Citation Nr: 1335574 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 08-28 104 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a left arm disorder. 2. Entitlement to service connection for an ear disorder, to include hearing loss. 3. Entitlement to service connection for a nervous system disorder with manifestations to include a speech condition. 4. Entitlement to service connection for a speech disorder. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD John Kitlas, Counsel INTRODUCTION The Veteran served on active duty from June 1957 to September 1958. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions promulgated in October 2007 and March 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran provided testimony at a hearing before a Decision Review Officer (DRO) in June 2008. A transcript of this hearing is of record. This case was previously before the Board in February 2011 and November 2012, at which time the case was remanded for further development to include VA medical examinations to address the nature and etiology of the claimed disabilities. Such examinations were accomplished in June 2011, September 2012, December 2012, and January 2013. All other development directed by the Board's remands appears to have been substantially accomplished. Accordingly, a new remand is not required in order to comply with the holding of Stegall v. West, 11 Vet. App. 268 (1998). See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (Remand not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In May 2013, the Board requested a medical expert opinion from a member of the Veterans Health Administration ("VHA opinion") in accord with VHA Directive 20006-019 (April 3, 2006), 38 U.S.C.A. §§ 5103A , 7109 and 38 C.F.R. § 20.901 regarding the Veteran's claims of service connection for an ear disorder, a nervous system disorder, and a speech disorder. The requested opinion was subsequently promulgated in June 2013, the Veteran was provided with a copy of this opinion in July 2013, and was given 60 days in which to send any additional evidence or argument regarding the case pursuant to 38 C.F.R. § 20.903. The Veteran responded in August 2013 that he had no further argument or evidence to submit, and that he would like the Board to immediately proceed with the adjudication of his appeal. FINDINGS OF FACT 1. The preponderance of the competent medical and other evidence of record is against a finding the Veteran has a current left arm disorder that was incurred in or otherwise the result of his active service. 2. The preponderance of the competent medical and other evidence of record is against a finding the Veteran has a current an ear disorder, to include hearing loss, that was incurred in or otherwise the result of his active service. 3. The preponderance of the competent medical and other evidence of record is against a finding the Veteran has a current a nervous system disorder that was incurred in or otherwise the result of his active service. 4. The preponderance of the competent medical and other evidence of record is against a finding the Veteran has a current speech disorder n that was incurred in or otherwise the result of his active service. CONCLUSIONS OF LAW 1. The criteria for a grant of service connection for a left arm disorder are not met. 38 U.S.C.A. §§ 1131, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.1-2, 3.303 (2013). 2. The criteria for a grant of service connection for an ear disorder, to include hearing loss, are not met. 38 U.S.C.A. §§ 1131, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.385 (2013). 3. The criteria for a grant of service connection for a central nervous system disorder are not met. 38 U.S.C.A. §§ 1131, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). 4. The criteria for a grant of service connection for a speech disorder are not met. 38 U.S.C.A. §§ 1131, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters The Board notes at the outset that VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). VA is required to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has indicated that the notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA must provide a claimant notice before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Dingess/Hartman; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the Veteran was sent VA notification letters in September 2006, August 2007, November 2007, March 2011, July 2011, April 2012, and December 2012. Although all of these letters were clearly not sent prior to the initial adjudication of the Veteran's claims via the October 2007 and March 2008 rating decisions, they were all received prior to the last adjudication below via a March 2013 Supplemental Statement of the Case. This development "cures" the timing problem associated with inadequate notice or the lack of notice prior to the initial adjudication. Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (Mayfield III), citing Mayfield II, 444 F.3d at 1333-34. In pertinent part, these letters informed the Veteran of what was necessary to substantiate his current appellate claims, what information and evidence he must submit, what information and evidence will be obtained by VA, as well as the information and evidence used by VA to establish disability rating(s) and effective date(s) should service connection be established. In view of the foregoing, the Board finds that the Veteran was notified and aware of the evidence needed to substantiate his claims and the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. In any event, the Veteran has not demonstrated any prejudice with regard to the content or timing of any notice. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). In addition, the Board finds that the duty to assist a claimant in the development of his or her case has been satisfied. The Board acknowledges that the Veteran's service treatment records are not on file as they appear to have been destroyed in a fire. In such situations VA has a heightened obligation to explain its findings and conclusions and carefully consider the benefit-of-the-doubt rule. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). However, the case law does not lower the legal standard for proving a claim for service connection but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the Veteran. See Russo v. Brown, 9 Vet. App. 46 (1996). Moreover, there is no presumption, either in favor of the claimant or against VA, arising from missing records. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) (Wherein the Court declined to apply an "adverse presumption" where records have been lost or destroyed while in government control which would have required VA to disprove a claimant's allegation of injury or disease). Various other records were obtained and considered in conjunction with this case. Further, the Veteran has had the opportunity to present evidence and argument in support of his claims, to include at the June 2008 DRO hearing. Except for the service treatment records, nothing indicates the Veteran has identified the existence of any relevant evidence that has not been obtained or requested. For example, he has not identified outstanding evidence relating the claimed disabilities to his active service, to include the purported in-service ear and arm infections he contends caused the current disabilities. As to the June 2008 DRO hearing, in Bryant v. Shinseki, 23 Vet. App. 488 (2010) the Court held that 38 C.F.R. 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the DRO accurately noted the current appellate claims, and asked questions to clarify the Veteran's contentions and medical treatment history. Although the DRO did not specifically note the bases of the prior determinations or the elements that were lacking to substantiate the Veteran's appellate claims, he through his testimony and other statements of record, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. Finally, the Veteran has not 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 this hearing. As such, the Board finds that, consistent with Bryant, the duties set forth in 38 C.F.R. 3.103(c)(2) have been satisfied. The Board further notes that the Veteran was accorded VA medical examinations in June 2011, September 2012, December 2012, and January 2013 which included opinions that addressed the nature and etiology of the claimed disabilities. A VHA opinion was also promulgated on these issues in June 2013 based upon review of the Veteran's VA claims folder, which included the aforementioned VA examinations. As these opinions were based upon both a medical evaluation of the Veteran and/or an accurate understanding of his medical history based upon review of his VA claims folder, the Board finds they are supported by an adequate foundation. Although, as discussed in greater detail below, the Board found various deficiencies in the VA examinations, these deficiencies were addressed and corrected by the VHA opinion. Accordingly, the Board finds that this development is adequate for resolution of this case. In view of the foregoing, the Board finds that the duty to assist the Veteran has been satisfied in this case. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (The Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (Noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). 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); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. 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 United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court 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. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Legal Criteria Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Service connection may also be established for certain chronic diseases that are present to a compensable degree within the first post-service year to include organic diseases of the nervous system such as sensorineural hearing loss. See 38 C.F.R. §§ 3.307, 3.309(a). Further, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). For the purpose of applying the laws administered by VA, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; or when the auditory threshold for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Further, the Court has indicated that the threshold for normal hearing is between 0 and 20 decibels and that higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). When audiometric test results at a veteran's separation from service do not meet the regulatory requirements for establishing a "disability" at that time, he may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley, 5 Vet. App. at 160. Analysis In his statements and hearing testimony, the Veteran essentially contends that he was treated for ear problems during service and had ear problems at discharge from active duty. He attributes his speech difficulties to the ear problems that he reports had their onset in service. As such, he seeks service connection for an ear condition and a neurologic condition with speech symptoms. Essentially, he states that he had an ear infection at separation from service and has residual disability in the form of an ear disorder, to include hearing loss and ear pain, as well as a neurologic condition with manifestations to include speech dysfunction. In addition, he contends that he had a left arm infection at the site of a vaccine during service and has current residual disability of the left arm. As already indicated, the service treatment records, with the exception of his Certificate of Release at Discharge (DD Form 214), are unavailable and because they are presumed to have been destroyed in a fire. The Board observes, however, that the Veteran is competent and credible to report the circumstances of his service and his symptoms, and there is no evidence that conflicts his report of treatment for an ear and/or arm infection in service. However, the Board also observes that the residual effects of such infections, particularly as here when determining the potential relationship to disabilities first claimed and/or shown years thereafter, involves complex medical issues. Thus, the Board finds that competent medical evidence is required to address the nature and etiology of these claimed disabilities. Here, nothing on file shows that the Veteran has the requisite knowledge, skill, experience, training, or education to render a medical opinion. As such, his contentions cannot constitute competent medical evidence. 38 C.F.R. § 3.159(a)(1). Nevertheless, his account of his purported in- and post-service symptoms can serve as a basis for diagnosis and opinion by a medical professional. See Davidson, Jandreau. A review of the record reflects that the earliest medical evidence in the claims folder is a February 1999 private medical report. The report notes an initial evaluation in July 1988 for rashes on the arms and forearm, hoarseness and tinnitus. A significant past history and clinical course was noted to include chronic otitis externa. In addition, findings reported on examination in July 1988 were noted to have included severe tinnitus, vertigo and nasal congestion. It was further noted that on examination in June 1998 no impairment of hearing and no description of dizzy spells was noted. Neurologic examination was normal. The extremities were noted to be without deformities, inflammation, fracture and edema or trophic changes. Objective findings were noted to include rashes on the arms, and moderate nervousness, and laboratory tests were noted to include an ear culture. The report reflects that the Veteran was undergoing treatment and diagnoses included vertigo - chronic otitis externa, sinusitis and dermatitis, and although not entirely legible, it appears that a "neurodisturbance" was noted. A VA treatment report in April 2008, recorded the Veteran's report of speech problems since 1958, with no prior treatment. In May 2008 a speech pathologist noted an impression of dysfluent speech pattern. In June 2009, N.A. Ortiz, M.D., opined that it was more probable than not that the Veteran's right ear pain, hearing loss and speech problems were related to a traumatic ear and pharynx infection during service. Poor improvement with medication was noted. On VA ear disease examination in June 2011, the Veteran reported chronic right ear pain after he was treated for an ear infection in service in 1958. He also related occasional left ear pain. Examination was completely negative for ear disease. The examiner noted that the Veteran presented a classic temporomandibular (TM) joint disorder and TM joint pain usually referred to the ears. On VA neurological examination in June 2011 the Veteran reported an ear infection in service along with recurrent intelligible speech and pain since that time. Neurological examination revealed no abnormalities. Physical examination did show a painful lump on the right side of the pharynx. The examiner diagnosed dysfluent speech associated with dysarthria, and both the June 2011 report and a September 2012 VA neurological examination report reflect that the condition was typically, developmental, and as such, less likely than not due to service. However, both examination reports failed to definitively address whether condition was a congenital condition capable of improving or deteriorating, and a rationale was not provided in support of the opinions. In September 2012 a VA examiner noted that there was no evidence of ongoing ear problems such as otitis media or otitis externa of either ear. Rather the Veteran's only ear condition was hearing loss. The examiner opined that it would be mere speculation to provide an opinion as to whether the Veteran's sensorineural hearing loss, as noted post-service discharge in June 2011, or a right ear condition, was related to service due to the absence of audiologic evaluation at separation from active duty. The Board has determined that this examiner's opinion was inadequate for rating purposes because the examiner improperly relied on the absence of documented hearing loss at separation and a lack of corroborating medical evidence in determining there was no nexus between the Veteran's current disabilities and service, without addressing the competent and credible evidence of recurrence of symptomatology, particularly in light of the circumstances surrounding the unavailability of the service treatment records. The Court has held that a medical opinion based solely on the absence of documentation in the record is inadequate. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). The Veteran underwent a VA audiological examination in December 2012. The examiner determined that it was less likely than not that the Veteran's hearing loss was caused by or the result of service because there was no evidence of hearing problems until 2011. Moreover, the Veteran reported onset of hearing problems 10 years earlier. The examiner further explained that exposure to high levels of noise caused immediate hearing loss, such as in cases of noise acoustic trauma, or progressive deficits during prolonged periods of exposure during military service, but retroactive hearing effect was not expected so many years after being exposed to military noise. The examiner opined that the Veteran's hearing loss was most likely associated with expected changes in hearing sensitivity that occur with the normal aging process. The examiner did not address the Veteran's competent and credible report of an ear infection in service with complaints of intermittent ear pain post-service discharge. Moreover VA treatment records in September 2011 and July 2012 reflect complaints of right ear pain along with treatment for an ear infection. In addition, based in part on the December 2012 VA examiner's opinion that the Veteran's tinnitus, which became manifest many years after service was at least as likely as not related to the Veteran's in-service noise exposure, the RO granted service connection for tinnitus; the examiner explained that it was well established that exposure to hazardous noise can cause irreversible damage to inner ear structures and result in hearing deficits and tinnitus. On VA neurological examination in January 2013, the examiner noted that the Veteran had been diagnosed with intermittent dysfluent speech disorder by a speech pathologist in 2008. The examiner reported that because the Veteran's service treatment records were unavailable and there was no evidence of treatment for a speech condition within one year of service discharge, he could not render an opinion regarding the etiology of the claimed condition without resorting to speculation. The examiner also noted that he could not detect any speech disorder or neurological condition on examination and interview of the Veteran. The Board observes that an examiner's conclusion that it is not possible to provide a requested opinion without resort to speculation is a medical conclusion just as much as a firm diagnosis or a conclusive opinion, and before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, it must be clear that the procurable and assembled data was fully considered and the examiner must explain the basis for such an opinion. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). For the above reasons, the Board found the opinions of the VA examiners to be inadequate for a determination as to whether an ear condition or a nervous system condition with manifestations to include a speech condition were caused or aggravated by service. Therefore, the Board requested a VHA otolaryngologist opinion for clarification. In the subsequent June 2013 opinion, a VA Assistant Chief, Otolaryngology Section, noted that he had reviewed the claims folder in detail, page by page, including the Board remand. In pertinent part, this VHA specialist noted that while ear infection was reported while in service in 1958, subsequent information in the claims folder would seem to provide clear and convincing evidence that the ear infection in 1958 was more likely than not an acute infection and not representative of a chronic condition. This VHA specialist also noted that the results of the December 2012 VA audio examination appeared compatible with the Veteran's age. Further, review of the available records within the claims folder failed to reveal evidence of any specific ear disorder; and that the Veteran's current symptoms would not be consistent with what was reported as an ear infection in 1958 and such a connection would not be supported by current medical literature. It was stated that the most likely etiology of the Veteran's current hearing loss would be presbycusis. Although not specifically stated in the VHA opinion, the Board notes that presbycusis is a "lessening of hearing acuteness resulting from degenerative changes in the ear that occur especially in old age." Godfrey v. Brown, 8 Vet. App. 113, 120-21 (1995); see also Dorland's Illustrated Medical Dictionary 1534 (31st ed. 2007) (Defining presbycusis as "a progressive, bilaterally symmetric sensorineural hearing loss occurring with age"). In addition, the VHA specialist opined that it was less likely than not that any specific ear disorder, to include hearing loss and/or chronic ear infection might have had onset while in service, or is otherwise related to an injury or event in service, to include ear infection in 1958. Regarding the speech condition, the VHA specialist noted that review of the claims folder did show a diagnosis of dysfluent speech disorder, but it was unclear what the extent of the problem might actually be or whether or not such a problem actually might be present at all. The VHA specialist noted that he had reviewed the information in the claims folder with a speech pathologist on staff, and they both concluded that there was insufficient data to even suggest a possible nexus between dysfluent speech disorder and military service, and such a nexus would simply not be supported by current medical literature. It was also noted that one could only speculate what the history of the Veteran's speech issue might have been. However, it was stated that the most likely scenario would have been a childhood/developmental problem that improved as the Veteran grew out of childhood and then perhaps worsened as he grew older. Again, one could only speculate. Nevertheless, the VHA specialist opined that the Veteran's speech disorder was more likely than not of congenital origin and would have less likely than not worsened or aggravated while in service. In any case, it was less likely than not that the diagnosed dysfluent speech disorder would be related to military service. Additionally, the VHA specialist opined that it was less likely than not that the diagnosed dysfluent speech disorder was caused or aggravated, even in part, by any ear disability, to specifically include ear infections, to include the in-service 1958 ear infection; and that dysfluent speech disorder would less likely than not be caused by or related in any way to hearing loss. The VHA specialist emphasized that current medical knowledge would not support causation between dysfluent speech disorder and ear infection(s) and/or hearing loss. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. 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. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Initially, the Board has presumed that Dr. Ortiz, the VA examiners, and the VHA specialist are all qualified to render competent medical opinions. The VA examiners and VHA specialist appear to be familiar with the Veteran's overall medical history from review of the VA claims folder. Although Dr. Ortiz noted the Veteran's acknowledged in-service ear infection, it is not clear to what extent she was familiar with the overall history. Moreover, the Board cannot ignore the fact that the majority of competent medical professionals who have evaluated the case have concluded that the claimed ear disorder including hearing loss, central nervous system disorder, and speech disorder are not related to service. Granted, the Board found various deficiencies in the VA examiners' opinions, as discussed above. However, it is also noted that various examiners indicated the Veteran's current symptomatology was more consistent with the aging process, which is part of the rationale of the VHA specialist's opinions in this case. Further, as the VHA specialist's opinions included review of all of the prior opinions in this case, to include the VA examiners and Dr. Ortiz, it appears he is the medical professional most familiar with the aspects of this case. Thus, the Board finds that his opinions are entitled to the most weight regarding the etiology of the claimed disabilities. The Board further notes that the VHA specialist's opinion regarding the current ear disability, to include hearing loss, are not expressed in speculative or equivocal language. Although the VHA specialist did indicate that it would be speculation to determine the exact etiology of the Veteran's current speech disorder, he did opine that it was not related to service. In making these determinations, the VHA specialist acknowledged and did not dispute the Veteran's account of an in-service ear infection. However, as detailed above, the VHA specialist indicated the current symptomatology was not consistent with that of the in-service ear infection, and that current medical literature did not support an etiological relationship between the current disabilities and service. The Board finds these opinions, and the underlying rationale, to be persuasive and entitled to significant weight. For these reasons, the Board finds that the preponderance of the competent medical and other evidence of record is against a finding the Veteran has a current an ear disorder (including hearing loss), a central nervous system disorder, or speech disorder that was incurred in or otherwise the result of his active service. With respect to the left arm claim, the June 2011 VA joints examiner diagnosed degenerative joint disease of the left shoulder, and opined that it was caused by normal aging process, and was not caused by result from military service. However, the Board found the opinion to be inadequate because even though the examination reported noted the Veteran's reported history of having had a left arm cellulitis secondary to a vaccination injection during service, and of having been hospitalized for two or three weeks for such during service, the examiner noted no evidence that the Veteran received treatment for his left arm condition during active service and failed to adequately address the Veteran's competent report of a continuity of similar symptomatology since service. The December 2012 VA examination diagnosed the Veteran with left shoulder degenerative changes, and opined that it was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of this opinion, the examiner explained that the left shoulder condition was age related, and was not related to military service, or one year after separation, or congenital. In making this determination, the VA examiner noted the Veteran's account of recurrence of symptoms since service, which corrects the deficiency found by the Board regarding the June 2011 VA examiner's opinion in this case. In other words, it reflects the December 2012 VA examiner was accurately aware of the Veteran's medical history. Nevertheless, the December 2012 VA examiner reached the same essential conclusion as that of the June 2011 VA examiner - that the nature of the Veteran's current left shoulder disorder is consistent with the aging process, and not due to any disease or injury that occurred during service to include the infection from being vaccinated in the left arm. No equivocal or speculative language was used in this opinion, and no competent medical evidence is of record that explicitly refutes the findings of this VA examiner. In view of the foregoing, the Board finds that the preponderance of the competent medical and other evidence of record is against a finding the Veteran has a current left arm disorder that was incurred in or otherwise the result of his active service. The Board also notes that as there was no competent evidence of the claimed disabilities until decades after service, to include hearing loss, the Veteran is not entitled to a grant of service connection pursuant to the presumptive provisions of 38 C.F.R. §§ 3.307, 3.309(a). None of the other presumptive provisions appear applicable to this case. Further, nothing in the record indicates any of the claimed disabilities are secondary to an already service-connected disability. Simply put, no other basis for establishing service connection for the claimed disabilities is demonstrated by the record. For these reasons, the Board finds that the preponderance of the evidence is against the current appellate claims. As the preponderance of the evidence is against these claims, the benefit of the doubt doctrine is not for application in the instant case. See generally Gilbert; Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Consequently, the benefit sought on appeal must be denied. ORDER Service connection for a left arm disorder is denied. Service connection for an ear disorder, to include hearing loss, is denied. Service connection for a nervous system disorder with manifestations to include a speech condition, is denied. Service connection for a speech disorder is denied. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs