabetes is linked to in-service asbestos exposure. See August 2012 statement. The Veteran has not provided an explanation for this determination, however, and there are no medical findings or studies of record suggestive of such a link. Furthermore, the evidence does not suggest the Veteran possesses the specialized knowledge necessary to render him competent to determine the etiology of his diabetes. See Davidson, 581 F.3d at 1316. The Board acknowledges that the Veteran was a nurse's aide and respiratory therapy technician. The record does not suggest that these occupations provided the Veteran with the specialized medical knowledge necessary to determine the etiology of his diabetes, however. Thus, the Veteran's statements are not probative evidence of a link between the diabetes and service. Based on the absence of probative evidence of in-service herbicide exposure; the absence of evidence an in-service occurrence, the length of time between separation and the initial reported diagnosis; and the absence of a nexus opinion, service connection for diabetes must be denied. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for diabetes. Accordingly, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Nephropathy, Neuropathy, and Retinopathy The Board has carefully reviewed the record but finds no probative evidence of nephropathy, neuropathy, or retinopathy at any point during the pendency of the claim. The medical record does not reveal any medical findings or diagnoses of nephropathy, neuropathy, or retinopathy, during the claim period, though the record does reflect treatment for diabetes and urology and ocular examinations in 2012, and the Veteran has not alleged that there are outstanding treatment records reflecting such a diagnosis. The Board acknowledges that the Veteran submitted a document, entitled "To Whom It May Concern," which reports that peripheral neuropathy "occurs as a complication of another disorder, as in [the Veteran's] case, diabetes mellitus." The Board finds this document is not competent evidence of the existence of neuropathy, however. Although the Veteran reported in December 2012 that this document was from his primary care physician, he initially submitted the document in February 2010, at which time he reported that it was created by his former spouse. The Board finds the February 2010 description of the document is more credible, not only because it was provided first but also because the initials provided on the document are not followed by any medical abbreviation as would be expected if the document were drafted by a medical professional. The record does not suggest that the Veteran's former spouse possesses the specialized knowledge necessary to render such a diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Davidson, 581 F.3d at 1316. As such, the Board finds the document is not competent, and thus not probative, evidence of the existence of neuropathy. The Board further acknowledges that the Veteran was a nurse's aide and respiratory therapy technician. The record does not suggest that these occupations provided the Veteran with the specialized medical knowledge necessary to render diagnoses of nephropathy, neuropathy, retinopathy, however. The Veteran is not providing statements related to the existence of a simple disorder or even a pulmonary disorder but is rendering an opinion as to whether he has nephropathy, neuropathy, and retinopathy, each of which require specialized diagnostic testing and evaluation and are matters of medical complexity. Davidson, 581 F.3d at 1316. Thus, the Board concludes that the Veteran's statements do not constitute competent evidence on which the Board can make a service connection determination. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as there is no competent evidence of a current disability, the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for retinopathy, nephropathy, and neuropathy. Accordingly, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Erectile Dysfunction The record does not contain any medical diagnoses of erectile dysfunction. The Veteran is competent to report that he has erectile dysfunction, however, and the Board finds his statements are adequate evidence of the existence of a current disability. See 38 C.F.R. § 3.159(a)(2); Layno v. Brown, 6 Vet. App. 465, 471 (1994). Nevertheless, service connection is not warranted for erectile dysfunction because the probative evidence does not suggest that it began in service or is causally related to service. Initially, the Board notes that the competent and probative evidence does not suggest that erectile dysfunction began in service. The service treatment and examination records reflect no histories or findings suggestive of erectile dysfunction, and the first evidence of it is found in a January 2001 private treatment records, which reflects a history of "problems with erectile dysfunction." See Maxson, 230 F.3rd. at 1333. Furthermore, although competent to do so, the Veteran has not reported having symptoms indicative of erectile dysfunction during service. Additionally, the competent and probative evidence does not suggest that the erectile dysfunction is related to service or a service-connected disability. The Board acknowledges that the Veteran believes the erectile dysfunction is the result of diabetes. Service connection is not in effect for diabetes, however; as such, service connection is not available for erectile dysfunction as secondary to diabetes. In sum, the preponderance of the probative evidence does not suggest that the erectile dysfunction is related to service (either through date of onset or causation). As such, service connection is not warranted; the Veteran's claim is therefore denied. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for erectile dysfunction. Accordingly, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hypertension Hypertension is defined as diastolic blood pressure that is predominantly 90 millimeters (mm.) or greater, or systolic blood pressure that is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, DC 7101(Note 1). The service treatment and examination records, to include the May 1963 separation examination record, reflect no findings or histories suggestive of hypertension, to include elevated blood pressure readings. An October 1990 treatment record reflects a finding of borderline chronic hypertension based on evidence of blood pressure usually at 140/90. The Veteran was diagnosed with hypertension in approximately 1996. See January 2001 J.P. Hospital record. See also February 1993 J.P. Hospital record (reflecting negative history as to hypertension). Service connection is not warranted for hypertension. Initially, the Board notes that the competent and probative evidence does not suggest that hypertension had its onset in service or is causally related to service. The service treatment and examination records reflect no histories or findings suggestive of hypertension, and the first evidence suggestive of hypertension places its onset many years after separation from service. See Maxson, 230 F.3rd. at 1333. The Veteran has reported that he was treated for hypertension during his first period service. See August 2012 statement. Although the Veteran is competent to report his medical history, the Board finds this statement is not credible, and thus not probative, in light of the contradictory evidence of no hypertension prior to many years after separation from military service. The medical evidence does not reflect a definitive diagnosis of high blood pressure prior to 1998, though the Veteran underwent medical evaluation for chest pain, or any tentative diagnosis prior to 1990. Moreover, the current history of a diagnosis of and treatment for hypertension during service is contradicted by previous medical histories, namely those reported in the May 1959 Naval enlistment examination record, which reflects a negative history as to high blood pressure, and a February 1993 private treatment record, which reflects a negative history as to hypertension. See Cartright, 2 Vet. App. at 25; Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by a veteran). Furthermore, the record does not contain any competent evidence linking the Veteran's hypertension to service or a service-connected disability. The Board acknowledges that the Veteran believes the hypertension is the result of diabetes. Service connection is not in effect for diabetes, however; as such, service connection is not available for hypertension as secondary to diabetes. In sum, the preponderance of the probative evidence does not suggest that the hypertension is related to service (either through date of onset or causation). As such, service connection is not warranted; the Veteran's claim is therefore denied. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for hypertension. Accordingly, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Coronary Artery Disease The service treatment and examination records, to include the May 1963 separation examination record, reflect no findings or histories suggestive of coronary artery disease. The Veteran was diagnosed with coronary artery disease in January 2001. Although earlier records reflect histories of chest pain, the chest pain was determined to be noncardiac in origin, and cardiac workup in 1984 and September 1991 revealed no evidence of coronary artery disease. See, e.g., October 1990, September 1991, and January 2001 J.P. Hospital medical records. The Board acknowledges that an August 1994 discharge summary reports that the Veteran had a "previous history of some degree of coronary artery disease, status post angioplasty in 1989." No other record reports a history of angioplasty in 1989 or diagnosis of coronary artery disease in 1989, however, and the Board again notes that a 1991 cardiac work-up was negative for coronary artery disease. Thus, the Board finds the August 1994 discharge summary is not competent evidence as to the existence of coronary artery disease as of that date. Service connection is not warranted for coronary artery disease. The Veteran contends that the coronary artery disease is the result of herbicide exposure. Coronary artery disease is a disease presumptively caused by herbicide exposure. As discussed above, however, the Board finds the Veteran's account of in-service herbicide exposure is not credible. As such, service connection is not warranted on a presumptive basis under 38 C.F.R. § 3.309(e). Service connection is also not warranted on a direct basis because the competent and probative evidence does not suggest that coronary artery disease began in service or is causally related to service. The service treatment and examination records reflect no histories or findings suggestive of coronary artery disease, and the first evidence suggestive of coronary artery disease places its onset 37 years after separation from service. See Maxson, 230 F.3rd. at 1333. Furthermore, although competent to do so, the Veteran has not reported having symptoms indicative of coronary artery disease during service. The record also does not contain any competent evidence linking the coronary artery disease to service or to a service-connected disability. The Board acknowledges that the Veteran believes the coronary artery disease is possibly the result of diabetes. Service connection is not in effect for diabetes, however; as such, service connection is not available as secondary to diabetes. In sum, the preponderance of the probative evidence does not suggest that the coronary artery disease is related to service (either through date of onset or causation). As such, service connection is not warranted; the Veteran's claim is therefore denied. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for coronary artery disease. Accordingly, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Asbestos-related Lung Disease There is no specific statutory or regulatory guidance with regard to claims for service connection for asbestosis or other asbestos-related diseases. VA's Manual M21-1 Manual Rewrite (M-21MR) contains guidelines for the development of asbestos exposure cases. M-21MR, at Part IV, Subpart ii, Chapter 1, Section H(29) [IV.ii.1.H.29] and IV.ii.2.C.9, in essence acknowledges that inhalation of asbestos fibers can result in fibrosis and tumors and produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of the pleura and peritoneum, and certain cancers, among other diseases, with the most common of the diseases resulting from exposure to asbestos being interstitial pulmonary fibrosis (asbestosis). M-21MR notes that the latent period can vary from 10 to 45 years, or longer, between first exposure and development of disease. Exposure can be brief (as little as a month) or indirect (bystander disease). The clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. M-21MR (as in effect from August 2007). VA must determine whether military records demonstrate evidence of asbestos exposure in service and whether there is pre-service and/or post-service evidence of occupational or other asbestos exposure, and then make a determination as to the relationship between asbestos exposure and the claimed diseases, keeping in mind the latency and exposure information pertinent to the veteran. The Veteran asserts that he was exposed to asbestos while serving in the Navy. M-21MR, IV.ii.2.C.9(g) notes that there was widespread exposure to asbestos among Navy veterans due to their being stationed on ships which contained asbestos. The record indicates that the Veteran was never stationed on a ship. He has reported that he was frequently on ships to take photographs and films, however. Based on the Veteran's history of exposure during service and the evidence of asbestos on naval ships during the Veteran's service, in-service asbestos exposure is presumed for the purposes of this decision. Even finding the Veteran had in-service exposure to asbestos, competent medical evidence is required for a determination that the Veteran has an asbestos-related disorder and that asbestosis or other asbestos-related disorder is etiologically related to the Veteran's service. The May 1959 Navy enlistment examination record reflects the Veteran's history of treatment for a collapsed lung. The record clarifies that the Veteran was treated for severe pleurodynia eight months earlier, which had resolved with no sequaele. The Naval service treatment records reflect no findings or histories indicative of asbestosis or another asbestos-related disorder, and the May 1963 separation examination record reflects normal clinical findings for the lungs and a negative X-ray. Post-service medical records reflect treatment for asthma, beginning in 1992. The records do not reflect any treatment for COPD. A January 2001 emergency treatment record does reflect a past medical history of COPD, but COPD was not diagnosed on discharge. The post-service medical records also reveal that X-ray images of the chest, which date from July 1992 to August 2007, did not reveal any active abnormality, to include pleural effusion, fibrosis, or plaques. See generally J.P. Hospital treatment records. A November 2011 VA examination record reflects diagnoses of emphysema and COPD, which the examiner noted were initially diagnosed in 1963. The Veteran reported that he complained of COPD the day he got out of service. After examination and review of the record, the examiner found it less likely than not that COPD was incurred in or caused by service, to include the reported asbestos exposure, because there was no evidence of pleural plaques on X-ray and the Veteran's exposure was very minimal in service. An April 2012 addendum opinion reflects the determination that the Veteran did have COPD. The examiner did not find evidence of asbestos exposure on pulmonary evaluation, however, so the examiner found the COPD was at least as likely as not related to chronic tobacco use. A December 2012 VA examination record reflects a diagnosis of asthma. It does not reflect a diagnosis of COPD. After examination, which included pulmonary function testing and radiographic imaging, and review of the record, the examiner concluded that the Veteran's COPD was less likely as not caused by or the result of in-service exposure to asbestos. The examiner noted that the Veteran denied a history of smoking and/or tobacco use. The examiner further noted that the Veteran worked in a zinc production plant for approximately two years after service. The examiner explained that the computerized tomography (CT) scan of the chest did not support a finding of pleural plaques associated with asbestosis. The Veteran submitted a document, entitled "To Whom It May Concern" which reports that the Veteran has "COPD, possibly relating to asbestos exposure aboard a naval nuclear submarine." After a review of the evidence, the Board finds the Veteran does not have asbestosis or an asbestos-related lung disorder. The record does not include any findings of asbestosis or evidence of pleural abnormality which would be suggestive of asbestos-related disease, and VA examiners have provided competent and probative opinions that the Veteran does not have an asbestos-related lung disease. The Board acknowledges that the Veteran submitted a document reflecting an opinion that his COPD was possibly related to in-service asbestos exposure. The Board finds this document is not competent evidence of the existence of a relationship between in-service asbestos exposure and a lung disease, however. Although the Veteran reported in December 2012 that this document was from his primary care physician, he initially submitted the document in February 2010, at which time he reported that it was created by his former spouse. The Board finds the February 2010 description of the document is more credible, not only because it was provided first but also because the initials provided on the document are not followed by any medical abbreviation as would be expected if the document were drafted by a medical professional. The record does not suggest that the Veteran's former spouse possesses the specialized knowledge necessary to render such an opinion. See Jandreau v. Nicholson, 492 F.3d at 1376-77; Davidson, 581 F.3d at 1316. As such, the Board finds the document is not competent, and thus not probative, evidence of the existence of relationship between in-service asbestos exposure and COPD. Furthermore, even if the former spouse were competent, the Board finds the opinion lacks probative value because it is too conditional ("possibly") and is not supported by a detailed rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Obert v. Brown, 5 Vet. App. 30, 33 (1993). In contrast, the Board finds the opinions provided by the VA examiners are probative as they are each supported by a rationale that is consistent with the medical record. The Board further acknowledges that the Veteran has cited a medical and health guide which reportedly indicated that exposure to asbestos poisoning and herbicides cause emphysema and COPD. See March 2011 letter. Even assuming asbestos can cause COPD, however, the competent evidence does not suggest that the asbestos exposure caused COPD or any other lung disease in the Veteran. The mere fact that a disease can result from asbestos exposure is not probative evidence that it did. There is no medical finding that the Veteran's in-service asbestos exposure resulted in lung disease- rather the evidence consistently reflects negative findings as to asbestos-related changes - and the record does not suggest the Veteran is competent to diagnose an asbestos-related lung disease. Although the Veteran was a nurse's aide and respiratory therapy technician, the record does not suggest that these occupations provided the Veteran with the specialized medical knowledge necessary to render diagnoses of an asbestos-related lung disease. The Veteran is not providing statements related to the existence of a simple disorder but is rendering an opinion as to whether he has a lung disease due to asbestos, which requires specialized diagnostic testing and evaluation and is a matter of medical complexity. Davidson, 581 F.3d at 1316. Thus, the Board concludes that the Veteran's statements do not constitute competent evidence on which the Board can make a service connection determination. Furthermore, even if the Veteran were competent, the Board finds his determinations lack probative value because they are not supported by a rationale, to include a discussion of how he determined that he had asbestos-related lung disease in the absence of evidence of pleural abnormality suggestive of asbestos-related changes. See Nieves-Rodriguez v. Peake, 22 Vet. App. at 304. In sum, the preponderance of the probative evidence does not suggest that the Veteran has an asbestos-related lung disease. As such, service connection is not warranted; the Veteran's claim is therefore denied. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for an asbestos-related lung disease. Accordingly, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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). The 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 the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 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 the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice 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 a letter sent to the Veteran in June 2011 with regard to the claims of service connection, to include as secondary to diabetes, asbestos exposure, or herbicide exposure. The letter addressed all of the notice elements. Although the letter was sent after to the initial unfavorable decision by the AOJ in August 2009, the claims were readjudicated in May 2012 statement of the case and May 2013 supplemental statement of the case. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating claim and notifying claimant of such readjudication in the statement of the case). The duty to assist was also met in this case. The service treatment records are in the claims file. All pertinent VA and private treatment records have been obtained and associated with the file. All available service personnel records were associated with the file in 2011. The Veteran has been notified of the absence of any reported records, to include the unsuccessful attempt to obtain service personnel records in 2013. VA attempted to verify the reported service in Vietnam, to include by contacting the National Personnel Research Center. VA examinations were provided and opinions obtained with respect to the issues of entitlement to service connection for an asbestos-related lung disease. 38 C.F.R. § 3.159(c) (4). 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). The Board finds that the VA opinions as to the existence of an asbestos-related lung disease obtained are adequate, as they are predicated on a full reading of the private and VA medical records in the Veteran's claims file. Each opinion considers all of the pertinent evidence of record and the statements of the appellant, and the examiners provided a complete rationale for the opinion stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue of service connection for an asbestos-related lung disease has been met. 38 C.F.R. § 3.159(c)(4). The Board acknowledges that VA examinations were not provided in conjunction with the claims of service connection for diabetes, nephropathy, neuropathy, retinopathy, erectile dysfunction, hypertension, and coronary artery disease. With respect to the claims of service connection for nephropathy, neuropathy, and retinopathy, the record does not contain competent evidence of a diagnosed disability or symptoms of disability. With respect to the claims of service connection for diabetes, erectile dysfunction, hypertension, and coronary artery disease, although the evidence does contain competent evidence of diagnosed disability, the competent and probative evidence does not suggest that any such disability began in service or is associated with service. 38 C.F.R. § 3.159(c)(4). Thus, no examination is needed on any of these claims. Finally, the Board is satisfied that there has been substantial compliance with the directives issued in the previous Board remand. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002) ORDER Service connection for diabetes mellitus, type II is denied. Service connection for nephropathy with voiding dysfunction is denied. Service connection for neuropathy of the lower and upper extremities is denied. Service connection retinopathy for is denied. Service connection for erectile dysfunction is denied. Service connection for hypertension is denied. Service connection for coronary artery disease is denied. Service connection for an asbestos-related lung disease is denied. REMAND Further development is needed on the claim of service connection for a lumbar spine disorder; specifically, a VA examination with opinion is needed to determine the nature and likely etiology of any current disorder. The Board acknowledges that the record includes the results of a VA examination and opinions from the examiner. The Board finds the examination record and opinions are not sufficiently probative to adjudicate the matter, however. The examiner does not provide an opinion with respect to the diagnoses of osteoarthritis. Moreover, the examiner does not provide a rationale for the determinations that lumbar strain was diagnosed in 1963 or that the Veteran currently has radiculitis. The Board finds the latter is particularly problematic because the evidence does not corroborate the findings of lumbar strain in 1963 or current radiculitis. Accordingly, the case is REMANDED for the following action: 1. Ensure that all outstanding, relevant VA treatment records are associated with the file, notably those dated from May 17, 2013. The record suggests the Veteran has received his VA treatment through the Fayetteville, Arkansas, VA Health Care System. If the records are not available, the Veteran should be so informed. 2. Afford the Veteran a VA examination to determine the likely etiology of the lumbar spine disorder. The medical professional must review all relevant evidence, including those associated with non-VA treatment or contained on Virtual VA. All appropriate testing should be accomplished, and the examiner should identify any lumbar spine diagnosis and render an opinion as to whether it is at least as likely as not that any current lumbar spine disorder began during or is otherwise related to the Veteran's military service. The examiner should provide an explanation for any opinion rendered, preferably with discussion of the in-service treatment for radiculitis and the November 2011 VA examiner's determination (reported in the April 2012 addendum) that the Veteran currently has radiculitis. 3. Thereafter, readjudicate the appellant's claims. If the benefit sought on appeal remains denied, the appellant should be provided a supplemental statement of the case (SSOC). The SSOC must contain notice of all relevant actions taken on the claim for benefits, to include a summary of the evidence and applicable law and regulations considered pertinent to the issue currently on appeal. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs