Citation Nr: 1328110 Decision Date: 09/03/13 Archive Date: 09/10/13 DOCKET NO. 07-11 643 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for vertigo, to include as secondary to service-connected hearing loss and tinnitus. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The Veteran had active duty from November 1961 to October 1963. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2005 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. This appeal has been advanced on the Board's docket. 38 U.S.C.A. § 7107(a)(2) (West 2002); 38 C.F.R. § 20.900(c) (2012). FINDINGS OF FACT 1. While the Veteran complained of dizziness, the evidence of record shows that vertigo was not noted on clinical examination at the time of service entrance. 2. Clear and unmistakable evidence demonstrates that vertigo existed at the time of the Veteran's entrance into active military service. 3. Clear and unmistakable evidence demonstrates that the Veteran's preexisting vertigo was not permanently aggravated beyond normal progression by active service. 4. Vertigo is not related to service-connected hearing loss or tinnitus. CONCLUSION OF LAW Vertigo was not incurred in or aggravated by active military service, and is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1111, 1113, 1131, 1153, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.306, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION With respect to the Veteran's service connection claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. The RO's June 2005 and May 2006 letters, as well as the AMC's April 2013 letter, provided both before and after the initial adjudication of the service connection claim on appeal in December 2005, advised the Veteran of the foregoing elements of the notice requirements. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). These letters also provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Accordingly, with these letters, the RO and AMC effectively satisfied the remaining notice requirements with respect to the issue on appeal. After the notice letters were provided to the Veteran, the claim was readjudicated in a July 2013 supplemental statement of the case. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (finding that 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). In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's available service treatment records, service personnel records, and post-service VA treatment records have been obtained. Pertinent private treatment records from M. S., M. D., were likewise submitted and associated with the claims file. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran was also provided with VA examinations in conjunction with the claim on appeal in April 2006, October 2006, August 2010, January 2011, October 2012, and July 2013 to ascertain the nature and etiology of his vertigo. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159; see McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). The Board has found the July 2013 VA examination with medical opinion by a VA ear, nose, and throat (ENT) specialist to be adequate, it was based upon a complete review of the entire evidence of record, consideration of the Veteran's lay statements, and clinical examination of the Veteran by a specialist. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran's claim was previously before the Board in April 2010, November 2010, August 2012, and March 2013 and remanded for additional evidentiary development, to include obtaining outstanding VA treatment records, affording the Veteran the opportunity to identify any additional pertinent records not associated with the claims file, and obtaining VA examinations. As noted above, the Board obtained outstanding VA treatment records identified as pertinent by the Veteran as well as obtained multiple VA examinations in connection with the current claim. The Board is cognizant that the Veteran's representative argued that the July 2013 VA examination was not conducted by a VA ENT specialist as instructed by the Board. However, review of July 2013 VA examination report showed that the examination was conducted by a VA primary care physician, as well as a VA ENT specialist. Based on the foregoing, the Board finds substantial compliance with the April 2010, November 2010, August 2012, and March 2013 remand orders. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. In his June 2005 claim, the Veteran asserted that he experienced vertigo secondary to hearing loss and tinnitus. The RO issued a rating decision in December 2005 in which it denied entitlement to service connection for vertigo. The RO confirmed the denial of entitlement to service connection for vertigo in an August 2006 rating decision. The Veteran was notified of this decision and provided his appellate rights. He then perfected this appeal. The Veteran's claim was remanded for additional evidentiary development in April 2010, November 2010, August 2012, and March 2013 and is now before the Board for final appellate consideration. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §1131; 38 C.F.R. § 3.303. Service connection may also be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes 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). The Veteran is presumed to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious and manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by service. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). In the Veteran's August 1961 enlistment examination report, there was a notation of dizziness, "when hot or on getting up suddenly." In an August 1961 Report of Medical History, the Veteran marked "yes" to having dizziness or fainting spells. It was again noted that he was dizzy "when hot or on getting up suddenly." A November 1961 treatment note showed complaints of pain in chest and dizziness. Physical examination findings were negative at that time. While his August 1963 separation examination did not mention anything about dizziness or fainting spells, the Veteran again marked "yes" to having dizziness or fainting spells in an August 1963 Report of Medical History. The examiner noted that the Veteran had "momentary transient lightheadedness with sudden change of position". A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. Id. Aggravation for purposes of entitlement to VA compensation benefits requires more than that a preexisting disorder become intermittently symptomatic during service; rather, there must be permanent advancement of the underlying pathology. Furthermore, temporary or intermittent flare-ups of a preexisting disease during service are not sufficient to be considered aggravation of the disease unless the underlying condition, as contrasted to symptoms, is worsened. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Hunt v. Derwinski, 1 Vet. App. 292 (1991); Verdon v. Brown, 8 Vet. App. 529, 536-7 (1996). In his June 2005 claim, the Veteran asserted that he experienced vertigo secondary to hearing loss and tinnitus. A January 2006 VA treatment note listed an assessment of possible benign paroxysmal positional vertigo (BPPV). In private treatment notes and a statement dated in January 2006, a private audiologist noted that the Veteran was seen for an electronystagmography (ENG) per the VA. The Veteran presented with asymmetric optokinetic nystagmus (OKN) with otherwise normal and essentially age appropriate oculomotor tests, no gaze nystagmus, some positional nystagmus and rotary nystagmus in the Dix-Hallpike left, and some horizontal nystagmus in the Dix-Hallpike right. Nystagmus and dizziness were noted to fatigue in all conditions. The examiner listed an impression of left BPPV. Following testing in January 2006, an April 2006 VA examiner noted that the Veteran's condition was not due to injury but occurred over time. Symptoms of the condition were listed as dizziness resulting in blackout, vertigo, balance problems, yellow pus/cerumen discharge from both ears, and pain from both ears described as ringing to sharp pain, left worse than the right. The Veteran's described symptoms were noted to occur intermittently as often as 15 times per day, each time lasting for one minute. The treatment for his condition was listed as Meclizine HCL 12.5 milligrams, two tablets three times per day. The functional impairment resulting from his condition was listed as difficulty walking and use of a cane or walker to keep from falling. The examiner stated that there was no diagnosis because there was no pathology to render a diagnosis. In an attached addendum report, the examiner noted that the Veteran had abnormal Dix Hallpike testing for both right and left ears, indicating that an ENG should be done to determine pathophysiology of that symptom. Thereafter, the examiner noted that the subsequently conducted ENG was normal and that the Veteran "may be having dizziness but [there is] no objective evidence for vertigo." VA treatment notes dated in 2006 show a past medical history of BPPV per the Veteran's report, findings of BPPV, and complaints of balance problems. During a February 2006 VA consultation, it was noted that the Veteran was unable to do heel-toe walking or Romberg testing due to vertigo problems. It was noted that the Veteran had mild vertigo on the right, with no nystagmus. A September 2006 VA ENT consult report showed complaints of vertigo that was "getting worse". The examiner noted that ENG had showed rotator nystagmus on Dix Hallpike maneuver on left and positional nystagmus. In an October 2006 VA audiology consult, the Veteran was seen for repeat Canalith Repositioning Maneuver (CRM) to the left side. The Veteran reported only a slight feeling of "off balance" when his head was being positioned to head hanging left and turned to right side. No visual nystagmus was noted. The Veteran indicated that his typical balance problem at home included an episode where he was standing still and felt himself fall backward, knees collapsing and vision going black. An additional October 2006 treatment record listed an impression of benign vertigo. In an October 2006 VA ear disease examination report, the Veteran indicated that he had experienced vertigo since service, first noticing his inability to balance while standing in 1962. After examining the Veteran and reviewing the claims file, the examiner diagnosed BPPV, but indicated that it was "not likely" due to the Veteran's hearing loss and tinnitus. The examiner further stated that, "It is only due to the positional change, sometimes due to postural hypotension." The Veteran submitted a statement by a private physician, M. S., M. D., dated in February 2007, who, referring to the history portion of the report of the Veteran's separation examination in August 1963, opined that, "I believe the patient had chronic benign positional vertigo back at that time and he continues to have this today." In an April 2010 Board Remand, the Board determined that neither the April 2006 VA examiner nor the October 2006 examiner commented on the relationship, if any, between the Veteran's current symptoms and the symptoms noted in service. It was further noted, that although the private physician appeared to relate the Veteran's current symptoms to the symptoms noted in service in his February 2007 statement, he did not explicitly say so. Moreover, the Board found that those medical opinions appeared to reach conflicting conclusions as to whether the Veteran had a current diagnosed disorder. Thereafter, in an August 2010 VA ear disease examination report, the VA examiner diagnosed BPPV, opining that it was "less likely" due to his hearing loss and tinnitus and most likely due to his hypertension and antihypertensive medication. Unfortunately, the August 2010 VA examiner did not discuss the other medical opinions of record noted above, as was specifically requested in the April 2010 Board remand. The examiner also did not discuss the relationship, if any, between the Veteran's current symptoms and those noted in service, including those noted on service entrance, as specifically requested in the Board's April 2010 remand. Nor did the examiner comment on whether any such disorder pre-existed service and, if so, whether the disorder increased in disability during service beyond that to be expected due to the natural progression of the disorder, also as specifically requested by the Board. Although the August 2010 VA examiner opined that it was less likely that the Veteran's vertigo was due to his service-connected hearing loss or tinnitus, the examiner did not provide an opinion as to whether the hearing loss or tinnitus aggravated the vertigo, also as specifically requested by the Board in the April 2010 remand. Finally, the August 2010 VA examiner suggested that the Veteran be seen by an ENT specialist and/or by a neurologist to determine whether he has any inner ear disease or other neurological disease. However, no additional evaluation was obtained. In a November 2010 Board remand, the Board found that the August 2010 VA examination report was inadequate for rating purposes for all the foregoing reasons and instructed the RO to obtain an additional examination. In a January 2011 VA examination report, the VA examiner first found that the Veteran "has a current 'dizziness' condition (diagnosed as possible benign postural vertigo) with history or physical findings consistent with vertigo". However, the examiner ultimately concluded that "at least as likely as not, there is no definitive diagnosis of vertigo." He found the February 2007 opinion from M. S., M. D., to be without merit, highlighting the Veteran's reports that there was no change in his pre-existing condition until about 20 years after service as well as noting that the private physician's opinion did not satisfy the "at least as likely as not" standard. Based on review of the file, performing the examination, and review of medical literature, the January 2011 VA examiner opined that the Veteran's "'dizziness' complaints are less likely as not permanently aggravated or a result of any event and/or condition that occurred and/or expressed in-service and/or within one year of discharge including tinnitus and/or hearing loss". The January 2011 VA examiner then opined that the Veteran's dizziness complaints "are at least as likely as not a result of dizziness complaints that were reported on the entrance history and physical examination and/or the effect of smoking 2 packs a day for 50 years and/or diabetes and/or other post service events and/or other neurological and/or vascular conditions". The examiner opined that the Veteran's dizziness complaints were not caused by and/or worsened by an already service-connected disability, including tinnitus and/or hearing loss. The examiner also stated that the "natural progression of the possible benign positional vertigo 'dizziness' was not altered or worsened by any event and/or condition that occurred and/or expressed during active service including tinnitus and/or hearing loss". As part of his cited rationale, the examiner included the full text of an article on dizziness from a medical literature source, "Up To Date On Line", in the January 2011 report. In a February 2012 VA emergency room note, the Veteran denied dizziness or syncope. In a May 2012 lay statement contained in the Veteran's Virtual VA file, the Veteran's spouse commented that he gets dizzy quite a bit. In an August 2012 Board remand, the Board found that the January 2011 VA examination report was inadequate for rating purposes. The Board determined that the January 2011 VA examiner's findings seemed contradictory to one another, as it was not clear whether the VA examiner's conclusion was that the Veteran does have a current disorder manifested by vertigo or dizziness, or whether he does not. It was further noted that the VA examiner provided no explanation or rationale for other opinions provided as to etiology of the Veteran's claimed disorder as directed in the Board's November 2010 remand. Finally, although the January 2011 VA examiner cited various medical treatises in support of the opinions provided, the Board noted that the examiner did not explain how the findings noted in the medical treatises applied to the Veteran's case or related to the conclusions reached by the examiner. For all the foregoing reasons, the Board instructed the RO to contact the VA examiner who conducted the January 2011 VA examination and request that further explanation and rationale be provided for the opinions reached with regard to whether the Veteran currently has a disorder manifested by vertigo and/or dizziness, and if so, whether that disorder was incurred in or aggravated by active duty service or a service-connected disorder. A complete rationale for all opinions was requested. The examiner was also instructed to discuss and distinguish the previous VA and private medical opinions on this issue, and explain the findings reached in those instances in relation to his own. In addition, it was specifically noted that if the VA examiner relied upon any outside medical treatises in the opinion provided, the examiner must include copies of all such sources. An October 2012 VA examination was conducted by the same VA examiner who performed the January 2011 VA examination. The examiner indicated that the Veteran's record showed subjective reports of dizziness, with no neurological abnormalities recorded to correlate with the subjective complaints, such as vertigo. Severe chronic obstructive pulmonary disorder with hypoxia, obesity, congestive heart failure, anemia, and general deconditioning was diagnosed. The examiner opined that the Veteran "at least as likely as not" has dizziness and "less likely as not" has vertigo. It was indicated that each of the above medical conditions alone and the summation of the effect of all of these conditions may result in dizziness related to postural hypotension. The examiner concluded that the current dizziness was "at least as likely as not" a post service condition, as the record reports the Veteran was symptom free for 20 years. The examiner indicated that any alleged EPTS (existed prior to service) condition was "less likely as not" aggravated (a change in the natural progression of the condition) by an event/condition that occurred in/expressed in or within one year of discharge and was not aggravated by a service-connected condition. The examiner highlighted that the record reported no nystagmus with nystagmus, reported in literature as a common findings with vertigo. The examiner concluded that the Veteran's current dizziness was "less likely" a continuation of the EPTS condition as reported on the service entrance examination and was "at least as likely as not" a post-service condition. The examiner again cited that the record showed the Veteran to be symptom free for 20 years. It was noted that the Veteran had been diagnosed with BPPV but that nystagmus had not been found, which caused the diagnosis of BPPV to be in doubt. The examiner commented that symptoms such as dizziness are vague, nonspecific, subjective, and mean different things to different patients, and generally do not result in a definitive diagnosis. The examiner noted that there was no definitive study to definitively determine the etiology of dizziness. The examiner cited to a March 2011 notation in the record that the Veteran could walk 100 feet, noting it to be inconsistent with vertigo. Finally, the examiner opined that the alleged dizziness was "less likely as not" related to tinnitus/hearing. The examiner then noted that his January 2011 examination report was supported by "Up To Date On Line", a recognized medical literature source. As noted above, the actual text of the referenced medical literature source article concerning dizziness was included in the January 2011 report. In a March 2013 Board remand, the Board found that the January 2011 and October 2012 VA examination reports were inadequate for rating purposes. In the August 2010 VA examination report of record, the examiner specifically recommended that the Veteran be seen by an ENT specialist and/or by a neurologist to determine whether he has any inner ear disease or other neurological disease. As the examiner who conducted the January 2011 and October 2012 VA examinations was neither an ENT specialist nor neurologist, the Board instructed the RO to afford the Veteran an additional VA examination with an ENT specialist and/or neurologist in order to clarify the nature and etiology of his claimed vertigo on appeal. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In a May 2013 VA audiology treatment record, the Veteran reported a history of vertigo when lying down, primarily on the right side. He reported that the vertigo was episodic in nature, lasting for 30 seconds to one minute and then subsiding. The examiner indicated that review of records showed the Veteran had videonystagmography (VNG) testing in past, revealing left-side BPPV. He stated that he was treated with a CRM. Given Veteran's history and report of current symptoms, the examiner noted that the Veteran was laid on both right and left for Dix Hallpike testing. The examiner detailed that right Dix Hallpike testing revealed symptoms consistent with right posterior canal BPPV. Classic latency and fatigue of symptoms with BPPV were noted. In a July 2013 VA examination report, the examiner, the same VA physician who conducted the January 2011 and October 2012 VA examinations, discussed a detailed review of the claims file and diagnosed BPPV. The Veteran was noted to report vertigo with a frequency of less than once a month. Duration of episodes was listed as less than one hour. On physical examination, the Veteran's gait was normal. The results of his Dix Hallpike test (Nylen-Barany test) for vertigo were noted to be abnormal with references made to the May 2013 VA treatment record discussed above. The examiner noted that the Veteran, on July 5, 2013, denied any symptoms of vertigo and that examination, therefore, was not indicated. Previous ear examination was noted to be normal. The Board is cognizant that the same VA physician who conducted the January 2011 and October 2012 VA examinations conducted the examination portion of the July 2013 report. However, as requested by the Board, a medical opinion from a VA ENT specialist regarding vertigo was obtained. The VA ENT specialist, a provider that had also previously seen the Veteran in 2005 and 2006, noted examination of the Veteran and a detailed review of the claims file, to include the exact text from two of the ENT specialist's own VA treatment notes dated in 2005. The June 2005 and September 2005 VA treatment notes show the ENT specialist listed a diagnosis of vertigo at that time. The specialist then opined that the claimed vertigo condition was "less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness." The VA ENT specialist indicated that the Veteran's service medical records, private medical records, military service, and VA medical records had been considered in arriving at the conclusions. The VA ENT specialist then concluded that the Veteran had BPPV and that the Veteran had similar complaints prior to service, opining that the Veteran's "complaints of dizziness and/or vertigo were less likely as not permanently aggravated or a result of any event and/or condition that occurred and/or expressed in-service and/or within one year of discharge and are at least as likely as not a result of the underlying condition with pre-service complaints". In addition, the VA ENT physician noted that complaints of dizziness and/or vertigo "were not caused by and/or worsened by an already service connected disability". The VA ENT physician determined that the natural progression of the Veteran's condition was not altered or worsened by any event and/or condition that occurred and/or expressed during active service. In the cited rationale for those opinions, the VA ENT physician highlighted that the Veteran left active service 1963 and then reported 20 years of positional vertigo symptoms, with improving symptoms in 2005, over 40 years after separation from service. It was also indicated that a March 2006 ENG showed left BPPV and an April 2013 evaluation showed right BPPV. The VA ENT physician further commented that symptoms reported at separation and reported by M. S., M. D. in February 2007, were the same complaints reported on the Veteran's August 1961 pre-service examination report. Upon consideration of all of the evidence of record, the Board finds that clear and unmistakable evidence demonstrates that the Veteran's vertigo, diagnosed as BPPV, existed prior to service and clear and unmistakable evidence demonstrates that his pre-existing vertigo was not aggravated by service. 38 U.S.C.A. §§ 1111, 1153; 38 C.F.R. § 3.304, 3.306. While complaints of dizziness when hot or on getting up suddenly were noted on entrance, the Board is cognizant that while symptoms of vertigo were noted at entrance, a diagnosis of vertigo was not shown at the time he was initially examined for service entrance as the clinical examination was normal. Thus, the Veteran is presumed to have been in sound condition. Id. However, the presumption of soundness is rebutted in this case, as there is clear and unmistakable evidence in the record that the Veteran's vertigo both preexisted service and was not aggravated by service. A longitudinal review of the record reveals a complex factual background for this appeal. Here, service treatment records reflect that the Veteran's complaints of dizziness when hot or on getting up suddenly were evident at service entrance. At service exit, an examiner again noted that the Veteran had "momentary transient lightheadedness with sudden change of position". The record also contains multiple conflicting medical opinions by VA examiners as to whether the Veteran has a current vertigo disorder, whether the claimed vertigo disorder preexisted service, and whether vertigo was aggravated during service. As discussed at length above, the Board has reviewed each of the VA medical opinions and specifically detailed why the April 2006, October 2006, August 2010, January 2011, and October 2012 VA examination reports, obtained to determine the nature and etiology of the Veteran's vertigo, are inadequate for adjudication purposes. However, the Board finds the final July 2013 VA examination report with VA ENT specialist medical opinion to be competent, adequate, and entitled to probative weight, as it is based on a thorough review of the Veteran's entire claims file and the examiner provided supporting rationale for the conclusions reached. Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (holding that factors for assessing the probative value of a medical opinion include access to the claims file and the thoroughness and detail of the opinion); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (stating that the failure of the physician to provide a basis for an opinion goes to the weight or credibility of the evidence). In that report, the VA ENT specialist definitively concluded that the Veteran had a diagnosis of BPPV and that the Veteran had similar complaints prior to service, opining that the Veteran's "complaints of dizziness and/or vertigo were less likely as not permanently aggravated or a result of any event and/or condition that occurred and/or expressed in-service" and "are at least as likely as not a result of the underlying condition with pre-service complaints". The VA ENT physician further determined that the natural progression of the Veteran's condition was not altered or worsened by any event and/or condition that occurred and/or expressed during active service. In the cited rationale for those opinions, the VA ENT physician highlighted that symptoms reported at separation in 1963 and reported by Dr. M. S. in February 2007, were the same complaints reported on the Veteran's August 1961 pre-service examination report. The Veteran's complaints at service entrance and exit, coupled with the well reasoned, thorough, and highly probative opinion provided by the VA ENT specialist in the July 2013 VA examination report, constitutes clear and unmistakable evidence that the Veteran's vertigo preexisted service and clear and unmistakable evidence that the Veteran's vertigo was not aggravated during service. In this, and in other cases, only competent evidence may be considered to support Board findings. Accordingly, the Board is not free to substitute its own judgment for that of an expert. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). By contrast, the sole private opinion of record, the February 2007 statement from M. S., M. D., is of little probative value. The physician did not provide any type of rationale his opinion and simply noted that the Veteran had chronic benign positional vertigo at separation based on a review of the Veteran's August 1963 separation examination and that the Veteran continued to have the disorder today. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). Consequently, the Board notes that the private medical evidence is insufficient to show that the Veteran's pre-existing vertigo was permanently worsened or aggravated beyond the natural progression of the disability during active service. During the pendency of the appeal, the Veteran asserted in an October 2006 VA examination report that he first experienced symptoms of vertigo during service in 1962. These lay statements are competent evidence as to what the Veteran experienced at that time. See Layno, 6 Vet. App. at 469-70. Once lay evidence has been determined to be competent, the Board must also determine whether such evidence is credible. However, the Veteran's assertions that his vertigo symptoms first onset during service in 1962 are inconsistent with his assertions of dizziness when hot or on getting up suddenly in his August 1961 entrance examination report. Accordingly, to the extent that the Veteran asserted that his vertigo symptoms first onset during service in 1962, the Board finds such statements to lack credibility and, therefore, accords little, if any, probative weight to such assertions. Caluza v. Brown, 7 Vet. App. 498 (1995) (finding that in weighing credibility, VA may consider inconsistent statements, internal inconsistency, and consistency with other evidence of record). In this case, the Board finds that the most probative evidence that specifically addresses the questions of whether the Veteran's vertigo preexisted service and whether it was aggravated during service, weighs against the claim. Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (finding that it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)); see also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (holding that the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). Accordingly, the Board concludes that the presumption of soundness of the Veteran regarding vertigo at enlistment is rebutted by clear and unmistakable evidence that vertigo existed prior to his entry into service and by clear and unmistakable evidence that vertigo was not aggravated by active service. 38 U.S.C.A. §§ 1111, 1113; 38 C.F.R. §§ 3.304, 3.306. Turning to Veteran's primary assertion, service connection may be granted where a disability is determined to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). With regard to aggravation of nonservice-connected disabilities, for claims filed on or after October 10, 2006, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be awarded service connection. However, a nonservice-connected disease or injury will not be found aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The baseline and current levels of severity will be determined under the VA Schedule for Rating Disabilities, and the extent of aggravation will be determined by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). As discussed above, probative evidence of record demonstrates that the Veteran has a current diagnosis of vertigo. It is also undisputed that service connection for tinnitus and bilateral hearing loss has been granted. The October 2006, August 2010, January 2011, October 2012, and July 2013 VA examiners each addressed the issue of a nexus between the service-connected tinnitus and hearing loss and the Veteran's current vertigo. Specifically, the VA examiners opined that vertigo was "less likely" due to the Veteran's service-connected tinnitus and/or hearing loss or, in the alternative, that vertigo was not aggravated by service-connected hearing loss and/or tinnitus. Cited rationale for those stated opinions included that vertigo was due to positional change only or due to other medical conditions like hypertension. In addition, the Veteran has not provided any competent medical opinion, despite be given the opportunity to do so, that rebuts these findings. As such, the Board finds that the most persuasive medical evidence that specifically addresses the question of whether the Veteran's service-connected hearing loss and/or tinnitus caused or aggravated his vertigo weighs against the claim. The Board has also considered the Veteran's repeated contentions that his vertigo is secondary to his service-connected tinnitus and bilateral hearing loss. While the statements of the Veteran and his spouse are competent and credible as to the lay observable manifestations of the Veteran's vertigo, such as dizziness, the Board finds that their statements are not competent evidence as to the etiology of the vertigo, to include any causal relationship with his service-connected tinnitus and hearing loss. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that a veteran's statements are competent evidence of what comes to him/her through his/her senses). The evidence of record does not demonstrate that the Veteran or his spouse possess the ability, knowledge, or experience to provide competent medical opinions of such a complex nature. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Accordingly, the Board finds that the Veteran's lay statements as to medical causation are not competent evidence to establish service connection for vertigo. The criteria to establish entitlement to service connection for vertigo have not been established on a direct or secondary basis, either through medical or probative lay evidence. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim of entitlement to service connection for vertigo that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for vertigo, to include as secondary to service-connected hearing loss and tinnitus, is denied. ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs