Citation Nr: 1329808 Decision Date: 09/17/13 Archive Date: 09/25/13 DOCKET NO. 07-07 920 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for diabetes mellitus, type II. 2. Entitlement to service connection for an acquired psychiatric disability, including posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for coronary artery disease (CAD). 4. Entitlement to service connection for peripheral neuropathy of the right and left lower extremities, to include as secondary to diabetes mellitus, type II. REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION The Veteran had active duty service from December 1945 to December 1949 with the United States Navy and from March 1951 to December 1953 with the United States Air Force. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2006 rating decision issued by the Department of Veterans Affairs (VA) "Tiger Team" at the Regional Office (RO) in Cleveland, Ohio. The claims file in this matter was subsequently transferred to the New York, New York, RO for further handling. The Veteran testified at a personal RO hearing in May 2007. In his substantive appeal, he requested a Board hearing at the local RO, which was scheduled by the New York RO in September 2008. However, the Veteran failed to appear. His claims file was subsequently transferred to the Winston-Salem, North Carolina RO as the Veteran had moved. The Winston-Salem RO scheduled the Veteran for another Board hearing in October 2011. However, prior to the hearing, the Veteran cancelled his hearing request. These matters were remanded by the Board in May 2012 for further development. The Board also remanded the issues of entitlement to service connection for bilateral hearing loss and tinnitus. The RO issued an April 2013 rating decision in which it granted service connection for each of these issues. The award of service connection constitutes a complete grant of these claims. Consequently, they are not before the Board. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Diabetes mellitus, type 2 was not manifested during the Veteran's active duty service or for many years after service, nor is it otherwise related to service. 2. PTSD has not been attributed to a verified stressor or an alleged stressor consistent with the Veteran's active service. An anxiety disorder was not manifested during active duty service or for many years after service, nor is it otherwise related to service. 3. Coronary artery disease was not manifested during the Veteran's active duty service or for many years after service, nor is it otherwise related to service. 4. Peripheral neuropathy of the lower extremities was not manifested during the Veteran's active duty service or for many years after service, nor is it otherwise related to service; the evidence does not shown it to have been caused or aggravated by a service connected disability. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for diabetes mellitus type 2 have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 2. The criteria for an award of service connection for an acquired psychiatric disability, to include PTSD, have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 3. The criteria for an award of service connection for coronary artery disease have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 4. The criteria for an award of service connection for peripheral neuropathy of the right and left lower extremities have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Notify As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent a letter in August 2006 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the service treatment records are silent as to any complaints or treatment for diabetes mellitus type 2 and peripheral neuropathy. Moreover, the post-service evidence does not indicate any current complaints or treatment referable to either disability until several years following separation. Furthermore, the records contain no competent evidence, including lay statements, suggesting a causal relationship between the current disability and active service or a continuity of symptomatology. For all of these reasons, the evidence does not indicate that the claimed disability may be related to active service such as to require an examination, even under the low threshold of McLendon. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claims are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Applicable law provides that service connection will be granted if it is shown that the Veteran suffers from disability resulting from an injury suffered or disease contracted in 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; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). However, a grant of service connection based on continuity is only available for disorders listed as a chronic disease under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as diabetes mellitus, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. 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). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet.App. 439 (1995). Diabetes mellitus In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). In this case, the Veteran has established the first of these elements. Indeed, there is no doubt that he has been diagnosed with diabetes mellitus type 2. A July 2006 VA outpatient treatment report reflect that the Veteran reported that he moved to Florida in 2003 and that he was diagnosed with diabetes while living there. More recent outpatient treatment reports reflect continued treatment for diabetes mellitus type 2. With respect to the second element of service connection, the Board finds that the service treatment records fail to reflect any findings attributable to diabetes mellitus. At a May 2007 RO hearing, the Veteran testified that he developed diabetes mellitus within one year of service and that he was treated when he first got out of service. However, the Board notes that none of the private treatment records or the VA treatment records make any mention of diabetes mellitus until July 2006 (more than 50 years after service). Moreover, when the Veteran did report a past history of diabetes, he specifically stated that he was diagnosed after having moved to Florida in 2003. Consequently, the Veteran's hearing testimony conflicts with his own report to the VA clinicians. Finally, once the Veteran began being treated for diabetes mellitus, none of the treatment reports include a history of that disability dating back to service. Overall, then, the Board finds that a preponderance of the evidence is against a finding of an in-service incurrence of diabetes mellitus or of continuity from that time forward. In the absence of any in-service findings of diabetes in the service treatment records or for decades after service, and without a competent opinion linking diabetes mellitus to service, the Board finds that a preponderance of the evidence weighs against the claim. As such, the benefit-of-the-doubt doctrine does not apply, and the claim for service connection for diabetes mellitus must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Peripheral neuropathy As to this disability, the evidence is in question as to whether a current disability exists. In this regard, the most recent treatment reports (located in Virtual VA) fail to reflect any diagnoses of peripheral neuropathy. To the contrary, in a December 2010 pre-operative report, under past medical history, neuropathy (as well as other neurological conditions) is left unchecked. This is the only reference to neuropathy. Likewise, an October 2008 treatment report included a review of systems in which the Veteran denied any significant history of the peripheral vascular system and neurology. Direct service connection is not warranted because there are no findings attributed to peripheral neuropathy in service; no current diagnosis of peripheral neuropathy; and no competent medical opinion linking a current diagnosis to service. It appears that the crux of the Veteran's claim for service connection for peripheral neuropathy is that the alleged disability is secondary to diabetes mellitus. While the Board recognizes that peripheral neuropathy is frequently associated with diabetes mellitus, a claim for secondary service connection is not warranted inasmuch as the Veteran is not service connected for diabetes mellitus. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for service connection for peripheral neuropathy of the right and left lower extremities must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Psychiatric disability Establishing service connection for PTSD requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). See also Cohen v. Brown, 10 Vet. App. 128 (1997). A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a), which simply mandates that, for VA purposes, all mental disorder diagnoses must conform to the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV). See 38 C.F.R. § 3.304(f). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(1). See also 38 U.S.C.A. § 1154(b). The ordinary meaning of the phrase "engaged in combat with the enemy," as used in 38 U.S.C.A § 1154(b), requires that a Veteran have participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. The issue of whether any particular set of circumstances constitutes engagement in combat with the enemy for purposes of section 1154(b) must be resolved on a case-by-case basis. See VAOPGCPREC 12-99 (October 18, 1999). If there is no combat experience, or if there is a determination that the Veteran engaged in combat but the claimed stressor is not related to such combat, there must be independent evidence to corroborate the Veteran's statement as to the occurrence of the claimed stressor. Doran v. Brown, 9 Vet. App. 163, 166 (1996). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. Cohen v. Brown, 10 Vet. App. 128, 142 (1997). Just because a physician or other health professional accepted appellant's description of his service experiences as credible and diagnosed appellant as suffering from PTSD does not mean the Board is required to grant service connection for PTSD. Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). The Board is not required to accept an appellant's uncorroborated account of his active service experiences. See Swann v. Brown, 5 Vet. App. 229, 233 (1993) and Wood v. Derwinski, 1 Vet. App. 190, 192 (1991). The regulations pertaining to PTSD were amended, and 38 C.F.R. §3.304(f)(3) no longer requires the verification of an in-service stressor if the Veteran was in a location involving "fear of hostile military or terrorist activity." Such a location can be evidenced by awards such as the Iraq Campaign Medal or the Vietnam Service Medal. Lay testimony alone can be used to establish the occurrence of an in-service stressor in these situations. The new regulatory provision requires that: (1) A VA psychiatrist or psychologist, or contract equivalent, must confirm that the claimed stressor is adequate to support a diagnosis of PTSD; (2) the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service; and (3) the Veteran's symptoms are related to the claimed stressor. Id. The liberalizing criteria contained in the new § 3.304(f)(3) will be applied to PTSD service connection claims that are pending as of the effective date of the regulation (July 13, 2010) and to claims filed on or after this effective date. Taking into account all relevant evidence, the Board finds that service connection is not warranted for any psychiatric disorder, to include PTSD. Initially, the evidence does not show that the Veteran engaged in combat. Consequently, either the Veteran's alleged stressors must be verified, or the stressors must at least be consistent with the places, types, and circumstances of his service. In this case, the Veteran contends that while on grave registration duty, he had to pick up dead bodies along the South Pacific. He stated that the weight of the bodies and the odor made him constantly sick and stressed and that he started having nightmares, flashbacks, headaches, and nervous body aches (see September 2006 correspondence). Pursuant to the Board's May 2012 remand, the RO requested the ship histories for the time period that the Veteran was stationed on the USS LST 803. In May 2013, the National Archives searched the ship histories for evidence that the Veteran had been required to assist in digging up dead bodies, tagging and bagging them, and placing them in coffins. The National Archives searched Record Group 24 (Bureau of Naval Personnel) and located each of the deck logs from June 1946 to February 1947 (a total of 600 pages). However, no information supported the Veteran's contention. LST-803 was involved in movements between ports in the Western Pacific, mostly embarking/debarking passengers, materials and supplies, and on one occasion a Japanese prisoner of war. A May 2013 Defense Personnel Records Information Retrieval System (DPRIS) report reflects that the LST-803 participated in the assault and occupation of Okinawa from April 1945 to June 1945. However, the Board notes that the Veteran did not enter the service until December 1945 and was not stationed aboard the LST-803 until June 1946. Regarding the time that the Veteran served on the LST-803, the DPRIS report simply notes that the LST-803 performed occupation duty in the Far-East until mid-May 1947. It stated that the deck logs do not reveal the day to day activities of the crew or document the incident described in the Veteran's claim. The Board's May 2012 remand instructed that a VA examination was necessary if, and only if, the Veteran's stressor was verified. However, the Veteran underwent a VA examination in February 2013, even in the absence of verified stressors. The examiner reviewed the claims file in conjunction with the examination. After a thorough examination report, the examiner opined that the Veteran did not meet the diagnostic criteria for PTSD. She found that he met criterion A for PTSD, but that he did not fulfill criterion D (as he endorsed only one symptom rather than the required two symptoms in that cluster). However, the examiner did diagnose the Veteran with an anxiety disorder and a cognitive disorder. She found that the cognitive disorder was less likely than not related to military service because no such cognitive disorder was noted during service. Moreover, records dated 2002 also showed that the Veteran's cognitive function was normal at that time. Consequently, she found that the cognitive disorder was of recent origin and less likely related to events occurring as far back as his discharge from service. With regard to the Veteran's anxiety disorder, the examiner found that it was at least as likely as not that his anxiety disorder symptoms are related to military service. She reasoned that the Veteran's symptoms included distressing thoughts/memories of traumatic events, nightmares of traumatic events, mild psychological and mild physiological reactions to trauma cues, avoidance of thoughts/feelings/talking about traumatic events, avoidance of situational reminders of events, difficulty in recalling aspects of the traumatic events he experienced, persistent sleep problems, and irritability. The Veteran was unable to identify when these symptoms began, but he remembered being disturbed by the events at the time they occurred. He reported that some time after service, he noted that his "nerves were shot." The examiner noted that he did not appear to seek treatment until 2006-2007. The examined acknowledged that the stressors had not been verified, but noted that the Veteran denied any pre-military traumatic history that would account for his current anxiety symptoms. The Board notes that neither the service treatment records nor any of the post service records have been sufficient to verify the Veteran's alleged stressor, which also falls outside the scope of the revisions to 38 C.F.R. § 3.304(f) as they do not involve fear of hostile military or terrorist activity. Moreover, the May 2012 examiner found that the Veteran did not meet the diagnostic criteria for PTSD. Consequently, the preponderance of the evidence weighs against a finding of service connection for PTSD. With regard to the February 2013 VA examiner's diagnosis of an anxiety disorder and the positive nexus opinion that she provided, the Board notes that the anxiety disorder has not been attributed to a verified in-service stressor. The VA examiner specifically acknowledged that the alleged stressor has not been verified. Moreover, the service treatment records fail to contain any findings attributed to anxiety. The Board notes the gap of approximately 5 decades between the Veteran's separation from service and the first documented treatment of a psychiatric disorder. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. However, such absence of documented treatment, in and of itself, is not a basis for discrediting his lay statements of continuity. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Thus, the Board must consider the totality of the record, and not just the absence of clinical treatment, in weighing the Veteran's statements asserting continuity of symptomatology. In this case, the Veteran's has not specifically asserted continuity of symptomatology. At his February 2013 VA examination, he reported that he did not remember when his symptoms began. He only reported that sometime after service, he noticed that his nerves were shot. Additionally, it is noted that the Veteran did not file a claim of service connection for a psychiatric disability until 2006, decades after he separated from service. Had he been experiencing psychiatric symptoms since service it would be reasonable to expect that he would have filed a claim sooner. Indeed, in October 2004, he sought service connection for hypertension and diabetes. Thus, he was clearly aware of the process for applying for benefits. The fact that he did not seek service connection for PTSD or other psychiatric disability in conjunction with these claims very strongly suggests that he was not indeed experiencing psychiatric symptoms since service or, if he was, that he did not attribute them to his service. For the above reasons continuity of symptomatology is not demonstrated here, either by the clinical record or by the Veteran's own statements. As noted above, service connection is not warranted in this case on the basis of continuity of symptomatology. However, if the competent medical evidence indicates that the current psychiatric disability is related to the Veteran's active service, then an award of service connection would be appropriate. In this vein, the VA examiner in February 2013 concluded that the Veteran's mild anxiety disorder was related to military service. However, her rationale was based on an inaccurate factual premise, inasmuch as she relied on the Veteran's allegations of what occurred in service despite the fact that she acknowledged that the alleged stressor had not been verified. Given that the opinion was based on an inaccurate factual premise, it is of little probative value and does not overcome the weight of evidence against the claim. The Veteran himself believes that his current psychiatric symptoms are related to service. However, while he is competent to describe symptoms, he has not demonstrated the expertise generally required to opine on causation. Indeed, in this case, the question of etiology extends beyond an immediately observable cause-and-effect relationship, such as a fall leading to a broken leg. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau)). Here, psychiatric disabilities are not simple medical conditions that the Veteran can identify based on mere personal observation, that is, by visual observation or by any other of the senses. In sum, his statements as to etiology in this case are not competent and therefore lack probative value. As the preponderance of the evidence is against the claim under the applicable the theories of service connection under 38 C.F.R. § 3.303(b) and (d), the benefit of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). With respect to the question of entitlement to service connection on a presumptive basis, while there is medical evidence of mild anxiety during service, there is no competent medical evidence of any psychosis within one year of the Veteran's separation from active duty service, as required for service connection under 38 C.F.R. § 3.307(a), so service connection under the presumptive provisions of 38 C.F.R. §§ 3.307 and 3.309 is not warranted, and the benefit of-the-doubt standard of proof does not apply. 38U.S.C.A. § 5107(b). The Board finds that the Veteran's PTSD has not been attributed to any verified in-service stressor or to any alleged stressor that is consistent with the circumstances of the Veteran's service. Moreover, the service treatment records fail to reflect any findings attributable to anxiety. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) and anxiety must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Coronary artery disease The service treatment records reflect that the Veteran underwent an examination in January 1948. Examination of the heart and blood vessels revealed a systolic murmur at apex. His December 1949 separation examination yielded normal findings. His March 1951 enlistment examination into the Air Force, and his December 1953 separation examination also yielded normal findings. The Veteran completed a Report of Medical History in March 1951 in which he denied (by checked box) ever having had shortness of breath, pain or pressure in his chest, palpitation or pounding heart, or high or low blood pressure. The first post service treatment records are dated decades after service. A Discharge summary from Beth Israel Medical Center reflects that the Veteran complained of chest pain of four days duration. He had a significant history for hypertension, two myocardial infarctions (the most recent one in January 2001), status post angioplasty and stent placement, and hypercholesterolemia. His discharge diagnoses were (1) chest pain, myocardial infarction ruled out, (2) hypercholesterolemia, and (3) hypertension. An April 2002 VA outpatient treatment record reflects a past history of hypertension (of 8 years duration); CAD; and angina (of 8 years duration). A December 2006 psychiatric treatment report reflects that the Veteran reported that he stopped smoking due to a myocardial infarction that he experienced in 1986. The Veteran underwent a VA examination in February 2013. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported that during military service, "something was going on" with his heart. He denied treatment for angina or other cardiovascular related conditions. The examiner noted that with the exception of the January 1948 examination, there was no documentation of any heart related conditions or symptoms. She noted that the Veteran was a poor historian, who was unable to provide clear information concerning the claimed condition and health events/evaluations since his discharge from service, except that he was able to report that he had a myocardial infarction. He also stated that he had a cardiac catheterization; but the examiner found no documentation of it in the claims file. After a thorough examination of the Veteran and the claims file, the examiner opined that it was less likely than not that the Veteran's cardiac disability began during or was caused by service. She noted the lone service treatment record reflecting a systolic murmur at apex; and that the Veteran was asymptomatic at that time. She noted the wide gap in treatment records from discharge from service in 1953 to 1997. She stated that identification and verification of any heart disability during that gap was not feasible. She stated that a systolic ejection murmur, loudest at the apex, is inconsistent with the years of heart examinations documented in the claims file. She reasoned that as a result, the detection or non-detection of such a cardiac murmur is either subjective to clinician auscultation skill variation and/or the non-prominence of this finding in the Veteran. She stated that the preponderance of the medical evidence does not support an isolated "systolic murmur at the apex" as being related to military service. Analysis In this case the service treatment records include a single finding of a systolic murmur at apex, so there is affirmative evidence of a cardiac symptom. However, the service treatment records lack the documentation of the combination of manifestations sufficient to identify a chronic disability. As chronicity in service is not adequately supported by the service treatment records, then service connection may be established by continuity of symptomatology under 38 C.F.R. § 3.303(b) or based on initial diagnosis after service under 38 C.F.R. § 3.303(d). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran is competent to describe symptoms of coronary artery disease. 38 C.F.R. § 3.159 (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms, which are within the realm of one's personal knowledge, personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness). At the outset, the Board notes the gap of more than 4 decades between the Veteran's separation from service and the first documented treatment for a cardiac disability. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. However, such absence of documented treatment, in and of itself, is not a basis for discrediting his lay statements of continuity. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Thus, the Board must consider the totality of the record, and not just the absence of clinical treatment, in weighing the Veteran's statements asserting continuity of symptomatology. In this case, the Veteran does not appear to have specifically stated that he has had symptoms of coronary artery disease since service. He recalled that there was something wrong with his heart in service (but he does not know what it was). Post service treatment records simply reflect a longstanding history of heart disease. However, the earliest reference to any disability is a December 2006 psychiatric treatment report that references a myocardial infarction that the Veteran supposedly experienced in 1986. The Board notes that there are no contemporaneous treatment reports to substantiate the contention that the Veteran experienced a myocardial infarction in 1986. However, even if there were, it would still mean that the first post service medical evidence of a coronary disability was three decades after service. Additionally, it is noted that the Veteran did not file a claim of service connection for a coronary disability until 2006 (and did not file a claim for hypertension until 2004), many decades after he separated from service. Had he been experiencing a coronary disability since service it would be reasonable to expect that he would have filed a claim sooner. The fact that he did not seek service connection for a coronary disability very strongly suggests that he was not experiencing chronic coronary symptoms since service. For the above reasons continuity of symptomatology is not demonstrated here, either by the clinical record or by the Veteran's own statements. As noted above, service connection is not warranted in this case on the basis of continuity of symptomatology. However, if the competent medical evidence indicates that the cardiac disabilities are related to the Veteran's active service, then an award of service connection would be appropriate. In this vein, the VA examiner in February 2013 concluded that the Veteran's coronary artery disease was less likely as not related to service because there was no evidence of a chronic disability during service or for many years after service. She also noted that the single abnormal finding was inconsistent with the rest of the service treatment records and that the detection or non-detection of such a cardiac murmur can be subjective to clinician auscultation skill variation. The Board finds the opinion of the VA physician to be persuasive evidence. Indeed, it was based on a review of the record and was offered following a physical evaluation of the Veteran. Moreover, it was accompanied by a clear rationale. Moreover, no other competent evidence of record refutes that opinion. The Veteran himself believes that his current coronary artery disease is related to service. The Veteran is considered competent to report the observable manifestations of his claimed disability. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) ("ringing in the ears is capable of lay observation"); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (lay testimony iterating knowledge and personal observations of witness are competent to prove that claimant exhibited certain symptoms at particular time following service). However, the Veteran is not competent to opine on the diagnosis or etiology of his disability. Where a determinative issue involves medical causation or a medical diagnosis, competent medical evidence is required. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer.") "Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, [describe that issue] falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." In sum, his statements as to etiology in this case are not competent and therefore lack probative value. As the preponderance of the evidence is against the claim under the applicable the theories of service connection under 38 C.F.R. § 3.303(b) and (d), the benefit of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). With respect to the question of entitlement to service connection on a presumptive basis, while there is medical evidence in this case of coronary artery disease, there is no competent medical evidence of it within one year of the Veteran's separation from active duty service, as required for service connection under 38 C.F.R. § 3.307(a), so service connection under the presumptive provisions of 38 C.F.R. §§ 3.307 and 3.309 is not warranted, and the benefit of-the-doubt standard of proof does not apply. 38U.S.C.A. § 5107(b). ORDER Entitlement to service connection for diabetes mellitus, type II is denied. Entitlement to service connection for an acquired psychiatric disability, including PTSD is denied. Entitlement to service connection for coronary artery disease is denied. Entitlement to service connection for peripheral neuropathy of the right and left lower extremities is denied. ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs