Citation Nr: 1330864 Decision Date: 09/25/13 Archive Date: 09/30/13 DOCKET NO. 05-03 589 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for disability manifested by joint pain in the bilateral hips. 2. Entitlement to service connection for disability manifested by joint pain in the bilateral shoulders. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The Veteran had active service from January 1986 to January 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2004 rating determination of a Regional Office (RO) of the Department of Veterans Affairs (VA). This matter was previously before the Board in December 2007, in November 2009, in January 2012, and October 2012, when the issues remaining on appeal were remanded for additional development. FINDINGS OF FACT 1. The Veteran served in Southwest Asia during the Persian Gulf War. 2. The claimed bilateral hip disability has been shown to be attributable to degenerative joint disease / arthritis, a known clinical diagnosis; it is not otherwise shown to be related to service or to a service-connected disability. 3. The claimed bilateral shoulder disability has been shown to be attributable to degenerative joint disease / arthritis, a known clinical diagnosis; it is not otherwise shown to be related to service or to a service-connected disability. CONCLUSIONS OF LAW 1. The claimed bilateral hip disability was not incurred in or aggravated by active duty service, including as due to an undiagnosed illness based on Persian Gulf War service, nor has the disability been proximately caused by or permanently aggravated by service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1117, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.317 (2013). 2. The claimed bilateral shoulder disability was not incurred in or aggravated by active duty service, including as due to an undiagnosed illness based on Persian Gulf War service, nor has the disability been proximately caused by or permanently aggravated by service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1117, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.317 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (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). Duty to Notify Upon receipt of a complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 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 v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant notice pertinent to establishing service connection most recently by letters dated in February 2008 and April 2010. The notification complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. Additionally, these letters (among others) provided notice concerning the evaluation and the effective date that could be assigned should service connection be granted, in accordance with Dingess v. Nicholson, 19 Vet. App. 473 (2006). The VCAA letters were sent prior to the most recent RO-level readjudication of the case, as evidenced by the March 2013 supplemental statement of the case. The VCAA notice was therefore effectively timely. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim is sufficient to cure a timing defect). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist VA has obtained service treatment records, obtained private and VA post-service treatment records, assisted the Veteran in obtaining evidence, and afforded the Veteran VA examinations with pertinent reports of record dated in March 2008, August 2010 (with a November 2010 addendum), February 2012, and February 2013. The Board finds that the most recent VA examination report dated in February 2013 now properly addresses the critical questions at issue; the February 2013 VA examination report presents sufficient discussion of the pertinent history, current findings, and expert determinations informed by review of the claims file such that it presents adequate and probative evidence in this case. All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Board finds that the February 2013 VA examination report provides the information and medical opinions sought by the Board's October 2012 remand of these issues on appeal. The medical opinions of record now adequately address all of the essential questions raised by the Board's remand and the issues on appeal. The Board finds that the actions directed by the prior remands have been completed in substantial compliance with the terms and purposes of those remands. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision at this time. Analysis The issues before the Board involve claims of entitlement to 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 or disease 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). Additionally, 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 arthritis, 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). See also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Service connection may be established for a chronic disability resulting from an undiagnosed illness or medically unexplained chronic multisymptom illness that became manifest either during active service in the Southwest Asia Theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2016. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1)(i). Muscle pain and gastrointestinal signs or symptoms may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness. 38 C.F.R. § 3.317(b)(4) and (10). The term "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a). 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). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Competent medical evidence may include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is 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. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends that he experiences pain in joints throughout his body due to an undiagnosed illness associated with his service in the Persian Gulf. In October 2012, a Board decision granted service connection for undiagnosed illnesses associated with service in the Persian Gulf manifested by pain of the bilateral ankles, bilateral knees, bilateral wrists, and bilateral elbows. The remaining issues on appeal involve the questions of whether service connection is warranted for the Veteran's disabilities of the hips and shoulders. The Board has reviewed all the evidence in the Veteran's claims file, including in "Virtual VA." Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran had active service in the Southwest Asia Theater of Operations during the Persian Gulf War. This fact is not in dispute and has already served as part of the basis of the grant of service connection in the October 2012. The Veteran's claim must be considered with attention to three theories: (1) that his claimed disabilities may be due to undiagnosed illnesses due to Persian Gulf service; (2) that his claimed disabilities, even if not due to undiagnosed illnesses, may be the direct result of service; and (3) that his claimed disabilities may be otherwise caused or aggravated by an already established service-connected disability (such as the recently service-connected disabilities of other joints). The Board will address each contention in turn. Undiagnosed Illness Due to Persian Gulf Service The Veteran contends that his hip and shoulder disabilities are manifestations of undiagnosed illnesses due to his service in the Persian Gulf, and that he should be compensated for such under 38 U.S.C.A. § 1117 (West 2002). A careful review of the claims file shows that each of the Veteran's claimed symptoms of the hips and shoulders has been attributed to a known diagnosis. Most recently, a February 2013 VA examination report contains separate examination Disability Benefit Questionnaires (DBQs) for the hips and the shoulders and clearly shows objective diagnostic confirmation that the Veteran has arthritis in both hips and both shoulders. For the hips, the Veteran is diagnosed with "Degenerative Joint Disease." The section of the DBQ concerning imaging studies of the hips clearly indicates that imaging studies were performed and documented arthritis in "both" hips. Likewise, for the shoulders, the Veteran is diagnosed with "Degenerative Joint Disease," and imaging studies revealed arthritis in "both" shoulders. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a). The Veteran's symptoms of the hips and shoulders are attributed to known medical diagnoses. The competent medical evidence is therefore against the conclusion that the claimed symptoms of the hips and shoulders may be presumptively linked to an undiagnosed illness that is based on his service in the Persian Gulf. Accordingly, the provisions of 38 C.F.R. § 3.317 do not apply. Direct and Secondary Service Connection The Board must also address whether any claimed disorder is the direct result of a disease or injury of his service, or may otherwise be a secondary result of an established service-connected disability such as the Veteran's recently service-connected disabilities of various other joints. As noted, in order to establish direct service connection for a 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) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden, supra. The Veteran's service treatment records are negative for indications of hip or shoulder disability or symptomatology. Multiple July 1990 service treatment records show that the Veteran's complaints associated with pain in the upper right abdominal wall were associated with a protruding mass in that area associated with a hernia issue and not related to any shoulder issue. A June 1991 medical history questionnaire shows that the Veteran denied having ever experienced arthritis, painful shoulder symptoms, or any other manner of symptom complaints aside from pain or pressure in the chest. Significantly, the Veteran's November 1991 service separation examination report shows that trained medical professionals found that the Veteran was clinically normal in all pertinent respects with no abnormalities noted other than scar on the mid-abdomen region. Also significantly, the attached medical history questionnaire form shows that the Veteran expressly denied having ever had any arthritis, painful shoulder symptoms, or any other manner of symptom complaints aside from a rupture or hernia. The Board finds that the Veteran's service treatment records, as a whole, strongly suggest that neither trained medical professionals nor the Veteran himself believed that the Veteran had any disability of either hip or shoulder during military service or at the time of the conclusion of his military service. Post-service, the Veteran has been diagnosed with arthritis of both hips and both shoulders, including as confirmed by the February 2013 VA examination report as discussed above. The February 2013 VA examiner reviewed the claims-file and concluded that the current arthritis of the hips and shoulders is unlikely ("less than 50 percent probability") caused by or incurred in military service. The VA examiner provided the rationale that the Veteran's service treatment records contain no evidence of any complaints of or treatment for any hip or shoulder injuries. Additionally, the February 2013 VA examiner concluded that the Veteran's arthritis of the hips and shoulders is unlikely ("less than 50 percent probability") due to or the result of the Veteran's service-connected disabilities. The VA examiner provided a rationale explaining that the examiner considered the Veteran's newly service-connected joint pain in the bilateral ankles, knees, wrists, and elbows and finds no relationship between the service-connected joint pain and the arthritis on appeal; the examiner explains his medical opinion that "arthritis is not a referred condition, but is more likely than not related to changes consistent with aging and normal activities of daily living." The February 2013 VA examiner furthermore concluded that the Veteran's arthritis of the hips and shoulders is unlikely to have been aggravated (answering "no" to whether it is "at least as likely as not aggravated beyond its natural progression") by his service connected disabilities of the bilateral ankles, knees, wrists, and elbows. The examiner found that "there is no nexus between pain in the ankles, knees, wrists and elbows and the development of DJD in the hips and shoulders." The examiner cited that the findings of degenerative joint disease in the hips and shoulders are "mild" and "are not aggravated beyond the normal findings for normal aging in an active 46 year old man." The Board finds that the February 2013 VA examination report is probative, competent evidence with regard to addressing the key etiological questions at issue in this appeal. The author is a trained medical professional informed by review of the claims-file and direct examination of the Veteran. The VA examiner specifically found that the Veteran's diagnosed arthritis of the hips and shoulders is unlikely etiologically linked to the Veteran's military service or to his service-connected disabilities of other joints (with consideration of possible causation and aggravation); the VA examiner presented a persuasive rationale citing the absence of any hip or shoulder issues shown during service and current medical findings showing only mild arthritis consistent with the normal aging process consistent with the Veteran's age and activity. The probative weight of the February 2013 VA examination report is against the Veteran's claims, as it presents a negative opinion with regard to both the direct and secondary theories of entitlement. Significantly, there is no other medical opinion of record contradicting or disagreeing with the findings and conclusions of the February 2013 VA examination report. Thus, the most probative evidence indicates that the Veteran's arthritis of the hip and the shoulders has no etiological nexus to service or to service connected disability. The Board notes that although the February 2013 VA examination report only expressly addresses the secondary theory of service connection with regard to the service-connected disabilities of the Veteran's other joints, there has been no evidence or contention of record to suggest that the Veteran's arthritis has been caused or aggravated by his other service-connected disabilities (posttraumatic stress disorder, sleep apnea, abdominal scar, and erectile dysfunction). The Board additionally finds that the evidence of record does not support a finding that his diagnosed arthritis of the hips and shoulders manifested to a compensable degree within a year following service. The Board again notes that the Veteran denied experiencing any pertinent symptoms at his service separation examination and was medically evaluated as being free from any pertinent diagnoses or abnormalities during his service separation examination. The post-service medical evidence, including the Veteran's private medical records, do not show compensable manifestations of arthritis in either hip or shoulder during the first year following service. (The Board also observes that the Veteran's later complaints of left shoulder pain in July 1996 are shown in his private medical records to have resulted in diagnostic testing showing that he did not have associated arthritis even at that time.) Additionally, the August 2010 VA examination report shows that the Veteran recalled "the he began having a constant shoulder pain in 1998. ... About a year later he began having back and hip pains." The Veteran's statement does not support a finding of compensable manifestations of chronic hip and shoulder disability within a year of the Veteran's separation in January 1992. There is no showing of compensable manifestations of arthritis of the hips or shoulders within the presumptive period following service. See 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The Board concludes that the preponderance of the evidence is against the claims of entitlement to service connection for disability of the hips and shoulders on either direct or secondary theories, to include consideration of the one-year presumptive period for chronic disabilities. Conclusion The Board finds that the preponderance of the evidence is against the claims of entitlement to service connection for disabilities of the hips and shoulders on any basis. In reaching this decision, the Board has reviewed the entirety of the evidence of record but finds that there is no other evidence of record which probatively contradicts the findings presented in the most probative evidence discussed above with regard to the issues on appeal. The Board acknowledges that the claims file contains a quantity of other documents, but none of the information in these records substantially supports the Veteran's claims or otherwise contradicts the evidence deemed to be most probative in the discussion above. Here, the evidence weighs against finding that any of the claimed disabilities is etiologically linked to military service or linked to any other claimed service-connected disability. The evidence also indicates that the Veteran's claimed disabilities have been attributed to known medical diagnoses and thus the evidence weighs against finding that the claimed disabilities may be service-connected as undiagnosed illnesses. The Veteran has been afforded VA examinations to ensure adequate competent medical evidence addressing the claims. The evidence now presents adequate medical information and opinion in connection with these claims; the February 2013 VA examination report provides clear findings and opinions with persuasive discussions of rationale weighing against the claims on all pertinent bases. The February 2013 VA examination report's pertinent findings and opinions address, with persuasive rationale, the pertinent facts and evidence of record; the Board finds that the February 2013 VA examination report is the most probative evidence of record regarding the nexus element on these issues. In this case, some of the Veteran's contention suggest that he asserts the he has experienced continuity of hip and shoulder symptomatology since service; the Veteran's private medical records in the years following service do indicate complaints associated with "polyarthritis" (including in May 1996) and even left shoulder pain (in July 1996) found to be normal without arthritis on diagnostic imaging. The Veteran's original August 2003 claim asserted that he has experienced his joint pain symptoms since 1992. The Board notes, however, that the August 2010 VA examination report shows that the Veteran recalled "he began having a constant shoulder pain in 1998. ... About a year later he began having back and hip pains." This statement of the Veteran's does not seem to indicate chronicity. Even considering the Veteran's other assertions suggesting a continuity of symptomatology, however, no basis for a grant of service connection is demonstrated in the complete absence of any hip or shoulder symptomatology during service. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease entity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). In this case, the alleged continuity of symptomatology following service is insufficient to establish a basis of service connection in the absence of any in-service manifestation of any hip or shoulder symptoms to possibly consider chronic. Although a continuity of symptomatology following service might serve to establish the chronicity of a hypothetical in-service instance of hip or shoulder symptomatology, in this case the evidence persuasively shows that the Veteran had no hip or shoulder symptoms or disability during service (his service treatment records contain no suggestion of such symptoms and the Veteran expressly denied ever having pertinent symptoms twice during his final year of service, including in his separation examination). The Board also again notes that there is no probative evidence of compensable manifestations of arthritis of the hips or shoulders within the first year following the Veteran's separation from military service. Thus, even with consideration of the Veteran's allegation of continuity of symptomatology since service, there is no basis for awarding service connection in this case. The most persuasive evidence persuasively establishes that the Veteran had no symptom complaints attributable to hip or shoulder disability during service or proximately following service. Again, the Veteran's service treatment records show that both the Veteran and trained medical professionals considered him to be free of any pertinent symptoms or disabilities during service, and the Veteran's post-service medical records do not show compensable manifestations of hip or shoulder arthritis within the first year post-service; the Veteran's post-service medical records show treatment for various complaints following service but without indications of compensable manifestations of hip or shoulder disability in the first post-service year. Also, again, the Veteran's own description of his hip and shoulder symptom history suggests that his pertinent symptomatology of chronic disability began in 1998 and 1999 (several years after service). The Board acknowledges the Veteran's belief that his disabilities on appeal are related to his military service. However, there is no evidence of record showing that the Veteran has the specialized medical education, training, and experience necessary to render a competent medical opinion as to the diagnosis and etiology of a disability. He is a "layperson," not a medical expert. A layperson is not categorically unable to render a competent diagnosis. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (laypersons capable of diagnosing varicose veins due to the unique and readily identifiable and observable features of varicose veins). All conditions, however, are not amenable to lay diagnosis. Of importance is the complexity of the question at issue. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a layperson is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions, such as a type of cancer). The Board finds that questions of identifying the specific etiology of complex internal pathologies such as arthritis are medical questions requiring specialized knowledge and expertise; such questions are not generally resolvable through information available to lay senses. Consequently, the Veteran's own assertions as to diagnosis and etiology of these disabilities have no probative value. The Veteran's own assertions are not sufficient to establish nexus between his current arthritis and military service, nor are his assertions alone sufficient to establish the onset of the internal arthritis pathology. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). See also Robinson v. Shinseki, 312 Fed. Appx. 336 (Fed. Cir. 2009) (non-precedential) (confirming that, in some cases, lay evidence will be competent and credible evidence of etiology). However, a determination concerning diagnosis of a specific disease or a determination concerning the possibility of a causal relationship between two different disease pathologies requires specialized training, and may therefore not be established by lay opinions on etiology. As the preponderance of the evidence is against the Veteran's claims of entitlement to service connection in this case, the benefit-of-the-doubt rule does not apply and this claims are denied. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER The appeal is denied as to both issues. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs