Citation Nr: 1335200 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 03-14 552 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for a prostate disability. 2. Entitlement to service connection for a renal and urinary tract disability. 3. Entitlement to service connection for a cardiovascular disability. 4. Entitlement to compensation under 38 U.S.C.A. § 1151 for a cardiovascular disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran had active military service from June 1974 to June 1977. This appeal arises before the Board of Veterans' Appeals (Board) from a September 2000 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois, which denied the Veteran's claims seeking entitlement to service connection for, among other issues, a prostate disability, a renal and urinary tract disability, a cardiovascular disability, and entitlement to compensation under 38 U.S.C.A. § 1151 for a cardiovascular disability. The Veteran testified at a December 2004 video hearing before a Veterans Law Judge that is no longer at the Board. The Veteran was provided notice that he was entitled to a new hearing. See Arneson v. Shinseki, 24 Vet. App. 379 (2011). The Veteran failed to respond, and so he is presumed to not desire an additional hearing. In June 2005 and September 2012, the Board remanded this case which is now ready for appellate review. FINDINGS OF FACT 1. The Veteran's benign prostatic hypertrophy, now present with associated voiding dysfunction, was first shown during service and continued thereafter. 2. A renal and urinary tract disability to include a right renal cyst is not attributable to service. 3. A heart murmur was first shown during service. 4. A heart disability other than a heart murmur was not demonstrated during service, within the first post-service year, and is not attributable to service. 5. The Veteran's current heart disability is not the result of VA hospital/medical care or treatment or the lack thereof nor is the proximate cause of the heart disability carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital/medical treatment; or due to an event not reasonably foreseeable. CONCLUSIONS OF LAW 1. Benign prostatic hypertrophy with associated voiding dysfunction was incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2012). 2. A renal and urinary tract disability to include a right renal cyst was not incurred or aggravated in active service. 38 U.S.C.A. §§ 1101, 1110, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.306, 4.9 (2012). 3. A heart murmur was incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2012). 4. A heart disability other than a heart murmur was not incurred in or aggravated by service and may not be presumed to have been incurred or aggravated therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.306, 3.307, 3.309 (2012). 5. The criteria for entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for cardiovascular disability, have not been met. 38 U.S.C.A. § 1151 (West 2002 & Supp. 2012); 38 C.F.R. § 3.361 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) 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. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim, including apprising him or her of the information and evidence he or she is responsible for providing versus the information and evidence VA will obtain for him or her. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These 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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). So this notice must include information that a "downstream" disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, this notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary notice and then readjudicating the claim - including in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Supreme Court has made clear that VCAA notice errors are not presumptively prejudicial, rather, must be determined on a case-by-case basis, and that, as the pleading party attacking the agency's decision, the Veteran, not VA, bears this burden of proof of establishing there is a VCAA notice error and, moreover, above and beyond this, that the error is unduly prejudicial, meaning outcome determinative of the claim. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of the claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). VCAA letters were sent in July 2002, June 2005, March 2006, November 2006, and in November 2012. The letters, especially in combination, indicated the type of evidence and information needed to substantiate the claims and apprised the Veteran of the Veteran's and VA's respective responsibilities in obtaining this supporting evidence. The letters also notified the Veteran that a "downstream" disability rating and an effective date for the award of benefits would be assigned if service connection was granted, in compliance with Dingess. The Veteran has been afforded a hearing before a Veterans Law Judge (VLJ) in which he presented oral argument in support of his claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims ("the Court") held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issue and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ did not specifically note the bases of the prior determinations or the elements that were lacking to substantiate the claims. The VLJ asked specific questions, however, directed at identifying whether the Veteran met the criteria pertinent to his claims. In addition the Veteran volunteered his treatment history and symptoms since service. Accordingly, the Veteran is not shown to be prejudiced on this basis. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Regarding the duty to assist, VA also satisfied this obligation in terms of obtaining all potentially relevant evidence concerning these claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records (STRs), VA medical treatment records, Social Security Administration (SSA) records, and identified private medical records were obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication that any additional evidence, relevant to these claims, is available and not part of the claims file. The Veteran also was provided VA compensation examinations, including for medical nexus opinions concerning the etiology of the claimed disorders and their potential relationship with military service, as the Board directed when remanding these claims most recently in September 2012. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). See also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The medical nexus opinions obtained are responsive to the determinative issue of causation, so additional examinations and opinions are not needed. 38 C.F.R. § 4.2. See also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (VA's duty to assist includes providing an adequate examination when such an examination is indicated). The examinations of record are adequate to address all pertinent concerns, as the claims file was reviewed for the relevant medical and other history, the Veteran examined, the findings reported in sufficient detail, and there was discussion of the underlying medical rationale, which is where most of the probative value of an opinion is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The VA examination reports are thorough and supported by the record. The records taken as a whole satisfy 38 C.F.R. § 3.326. Furthermore, in obtaining this additional medical evidence, the Board is satisfied there was compliance with this remand directive. See Stegall v. West, 11 Vet. App. 268 (1998) (indicating the Veteran is entitled, as a matter of law, to compliance with a remand directive and that the Board, itself, commits error in failing to ensure this compliance). See also Dyment v. West, 13 Vet. App. 141, 146-47 (1999); and D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (discussing situations when it is acceptable to have "substantial", though not "exact", compliance with a remand directive). In summary, the Board finds that "it is difficult to discern what additional guidance VA could have provided to the Veteran regarding what further evidence he should submit to substantiate his claim." See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances as to when a remand would not result in any significant benefit to the Veteran). Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. In addition, valvular heart disease will be presumed to have been incurred in or aggravated by service if it had become manifest to a degree of 10 percent or more within one year of a veteran's separation from service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The Board notes that 38 C.F.R. § 3.303(b) provides that with chronic diseases shows as such in service or within the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of cases, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clearcut clinical entity, at some later date. 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 identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service or the presumptive period 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 service is required to support the claim. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and the Department of Veterans Affairs regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). The U. S. Court of Appeals for the Federal Circuit (Federal Circuit) recently held that the regulation creating a presumption of service connection for "chronic diseases" manifesting during service and then again at any later date (38 C.F.R. § 3.303(b)), is only available to establish service connection for the "chronic diseases" enumerated in 38 C.F.R. § 3.309(a) (listing named chronic diseases). Walker v. Shinseki, 708 F.3d 1331, 1336-37 (Fed. Cir. 2013). In the same case, the Federal Circuit clarified that the continuity of symptomatology language in § 3.303(b) also "restricts itself to chronic diseases" found in 38 C.F.R. § 3.309(a). Id. at 1335. With respect to the current appeal, this list includes cardiovascular disease and valvular heart disease. See 38 C.F.R. § 3.309(a). Walker held that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). The Federal Circuit noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a veteran can establish service connection for a chronic disease" under subsection 3.303(b). Walker, supra. Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation"). Significantly, the Federal Circuit indicated that showing a continuity of symptomatology after service is a lesser evidentiary burden than the nexus requirement of the three-part test discussed above. The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection or service connection via continuity of symptomatology. A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). However, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). When, for example, 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. In such cases, the Board is within its province to weigh that testimony and make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Thus, medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As held in Davidson, section 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. See also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence" such as actual treatment records). The Veteran is competent to report the Veteran can observe and feel through the senses. See Layno. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). Once evidence is determined to be competent, the Board must determine whether the evidence also is credible, as only then does it ultimately have probative value. See Layno (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons or bases for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). To this end, the Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the Federal Circuit citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court similarly has declared that, in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing when he/she has testified. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, aff'd per curiam, 78 F.3d 604(Fed. Cir. 1996). See, too, Macarubbo v. Gober, 10 Vet. App. 388 (1997) (similarly holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record, medical and lay, and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. As already explained, competent lay evidence may establish the presence of observable symptomatology and, in certain circumstances, it may provide a basis for establishing service connection. See Barr. Although claimants may be competent to provide the diagnoses of simple conditions, such as a broken leg, they are not competent to provide evidence on more complex medical questions beyond simple observations. Jandreau; see Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). Indeed, even if lay testimony is competent, should VA find it to be mistaken or lacking credibility, the Board may reject it as unpersuasive and, thus, not ultimately probative. Buchanan; see also Rucker and Layno. The Board may find a lack of credibility in, for example, conflicting medical statements or witness biases. Buchanan at 1337. The lack of contemporaneous medical evidence is also relevant; however, the mere lack of such evidence may not constitute the sole basis for discrediting the lay evidence. Id. Although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the Veteran is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Veteran is competent in this case to report his symptoms, but nothing in the record demonstrated that he has received any special training or acquired any medical expertise in evaluating and determining causal connections for the claimed conditions. Therefore, a medical expert opinion would be more probative regarding the causation question in this case. King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). Thus, VA procured such opinions in this case, as discussed below, which are more probative than the Veteran's personal assertions, as also discussed below. Prostate, Renal, and Urinary Tract Disabilities The STRS revealed that in September 1975, the Veteran was treated for pain the area of his kidney and lower back. He was diagnosed as having a possible kidney infection. In December 1976, the Veteran complained of having painful urination. In May 1977, it was noted that the Veteran had evidence of bladder outlet obstruction. On his May 1977 separation examination, the genitourinary system was noted to be normal. A slightly enlarged prostate was documented. In June 1977, the Veteran had a urinary flow study done and some abnormality was present, but nothing that needed correcting. In January 1999, the Veteran was afforded a VA examination. He reported that he had been told that he had a herniated urinary bladder as well as a kidney problem. He denied having urinary frequency. In September 1999, the Veteran was afforded another VA examination. The Veteran reported that while in the military, he had a urinary obstruction. The examiner noted that the service records noted outlet obstruction as well as an enlarged prostate. The Veteran reported that he currently had urinary urgency and nocturia. There did not appear to be a problem with his kidney or bladder. It was noted that earlier in the year, the Veteran's creatinine was 1, his BUN was 11, and a urinalysis was unremarkable. Physical examination revealed a mild enlargement of the prostate. The diagnosis was benign prostatic hypertrophy and a history of urinary outlet obstruction during service. A November 1999 intravenous pyelogram revealed diverticula in the urinary bladder with moderate to severe urinary retention. A December 1999 renal scan revealed normal symmetrical renal function; rapid excretion in response to lasix; and good emptying of bladder. In March 2000, the Veteran was seen by the urology department for urinary complaints. In June 2000, the Veteran underwent an intravenous pyelogram which revealed a slight coarse trabeculatin of the bladder wall and a small right-sided diverticula. There was also an uplifting of the bladder bade which suggested an enlarged prostate. In August 2000, he underwent a cystoscopy which revealed a normal bladder. In a September 2000 rating decision, a prostate disability was denied on the basis that even though the Veteran had an enlarged prostate on his separation examination, that clinical finding is not a disability in itself. With regard to the kidneys, the inservice bladder findings were reviewed, but the RO determined that the urinary outlet obstruction appeared to have been acute and transitory as there was no mention in the post-service outpatient reports and only noted in a historical context on the VA examination. In January 2001, the Veteran underwent a sonogram of the urinary bladder and kidneys which revealed no evidence of hydronephrosis and mild urinary retention. In August 2002, the Veteran was afforded a VA examination. The examiner noted that in 1999 and 2000, the Veteran had some ultrasound done of his urinary tract which revealed some small diverticulum of the bladder. The examiner stated that the diagnoses, which are made of urinary retention and from ultrasound and/or pyelogram, are not very accurate. He stated that the only way to truly judge what is residual urine is to catheterize the patient after he urinates, a procedure that had not been performed. Current physical examination revealed renal cyst, bladder and right flank pain. The examiner opined that the Veteran had a renal cyst which was most likely congenital and not related to service. His flank pain was not related to the renal cyst and was not service connected. A February 2003 ultrasound of the urinary bladder revealed no mass or stone. There was no residual urine detected post-voiding. The prostate was enlarged. In May 2003, the Veteran was afforded genitourinary treatment, but the examiner indicated that there was no cure for the Veteran's urinary symptoms (pain in both flanks between urination) had no known cause. He was told to remain on Terazosin. The examiner indicated that he had no proof that the Veteran had obstructive outlet syndrome. In September 2003, it was noted that a renal ultrasound which was unremarkable except for a right renal cyst. In December 2004, the Veteran testified at a Board hearing. He stated that he had an enlarged prostate during service. He described having pain with urination. He indicated that he had been told that the pain in his urinary tract was due to the fact that he had an enlarged prostate and that he also had diverticuli in his bladder which was causing urinary outlet obstruction. In June 2005, the case was remanded. In pertinent part, the Veteran was to be afforded a VA examination. In March 2007, the Veteran was afforded a VA examination. At that time, the Veteran reported frequent urination and nocturia. It was noted that an August 2000 cystoscopy revealed a normal membranous urethra and anterior urethra. The posterior urethra revealed some mild enlargement if his prostate. There was 2+ trabeculatin of the bladder noted and the bladder had normal capacity. The Veteran was noted in some notes to have chronic cystitis, but there was no actual evidence that he had chronic cystitis. What there was evidence of on some ultrasounds was irregularity of the bladder walls, simulating cystitis, but he was never treated for cystitis. Basically, the examiner indicated that these could be the result of some mild obstructive problems. The Veteran was also cystoscoped and had a cystometrogram in September 2003. The cystoscopy done then revealed no outlet obstruction. The cystometrogram was normal. The Veteran had normal bladder capacity as well as a normal muscle spike. Prostate examination revealed that it was minimally enlarged which was not unusual for his age (51 years). The examiner stated that he did not know if he could related the enlarged prostate to service as enlargement of the prostate occurred in all men with respect to aging. The examiner noted that his prostate disorders were related to the enlargement. The diagnosis was benign prostatic hypertrophy. The Veteran's renal status was also evaluated. It was noted that multiple kidney imaging had documented the presence of a right renal cyst. The Veteran complained of frequent urination, nocturia, and right flank pain. The examiner opined that testing revealed stable normal renal function and the well-documented renal cyst. The examiner indicated that the renal cyst should not have any consequence of kidney function and, again, the renal function was normal. In an addendum, another VA examination indicated that the Veteran's enlarged prostate was typical of his age and less likely than not related to inservice prostate problems. His renal and urinary tract complaints were also less likely than not related to his inservice kidney infection. In March 2010, the Veteran was afforded a VA examination which evaluated his employment status. In September 2012, the Board remanded this case for an addendum opinion. Thereafter, the Veteran was afforded a VA examination in November 2012. The examiner opined that the Veteran's prostate condition was related to the natural aging of men and it had nothing to do with his military service, although it was noted that the benign prostatic hypertrophy was present since 1976. The examiner indicated that current examination as well as the 2007 examination revealed an unchanged small soft prostate gland rectally. The cystoscopy performed in 2003 revealed no bladder outlet obstruction and a cystometrogram done at same time was normal. At the present time the Veteran had a small prostate gland with minimal enlargement on rectal examination. The examiner explained that the prostate begins to enlarge in all men after the age of 40 due to normal aging. His rectal examination was basically unremarkable for a 57 year old male. Rectally, his prostate was small and minimally enlarged. With regard to the renal and urinary tract problems, the examiner noted the date of diagnosis for a kidney cyst was in 2003 and stated the presence of the cyst appeared to be congenital in origin. The examiner opined that the Veteran's urinary and prostate problems were less likely than not related to his military service. The Veteran reported his voiding problems were intermittent and he did not take medication. He stated other than an outpatient treatment for possible urinary tract infection years ago, there was no history of recurrent kidney infections. At the present time, the Veteran had a small prostate gland with minimal enlargement on rectal examination. The cystoscopies noted in the chart revealed minimal if any obstruction of the bladder neck. The Veteran's chart revealed adequate evaluation of his urinary tract problems and he was on no medications for same at the present time. He had no history of recurrent kidney infections and only had one treated outpatient urinary tract infection which was unrelated to his present complaints. Additionally, he had no current renal problems and his renal function had been stable since 2007. The presence of a right renal cyst was well documented, but was less likely than not related to the Veteran's military service. With regard to the Veteran's claimed prostate disability, the STRs revealed that the Veteran had a slightly enlarged prostate when he exited service. The post-service VA examinations all note a slightly or minimally enlarged prostate and the Veteran was diagnosed as having benign prostatic hypertrophy. In a September 2000 rating decision, a prostate disability was denied on the basis that even though the Veteran had an enlarged prostate on his separation examination, that clinical finding is not a disability in itself. However, hypertrophy is recognized as a disability in VA's rating schedule. See38 C.F.R. § 4.115b, Diagnostic Code 7527 (2012). The two VA opinions provided in 2007 and 2012 acknowledged that the Veteran had prostate and associated urinary symptoms, but indicated that an enlarged prostate was usual to men the Veteran's age and was related to aging and not related to military service. However, there was no clear explanation regarding the separation examination finding which has remained a consistent finding over the years. The Board notes that the post-service evidence does not include a prostate examination where the prostate was not enlarged; rather, the Veteran has had the same clinical finding since his separation examination. The Board recognizes that an enlarged prostate is apparently found in all men of a certain age according to a VA medical opinion, but finds that absent a clear explanation by a VA examiner regarding why the Veteran's currently enlarged prostate condition, benign prostatic hypertrophy, is separate and distinct from the exact same clinical finding on separation, the Board cannot make that distinction. Thus, in affording the Veteran all reasonable doubt, service connection is warranted for benign prostatic hypertrophy and the associated voiding dysfunction. With regard to renal and urinary tract disabilities, the Veteran was treated during service for kidney infection, painful urination and bladder outlet obstruction. However, the VA examiners have indicated that the Veteran currently does not have any renal/kidney disorder other than a right renal cyst nor does he had a urinary disorder, other than the voiding issues associated with the prostate disability (now service-connected). His current renal function is normal. The Court consistently has held that, under the law, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). This principle has been repeatedly reaffirmed by the Federal Circuit Court, which has stated, "a Veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the Veteran's service and the disability." Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed). In Brammer v. Derwinski, 3 Vet. App. 223 (1992), the Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability. See also Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). A "current disability" means a disability shown by competent evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). The VA examiners have opined that there is no current renal/kidney/urinary tract disorder other than the right renal cyst. The Board attaches significant probative value to the opinions, and the most probative value in this case, as they are based on clinical examinations, testing, and review of kidney/urinary tests. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). See also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (indicating most of the probative value of an opinion comes from its underlying reasoning, not just from mere review of the claims file, although that, too, has its importance if evidence in the file may affect the underlying basis of the opinion such as by revealing relevant facts). Thus, service connection is not warranted for a kidney or urinary tract disorder. With regard to the right renal cyst, the STRs are negative for any complaints or findings of this condition and there is no competent and credible evidence of record relating it to any in-service disease, event, or injury. To the contrary, the VA examination reports indicated that this is a congenital condition and the Veteran does not dispute the congenital nature. See 38 C.F.R. §§ 3.303(c), 4.9. Congenital or developmental defects are not considered to be a disease or injury with the meaning of the statutes governing service connection. See 38 C.F.R. §§ 3.03(c), 4.9. Inservice incurrence of a disease or injury is not possible with respect to manifestations of a congenital or developmental defect, and as a result. See Winn v. Brown, 8 Vet. App. 510 (1996) (upholding VA regulations that distinguish a congenital or developmental defect from a disease). Although a congenital or developmental defect may not be considered a disease or injury incurred during service, service connection may nevertheless be available for a disability shown to have resulted from a congenital defect which was subject to a superimposed disease or injury during service. See VAOPGCPREC 82-90 (July 18, 1990). As noted, there is no reference whatsoever to a right renal cyst during service and no suggestion of any superimposed disease or injury. Accordingly, the Board finds that service connection for a right renal cyst is not warranted. In sum, the preponderance of the evidence is against the Veteran's claims of service connection for renal/kidney as well as urinary tract disabilities; therefore, service connection is not warranted. Cardiovascular Disability The STRS reveal that on May 25, 1976, the Veteran reported having complaints of nausea, a 25 pound weight loss in 6 months, and pains in his right side and back. The examiner noted that the Veteran had a heart murmur. Chest x-rays for chest pain were pertinent to respiratory complaints, but not heart disease. On a March 1977 Dental Service History medical form, the Veteran stated that he did not have any heart trouble, abnormal blood pressure, or rheumatic fever. On his May 1977 separation examination, the heart was noted to be normal. Blood pressure was 110/66. October 1995 cardiac testing revealed that the Veteran did not have a mitral valve prolapse as the echocardiogram (ECG) was normal. In January 2006, the Veteran underwent an upper lobectomy for a hamartoma, without any cardiac complications. In April 1998, the Veteran suffered a myocardial infarction (MI). He was subsequently diagnosed with coronary artery disease (CAD) as well as arteriosclerotic heart disease (ASHD) and underwent various cardiac procedures including angioplasty with stent placement as well as catherization and echocardiogram. In January 1999, the Veteran was afforded a VA examination. He stated that he had suffered an MI. The examiner noted that a recent echocardiogram revealed normal left ventricular systolic function, normal wall motion, ejection fraction of 55 percent, which indicated an essentially normal echocardiogram. The diagnoses were residuals of CAD, status post insertion of stent in the right coronary artery; transluminal angioplasty; and status post angioplasty of the left ileac. In an April 1999 letter, the Veteran's treating VA physician indicated that the Veteran was under his care and had been unable to work for at least 6 months, including for peripheral vascular disease and CAD. In June 1999, the Veteran underwent a stress test. There was no angina or ST changes on EKG. However, on a June 1999 treadmill test, the Veteran felt dizzy, had left side numbness with tingling in his face and extremities. The Veteran suffered a transient ischemic attack (TIA). In April 2000 correspondence, the Veteran indicated that he reported having chest pain to the VA Bay Pines facility, but it was not treated from October 1995 to April 1998. He stated that the Veteran had a heart murmur during military service in May 1976. He also related that he had a history of lightheadedness, numbness and tingling, and tiredness since he underwent an angioplasty after a heart attack in 1998. He reported that he should have been treated from 1976-1998. In August 2002, the Veteran was afforded a VA examination. Physical examination was performed. The examiner stated that the Veteran had single vessel CAD with a history of an inferior MI in 1998. It was noted that he had undergone lytic therapy and percutaneous transluminal coronary angioplasty (PTCA)/stenting of right coronary artery (RCA) as well as repeat catherization which showed 30 percent proximal RCA non-critical disease. He continued to have atypical chest pain, but several evaluations revealed no evidence of progression of the CAD since the MI. The examiner noted that the Veteran had some atypical symptoms during active duty and it was unlikely that his MI and CAD had any relationship to service. His cardiac murmur was not very significant and it was unlikely related to his MI and CAD. It was indicated that his lung disease and heart disease were not etiologically related to each other. In March 2003, the Veteran underwent a myocardial perfusion study which revealed irreversible hypoperfusion at the apex and inferior wall as well as reversible hypoperfusion at the septum and the anterior wall. In December 2004, the Veteran testified at a Board hearing. He indicated that he was told that he had a heart murmur during service. He reported that he had a heart attack in April of 1998. The Veteran stated that several years prior to the heart attack, he was being treated for a lung condition by VA and was told that he had cardiac symptoms including abnormal heart sounds. He had an ECG in 1995 or 1996 which was negative with no mitral valve prolapse. He continued to be treated for his lungs and the heart symptoms were noted, but he was never provided treatment by a cardiologist.. He had an abnormal EKG and never had any follow-up until he had the heart attack. In June of 2000, he performed a treadmill test. He related that there were instructions that his heart rate should not be raised above 90, but VA personnel let it go up to 99 and he ended up having to go to the emergency room, but was initially refused treatment. Eventually he was seen for a TIA. In May 2003, he reported that he had another heart attack. In June 2005, the case was remanded for another VA examination regarding the Veteran's 38 U.S.C.A. § 1151 claim. In April 2007, the Veteran was afforded a VA examination. The examiner noted that in 1995, nurse practitioners suspected that the Veteran had a mitral valve prolapse, but ECG showed a normal mitral valve. He was complaining of chest pain which was attributed to mitral valve prolapse (MVP) syndrome. In November 1995, he had recurrent chest pain and was seen in the emergency room and was told that the chest pains were non-cardiac. The electrocardiogram (EKG) on that day showed non-specific ST changes. In January 2006, the Veteran underwent an upper lobectomy for a hamartoma, without any cardiac complication. He had his first MI in 1998, followed by a PTCA and one stent for 80 percent RCA disease. He had no stress tests prior to his first MI, despite three years of recurrent chest pain. He continued to have recurrent chest pain and repeat angiogram in November 1998, and in March 1999, there was a 30 percent non-critical right coronary artery (RCA) stenosis. There was no need for PTCA or stents. In June 1999, he had a symptom limited stress test and was able to walk for 5 minutes at a 2.5 m.p.h. and 12 percent inclination. There was no angina or ST changes on EKG. On June 21, 1999, while on a treadmill, the Veteran felt dizzy, had left side numbness with tingling in his face and extremities, then had a TIA, which was not recognized by personnel in rehab. He was seen by a neurologist and given a computerized tomography (CT) scan of the brain which was normal, the carotids were normal, and there was no recurrence of the symptoms. He requested to be admitted, the request was not honored, but then he ultimately was admitted for the TIA which resolved within 3 days. The examiner noted that the Veteran continued to have some aphasic components and on June 30, 1999, he had a recurrence of symptoms, He had an angioplasty in 2003 with abnormal stress test prior to this procedure, and during the angioplasty there was acute ST elevation complicated by hypotension and heart block. The procedure was stopped and the Veteran was transferred to the intensive care unit (ICU) in stable condition with a nitro intravenous drip. He had continued to have anginal pains since with mild to moderate exertion. The pains were controlled or treated with nitrogen and diltiazem. At present, he had angina about once per week. He had shortness of breath on walking a half block and going uphill was very difficult. He also had nocturnal angina. The Veteran expressed that he was unhappy about the lack of response to his anginal pains from 1995 to 1998 and what appeared to be poor response in medical care during the TIA symptoms. It was also noted that he had had high blood pressure since 1995. He had a negative family history for CAD, diabetes, or stroke. Physical examination revealed that normal findings with no murmur. The current diagnosis was status post acute MI status post PTCA and one stent; chronic stable angina associated with recurrent coronary artery spasms, status post TIAs. It was noted that the Veteran had a history of high blood pressure, but was more normotensive now. The examiner noted that it appeared that there was no recognition of the Veteran's anginal symptoms for 3 years. He never had a stress test prior to his first heart attack and his chest pains were interpreted as being indigestion in nature. Although he was given reasonable medical care, it appeared that the lack of recognition of the anginal pains and the fact that he never had a stress test prior to the heart attack, there was some element of carelessness in the work up of symptoms that eventually precipitated his acute MI 3 years later. In an addendum, another VA examiner opined that the Veteran's heart attack in April 1998 was not caused by VA treatment provided from 1995 to 1998, and was not due to negligence or carelessness. There was also no fault on the part of VA. The examiner indicated that the Veteran's complaints were non-specific prior to his 1998 heart attack. In fact, in January 1996, he underwent pulmonary surgery without complication and it was mere speculation to state that the Veteran should have had a stress test prior to 1998; the care provided by VA was reasonable. In March 2010, the Veteran was afforded a VA examination which evaluated his employment status. In September 2012, the Board remanded this case. With regard to the Veteran's claim for a cardiovascular disorder, the Board noted initially that at his December 2004 hearing (page 36), the Veteran claimed that a heart murmur was noted during hospitalization at Fort Hope. The Board noted that the Veteran also contended that his cardiovascular disorder was the result of negligent care by the Bay Pines VA medical center and he is therefore entitled to compensation under 38 U.S.C.A. § 1151 for a cardiovascular disability. Specifically, the Veteran claimed that he was not adequately treated by the VA Medical Center at Bay Pines for his reported chest pains during the time period from October 1995 until the heart attack he suffered in April 1998, and that such inadequate treatment was responsible for the heart attack he suffered. As in the current instance, when compensation is claimed for the continuance or natural progress of a disease, injury, care, treatment, or examination furnished by VA cannot be said to have caused additional disability unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). In other words, (1) VA failed to diagnose and/or treat a preexisting disease or injury; (2) a physician exercising the degree of skill and care ordinarily required of the medical profession reasonably should have diagnosed the condition and rendered treatment; and (3) the Veteran suffered disability or death which probably would have been avoided if proper diagnosis and treatment had been rendered. VAOPGCPREC 05-01; see also 38 C.F.R. § 19.5 (2012) (stating that the Board is bound by precedent opinions of the VA's General Counsel). In the instant case, with regard to the question of whether the VA treatment led to an additional disability, the Board notes that the Veteran was currently diagnosed with CAD and had a heart attack in 1998. The Board's previous June 2005 remand requested an opinion with regard to whether VA's failure to timely treat the Veteran's heart condition led to his 1998 heart attack and additionally if the VA failed to provide the degree of care expected by a reasonable health care provider. With regard to the Veteran's claim, an opinion was provided in April 2007 which was reviewed as was the addendum. With regard to the Veteran's cardiovascular claim to include the 38 U.S.C.A. § 1151 claim, neither the April 2007 opinion or the January 2008 opinion adequately addressed the question of whether VA's failure to timely diagnose and properly treat the Veteran's heart disease to include the Veteran's 1998 heart attack, proximately caused the continuance or natural progress of the Veteran's CAD. The April 2007 opinion noted "some element of carelessness," with regard to the failure to provide a stress test. The January 2008 opinion then noted that it would be "mere speculation" as to whether a stress test would be necessary. Both examiners stated that the level of care was "reasonable," but then seem to disagree on what "reasonable" care with regard to repeated complaints of chest pain would entail. As such, the Board determined that the Veteran should be afforded an addendum opinion with a complete rationale that addressed whether the failure by the Bay Pines VAMC to properly diagnose the Veteran's CAD was the proximate cause of the continuance or natural progress that led to the Veteran's 1998 heart attack and whether the VA failed to exercise the degree of care that would be expected of a reasonable health care provider. See 38 C.F.R. § 3.361(c)(2) and (d)(1). In April 2013, an opinion was provided. The examiner opined that it was less likely than not that the Veteran's cardiovascular care by VA from 1985 to the present warrants consideration under 38 U.S.C.A. § 1151 for careless, negligence, lack of proper skills, an error in judgment, or any similar instance of fault. In his opinion, the Veteran's care had been appropriate, skillful, well-judged, and conscientious. The examiner reviewed the Veteran's medical history which was noted to be complicated. He indicated that a review of 1995 to 1996 progress notes did not reference a cardiovascular condition. In addition, noncompliance had been an issue in the past. The Veteran continued to smoke despite his multiple medical conditions and chronic obstructive pulmonary disease (COPD). There were numerous references throughout the clinical files recommending that the Veteran stop smoking. The records showed that he underwent a lobectomy (1996) prior to his cardiac condition. Although he sought medical care at VA, beginning in 1985, he had no prior cardiac history until his admission on April 12, 1998 with chest pain. The clinical records, from his admission for chest pain, were consistent for appropriate standard of care. He was diagnosed with the right ventricular infarction and inferior wall MI. He underwent thrombolysis with tissue plasminogen activator (TPA). He was stabilized with vasopressors and fluids in the Bay Pines VA ICU. He was successfully transferred to Tampa VA and underwent a cardiac catheterization April 16, 1998. The overall assessment was single vessel CAD and stent insertion. The Veteran tolerated the procedure well. On April 16, 1998, the administrative note indicated the Veteran was abusive to the staff and he was given Ativan and emotional support to try to calm down. Although the Veteran was stabilized and being monitored for continuous care, he developed chest pain and was transferred to the critical care unit (CCU) while awaiting your stent procedure. The Veteran then underwent a stent placement on April 27, 1998 and June 30, 1998 reports indicated normal sinus rhythm. Currently, the examiner noted that the Veteran was living with multiple medical conditions and continue to smoke. The examiner opined that the Veteran had appropriate and prompt attention concerning your cardiovascular events. The medical care provided by the Bay Pines VA Medical Center and Tampa VA did not fail to properly diagnose CAD nor was the care a proximate cause of the continuance or natural progress that led to your 1998 heart attack. The VA exercised the proper and appropriate degree of care expected of a reasonable health care provider. The examiner concluded that there had been no unforeseen complications, carelessness, negligence, lack of proper skill, error in judgment or similar instances of fault on the part of the VA facility care or medical treatment or an event not reasonably foreseeable. Direct and Presumptive Service Connection for Cardiovascular Disability With regard to service connection, the May 25, 1976 STR indicated that the Veteran had a heart murmur. The Veteran's post-service cardiac records have focused primary on CAD, MI, and ASHD and not the murmur. In the September 2000 rating decision, entitlement to service connection for a heart disability was denied on the basis that there was no heart disability during service or the initial post-service year. It noted that the Veteran indicated that he was told that he had a heart murmur during service in May 1976, but this was not documented, and even if it had been, it would not be indicative of a disability. However, it was documented. An August 2002 examination confirmed that the Veteran had a heart murmur, although it was not significant. The Board finds that in resolving all doubt in the Veteran's favor, service connection for a heart murmur is warranted. However, the examiner in August 2002 also indicated that the cardiac murmur was not very significant and it was unlikely related to his MI and CAD. The VA examiner's opinion, rendered by a medical professional, is afforded significant probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (holding that the probative value of medical opinion evidence is based on the personal examination of the patient, the knowledge and skill in analyzing the data, and the medical conclusion reached); see also Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is factually accurate, fully articulated, and has sound reasoning for the conclusion.) The Board finds that this examiner's opinion is more probative than the Veteran's personal opinion that the inservice heart murmur developed into CAD, MI, or ASHD. This type of assessment is complex in nature and examined have noted the complex medical history in this case. The Veteran is competent in this case to report his symptoms, but nothing in the record demonstrated that he has received any special training or acquired any medical expertise in evaluating and determining causal connections for the claimed conditions. Therefore, the medical expert opinion is more probative regarding the causation question in this case. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Further, other than the heart murmur, a heart disability was not demonstrated during service or within the post-service year. Although the Veteran is competent to report chest pain over the years as being continuous or chronic, the medical history in this case was complex with certain symptoms being evaluated as non-cardiac in nature while being evaluated as cardiac at other times, as indicated in the medical reports. Thus, the medical opinion in this case is more probative than the Veteran's statements regarding the nature of the cardiac symptoms. This medical opinion, the most probative evidence on this specific point, establishes that there is no etiological connection between the post-service diagnoses and service. Accordingly, service connection for a heart disability, other than the heart murmur, is not warranted on either a direct or presumptive basis. Compensation under 38 U.S.C.A. § 1151 for a Cardiovascular Disability Regarding the Veteran's claim of entitlement to compensation under 38 U.S.C.A. § 1151 for a cardiovascular disability, he claims that he was not adequately treated by the VA Medical Center at Bay Pines for his reported chest pains during the time period from October 1995 until the heart attack he suffered in April 1998, and that such inadequate treatment was responsible for the heart attack he suffered. Compensation shall be awarded for a qualifying additional disability or a qualifying death of a veteran in the same manner as if such additional disability or death were service-connected. For purposes of this section, a disability or death is a qualifying additional disability or qualifying death if the disability or death was not the result of the veteran's willful misconduct and the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by the Secretary, either by a Department employee or in a Department facility. In addition, the proximate cause of the disability or death must be either carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or an event not reasonably foreseeable. 38 U.S.C.A. § 1151. Effective September 2, 2004, 38 C.F.R. § 3.361 was promulgated for claims filed as of October 1, 1997. Prior to that time, 38 C.F.R. § 3.358 is to be applied. In this case, the veteran's claim was received after October 1, 1997. Thus, 38 C.F.R. § 3.361 is for application. 38 C.F.R. § 3.361(b) states that to determine whether a veteran has an additional disability, VA compares the veteran's condition immediately before the beginning of the hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy (CWT) program upon which the claim is based to the veteran's condition after such care, treatment, examination, services, or program has stopped. VA considers each involved body part or system separately. 38 C.F.R. § 3.361(c) states that claims based on additional disability or death due to hospital care, medical or surgical treatment, or examination must meet the causation requirements of this paragraph and paragraph (d)(1) or (d)(2) of this section. Claims based on additional disability or death due to training and rehabilitation services or compensated work therapy program must meet the causation requirements of paragraph (d)(3) of this section. Actual causation is required. To establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in a veteran's additional disability or death. Merely showing that a veteran received care, treatment, or examination and that the veteran has an additional disability or died does not establish cause. Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. The provision of training and rehabilitation services or CWT program cannot cause the continuance or natural progress of a disease or injury for which the services were provided. Additional disability or death caused by a veteran's failure to follow properly given medical instructions is not caused by hospital care, medical or surgical treatment, or examination. 38 C.F.R. § 3.361(d) states that the proximate cause of disability or death is the action or event that directly caused the disability or death, as distinguished from a remote contributing cause. To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability or death, it must be shown that the hospital care, medical or surgical treatment, or examination caused a veteran's additional disability or death (as explained in paragraph (c) of this section); and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care, medical or surgical treatment, or examination without the veteran's or, in appropriate cases, a veteran's representative's informed consent. To determine whether there was informed consent, VA will consider whether the health care providers substantially complied with the requirements of § 17.32 of this chapter. Minor deviations from the requirements of § 17.32 of this chapter that are immaterial under the circumstances of a case will not defeat a finding of informed consent. Consent may be express (i.e., given orally or in writing) or implied under the circumstances specified in § 17.32(b) of this chapter, as in emergency situations. Whether the proximate cause of a veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of § 17.32 of this chapter. To establish that the provision of training and rehabilitation services or a CWT program proximately caused a veteran's additional disability or death, it must be shown that the veteran's participation in an essential activity or function of the training, services, or CWT program provided or authorized by VA proximately caused the disability or death. The veteran must have been participating in such training, services, or CWT program provided or authorized by VA as part of an approved rehabilitation program under 38 U.S.C. chapter 31 or as part of a CWT program under 38 U.S.C.§ 1718. It need not be shown that VA approved that specific activity or function, as long as the activity or function is generally accepted as being a necessary component of the training, services, or CWT program that VA provided or authorized. 38 C.F.R. § 3.361(e) provides for Department employees and facilities. A Department employee is an individual (i) who is appointed by the Department in the civil service under title 38, United States Code, or title 5, United States Code, as an employee as defined in 5 U.S.C. § 2105; (ii) who is engaged in furnishing hospital care, medical or surgical treatment, or examinations under authority of law; and (iii) whose day-to-day activities are subject to supervision by the Secretary of Veterans Affairs. A Department facility is a facility over which the Secretary of Veterans Affairs has direct jurisdiction. 38 C.F.R. § 3.361(e) explains activities that are not hospital care, medical or surgical treatment, or examination furnished by a Department employee or in a Department facility. The following are not hospital care, medical or surgical treatment, or examination furnished by a Department employee or in a Department facility within the meaning of 38 U.S.C. § 1151(a): (1) hospital care or medical services furnished under a contract made under 38 U.S.C. 1703; (2) nursing home care furnished under 38 U.S.C. § 1720; (3) hospital care or medical services, including examination, provided under 38 U.S.C. § 8153 in a facility over which the Secretary does not have direct jurisdiction 38 C.F.R. § 3.361(g) provides for benefits which are payable under 38 U.S.C. § 1151 for a veteran's death. Pursuant to 38 U.S.C. § 1151, entitlement to benefits based on the failure to diagnose a preexisting condition requires a determination that: (1) VA failed to diagnose or treat a preexisting disease or injury; (2) a physician exercising the degree of skill and care ordinarily required of the medical profession reasonably should have diagnosed the condition and rendered treatment; and (3) the Veteran suffered a disability that probably would have been avoided if the proper diagnosis and treatment had been rendered. 38 U.S.C. § 1151; Roberson v. Shinseki, 607 F.3d 809, 816-17 (Fed.Cir.2010); see also Hyatte v. Shinseki 2010 WL 5230879, 2 (Vet. App.) (Vet .App.,2010). Upon careful consideration of the evidence of record, the Board finds that the preponderance of the evidence is against the Veteran's claim for compensation as permitted under the provisions of 38 U.S.C.A. § 1151 and 38 C.F.R. § 3.361. The Board obtained a medical opinion in November 2012 because, as noted above, there were deficiencies in the prior medical opinions as they were incomplete and unclear regarding "reasonable" care. The November 2012 examiner reviewed the entire record, answered the inquires posed, and provided rationale. This examiner concluded that VA did not fail to diagnose or treat a preexisting cardiac disease. The records dated prior to the 1998 heart attack did not show a cardiac condition. The examiner also determined that VA personnel exercised the degree of skill and care ordinarily required of the medical profession and stated that the care was not the proximate cause of the continuance of the natural progress of his cardiac disease. In other words, the evidence does not show that the Veteran's MI and development of heart probably would have been avoided if the proper diagnosis and treatment had been rendered prior to that heart attack in April 1998. Further, the Board notes that it is not contended nor shown that the Veteran was furnished hospital or medical treatment without his consent. The Veteran does not have any additional disability as a result of VA medical treatment administered in conjunction with the April 1998 heart attack or thereafter; separate from the contention that he had a lack of treatment before and after the April 1998 heart attack. The VA examiner indicated that there was no carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care and medical and surgical treatment, nor was there any additional disability due to an event that was not foreseeable. In order to establish eligibility under 38 U.S.C.A. § 1151, the Veteran's heart surgery/medical care by VA must have been a factor and the other listed criteria must be met. That is not the case here. In sum, VA hospital/medical treatment or lack of treatment did not result in the Veteran's heart attack in April 1998 or other heart disease. The Board finds the VA medical opinion to be probative evidence because it was based on a comprehensive review of the record and was specific to inquiries regarding the criteria for entitlement under 38 U.S.C.A. § 1151. See Prejean. Accordingly, the criteria for entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for heart disability have not been met. In reaching this decision, the Board has considered the doctrine of doubt, however, as the preponderance of the evidence is against the veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for benign prostatic hypertrophy with voiding dysfunction is granted. Entitlement to service connection for a renal and urinary tract disability is denied. Entitlement to service connection for a heart murmur is granted. Entitlement to service connection for a cardiovascular disorder other than a heart murmur is denied. Entitlement to compensation under 38 U.S.C.A. § 1151 for a cardiovascular disability is denied. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs