Citation Nr: 1338145 Decision Date: 11/20/13 Archive Date: 12/06/13 DOCKET NO. 07-07 390 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, including as secondary to service-connected disability. 2. Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for additional disability due to kidney stone surgery in October 2008 and follow-up care provided by VA. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from November 1963 to September 1964. This case has a lengthy procedural history and comes to the Board of Veterans' Appeals (Board) on appeal from August 2005 and December 2009 rating decisions of the RO in Chicago, Illinois. In its August 2005 rating decision, in pertinent part, the RO denied service connection for a depressive disorder. In its December 2009 rating decision, the RO denied compensation under 38 U.S.C.A. § 1151 for additional disability due to VA surgery in October 2008 for kidney stones. In December 2010, the Veteran and his wife provided testimony at a video hearing before the undersigned Veterans Law Judge. A transcript of this hearing is of record. In April 2011, the Board remanded the issues of entitlement to compensation under 38 U.S.C.A. § 1151 and whether new and material evidence had been submitted to reopen the claim of service connection for a major depressive disorder to the RO via the Appeals Management Center (AMC), for additional development. The case was returned to the Board, and in an April 2013 decision, the Board reopened the issue of entitlement to service connection for an acquired psychiatric disorder, and remanded the issues of entitlement to service connection for an acquired psychiatric disorder, and entitlement to compensation under 38 U.S.C.A. § 1151 to the AMC for additional development. The case was subsequently returned to the Board. In a May 2013 rating decision, while this case was on remand at the AMC, the RO granted entitlement to service connection for radiculopathy of both lower extremities, and to a total disability compensation rating based on individual unemployability (TDIU), effective June 8, 2011. These issues are not before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). FINDINGS OF FACT 1. The preponderance of the competent and credible evidence does not show that the Veteran's current psychiatric disorder (depressive disorder) manifested during active service. Nor does the evidence show that a psychiatric disorder was presumptively incurred during active service or that this disability is otherwise related to service or a service-connected disability. 2. The Veteran was shown to have benign prostatic hypertrophy (BPH) and lower urinary tract symptoms (LUTS) in 2007, prior to the October 2008 surgery that is the subject of this appeal. 3. On October 30, 2008, he underwent surgery at the Jesse Brown VA Medical Center (VAMC) in Chicago for an obstructing left kidney stone. He underwent a cystoscopy, left retrograde pyelogram, and left ureteroscopy with laser lithotripsy. The operative report noted a complication of a left ureteral perforation. 4. On October 31, 2008, he underwent percutaneous nephrostomy tube and antegrade ureteral stent placement. The nephrostomy tube was subsequently removed in November 2008, and the left ureteral stent was subsequently removed in January 2009. 5. He has additional disability - mild residual stenosis of the left ureter - as a result of that surgery at the Jesse Brown VAMC on October 30, 2008. No other additional disability has been shown a result of that procedure or the follow-up procedures, and the competent and credible evidence shows that the Veteran's current BPH and LUTS with voiding symptoms were not caused by the surgery. 6. In October 2008, prior to undergoing that October 30, 2008 and October 31, 2008 surgery at issue, he gave his informed consent to these procedures (in writing). 7. The evidence of record indicates his mild residual stenosis, left ureter was not incurred as a result of VA failure to exercise the degree of care that would be expected of a reasonable health care provider; there also is no indication VA treatment was performed without his informed consent or that he sustained additional disability as a result of VA treatment due to an event that was not reasonably foreseeable. CONCLUSIONS OF LAW 1. Depressive disorder was not incurred in or aggravated by his military service or a service-connected disability, nor may it be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria are not met for entitlement to § 1151 compensation for residuals of the October 2008 cystoscopy, left retrograde pyelogram, and left ureteroscopy with laser lithotripsy and subsequent hospital care in October and November 2008. 38 U.S.C.A. § 1151 (West 2002 & Supp. 2012); 38 C.F.R. § 3.361 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance As provided by the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the appellant of any information and medical or lay evidence not of record: (1) that is necessary to substantiate the claim; (2) that VA will obtain and assist him in obtaining; and (3) that he is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). These VCAA 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). Further, 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. In this case, VCAA notice letters were sent to the Veteran in September 2004, prior to adjudication of the claim for service connection for a psychiatric disorder (claimed as depression) in August 2005, and in February 2009, prior to initially adjudicating the § 1151 claim in December 2009, so in the preferred sequence. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). These letters informed him of the evidence required to substantiate these claims and of his and VA's respective responsibilities in obtaining this supporting evidence. He was advised of the "downstream" disability rating and effective date elements of his service connection claim in a March 2006 letter. Additional notice was provided in May 2011. The Board then reopened the previously denied claim for service connection for a psychiatric disorder in an April 2013 decision. The remaining claims on appeal were last readjudicated in a June 2013 supplemental statement of the case. As the pleading party attacking the agency's decision, the appellant, not VA, has the evidentiary burden of proof of showing there is a VCAA notice error in timing or content and, moreover, above and beyond this, that the error is unduly prejudicial, meaning outcome determinative of his claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). There is no such pleading or allegation in this instance. VA also fulfilled its duty to assist him by obtaining all potentially relevant evidence in support of this claim that is obtainable. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). The RO obtained his voluminous VA treatment records (including from his 2008 surgery and hospitalization), the informed consent forms for each procedure for the 38 U.S.C.A. § 1151 claim, private treatment records, records from the Social Security Administration (SSA), documentation developed in association with the Veteran's Federal Tort Claims Act (FTCA) claim, and all relevant lay statements and testimony. VA examinations and medical opinions were obtained in June 2005, November 2009, May 2011, July 2012, and May 2013 concerning these claims. A medical opinion is adequate when it is based upon consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The November 2009 (and addenda in May 2011 and July 2012) and May 2013 VA examinations were conducted by medical professionals, and the associated reports reflect review of the appellant's prior medical history as well as the examination findings. Therefore, the Board concludes that the appellant was afforded adequate examinations. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). There has been compliance with the Board's April 2011 and April 2013 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (A Veteran is entitled to compliance with remand directives, and the Board itself commits error as a matter of law in failing to ensure compliance). The Board finds that there has been substantial compliance. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); 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). Concerning this, the Board directed that the RO/AMC obtain the 2008 surgical and hospital records, and this has been done. The Board also directed that the Veteran be provided with a VA compensation examination and medical opinion regarding the claims on appeal, and these have been obtained, as requested in the prior remands, and the medical opinions were responsive to the questions posed in the remands. The reports of the VA examinations and the medical opinions obtained provide the necessary evidence to adjudicate this appeal. Therefore, the Board is satisfied that VA has provided all assistance required by the VCAA and that appellate review may proceed without prejudicing the Veteran. At this time, the Board also notes that it is cognizant of the ruling in Bryant v. Shinseki, 23 Vet. App. 488 (2010), 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. The Board finds that this was done at the December 2010 Board hearing. Moreover, as discussed above, to the extent possible, VA has obtained the relevant evidence and information needed to adjudicate this appeal. 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 December 2010 Board hearing. Analysis The Board has reviewed all of the evidence in the Veteran's claims file and electronic ("Virtual VA") file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the appellant's claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Service Connection The Veteran contends that he incurred a psychiatric disorder either during service, or as a result of his service-connected disabilities. At various times, he has asserted that he has depression and/or posttraumatic stress disorder (PTSD). In this regard, the Board notes that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). His established service-connected disabilities are degenerative changes of the lumbosacral spine, radiculopathy of both lower extremities (associated with the spine disability), reflux esophagitis, and left otitis media. VA compensation may only be awarded to an applicant who has disability existing on the date of application, not for past disability. Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997)); but see McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (further clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the regulations, the United States Court of Appeals for the Federal Circuit (Federal Circuit Court) held that a three-element test must be satisfied in order to establish entitlement to service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Walker v. Shinseki, 708 F.3d. 1331, 1333 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases - namely those listed in 38 C.F.R. § 3.309(a) - benefit from a somewhat more relaxed evidentiary standard. See Walker, 708 F3d. at 1339 (holding 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."). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes"). 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show 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." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain or abnormal heart action in claims for arthritis or heart disease, for example) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. The Federal Circuit Court 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, 708 F3d. at 1336. 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 Court 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" Id. at 1339. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit Court held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Id. at 1338-40. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). Psychoses will be presumed to have been incurred in service if manifested to a compensable degree of at least 10 percent within one year after service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The term "psychosis" includes the following specific disorders: brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder, not otherwise specified, schizoaffective disorder, schizophrenia, schizophreniform disorder, shared psychotic disorder, and substance-induced psychotic disorder. 38 C.F.R. § 3.384. Under 38 C.F.R. § 4.125(a) (2012), for VA purposes, all mental disorder diagnoses must conform to the fourth edition of the American Psychiatric Association 's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV). Psychoses are chronic conditions under 38 C.F.R. § 3.309(a), but other psychiatric disorders are not. Service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may also be granted for disability which is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). An increase in severity of a non-service-connected disorder that is proximately due to or the result of a service-connected disability, and not due to the natural progress of the non-service-connected condition, will be service connected. Aggravation will be established by determining the baseline level of severity of the non-service-connected condition and deducting that baseline level, as well as any increase due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). When determining service connection, all theories of entitlement - direct, presumptive and secondary, must be considered. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). 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, the 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). 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). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). 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). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record 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). Turning to the evidence of record. The medical evidence on file demonstrates that the Veteran has been diagnosed with a psychiatric disorder during the pendency of this appeal, specifically depressive disorder and depression. Other psychiatric diagnoses were indicated in the past, but repeated VA psychiatric examinations have indicated that he does not have a current diagnosis of PTSD. On VA examination in January 2004, the examiner diagnosed depressive disorder, not otherwise specified (NOS), and found that PTSD was not shown. On VA examination in June 2005, the examiner diagnosed depressive disorder due to heart attack. On VA examination in May 2013, the examiner diagnosed depressive disorder NOS. VA medical records reflect treatment for depression. Therefore, there is competent medical evidence establishing the Veteran has a current acquired psychiatric disorder, namely depressive disorder or depression. See Degmetich, supra. The weight of the competent and credible evidence does not show that he had a current diagnosis of PTSD during the pendency of this appeal. See McClain, supra. Resolution of his appeal turns on whether the current depressive disorder is attributable to his military service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("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."). See Maggitt v. West, 202 F.3d 1370, 1375 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); and Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998). Service personnel records reflect that the Veteran served in the U.S. Navy, including service aboard the USS Sperry in 1964. He received no decorations or combat citations. He was discharged from service in September 1964 due to unsuitability. Service treatment records from his November 1963 to September 1964 period of active service reflect that on enlistment examination in mid-November 1963, his psychiatric system was listed as normal. In a report of medical history completed upon enlistment in November 1963, the Veteran reported a history of frequent or severe headaches. One week later, he was brought to the dispensary in a semi-conscious state. A neurological examination was negative, and the findings suggested a hysterical reaction, although a diagnosis of epilepsy was also considered. On neurology consultation examination in April 1964, the Veteran had numerous complaints of almost all organ systems. A physical examination was entirely within normal limits, as was a neurological examination. The examiner found no organic disease, and diagnosed immature personality after a consultation with a psychiatrist. Administrative discharge was recommended. On psychiatric evaluation in June 1964, the Veteran reported multiple vague physical complaints. He reported frequent pains in the legs, headaches several times per week, dizzy spells, nightmares, chronic tenseness and irritability, shortness of breath, anorexia (however, the examiner noted that he had gained ten pounds since enlistment), general feelings of ill health, and dissatisfaction with the service. It was noted that these problems had been present since before coming on active duty, but their continuance had precluded his rendering effective service. The Veteran reported that he had nightmares several times per week from childhood to the present. On examination, his thought processes were intact, his mood was even, his affect was appropriate, and there were no defects in sensorium or mentation, and no manifestations of overt mental illness. The diagnostic impression was passive-dependency reaction, moderate. Administrative separation was recommended. On separation examination in September 1964, the examiner indicated that the Veteran had been diagnosed with passive-dependency reaction, moderate, in June 1964. STRs are negative for treatment or diagnosis of depression. A January 1965 VA psychiatric examination reflects that the Veteran denied delusions, hallucinations, and paranoid ideas. He showed no noticeable tension, no emotional instability, hostility, or resentment. The examiner indicated that he showed no evidence of any depression. The examiner commented on the service treatment records, and indicated that there was insufficient evidence to continue the diagnosis of a personality disorder, of a passive-aggressive personality. The examiner indicated that no neuro-psychiatric disorder was found at present. A report of an August 1967 VA hospital admission shows that the Veteran was treated for rheumatoid arthritis of the spine and conversion reaction. A report of an April 1970 VA neuropsychiatric examination reflects that the Veteran reported that he was depressed frequently because his mother and wife both nagged him frequently, and reported suicidal ideas at times. The examiner indicated that there were no signs of psychosis, and diagnosed anxiety neurosis. A report of VA hospital admission from April to May 1970, reflects that the Veteran was treated for ankylosing spondylitis and anxiety reaction. A report of a March 1983 VA neuropsychiatric examination reflects that the Veteran reported that he had been nervous since about 1968. He said he had been frequently depressed since 1982, and also reported a prior suicide attempt. He had no psychiatric treatment for the past seven or eight years. The examiner found no signs of psychosis, and diagnosed generalized anxiety disorder. A report of a March 1983 VA examination by an internist reflects that the Veteran had a strong emotional overlay which probably contributed to his symptomatology. VA medical records show episodic evaluation and treatment for psychiatric symptoms, variously diagnosed. Reports of VA gastrointestinal examinations dated in February 1985 and November 1988 were completed by the same internist who performed the March 1983 examination. In February 1985, the examiner said that the Veteran had anxiety with multiple symptoms in the service as well as out of the service. In both examination reports, he opined that the Veteran's symptomatology was a picture of anxiety. In February 1985, he said that this was one of the reasons that the Veteran was only in service for such a short period of time. In November 1988 he observed that the rating board had never rated the Veteran for anxiety, which surprised him. Subsequent VA medical records reflect diagnoses of depression and adjustment disorder. On VA spine and gastrointestinal examination in October 1994, it was noted that the Veteran was somewhat depressed and was taking medication for depression. Diagnoses included a lumbar spine disability, chronic gastritis, and history of hypertension. He had a history of two heart attacks. A November 1999 VA affective disorders initial evaluation reflects that the Veteran had been ordered by a court to seek psychiatric treatment. He complained of depression, and it was noted that he was recently released from prison. The diagnostic assessment was rule out depression NOS, and pedophilia. A December 1999 VA mental health initial evaluation reflects that the Veteran reported that he was abused as a child. In February 2000 he was diagnosed with adjustment disorder, with depressed mood. On VA psychiatric examination in February 2000, the Veteran reported that he had a longstanding psychiatric history that began in 1968 when he was hospitalized. The examiner diagnosed generalized anxiety disorder, and noted that the Veteran had a multitude of medical, legal, and financial problems. On internal medicine examination performed in December 1999 for purposes of obtaining benefits from the Social Security Administration (SSA), the examiner noted that the Veteran had a myocardial infarction in April 1999 and underwent triple coronary bypass surgery. The examiner stated that after this surgery, he became depressed and was currently under psychiatric care. After an examination, the examiner diagnosed coronary artery disease, hypertension, hiatal hernia and possible peptic ulcer, low back pain, and depression. Records reflect that the Veteran was awarded disability benefits from the Social Security Administration (SSA) in August 2000, based on a primary diagnosis of coronary artery disease, and a secondary diagnosis of a back disability. It was noted that he suffered a myocardial infarction (heart attack) in 1987, and in April 1999, at which time he underwent triple bypass surgery. The SSA determined that he became disabled in April 1999. VA medical records reflect that the Veteran was hospitalized for chest pain in May 2003. On psychiatry consult, he reported that he was a little depressed about all of his medical problems and family conflict. After an examination, the diagnosis was coronary artery disease and adjustment disorder. In November 2003, the Veteran filed a claim for service connection for PTSD. He said that his in-service stressor was a bad fall while aboard a ship. In a May 2004 statement, he described his many current medical problems and reported taking medication for depression. On VA PTSD examination in January 2004, the Veteran said that he did not witness active combat. He reported that he was discharged from service after he fell aboard ship and incurred a back injury. The examiner noted that the Veteran had an extensive history of medical problems for which he took numerous medications. After a mental status examination, the examiner diagnosed depressive disorder NOS. The examiner stated that there was insufficient evidence to support a diagnosis of PTSD. A March 2004 VA psychiatry note reflects that the Veteran had been treated for depression intermittently since 1996. An April 2004 VA psychotherapy note reflects that the Veteran had a stroke five years ago that resulted in partial paralysis on the left side of his body and blindness in the left eye. In connection with the current appeal, a VA psychiatric examination was conducted in June 2005. The Veteran reported that his last full-time job ended after eight years in 1996 because of a heart attack. He said he had been depressed for the past four or nine years because of "worries, stress about life, different things." After an examination, the examiner diagnosed depressive disorder due to non-service-connected heart attack. The examiner stated that the entire claims file had been reviewed, with special attention to his service treatment records and prior VA examinations. She opined that it was less likely than not that the current depression was related to in-service mental condition or that his in-service mental condition played a role in his current depression. The only Axis I diagnosis was depressive disorder due to heart attack. (The Board notes that the Veteran's current cardiac disorder is not a service-connected disability.) At his Board hearing in December 2010, the Veteran testified that he first noticed depression symptoms ten years ago, and did not recall having these symptoms prior to that time. He testified that he had never been diagnosed with PTSD. His representative nonetheless asserted that the Veteran had some symptoms of PTSD. As the June 2005 VA examiner did not provide an adequate supporting rationale for her medical opinion as to the etiology of the current depression, the Board remanded this issue in April 2013 for another VA examination. On May 2013 VA psychiatric examination, the examiner stated that the claims file was reviewed. The Veteran reported that he received ongoing psychiatric treatment on an outpatient basis, including medication. He saw his psychiatrist every six months. The Veteran reported that his depression started in 1996 precipitated by "things that happen to me." When asked what happened, he did not want to state what happened. He said he did not sleep too well, and that this began in 2005. He said he had nightmares every night, about being chased and about an explosion on the "USS Charles S. Sperry." He also reported hearing a man's voice talking to him since 2006. He heard the voice three to four times per day. He denied that the voice could be his own thoughts. He also reported anxiety, crying spells, irritability, insecurity, inferiority, guilt and passive suicidal ideation. The examiner opined that it was unlikely that the Veteran's current psychiatric disorder was related to military service, or caused by or permanently aggravated by a service-connected disability. The examiner indicated that the claims file was silent about in-service depression, and a January 2013 note reflected that he had late onset depression, and today he reported depression beginning in 1996 following an event he did not wish to share. The examiner summarized relevant medical records and stated that since the evidence was silent about depression related to his service-connected conditions and he reported depression as beginning in 1996 related to undisclosed events and not to his service-connected conditions, aggravation of his depression is not shown. In addition, his service-connected conditions have been described, over years, as not active, mild moderate and the frequency of being seen for depression has been quarterly and now is every six months. The examiner diagnosed depressive disorder, NOS. No other psychiatric disorders were found. After a review of all of the evidence of record, and for the reasons and bases below, the Board finds that the Veteran's only current psychiatric disorder is depressive disorder or depression, and that the weight of the competent and credible evidence does not show that this disorder is related to service, or that it was caused or aggravated by a service-connected disability. The weight of the competent and credible evidence does not show that the Veteran has a current diagnosis of PTSD, or indeed any psychiatric disorder other than depressive disorder, during the pendency of this appeal. With respect to these other claimed psychiatric disorders, absent establishment of a current disability, there necessarily is no disability to attribute to his military service in order to warrant service connection. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("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."). Service connection is therefore not warranted for PTSD. The June 2005 VA examiner diagnosed depressive disorder due to non-service-connected heart attack. The May 2013 VA psychiatric examiner opined that it was unlikely that the Veteran's current depressive disorder NOS was related to military service, or caused by or permanently aggravated by a service-connected disability. In providing this opinion, the May 2013 VA examiner considered the Veteran's pertinent medical and other history and, more importantly, thoroughly discussed the underlying rationale for this opinion, which is where most of the probative value is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (wherein the Court discusses, in great detail, how to assess the probative weight of medical opinions and the value of reviewing the claims file. The Court holds that claims file review, as it pertains to obtaining an overview of the claimant's medical history, is not a requirement for medical opinions. The Court added, "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion.") The Board finds that the May 2013 VA medical opinion is competent and highly probative, and based on an adequate rationale. The Veteran has not asserted that his symptoms from depression have been continuous since service. Although he now contends that he has a current psychiatric disorder due to a service-connected disability, he is not competent to make this conclusion. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the issue of whether depression is related to service or a service-connected disability falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." Opinions as to the nature and etiology of a psychiatric disorder are complex medical issues about which lay persons may not provide competent evidence. Thus, in the absence of competent medical evidence linking his current depressive disorder to service or a service-connected disability, there is no basis on which service connection can be established. Moreover, the evidence does not reflect that depressive disorder or depression began in service or that a psychosis manifested to a compensable degree within the first post-service year. As discussed above, the Board finds that the most probative evidence demonstrates that the Veteran's depression is not attributable to his military service. Even considering the Veteran's lay testimony with regard to the matters it is competent to address, the most probative evidence weighs against the claim of entitlement to service connection. In sum, the Board finds that the preponderance of the evidence indicates that a depressive disorder was not shown in service or for years thereafter, and the current depressive disorder has not been shown by competent and probative medical evidence to be etiologically related to his active service. As the preponderance of the evidence is against the claim for service connection for an acquired psychiatric disorder to include depressive disorder, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 49. Compensation under 38 U.S.C.A. § 1151 The Veteran contends that he has additional disability due to kidney stone surgery in late October 2008, and that compensation under 38 U.S.C.A. § 1151 should be awarded for this claimed additional disability. At his December 2010 Board hearing, he stated that he was in a lot of pain after his surgery, and that doctors told him afterward that there was a sharp edge on one of the stones and that it "tore a hole in my tube." He related that he had a second surgery to repair the hole, and a stent was inserted, as well as a tube from his side to drain urine. He testified that he later had an MRSA infection and high fever, for which he was treated with antibiotics. At his hearing, he claimed that he had additional disability from this surgery, specifically, urine leakage for which he had to wear a diaper. He and his representative have also contended that the claimed additional disability includes chronic pain. See August 2013 written brief. A Veteran may be awarded compensation for additional disability, not the result of his willful misconduct, if the disability was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by VA, either by a VA employee or in a VA facility as defined in 38 U.S.C.A. § 1701(3)(A), and the proximate cause of the disability was (1) 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 examination, or (2) an event not reasonably foreseeable. 38 U.S.C.A. § 1151 (West 2002 & Supp. 2012). See also 38 C.F.R. § 3.361(c), (d)(1), (d)(2) (2012). To determine whether a Veteran has additional disability, VA compares the Veteran's condition immediately before the beginning of the hospital care, medical or surgical treatment, or examination to the veteran's condition after such care, treatment, or examination has stopped. 38 C.F.R. § 3.361(b) (2012). VA considers each involved body part or system separately. Id. To establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the Veteran's additional disability. 38 C.F.R. § 3.361(c)(1) (2012). Merely showing that a Veteran received care, treatment, or examination, and that the Veteran has additional disability, does not establish cause. Id. Hospital care, medical or surgical treatment, or examination cannot cause the continuation 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. 38 C.F.R. § 3.361(c)(2) (2012). Additional disability 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(c)(3) (2012). The proximate cause of disability is the action or event that directly caused the disability, as distinguished from a remote contributing cause. 38 C.F.R. § 3.361(d) (2012). 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, it must be shown that the hospital care, medical or surgical treatment, or examination caused the veteran's additional disability and (1) VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or (2) VA furnished the hospital care, medical or surgical treatment, or examination without the Veteran's or, in appropriate cases, the Veteran's representative's, informed consent. 38 C.F.R. § 3.361(d)(1) (2012). To determine whether there was informed consent, VA will consider whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(1) (2012). Minor deviations from the requirements of § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. Id. Consent may be express (i.e., given orally or in writing) or implied under the circumstances specified in § 17.32(b), as in emergency situations. Id. Whether the proximate cause of a Veteran's additional disability was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. 38 C.F.R. § 3.361(d)(2) (2012). 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. Id. 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). A January 2009 letter from VA's Regional Counsel in Hines, Illinois indicates that that office had received the Veteran's medical malpractice tort claim. A copy of the Veteran's December 2008 Standard Form (SF) 95 (Claim for Damage, Injury or Death) is also of record, and reflects that the tort claim pertains to the October 30 and 31, 2008 surgeries and follow-up treatment in November 2008. In a June 2010 letter to the Veteran, VA's Regional Counsel informed him that after a review of the medical records, it found that VA staff performed the kidney stone removal surgery within the standard of care, and that prior to surgery, he was advised of the risks of surgery, including ureter perforation, and consented. A nephrostomy tube was placed and any infection successfully remedied with antibiotics. It was found that VA staff was not negligent in this matter, and his claim under the Federal Tort Claims Act (FTCA) was denied. VA medical records dated prior to the surgery in question reflect that the Veteran had benign prostatic hypertrophy (BPH) and lower urinary tract symptoms (LUTS). A July 2007 VA genitourinary surgery consult reflects that a computed tomography scan showed bilateral nephrolithiasis (the presence of renal calculi, or kidney stones). It was noted that the Veteran had been seen previously in the genitourinary clinic for "BPH/LUTS." He currently complained of urgency and occasional hesitancy, but no nocturia, frequency, dribbling or incomplete emptying. The diagnostic impression was bilateral renal stones, and bilateral renal cysts. A December 2007 computed tomography scan showed bilateral non-obstructive calculi, and benign renal cysts. An October 20, 2008 VA genitourinary note reflects that an October 20, 2008 ultrasound showed bilateral renal cysts and small echogenic foci in both kidneys which may represent non-obstructing stones, and a enlarged prostate gland. An October 10, 2008 computed tomography scan showed an obstructive calculus in the left renal pelvis, and a non-obstructive calculus in the right kidney. The diagnostic assessment was obstructing left and non-obstructing right renal stones, bilateral renal cysts, and complaints of constant pain. Voluminous VA medical records from Jesse Brown VA Medical Center (VAMC) reflect that on October 30, 2008, after the Veteran was diagnosed with an obstructing left kidney stone, he underwent a cystoscopy, left retrograde pyelogram, and left ureteroscopy with laser lithotripsy. The operative report noted a complication of a left ureteral perforation. On October 31, 2008, he underwent percutaneous nephrostomy tube and antegrade ureteral stent placement. In November 2008, the nephrostomy tube was removed, and he was thereafter treated for pyelonephritis. The left ureteral stent was removed in January 2009. A January 2009 postoperative note reflects that the left ureteral stent was removed, and a left retrograde percutaneous gastrostomy was performed. The pre-operative diagnosis was left ureteral perforation status post antegrade stent placement. The study showed no stricture, filling defects, or extravasation, and mild-moderate delay in drainage. The post-operative diagnosis was a normal left ureter. The claims file contains a copy of a Consent for Treatment/Procedure dated on October 20, 2008, signed by the Veteran, relating to a planned cystoscopy with placement of ureteral stent ureter - ureteroscopy/stone extract/possible lithotripsy. In this document, the known risks of the procedure included "damage to ureter, requiring repair or placement of tube directly into kidney to allow drainage of urine and healing," "perforation of ureter with need for open drainage," "scarring or stricture of ureter requiring further procedures," and "pain in area of surgery." The claims file contains a copy of a Consent for Treatment/Procedure dated on October 30, 2008, signed by the Veteran's wife, relating to a planned nephrostomy with ureteral stent placement. The claims file contains a copy of a Consent for Treatment/Procedure dated on October 31, 2008, signed by the Veteran, relating to a planned left percutaneous nephrostomy. In this document, the known risks of the procedure included "infection." A June 2009 VA genitourinary clinic note reflects that the Veteran had a history of nephrolithiasis and BPH. His recent genitourinary history was significant for left obstructing ureteral stone status post ureteroscopy with laser lithotripsy on October 30, 2008 complicated by ureteral perforation and pyelonephritis on November 16, 2008. He underwent a left percutaneous nephrostomy and antegrade stent placement without event on November 1, 2008. The nephrostomy was removed in the genitourinary clinic in mid-November 2008, and the stent was removed in the operating room in January 2009. The examiner noted that medication had been prescribed for an enlarged prostate and to aid in stone fragment passing, but the Veteran said he had not been taking his medication. He had mild LUTS including frequency/urgency, good stream, nocturia, and occasional double voiding/leaking. The diagnostic assessment was history of nephrolithiasis status post intervention and mild LUTS. The Veteran said he was not interested in medication for LUTS, and said the symptoms were not bothersome. A November 2009 VA genitourinary examination report prepared in connection with the 38 U.S.C.A. § 1151 claim reflects that the examiner reviewed the claims file. The examiner summarized the medical history, noting that the Veteran underwent a left retrograde stone removal in October 2008 at the Jesse Brown VAMC in Chicago. At that time, the stone was extracted, however, there was a perforation of the left ureter, and the following day there was a need for placement of an antegrade stent at the site of perforation along the left ureter. The Veteran had a tube exiting his side for several weeks. After several weeks, that tube was removed. Subsequently, he developed an MRSA infection, and was re-hospitalized for approximately three days. Prior to that time, and continuing, he has symptoms of frequency, nocturia and urgency. He was awakened from sleep twice a night to urinate. He kept a urinal near his bed, since he had extensive spinal stenosis and had difficulty mobilizing. During the day he urinated frequently. He did not use any absorbent pads during the day or at night. He was not currently showing any signs of incontinence. His prostate had been checked on a regular basis. The examiner indicated that the Veteran has an enlarged prostate, and was on medication (alpha blockers) for this condition. He was not on dialysis. His weight had been stable. He had not been treated for malignancies, and his current medications included medication for diabetic control. He was on a statin medication because of his coronary artery disease, and was on other medications because of pain secondary to his diabetic condition. The examiner indicated that at the time of the operative procedure, the left ureter was perforated. After the antegrade tube was removed, he had periodic checks to determine that the left ureter would drain freely. In January 2009 he had a retrograde study. The stent was removed. An X-ray study showed that there was only mild narrowing at the site of the perforation. He had been followed on a frequent basis by the genitourinary clinic at Jesse Brown VAMC, and to date he has had no recurrent stenosis at the site of the left ureteral injury. He has erectile dysfunction and was not on any medication for this because of his coronary artery disease. On current VA examination, the prostate was enlarged. The examiner diagnosed benign prostatic hypertrophy (BPH) with mild obstructive symptoms and mild residual stenosis, left ureter, post perforation during his stone extraction. The examiner opined that the Veteran's lower urinary tract symptoms are less likely than not related to the remote ureteral injury and more likely related to BPH. "It is less likely than not that personnel at Jesse Brown Medical Center committed any act of negligence, lack in judgment, poor judgment or any such fault. The perforation of the left ureter that happened during the stone extraction is a low-frequency complication of this procedure. It was discovered in a reasonable amount of time and treated appropriately. To date, the left ureter and left kidney system is functioning with only a mild narrowing of the left ureter at the site of the perforation." In a May 2011 addendum, the same VA examiner stated that he had again reviewed the claims file. He stated, "The veteran does not have any additional disability as a result of the kidney stone operation performed at JBVA in October 2008, the veteran's urinary symptoms are urgency, decreased stream, frequency and nocturia which are attributable to BPH." In a July 2012 addendum, the examiner stated that he had again reviewed the claims file. He stated, "It is as likely as not that the additional disability BPH was reasonably foreseeable. BPH is a natural progression that accompanies aging." In developing this claim for § 1151 compensation, VA has obtained multiple medical opinions, including in November 2009, May 2011, and July 2012, concerning the merits of this case. The November 2009 commenting VA examiner conceded the Veteran has additional disability, namely, mild residual stenosis of the left ureter, post perforation during his stone extraction, thus satisfying the threshold preliminary requirement of a § 1151 claim. Hence the Board finds that the October 30, 2008 VA surgery caused additional disability. The Board finds that no other additional disability has been shown, however, from the October 30, 2008 procedure and follow-up care. Multiple competent medical professionals have indicated that his voiding symptoms (LUTS) are due to BPH, and the medical evidence clearly shows that these conditions existed prior to the October 30, 2008 surgery, and thus were not caused by that surgery. The VA examiner opined that the Veteran's BPH is due to aging. Although additional disability from the October 2008 surgery has been shown, the Veteran's claim nonetheless fails, however, because he has not also established there was carelessness, negligence, lack of proper skill, error in judgment or other instance of fault on VA's part in the provision of that surgery or even in the evaluation and treatment he received in the aftermath of it. To this end, it must be shown either that VA failed to exercise the degree of care expected by a reasonable treatment provider or furnished the medical treatment at issue without his informed consent. See 38 C.F.R. § 3.361(d)(1). So merely having additional disability after the surgery and angiogram is not sufficient reason, alone, to grant his claim. This, incidentally, is the primary and critical distinction between claims filed before October 1, 1997, which fall under the purview of 38 C.F.R. § 3.358, versus those, as here, filed since that date, which instead fall under the purview of 38 C.F.R. § 3.361. And, unfortunately, the VA examiner has discounted this notion of any perceived negligence or substandard care. Since the November 2009 VA medical opinion and addenda were based on a review of the claims file and supported by sound rationale, they provide compelling evidence against the Veteran's claim. In other words, the physician in November 2009 and subsequent addenda applied valid medical analysis to the significant facts of this case in reaching his ultimate conclusions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran has not presented or identified any medical evidence refuting the VA examiner's unfavorable conclusions. The Veteran is certainly competent, even as a layman, to comment on things within the perception of his five senses, such as voiding symptoms since that surgery. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); and 38 C.F.R. § 3.159(a)(2). However, with respect to the Veteran's contention that his voiding symptoms were caused by the surgery, the Board notes that these assertions are simply not verified by the contemporaneous medical records. Moreover, physicians have related these symptoms to an unrelated condition, BPH. The Board finds that the conflicting statements by the Veteran and his representative are not competent or credible. See Macarubbo v. Gober, 10 Vet. App. 388 (1997) (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). See also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (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")). Moreover, the ultimate probative value of his lay testimony is not determined in a vacuum or isolation, rather, in relation to the other relevant evidence in the file, including the pertinent medical evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Finally, the evidence reflects that the Veteran signed surgical informed consent forms in October 2008 for the procedures in question. And there was explanation on the forms of the possible risks associated with this type of surgery. So there is probative evidence confirming the Veteran decided, in spite of these known risks and possible complications, to have the surgery - and was appropriately informed of its potential complications and consequences. See 38 C.F.R. §§ 3.361(d)(2) and 17.32 (2012). The Board therefore finds that the preponderance of the evidence is against the claims of entitlement to § 1151 compensation for residuals due to VA surgery in October 2008. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. See also Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Accordingly, the appeal of this claim must be denied. ORDER Service connection for an acquired psychiatric disorder, to include a depressive disorder, is denied. The claim of entitlement to §1151 compensation for additional disability, including voiding symptoms and pain, alleged to be due to or the result of VA cystoscopy, left retrograde pyelogram, and left ureteroscopy with laser lithotripsy on October 30, 2008, and percutaneous nephrostomy tube and antegrade ureteral stent placement on October 31, 2008, and subsequent treatment is denied. ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs