Citation Nr: 1335236 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 07-28 306 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for right lower extremity peripheral vascular disease and neuropathy, status post right leg amputation. 2. Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for left lower extremity peripheral vascular disease and neuropathy. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. A. Rein, Counsel INTRODUCTION The Veteran served on active duty from November 1966 to August 1968. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2006 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. In October 2009, the Veteran testified at a Board video conference hearing before the undersigned Acting Veterans Law Judge. A transcript of that hearing is of record. In March 2010, the Board remanded the claims for additional development. In a June 2011 decision, the Board denied the claims. The appellant appealed to the U.S. Court of Appeals for Veterans Claims (Court). In April 2012, while his case was pending at the Court, the VA's Office of General Counsel and appellant's representative filed a Joint Motion requesting that the Court vacate the Board's June 2011 decision. That same month, the Court issued an Order vacating the June 2011 Board decision. In March 2013, the Board remanded these claims for additional development consistent with the Joint Motion. FINDINGS OF FACT 1. The Veteran's right lower extremity peripheral vascular disease and neuropathy, status post right leg amputation, was not the result of carelessness, negligence, lack of proper skill, or error in judgment on the part of VA in furnishing medical treatment to the Veteran, or was the result of an event that was not reasonably foreseeable. 2. The Veteran's left lower extremity peripheral vascular disease and neuropathy was not the result of carelessness, negligence, lack of proper skill, or error in judgment on the part of VA in furnishing medical treatment to the Veteran, or was the result of an event that was not reasonably foreseeable. CONCLUSIONS OF LAW 1. The requirements for compensation under 38 U.S.C.A. § 1151 for an additional disability claimed as right lower extremity peripheral vascular disease and neuropathy, status post right leg amputation are not met. 38 U.S.C.A. §§ 1151, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.361 (2012). 2. The requirements for compensation under 38 U.S.C.A. § 1151 for an additional disability claimed as left lower extremity peripheral vascular disease and neuropathy are not met. 38 U.S.C.A. §§ 1151, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.361 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to notify and assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. 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, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in January 2005, June 2005, and March 2010. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. The Board considers it significant that the subsequent statements made by the Veteran and his representative suggest actual knowledge of the elements necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the adjudication in the most recent August 2013 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the claims on appeal and the Board finds that the examination reports contain sufficient findings to properly evaluate the Veteran's claims and are adequate for rating purposes. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Analysis When a Veteran suffers additional disability or death as the result of training, hospital care, medical or surgical treatment, compensated work therapy, or an examination furnished by the VA, disability compensation shall be awarded in the same manner as if such additional disability or death were service-connected. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. § 3.361 (2012). A showing of carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault is necessary for claims for compensation pursuant to 38 U.S.C.A. § 1151 filed on or after October 1, 1997. 38 U.S.C.A. § 1151 (West 2002). To establish causation, the evidence must show that VA's hospital care, medical or surgical treatment, or examination resulted in 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. 38 C.F.R. § 3.361(c)(1) (2012). VA treatment cannot cause the continuance or natural progress of a disease or injury for which such care was furnished 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) (2012). Under these circumstances, it must be determined whether (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 (Feb. 5, 2001). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has noted that the courts have determined that it is impossible to delineate proximate cause without speaking in terms of duty when considering a claim based on failure to diagnose. Roberson v. Shinseki, 607 F.3d 809, 816 (Fed. Cir. 2010), aff'g 22 Vet. App. 358 (2009). In addition to a showing of additional disability or death, there must be evidence showing either that VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or that VA furnished treatment without the informed consent of the Veteran and his representative, in compliance with 38 C.F.R. § 17.32 (2012). Minor deviations from the 38 C.F.R. § 17.32 requirements that are immaterial under the circumstances of a case will not defeat a finding of informed consent. Consent may be express or implied as specified under 38 C.F.R. § 17.32(b), as in emergency situations. 38 C.F.R. § 3.361(d)(1) (2012). 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 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2) (2012). Whether lay evidence is competent and sufficient in a particular case is an issue of fact and lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example, a broken leg, and sometimes not, for example, a form of cancer), (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. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) Lay evidence presented by a veteran concerning his continuity of symptoms after service may generally be considered credible and ultimately competent, regardless of a lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (2006). It is the Board's duty to assess the credibility and probative value of evidence. Hayes v. Brown, 5 Vet. App. 60 (1993); Wood v. Derwinski, 1 Vet. App. 190 (1992)). Moreover, providing that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. Owens v. Brown, 7 Vet. App. 429 (1995). With any piece of evidence, the credibility and weight to be assigned to the opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467 (1993). When all the evidence is assembled, 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 a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran asserts that he is entitled to compensation under the provisions of 38 U.S.C.A. § 1151 for bilateral lower extremity peripheral vascular disease and neuropathy, and status post right leg amputation. He contends that as a result of VA medical care (1) he received improper anticoagulation treatment in association with peripheral vascular disease treatment as early as 1996; (2) he was improperly taken off of Coumadin therapy in April 2001 in preparation for a colonoscopy; and (3) that follow up care failed to properly diagnose and treat his condition, to include the timely restart of Coumadin therapy, that caused occlusion of bilateral leg vein grafts and ultimately led to an above-the-knee right leg amputation in April 2004. Records from the Mayo Clinic dated in March and April 1993 showed that the Veteran had experienced pain in the left neck with swelling and headaches. Computed tomography (CT) of the neck revealed expansion and nonenhancement of the inferior left jugular vein, consistent with thrombosis. Records show a decision was reached not to use prophylacting anticoagulation and a follow up examination suggested some improvement of symptoms. An impression was given of seemingly idiopathic left internal jugular vein thrombosis with symptoms resolving. A careful study of coagulation mechanism was recommended and if no significant coagulation abnormalities were shown, then observation was recommended. Testing in November 1993 revealed normal results of thrombotic diathesis haemostatic testing, except for elevated factor VIII. A VA medical certificate in January 1995 noted the Veteran had poor circulation in his feet and had seen a private doctor who referred him to VA. He was given a diagnostic impression of peripheral vascular disease and was advised to seek a consult with vascular surgery. A December 1995 VA hospital record noted the Veteran was an active farmer who had increasing left foot and toe pain for one year. While hospitalized, he underwent revascularization, below knee popliteal to malleolar branch of the left peroneal artery. His discharge diagnosis was ischemic left lower extremity and his discharge medication included Coumadin (warfarin sodium). An April 1996 VA outpatient record noted that the Veteran was scheduled for polyp removal (of the colon) and that the gastroenterology service recommended holding Coumadin for four days. His INR (internationalized normalized ratio for anticoagulation monitoring) was to be rechecked two weeks after restarting Coumadin. A May 1996 record noted the Veteran was to take the same dose of warfarin. VA outpatient records dated in July 1999 noted the rheumatology clinic referred the Veteran to the neurology clinic for complaints of decreased sensation in his hands and feet that had worsened over the last few years. The Veteran had a noted history of jugular vein thrombus in 1993, and bypass in the left leg for loss of circulation in 1995. He also reported tingling, numbness and cramping in the left hand since the 1980s, and decreased sensory loss over the last year. EMG (electromyelogram) studies were ordered. In August 1999, the Veteran filed a claim for entitlement to service connection for circulatory and neurological problems of the upper and lower extremities. At a follow up VA outpatient visit in August 1999 with a physician's assistant, the Veteran complained of continuing hand swelling, but with recent improvement. The record noted that he continued to smoke 30 cigarettes a day. He was given an impression of polyarthralgia/myalgia, still with possible microvascular disease and possible vasculitis caused by the Coumadin. The physician's assistant stated that he would ask the pharmacist in anticoagulation about using some lose niacin and that the Veteran needed to quit smoking. VA outpatient records from the anticoagulation clinic in September 1999 show that the Veteran was currently on warfarin for vascular bypass graft and the duration of the warfarin was indefinite. The Veteran was noted to voice no complaints at that time except for pain in his feet and hands. A September 1999 Electromyography and Electrodiagnosis Report noted nerve conduction studies performed were normal and an EMG was not performed due to anticoagulation. The report also noted there was no evidence of neuropathy. At a VA general examination in November 1999, the Veteran reported that he first had a problem with lower extremity numbness and pain in 1994 at which time he had an abnormal ankle-arm indices and was scheduled for a vascular bypass. He said that since that time he had good blood flow to the lower extremities, but continued have alternative pain and numbness in the lower extremities. He also complained that over the last two years he had begun to experience tingling and pain in his hands. He was noted to be taking Coumadin at that time. He further reported that he smoked two packs of cigarettes a day. He was given an impression of multi-extremity peripheral neuropathy. The examiner opined that at that time the Veteran had been appropriately worked up and managed and that his problems would need to be followed up closely by neurology. He also recommended that the Veteran absolutely discontinue smoking as soon as possible and continue taking Coumadin due to his history of blood clot. VA outpatient records in February 2000 include a record from the anticoagulation clinic noting that the Veteran was currently on warfarin for vascular bypass graft and the duration of the warfarin was "indefinite." A record from the vascular clinic noted that the Veteran had chronic pains in various joints. He was assessed as having status post lost left upper extremity bypass and no signs or symptoms of occlusion. On file are letters from the Veteran's brothers, dated in March 2000, noting that they had to do most of the farm work since the Veteran's leg problems and surgery in 1995 and that this was due to his inability to be on his feet for very long. They said that the Veteran's ability to work and be on his feet had not improved since 1995 and that they sold their farm in 1999. The Veteran testified before a hearing officer at the RO in March 2000 that his feet began to bother him in 1995 and that at that point he could only be on his feet for an hour. He said he underwent surgery at that time. At a VA examination in April 2000, the examiner noted that the Veteran had a thrombus of the left internal jugular in 1993 and that he was found to have peripheral vascular disease in December 1995 and underwent a revascularization of the left peroneal artery. Follow up vascular studies showed normal arm ankle index measurements, most recently in December 1999. The Veteran's complaints included slight numbness in both hands, chronic sensitivity of the greater hallux of both feet, and chronic numbness of the second toes of both feet aggravated by cold exposure with occasional numbness and sensitivity of other areas of the feet. The Veteran was given an impression at that time of history of peripheral vascular disease with normal arm ankle index studies, and left foot with mild stasis dermatitis secondary to vascular changes. A June 2001 VA primary care record noted findings that include, "Ext: peripheral pulses 2+ rt. with 4+ of graft LLE." A June 2001 VA outpatient record from the anticoagulation clinic noted the Veteran had been off of warfarin from "May 21 to May 29" for colonoscopy and that there had been a scheduling confusion. He complained of having a left sore leg since then which was thought to be Achilles tendon sprain by primary care. A subsequent outpatient record from the anticoagulation clinic in June 2001 noted the Veteran complained of a left side bruise and of a red spot on his large left toe. He reported that he had been taken off Coumadin in April for a colonoscopy. VA outpatient records include a November 2001 primary care report noting the Veteran's complaints of left leg, foot, and ankle pain and right toe numbness and tingling. A Doppler study performed at that time showed a left femoral-popliteal bypass had clotted off and collapsed. The Veteran was noted to have been taken off of Coumadin by vascular surgery. He was given an impression of "status post vascular graft, now occluded; Coumadin discontinued; discussed smoking cessation again and at length, but does not think he can quit and is not ready to try again (had 3 failed attempts)." A VA follow up consult record in November 2001 noted the Veteran's complaint of claudication of the left leg after walking one block. He reported that he had discontinued his Coumadin in preparation for a colonoscopy several months earlier. He reported that since that time he had noticed a loss of pulse at the site of the graft with his claudication distances decreased from two blocks to one. The Veteran was assessed as status post below knee popliteal/perineal bypass, now clotted off. The record noted that Coumadin was discontinued with the intent to prevent graft from clotting off. Pulses were 2 on the right and left femoral and radial arteries. This report was signed by a physician assistant student and cosigned by a resident physician. An addendum VA record in November 2001 noted that he reported by telephone that since the last day he took Coumadin, in November 2001, his left leg looked sunburn, did not feel warm to touch, and had increased in pain. A December 2001 VA vascular surgery record from a physician noted that the Veteran had a "'fiasco' a few months ago in April wherein he stopped Coumadin for a colonoscopy and then was denied hospitalization for heparinization and was kept of[f] coumadin for over a week." It was reported that "[b]y the time of the procedure, [the Veteran] had apparently clotted off his graft and his exercise tolerance had decreased to one block." It was further noted that after seeing his physician, Dr. B., in November 2001, the Veteran stopped taking Coumadin as instructed and his pain increased in intensity. He then reportedly decided to restart the Coumadin on his own and his symptoms improved. The physician noted that "interestingly," the Veteran had pain in the right leg prior to the graft surgery on the left and that the pain would switch from side to side depending on the day. The physician stated that he would ask the Veteran to discontinue Coumadin and take aspirin instead. An angiogram was performed by VA in January 2002, and the Veteran underwent a right femoral-popliteal bypass in January 2002. A January 2002 VA anticoagulation clinic note, signed by a pharmacist, noted that it "[s]ounds like previous (sp) vascular graft occluded after 9 day warfarin hold for colonoscopy." An August 2002 VA primary care clinic record noted that the Veteran had a seven month history of right foot pain since femoral bypass procedure. An August 2003 VA primary care outpatient record noted he was seen for a follow up of leg pain with moderate to severe bilateral lower extremity pain for approximately seven to eight years due to peripheral artery disease and neuropathy. He was noted to have tried multiple medications without help. He was assessed as having pain syndrome due to peripheral vascular disease and neuropathy, poorly controlled, and peripheral vascular disease, on Coumadin. VA records show that the Veteran underwent right femoral below knee popliteal bypass with vein in April 2004 which occluded approximately four days later and was revised operatively. The revision occluded the day after surgery and was re-revised using arm vein for the patch angioplasty which also occluded. Later in April 2004, the Veteran underwent an above knee amputation on the right due to a dead right lower extremity. In December 2004, the Veteran filed a claim for service-connection under 38 U.S.C.A. § 1151 for vascular degeneration of the right and left legs and peripheral neuropathy of the right and left legs, to include amputation/loss of right leg. He explained that these conditions were due to the "misadministration of prescription medication and/or the absence thereof, to include but not limited to the medication Coumadin, resulting in the amputation/loss of right leg, to include pain and numbness in the left leg." In June 2005, the Veteran submitted a summary of his medical records covering the period from December 1995 to May 2003. He reported that a record in November 2000 stated that he was not really interested in surgery at that point and that as he was on Coumadin it would need to be done through a heparin window. In a detailed statement dated in December 2006, the Veteran asserted that the amputation of his right leg was the "culmination of a series of events" that began when his April 2001 scheduled hospitalization for a colonoscopy had not been entered into VA's computer and he was sent home without being heparinized. He asserted that this caused him to be off of Coumadin for 10 days and that he had lost the pulse in his left leg. He said this condition became "aggravated" in October 2001 when he was taken off of Coumadin for eight days to undergo a sigmoidoscopy and in November 2001 when he was taken off of Coumadin permanently. He stated he subsequently developed a blood clot in his right leg that required right leg bypass surgery in 2004 which failed and that this, in turn, required that his right leg be amputated above the knee in April 2004. At a VA examination in January 2007, the Veteran asserted that he had had pain in his feet with claudication since the 1970s, but the pain did not became severe enough to seek medical attention until 1995. He stated that he was put on Coumadin in 1995 and was off of the medication in April 2001 for 10 days due to a scheduling mix up related to a colonoscopy. He reported that after being restarted on Coumadin 10 days later his symptoms remained severe. He reported that his rest pain remained about the same, but that there was a significant increase in his claudication pain. He explained that after walking to his mailbox and back he would have severe pain lasting all day versus the 30-60 minutes of pain he previously experienced prior to being off of Coumadin. He stated that he also noticed at that time that he no longer had a pulse in his graft. He further reported being off of Coumadin in October 2001 due to a scheduled flexible sigmoidoscopy. He added that he was taken off of Coumadin in November 2001 after tests revealed an occlusion of vein graft and he took issue with a delay by VA in scheduling him for an angiogram. The examiner stated that review of the Veteran's medical records showed appropriate follow-up in the vascular clinic, both for routine surveillance as well as for addressing acute changes in symptoms and test results. He said that "the decision to treat with Coumadin (an anti-thrombotic agent) rather than aspirin or plavix (anti-platelet agents) is not necessarily wrong as there is evidence in the medical literature that this can be equally or in the case of autologous grafts possibly more effective." After a discussion with the Veteran and an examination, and after reviewing his medical records, the examiner stated that "[t]here is no doubting that the Veteran has had a complicated course with need for multiple surgeries including the above-the-knee amputation." He went on to state that "[w]hile it is the goal to avoid this, by aggressive management and treatment of the disease, it is not always possible." He stated that the Veteran did receive regular follow-up and was aggressively surgically treated when appropriate." He opined that the factor most likely responsible for the progression of the Veteran's disease was his continued smoking. The VA examiner addressed the Veteran's assertion that his failed left leg bypass was due to the cessation of Coumadin for his colonoscopy by stating that "there are not clear recommendations in the literature that bridging therapy with IV heparin is useful or needed in this situation, so the decision to not admit for IV heparin does not indicate 'malpractice.'" Although the examiner did note that it was "concerning" that left leg pain and decreased pulse did not prompt referral back to vascular surgery prior to November 2001, he also noted that review of the Veteran's medical record did not show evidence that the Veteran brought this to the physician's attention and that there was an inconsistency with respect to the Veteran's report of an absent pulse. In this regard, the examiner said that findings in June 2001 were reported as revealing "Ext: peripheral pulses 2+ rt. With 4+ of graft LLE. had tenderness and fullness in the region of the superior attachment of the Achilles tendon. Skin: good color." The examiner found no indication that a VA provider had been negligent. Regarding the Veteran's concern about the delay in an angiogram, the examiner stated that it had been delayed for a few days in order to present the Veteran's case to the Vascular Surgery Board at the university which he noted would seem appropriate given the complex nature and severity of the Veteran's disease. He further noted that while there was some delay in referring the Veteran to the Wound Clinic or Vascular Clinic for evaluation of his wound infection and subsequent graft infection, there was no evidence that this caused the Veteran additional disability. At a VA examination in July 2007, the Veteran reported that he developed neuropathic pain in the left lower limb in 2002. Bone scan results were consistent with reflex sympathetic dystrophy. The Veteran's symptoms were noted to be stable and consistent with pain. A problem found to be associated with this diagnosis was peripheral neuropathy. In this regard, the Veteran reported having cramping in his legs, mostly at night prior to entering service. He reported significant worsening of these symptoms in basic training. He also reported that these symptoms remained the same in nature after leaving service and that they intensified in the 1990's leading to the eventual diagnosis of peripheral vascular disease. At a Board video conference hearing in October 2009, the Veteran testified that he had an additional disability, to include a right above-the-knee amputation as a result of being taken off of Coumadin in 1996 and on several occasions in 2001. He also asserted that his repeated requests to undergo an angiogram in 2001 were denied until January 2002 at which time he was found to have blood clots in his right leg. When asked if any doctor had indicated that his peripheral vascular disease increased as a result of the Coumadin incident, the Veteran responded by saying that "if any doctor was to state something like that I would probably faint." The Veteran explained that the "anticoag clinic" had been in control of his Coumadin since 1996 and that he was unaware if the clinic ever discussed this with a doctor. In July 2010, the Appeals Management Center obtained a medical opinion by a VA Chief of Section Vascular Surgery. After reviewing the Veteran's claims folders in their entirety and reporting the Veteran's pertinent medical history, the examiner found that the Veteran's unfortunate clinical course fit within the natural history of his disease and that the clinical notes did not confirm any immediate proximately of arterial problems to disruption of the Veteran's anticoagulant therapy for the colonoscopy or flex sigmoidoscopy. He stated that clinical observations were in contract with the Veteran's statements. He opined that it was less likely that the arterial problems related to interruption of anticoagulation therapy and more likely within the natural history of the Veteran's disease and interventions. He went on to note that there was no clear consensus from published literature of improved patency rates and the presence of anticoagulation of lower extremity arterial disease, but the trend appeared to suggest a limited role. The examiner enclosed two medical text excerpts. The first one he explained showed that atherosclerosis was a progressive disease of the lower extremities with anticipated limb loss of 1.1 to 4.4% per year and that multivariant analysis of risk factors of lower extremity atherosclerosis if a person did not have diabetes appeared most closely related to two factors: (1) Severity of disease and contralateral disease and, (2) History of significant nicotine abuse. The examiner stated that the second medical text excerpt showed that the expected patency rates of vein popliteal distal bypass (which the Veteran underwent in December 1995) was 50 to 60% at five years. In conclusion, the examiner opined that the Veteran's left or right lower extremity disabilities were less likely to have been occurred or aggravated as a result of carelessness, negligence, lack of proper skill, error in judgment, or similarly instance of fault on the VA's part in furnishing treatment from April 2001 to April 2004 and more likely related to the natural history of the disease. In an April 2012 private medical opinion, D. J. H, M.D., stated that after a review of VA medical records, it was clear that the graft in the right leg became occluded when the Veteran was taken off his Coumadin for 10 days in 2001. The standard of care for a patient on chronic Coumadin anticoagulation for the indication of preservation of a graft would have been to place him on a heparin bridge until the time of his colonoscopy scheduled for April 25, 2001. Unfortunately, when he arrived for the heparin treatment on April 21, 2001, he was not admitted to the hospital as planned. He was sent home without heparin and without being told to resume his Coumadin until other plans could be made. Dr. H. further noted that shortly after this the graft occluded and the Veteran developed increased pain and decreased exercise tolerance. Ultimately, the foot became infected due to his vascular insufficiency and underwent lower extremity amputation on April 24, 2004, as a complication of the graft occlusion that occurred in April 2001. Dr. H. stated that it was very clear that many of the Veteran's providers at the VA were in agreement that a "fiasco" occurred at the medical center which ultimately led to the amputation. In summary, Dr. H. stated that he believed that the Veteran's amputation was due to a culmination of events that started on April 21, 2001, at the VA medical center in Iowa City. It was his medical opinion that it was as least as likely as not that the medical care provided to the Veteran at the Iowa City VA Medical Center between April 21, 2001, and April 24, 2004, contributed to/and or resulted in his right above the knee amputation on April 24, 2004. In March 2013, the Board remanded the claims for a supplemental opinion from the July 2010 VA physician, Dr. D.H.S., or if no longer available, for an opinion by an appropriate expert. In August 2013, an additional VA medical opinion was obtain from a compensation and pension examiner, G.M., D.O, who indicated that Dr. D.H.S was no longer available. The examiner noted that he had reviewed the claims file and indicated that the existing medical evidence provided sufficient information to prepare the opinion. It was noted further examination would likely provide no additional relevant evidence. In addition, the examiner noted that he had considered Dr. H.'s April 2012 private medical opinion. He concluded that it was Dr. H.'s contention that while off Coumadin for a colonoscopy the Veteran should have been placed on a heparin bridge. He cited and quoted medical literature in support of his conclusion that there was no evidence that "bridging" with heparin would significantly reduce the risk of graft occlusion and, in fact, that the use of Coumadin carried significant risk. The examiner also noted that he reviewed the July 2010 VA opinion and stated that it was supported. He found that the American College of Cardiology and American Heart Association released practice guideline for the treatment of peripheral arterial disease were followed in this case and met the standard of care. It was noted that the Veteran had a complicated disease and course of treatment which required aggressive treatment and management, and that he had multiple risk factors for the progression of this condition such that, in essence, the disease followed its natural course. The examiner found there was no evidence of aggravation of the condition beyond its natural progression. He opined that a review of the records in the claims file showed no evidence that the right or left lower extremity disabilities were incurred or aggravated as a result of carelessness, negligence, lack of proper skill, error in judgment, or similarly instance of fault on the VA's part in furnishing treatment from April 2001 to April 2004. After a careful review of the evidence in light of the above legal criteria, the Board finds that the weight of the probative evidence is against a finding that compensation is warranted under 38 U.S.C.A. § 1151 for right lower extremity peripheral vascular disease and neuropathy, status post right leg amputation and left lower extremity peripheral vascular disease. The evidence in this case includes a December 2001 VA record from the vascular clinic which notes in the medical history section of the record that the Veteran had a "'fiasco' a few months ago in April wherein he stopped Coumadin for a colonoscopy and then was denied hospitalization for heparination and was kept of[f] coumadin for over a week." It was further noted that "[b]y the time of the procedure, [the Veteran] had apparently clotted off his graft and his exercise tolerance had decreased to one block." The evidence also includes a January 2002 VA anticoagulation clinic note, signed by a pharmacist, stating it "[s]ounds like previous (sp) vascular graft occluded after 9 day warfarin hold for colonoscopy." Initially, the Board finds that the basis for these conclusions appears to be based on the Veteran's reported medical history, without any additional consideration of his documented complex medical history or pertinent medical literature. The Board finds that the December 2001 VA medical record is merely a recitation of the facts as presented by the Veteran without an actual opinion, or basis for any findings provided therein. As to the January 2002 VA clinic note, a finding by a health care professional that something " [s]ounds like..." renders such opinion questionable as to the basis for any conclusions reached. In this regard, it appears that the VA pharmacist was speculating based solely on the Veteran's reported history, as there is nothing in that note to show any other possible basis for such conclusion. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995); see also Swann v. Brown, 5 Vet. App. 229, 233 (1993). The Board concludes that such findings constitute conclusionary statements that are not supported by the discussion of the relevant facts nor provides any sort of medical explanation or rationale. In addition, the Veteran's private physician, Dr. H. provided an April 2012 medical opinion that it was as least as likely as not that the medical care provided to the Veteran at the Iowa City VA Medical Center between April 21, 2001, and April 24, 2004, contributed to/and or resulted in his right above the knee amputation on April 24, 2004. In support of his opinion, Dr. H. found that after a review of the VA medical records, it was clear that the graft in the right leg became occluded when the Veteran was taken off his Coumadin for 10 days in April 2001. He set forth that the standard of care for a patient on chronic Coumadin anticoagulation for the indication of preservation of a graft would have been to place him on a heparin bridge until the time of his colonoscopy scheduled for April 25, 2001. It was further found that, ultimately, the foot became infected due to his vascular insufficiency and underwent lower extremity amputation on April 24, 2004, as a complication of the graft occlusion that occurred in April 2001. The Board is aware that a review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. However, in this case, the Board finds that the April 2012 opinion of Dr. H. and the statements of the December 2001 VA physician and the January 2002 VA pharmacist) do not appear to account for the Veteran's complete medical history. Significantly, Dr. H. did not address the Veteran's complete, complex medical history nor his additional risks, to include his Veteran's smoking history. Nor did he address the extensive length of time between VA medical care in question, in April 2001, and the amputation that occurred three years later, in April 2004. By contrast, in January 2007, a VA staff physician, who, after examining the Veteran and reviewing his claims file, concluded that the Veteran's medical records showed appropriate follow-up in the vascular clinic both for routine surveillance and for acute changes in the Veteran's symptoms and test results. The physician found that the Veteran had been aggressively surgically treated when appropriate and stated that while it was the goal to avoid amputation by aggressive management and treatment of the disease, that was not always possible. The January 2007 examiner also set forth that "there are not clear recommendations in the literature that bridging therapy with IV heparin is useful or needed in this situation, so the decision to not admit for IV heparin does not indicate 'malpractice.'" He found that the factor most likely responsible for the progression of the Veteran's disease was his continued smoking. In addressing the Veteran's assertion that there was a delay in obtaining an angiogram in December 2001, the January 2007 examiner stated that the record showed the Vascular Clinic appropriately evaluated the Veteran. The examiner further explained that there was a delay in ordering the angiogram for a few days to present the Veteran's case to the Vascular Surgery Board and that this would seem appropriate given the complex nature and the severity of the Veteran's disease. The examiner additionally noted that there was some delay following the Veteran's multiple surgeries in 2004 in referring him to the Wound Clinic or Vascular Clinic for evaluation of his wound infection and subsequent graft infection, but that there was no evidence that this caused the Veteran additional disability. In a second July 2010 opinion, a VA Chief of Section Vascular Surgery who, after reviewing the Veteran's claims file, concluded that the Veteran's unfortunate clinical course fit within the natural history of his disease. In specific regard to the Veteran's concerns that the cessation of Coumadin in April 2001 for a colonoscopy and in October 2001 for a flexible sigmoidoscopy caused the Veteran additional disability, to include the above the knee amputation on the right, this examiner stated that the Veteran's clinical notes did not confirm any immediate proximity of arterial problems to disruption of his anticoagulant therapy for the colonoscopy or flex sigmoidoscopy. He stated that it would appear less likely that the arterial problems related to interruption of anticoagulant therapy and more likely fell within the natural history of the Veteran's disease and interventions. Both the January 2007 and July 2010 VA examiners reviewed the Veteran's claims files and accurately summarized his medical history. Incidentally, both examiners noted that there were multiple inconsistencies in the clinical record as well as between the clinical record and the Veteran's statements. In this regard, one of the Veteran's assertions was that he told a VA radiologist about the absent pulse in his left leg in June 2001 while undergoing a barium enema and that nothing was done about it until several months later. However, the January 2007 VA examiner noted out that medical findings from a June 2001 treatment record showed the Veteran, in fact, had a pulse in his left leg. It was noted that findings in June 2001 showed "Ext: peripheral pulses 2+ rt. with 4+ of graft LLE." These findings were noted on a June 2001 primary care record. Also on file in June 2001 is a record from the anticoagulation clinic. Although this record reflects the Veteran's complaint of having a sore left leg since he was taken off of warfarin for a colonoscopy from "5/21-5/29," the record does not reflect complaints of an absent pulse. The January 2007 examiner further stated that while a more prompt referral to vascular surgery would have been appropriate, there was no indication that a VA provider was negligent or that a more prompt exam would have changed the subsequent course of the disease. The August 2013 VA examiner concluded that in this case, the American College of Cardiology and American Heart Association's practice guidelines for the treatment of peripheral arterial disease were followed and met the standard of care. He further considered Dr. H.'s April 2012 contention that while off Coumadin for a colonoscopy, the Veteran should have been place on a heparin bridge. He cited and quoted medical literature in support of his conclusion that there was no evidence that "bridging" with heparin would significantly reduce the risk of graft occlusion and, in fact, that the use of Coumadin carried significant risk. He also noted that the Veteran had a complicated disease and he had multiple risk factors for the progression of this condition and, as such, the disease followed its natural course. There was no evidence of aggravation of the condition beyond its natural progression. Thus, based upon a comprehensive review of all the evidence in this case, the Board finds the opinions of the January 2007, July 2010, and August 2013 VA examiners are persuasive. The August 2013 VA examiner opinion is also persuasive, and supported by medical literature, that VA did not fail to diagnose and/or treat a preexisting disease or injury and that a physician exercising the degree of skill and care rendered the appropriate medical treatment within accepted medical practice. He further concluded that the disease followed its natural course, there was no aggravation, and that the Veteran did not have an additional disability as a result of VA treatment. In this case, the Board accords greater probative value to the collective findings, opinions, rationales provided by the January 2007, July 2010, and August 2013 VA medical examiners. These opinions were supported by clear rationale specific to the facts and medical complexity of the Veteran's lengthy medical history. Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the Veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). See also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the Veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). Thus, considering the medical opinions of record, in light of the complexity of the Veteran's medical history and medical literature in support of the VA examiner's opinions, the Board finds that the most probative medical opinions weigh against the claims. Accordingly, the Board finds that the persuasive medical evidence in this case demonstrates that the Veteran does not have additional disability, claimed as peripheral vascular disease and neuropathy, right and left lower extremities, and status post right leg amputation, that was caused by VA hospitalization or medical or surgical treatment, and proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or proximately caused by an event not reasonably foreseeable. In fact, the July 2010 and August 2013 VA examiners specifically opined that the Veteran's left or right lower extremity disabilities were less likely to have been occurred or aggravated as a result of carelessness, negligence, lack of proper skill, error in judgment, or similar fault on the part of VA in furnishing treatment from April 2001 to April 2004 and more likely related to the natural history of his disease. The Board has also considered written statements and hearing testimony advanced by the Veteran, and by his representative, on his behalf. The Board notes that the Veteran is competent to provide evidence as to observations and some medical matters, but that his statements are, at most, conclusory assertions of a nexus between his present disabilities and his VA treatment. Jandreau, 492 F.3d 1372; Buchanan, 451 F.3d 1331. As questions of medical diagnosis and a relationship to service are complex etiological questions akin to the type of medical matters which laypersons are not competent to provide, his statements are insufficient to substantiate his claims. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (Board must determine whether claimed disability is type of disability for which lay person is competent to provide etiology or nexus evidence). Based upon a comprehensive review of the entire record, the Board concludes that the Veteran does not have an "additional disability" due to VA medical or surgical treatment within the meaning of 38 U.S.C.A. § 1151. The Board finds that the preponderance of the evidence is against the Veteran's claims. Although the Veteran's service representative asserted that VA had a "tendency to overlook the portions of the law and regulations governing informed consent," it is unclear how the issue of consent applies in this case. The treatment issues in this case, in essence, involved the Veteran's own actions in taking medication himself upon the advice of his VA medical care providers. His informed consent in self-administering medications within the normal course of treatment is assumed. His claims must, therefore, be denied. In light of the above, the Board finds that the preponderance of evidence does not support the Veteran's claims of entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for right lower extremity peripheral vascular disease and neuropathy, status post right leg amputation, and for left lower extremity peripheral vascular disease and neuropathy. Accordingly, the benefit of the doubt doctrine is not for application. 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 Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for right lower extremity peripheral vascular disease and neuropathy, status post right leg amputation, is denied. Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for left lower extremity peripheral vascular disease and neuropathy is denied. ____________________________________________ T. L. Douglas Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs