Citation Nr: 1339151 Decision Date: 11/27/13 Archive Date: 12/13/13 DOCKET NO. 07-13 588 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for major depressive disorder, to include as secondary to service-connected bilateral hearing loss and tinnitus. 3. Whether new and material evidence has been received to reopen a claim for service connection for a dental disorder, claimed as chipped front teeth. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD J. Davitian, Counsel INTRODUCTION The Veteran served on active duty from June 1956 to September 1956. The Veteran passed away in October 2010 and he is survived by the appellant, his widow. In October 2010, the appellant filed a motion with the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska, to be substituted for the Veteran in the instant appeal. Under 38 U.S.C.A. § 5121A (West Supp. 2011) persons who would be eligible for accrued benefits may be substituted for a service person who dies during the pendency of an appeal. Pursuant to the cited statute, the RO granted the motion for substitution. See Veterans' Benefits Improvement Act of 2008, Pub. L. No. 110-389, § 212, 122 Stat. 4145, 4151 (2008). To that end, the Board of Veterans' Appeals (Board) herein refers to the Veteran's widow as the appellant in this matter. Turning to the procedural history of this claim, this matter comes before the Board on appeal in part from rating decisions of the RO dated in January 2006 and January 2009 which denied service connection for PTSD and major depressive disorder, respectively. The Veteran appealed these decisions to the Board, and the case was referred to the Board for appellate review. In February 2009, the Board remanded the Veteran's claim for entitlement to service connection for PTSD to obtain Agency of Original Jurisdiction (AOJ) consideration of newly submitted evidence. The AOJ considered such evidence in a June 2009 supplemental statement of the case (SSOC). Therefore, the Board finds that its remand directives have been complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). In an August 2009 decision, the Board denied service connection for PTSD and major depressive disorder, to include as secondary to service-connected bilateral hearing loss and tinnitus. The Veteran appealed the Board's decision to the Court of Appeals for Veterans Claims (Court). In a June 2011 memorandum decision, the Court noted that the Veteran had passed away in October 2010. The Court vacated the August 2009 decision with respect to the matters appealed to the Court and dismissed the appeal for lack of jurisdiction. Accordingly, a final decision has not been made with respect to the claims for service connection for PTSD and major depressive disorder and the Board will address these claims on their merits. This matter also comes before the Board on appeal from an April 2010 rating decision of the RO that held that new and material evidence had not been received to reopen a claim for service connection for a dental condition, claimed as chipped from teeth. FINDINGS OF FACT 1. The Veteran has not been shown to have PTSD that is causally or etiologically related to a verified in-service stressor. 2. The Veteran has not been shown to have major depressive disorder that is causally or etiologically related to his active service or a service-connected disability; and his preexisting schizoid personality has not been shown to have permanently worsened or increased in severity beyond its natural progression during service. 3. A February 2009 Board decision denied service connection for a dental disorder, claimed as chipped front teeth. 4. Evidence added to the record since the February 2009 Board decision does not relate to an unestablished fact necessary to substantiate the claim for service connection for a dental disorder, claimed as chipped front teeth, and does not raise a reasonable possibility of substantiating that claim. CONCLUSIONS OF LAW 1. PTSD was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 2. Major depressive disorder was not incurred in or aggravated by active military service, and is not proximately due to a service-connected disability. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2013). 3. The February 2009 Board decision that denied service connection for a dental disorder, claimed as chipped front teeth, is final. 38 U.S.C.A. § 7104(b) (West 2002). 4. Evidence received since the February 2009 Board decision is not new and material, and the claim for service connection for a dental disorder, claimed as chipped front teeth, is not reopened. 38 U.S.C.A. §§ 5107, 5108 (West 2002 & Supp. 2012); 38 C.F.R. § 3.156 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In Kent v. Nicholson, 20 Vet. App. 1 (2006), the Court clarified VA's duty to notify in the context of claims to reopen. With respect to such claims, VA must both notify a claimant of the evidence and information that is necessary to reopen the claim and notify the claimant of the evidence and information that is necessary to establish entitlement to the underlying claim for the benefit that is being sought. Notice for the Veteran's PTSD claim was provided in an April 2005 letter. The Veteran was provided Dingess notice in a September 2008 letter addressing his claim for major depressive disorder. The claim was subsequently readjudicated in a June 2009 supplemental statement of the case. Mayfield, 444 F.3d at 1333. Notice for the Veteran's claim for secondary service connection for major depressive disorder was provided by the September 2008 letter. Notice for the Veteran's dental disorder claim, including Kent notice, was provided by a February 2010 letter. Accordingly, the duty to notify has been fulfilled. With regard to the duty to assist, the claim's file contains the Veteran's service treatment records, VA medical records, private medical records, a VA examination report and statements by the Veteran and the appellant. The Board has carefully reviewed the record and concludes that there has been no identification of further available evidence not already of record. The Veteran was afforded a VA examination in September 2008 for his major depressive disorder claim. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA opinion obtained in this case is adequate, as it is predicated on a full reading of the private and VA medical records in the Veteran's claims file. It considers all of the pertinent evidence of record, to include the Veteran's private psychiatric evaluation in August 2008, as well as the statements of the Veteran. It provides a complete rationale for the opinion stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to this issue has been met. 38 C.F.R. § 3.159(c)(4). Turning to the Veteran's PTSD claim, the Board notes that the Veteran has not had a VA examination specifically for this claim. Although the September 2008 VA examiner discussed the August 2008 private examination which diagnosed the Veteran with PTSD, this VA examination was not specifically for his PTSD claim. An examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. McLendon v. Nicholson, 20 Vet. App. 79 (2006), The Board concludes that a medical opinion is not needed for the PTSD claim. Although the Veteran was diagnosed with PTSD at the August 2008 private evaluation, there is no competent evidence of record verifying any of the Veteran's claimed stressors, and as such a VA examination would not assist the appellant in substantiating this claim. See 38 C.F.R. § 3.304(f) (2012) (service connection for PTSD requires, inter alia, a link, established by medical evidence, between current symptoms and a [verified] in-service stressor). Accordingly, no medical opinion is necessary in this case. VA is not obligated to provide a medical examination if the appellant has not presented new and material evidence to reopen a final claim. 38 U.S.C.A. § 5103A(f). Thus, in this case a VA examination is not necessary for the Veteran's application to reopen a claim for service connection for a dental disorder, claimed as chipped front teeth. The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to her claim. Legal Analysis With respect to the claims, the Board has reviewed all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal. 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 of record. Indeed, the Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Furthermore, every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. History provided by the Veteran of the preservice existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. §§ 3.304(b)(1); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). To rebut the presumption of sound condition under section 1111 of the statute for disorders not noted on the entrance or enlistment examination, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). Clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than clear and unmistakable evidence). It is an "onerous" evidentiary standard, requiring that the no-aggravation result be "undebatable." Cotant v. West, 17 Vet. App. 116, 131 (2003) (citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993) (citing Akins v. Derwinski, 1 Vet. App. 228, 232 (1991)) and Vanerson, 12 Vet. App. at 258, 261; Id. at 263 (Nebeker, C.J., concurring in part and dissenting in part). Concerning clear and unmistakable evidence that the disease or injury was not aggravated by service, the second step necessary to rebut the presumption of soundness, a lack of aggravation may be shown by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); 38 U.S.C.A. § 1153. A presumption is an assumption of fact resulting from a rule of law which requires such fact to be assumed from another fact or group of facts found or otherwise established in the action. Black's Law Dictionary 1067 (5th ed. 1979). Therefore, where the presumption of sound condition at entrance to service cannot be rebutted, the fact for which the presumption stands -- that is, that the Veteran was in sound condition at entry to service as to the disability for which he seeks service connection -- must be assumed as a matter of law. Accordingly, service connection may not be granted on the basis of aggravation of a preexisting disease or injury in such a case. Rather, where the government fails to rebut the presumption of soundness under section 1111, the Veteran's claim must be considered one for service incurrence or direct service connection. See Wagner, 370 F.3d at 1094, 1096 (indicating that, in cases where the presumption of soundness cannot be rebutted, the effect is that claims for service connection based on aggravation are converted into claims for service connection based on service incurrence). In this case, the presumption of soundness applies because there are no references to a psychiatric disorder, to include PTSD and major depressive disorder, or any associated symptoms at the time of the Veteran's service entrance examination in June 1956. Although there is some evidence indicating that the Veteran may have had a preexisting psychiatric disorder, including the findings of the August 1956 Report of Aptitude Board, the Board finds that there is insufficient evidence establishing that a psychiatric disorder, to include PTSD or major depressive disorder, clearly and unmistakably existed prior to service. Therefore, the presumption may not be rebutted, and the Board's analysis must turn to the issue of whether the Veteran's current psychiatric disorder was incurred during the Veteran's active service. See Wagner, 370 F.3d at 1094-1096 (indicating that, in cases where the presumption of soundness cannot be rebutted, the effect is that claims for service connection based on aggravation are converted into claims for service connection based on service incurrence); VAOPGCPREC 3-03. PTSD In addition to the law set forth above, service connection for PTSD, in particular, requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e. DSM-IV); 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. See 38 C.F.R. § 3.304(f) (2013). Although service connection may be established based on other in-service stressors, if the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f)(1). Where VA determines that the Veteran did not engage in combat, his lay testimony, by itself, would not be sufficient to establish the alleged stressor. Instead, the record must contain service records or other independent credible evidence to corroborate his testimony as to the alleged stressor. See Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Those service records that are available must support and not contradict his lay testimony concerning the non-combat stressors. See Doran v. Brown, 6 Vet. App. 283, 289 (1994). In this regard, VA "is not required to accept doctors' opinions that are based upon the appellant's recitation of medical history." See Godfrey v. Brown, 8 Vet. App. 113, 121 (1995). In considering the evidence of record under the laws and regulations set forth above, the Board concludes that service connection for PTSD is not warranted. Although the Veteran was diagnosed with moderately severe schizoid personality during service, this was determined to be a pre-existing condition that was not aggravated by the Veteran's two and one half months of active service. Nonetheless, as was noted above, the presumption of soundness has not been rebutted by clear and mistakable evidence in this case, and therefore the Veteran's claim is construed as one of service incurrence rather than aggravation. In this regard, the Veteran's service treatment records are negative for any complaints or treatment for PTSD. See 38 C.F.R. § 3.303(d). The Veteran does not claim that he was diagnosed with or received treatment for PTSD during active military service. A review of the evidence of record indicates that the Veteran has been diagnosed with a variety of psychiatric conditions. Specifically, the August 2008 private physician diagnosed him with PTSD, adjustment disorder, major depressive disorder, sleepwalking disorder, alcohol dependence in remission and nicotine dependence in remission. However, the physician based this conclusion on the Veteran's reported history. There was no evidence that the above-cited private physician reviewed the Veteran's claims file or service records and there was no objective verification of the Veteran's claimed stressors. The Board notes that although a March 2006 letter from the Vet Center showed that the Veteran had PTSD symptoms, the August 2008 private physician is the only medical professional to have diagnosed the Veteran with PTSD. Nonetheless, service connection is still not warranted in this case because the Veteran's alleged stressors have not been verified. A review of the Veteran's personnel file does not contain any evidence of combat participation nor combat medals received. Therefore, the Veteran's lay testimony alone is insufficient to establish the occurrence of his claimed in-service stressors. See 38 C.F.R. § 3.304(f)(1). In this case, the Veteran claimed several stressful incidents during service, to include being harassed by a sergeant, being forced to shave off stitches in his chin and being told to bury his rifle and then dig it up and clean it off prior to inspection, witnessing a fellow trainee who had been beaten and that the Veteran thought had died, and witnessing a fellow trainee stuck inside a ring of fire. The Veteran did not know the names of the other personnel involved in the incidents described. As noted above, because the Veteran did not participate in combat with the enemy, the record must contain service records or other independent credible evidence to corroborate his testimony as to the alleged stressors. See Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Accordingly, in September 2006, the RO contacted the Marine Corps University Archives and provided a description of the Veteran's claimed stressors. In December 2006, a reply was received stating that records of training units that would record day-to-day activities were and are not considered permanent records. The Marine Corps University Archives therefore did not have such materials in their holdings, even for the major training facilities at Camp Lejeune and Camp Pendleton. The response continued that even if such records were available, it was highly unlikely that the personnel that ran the camp would record the fact that they abused recruits. The response then stated that if there was a formal investigation into the matter, then the pertinent documentation would be inserted into the personnel files of the individuals concerned, and a file would be maintained by JAG. To get those files, one would need the names of those pressing charges and those accused of the improper action. Thus, the response concluded that they were not able to provide the information sought. Thus, in December 2006 the RO prepared a Memorandum regarding the verification of the Veteran's stressors. The Memorandum stated that the Veteran's service treatment records were negative for treatment of or diagnosis for PTSD in service. VA outpatient notes were negative for treatment of PTSD. A letter from the Vet Center showed that the Veteran had PTSD symptoms. Service personnel records were negative for an in-service stressor. The Veteran reported his stressors as incidents that happened during training in the U.S. Marine Corps, and are described above. Request for information from National Archives Records Administration (NARA) was negative. Specifically, the response noted that "records of training units that would record day-to-day activities were and are not considered permanent records." These were the type of events that the Veteran described as his stressors. Accordingly, the RO concluded that they were unable to corroborate the Veteran's reported stressors. In an April 2010 Memorandum, the RO determined that the information required to verify the Veteran's claimed stressful events was insufficient to send to the Joint Services Records Research Center (JSRRC). The RO determined that all procedures to obtain this information from the Veteran had been properly followed. Evidence of written efforts to obtain this information was in the file. All efforts to obtain the needed information had been exhausted and any further attempts were futile. The RO listed the efforts to obtain the information necessary to verify the stressful events for the PTSD claim. It noted that additional statements from the Veteran, dated in January 2010 and received after the Board's vacated decision of August 2009, did not provide any additional stressors that could be verified, or any additional information that would assist in confirming the Veteran's previously claimed stressors. Furthermore, the Veteran has not submitted any other evidence corroborating his claimed stressors. The Board does observe that the Veteran has submitted several lay statements from family members, as well as his own contentions regarding his alleged stressors. However, the Board finds that these statements are of little probative value because as was noted above, the Veteran's lay testimony alone is insufficient to establish the occurrence of his claimed in-service stressors. See 38 C.F.R. § 3.304(f)(1). Similarly, the lay testimony of the Veteran's relatives, offered nearly 50 years after the occurrence of the claimed stressors, may not serve as verification of his in-service stressors without further corroborating evidence. Therefore, because there is no corroborating evidence of record to verify the Veteran's claimed stressors, the Board finds that service connection for PTSD cannot be granted. 38 C.F.R. § 3.304(f). Lastly, the Board does acknowledge the above cited August 2008 private opinion. This opinion diagnosed the Veteran with PTSD, and stated that according to the manner in which the Veteran explained it in the evaluation, he was subjected to an extremely severe trauma involving an individual who, for all practical purposes, the Veteran felt would burn to death. The examiner stated that this in and of itself was sufficient cause according to the DSM IV for a profoundly severe PTSD and virtually all symptoms thereof. Furthermore, the examiner stated that the issue of the Veteran receiving a discharge "under honorable conditions" was never satisfactorily answered during the evaluation. The examiner stated that this fact, superimposed on the Veteran's brother thinking that "[the Veteran] must have had a nervous breakdown," was "perhaps enough for [the examiner] to surmise that the Veteran's difficulties with emotionally adjusting to military life" to include "the horrendous types of feelings he had when again seeing the Marine almost burn to death" would, in his opinion, indicate that at least some of the Veteran's PTSD was recognized symptomatically during service. He continued that regardless of the fact that the Veteran's condition wasn't referred to as PTSD (the nomenclature for these kinds of symptoms had not yet been described [as PTSD] until 1980), it would be perhaps fair to assume that at least some of the symptomatology of the PTSD was in fact recognized by the Marine Corps. For several reasons, the Board finds this opinion to be of low probative value. Initially, there is no indication that the private examiner reviewed any of the Veteran's records. In this regard, the private examiner stated that the Veteran's discharge under honorable conditions had "never been satisfactorily explained" to him; however, the Veteran's service treatment records document a history of moderately severe schizoid personality, and an August 1956 Report of Aptitude Board decision explained that the Veteran was failing to progress during training and was therefore being discharged for unsuitability. Next, the private examination is in part factually incorrect. At several points during the examination, the private physician referred to the Veteran as a "Vietnam Veteran" and serving during the Vietnam War. The private examiner also stated that the Veteran was discharged "at the time at which his colleagues would surely have been sent to Vietnam for combat duty." However, a review of the Veteran's service records shows that he served for only two and a half months in 1956, which was not during the Vietnam War, nor any other period of war. In this regard, the September 2008 VA examiner, who reviewed this private evaluation in examining the Veteran's major depressive disorder, noted that he disagreed with this report and did not find it credible. In the VA examiner's opinion, this was a "shotgun" report; one that covered so many issues such as that of PTSD, major depressive disorder and an adjustment disorder, that it called into question the credibility of the diagnosis. It was obvious that when one diagnosis was not granted service connection, the private physician provided various angles of other diagnoses so that the Veteran has other diagnoses to be looked at for service connection. The VA examiner continued that this examination was unbelievable in clinical practice and that this was not how the Veteran presented in the real world. He continued that he had reviewed a host of reports by this private physician over the years and had found, as had his professional colleagues, that the private physician's reports tend to drastically portray the Veteran in a totally different social, occupational or diagnostic fashion than that of the consensus of the examiners at the VA. He stated that in summary, the impairments were so drastic as to be unbelievable. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from whether it is the factually accurate, fully articulated, and sound reasoning for the conclusion). The Board acknowledges the assertions by the Veteran and the appellant in support of the claim. They are competent to testify as to observable symptoms during and after active duty. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds that any such assertions are credible. However, the contentions that the Veteran incurred PTSD during active duty do not constitute medical evidence in support of the claim. Although lay persons are competent to provide opinions on some medical issues, the specific issue in this case (whether the Veteran had PTSD that was related to active duty) falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In a claim of service connection for PTSD, there is a specific legal requirement that the diagnosis of PTSD requires medical evidence diagnosing the condition in accordance with regulation. As a result, the assertions by the Veteran and the appellant cannot constitute competent medical evidence in support of the claim. The Board is aware that lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno, supra. Additionally, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Further, 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, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, supra. The Veteran and the appellant are competent to state that they observed the claimed PTSD symptoms during or after service. The Board finds them to be credible in this regard. However, neither the Veteran nor the appellant is competent to attribute the coincidence of symptoms occurring during or after service as establishing the diagnosis and etiology of PTSD. In summary, the claim for service connection for PTSD cannot be granted because the claimed in-service stressors have not been verified by any corroborating evidence. Absent a verified in-service stressor and a medical nexus between such a verified in-service stressor and a current diagnosis of PTSD, service connection for PTSD must be denied. Therefore, the Board finds that the preponderance of the evidence is against the claim for service connection for PTSD. Because the preponderance of the evidence is against the claim, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that service connection for PTSD is not warranted. See 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.303, 3.304 (2013). Major Depressive Disorder In addition to the relevant law set forth above, 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). The Board notes that there was an amendment to the provisions of 38 C.F.R. § 3.310, effective October 10, 2006. See 71 Fed. Reg. 52744-47 (Sept. 7, 2006). The amendment makes what appear to be substantive changes. As the Veteran submitted the claim for service connection for major depressive disorder, to include as secondary to bilateral hearing loss and tinnitus, after October 10, 2006, the Board will consider the current version of 38 C.F.R. § 3.310. In this regard, secondary service connection may be granted for a disability which is proximately due to, the result of, or aggravated by an established service-connected disorder. 38 C.F.R. § 3.310 ; Allen v. Brown, 7 Vet. App. 439 (1995). Secondary service connection includes instances in which an established service-connected disorder results in additional disability of another condition by means of aggravation. Allen, supra. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to service connection for major depressive disorder. Although the Veteran was diagnosed with moderately severe schizoid personality during service, this was determined to be a pre-existing condition that was not aggravated by the Veteran's two and one half months of active service. Specifically, an August 1956 Report of Aptitude Board finding stated that the Veteran met the minimum standards defined in AR 40-115 and his retention would not jeopardize his health or endanger that of his service associates. Therefore, he was not eligible for discharge by reason of psychiatric disability. The Aptitude Board concluded that the Veteran's general qualifications did not warrant his retention in service, but that he was not in need of hospitalization and that his condition existed prior to service and had not been aggravated by service. Thus, it was recommended that the Veteran be discharged by reason of unsuitability. On his September 1956 separation examination, his psychiatric system was determined to be clinically normal. Nonetheless, as was noted above, the presumption of soundness has not been rebutted by clear and unmistakable evidence in this case, and therefore the Veteran's claim is construed as one of service incurrence rather than aggravation. In this regard, the post-service medical evidence shows that the Veteran did not seek treatment for a psychiatric disorder, to include major depressive disorder, for many years after his separation from service. A prolonged period without medical complaint can be considered, along with other factors concerning a Veteran's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board must consider all the evidence including the availability of medical records, the nature and course of the disease or disability, the amount of time that elapsed since military service, and any other relevant facts in considering a claim for service connection. Id.; cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000) (holding that the absence of medical records during combat conditions does not establish absence of disability and thus suggesting that the absence of medical evidence may establish the absence of disability in other circumstances). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). Therefore, the Board finds that major depressive disorder did not manifest during service or for many years thereafter. In addition to the lack of evidence showing that major depressive disorder manifested during service or within close proximity thereto, the more probative medical evidence of record does not link the Veteran's current major depressive disorder to the his military service, to include as secondary to his service-connected bilateral hearing loss and tinnitus. In this regard, the Board notes that there is conflicting evidence of record. In August 2008, a private psychological evaluation was performed. The private physician opined that symptomatically, it did appear at first that the Veteran's depression was part of an adjustment disorder that was based almost solely on his tinnitus and hearing loss. Under the circumstances however, the private physician found the Veteran to be so severely depressed and not only non progressed up to that time but actually exacerbated in terms of virtually all of his symptoms that one must see that despite the depression that ordinarily occurred with PTSD, the Veteran was severely depressed with unmistakable melancholic features. Moreover, the adjustment disorder with depression that had been the result of the Veteran's exacerbating difficulties with hearing acuity also spoke for itself as it were. The Veteran was as likely as not to have developed shame, self-dejection, and general amotivational social behavior that he now demonstrates as a direct cause of the difficulties he had in hearing and understanding others. The private physician continued that the Veteran's major depressive disorder was obvious and consisted of his difficulties with insomnia, problems in even remembering the types of medications that he was taking, his lack of regular appetite and eating along with his withdrawal from people whom he is most fond of such as his grandchildren all weighed very heavily on the ideation of his deteriorating affectual response and the depression that was seen almost immediately upon first encountering the "hapless" Veteran. The private physician stated that there was a clear nexus between virtually all of the Veteran's Axis I disorders, which included major depressive disorder, and his unfortunate traumatic experiences he witnessed while in advanced rifle training at Camp Pendleton during the time that he served in the U.S. Marine Corps. On the other hand, the Veteran was afforded a VA examination in September 2008. At that examination, the examiner reviewed the Veteran's claims file, to include his medical records. The examiner took down the Veteran's medical and military history and performed a psychological examination. The examiner diagnosed the Veteran with depressive disorder due to a general medical condition (cardiac). As rationale for this opinion, the VA examiner noted that the Veteran had a noncompensable evaluation for his service-connected hearing loss. He stated that the depression was not secondary to a hearing loss that did not have any impairment rating. The Veteran had been rated for service-connected tinnitus, but the Veteran's records did not support that he had depression secondary to tinnitus. In this regard, research on tinnitus suggested that tinnitus could be irritating or frustrating, but the research did not support that tinnitus caused depression. In addition, the Veteran had a complex medical case with a serious heart condition. He noted that his heart was working around 5 percent capacity. He had numerous medical procedures to his heart since 1999. Earlier in 2008, he had a pace maker for atrial fibrillation. The Veteran also had another complicating medical issue of COPD. In 1999, he had a prostatectomy due to cancer. All of these disorders were serious and threatened his life, and are ones that could end one's career. The VA examiner continued that he had read the August 2008 private evaluation, and that he disagreed with this report and did not find it credible. In his opinion, this was a "shotgun report," meaning it was one that covered so many issues such as that of PTSD, major depression and adjustment disorder, that it called into question the credibility of the diagnosis. It was obvious that when one diagnosis was not granted service connection, the private physician provided angles of other diagnoses so that the he has another diagnosis to be looked at for service connection. The August 2008 report was unbelievable in clinical practice and it was not how the Veteran presented in the real world. He continued that he had reviewed a host of reports by the private physician over the years and had found, as had his professional colleagues, that the physician's reports tend to drastically portray the Veteran in a different social, occupational or diagnostic fashion than with that of the consensus of examiner's that he worked with. The impairments were so drastic as to be unbelievable. An evaluation of the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusion reached. The credibility and weight to be attached to such opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed by the physicians and whether or not and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). In the Board's judgment, the numerous references to the Veteran's medical history in the September 2008 medical opinion make for a more convincing rationale than the August 2008 private medical opinion. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.); Elkins v. Brown, 5 Vet. App. 474, 478 (1993) (medical opinions as to a nexus may decline in probative value where the physician fails to discuss relevant medical history). Again, by contrast there is no indication that the private physician reviewed the Veteran's claims file or any of his service records, as is reflected by the inaccuracies in the report, such as referring to the Veteran as a Vietnam Veteran. Rather, this opinion was based on the unsubstantiated history as provided by the Veteran. This history, as noted by the VA examiner, is at best questionable. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005); see, e. g., Coburn v. Nicholson, 19 Vet. App. 427, 432 (2006) (reliance on a veteran's statement renders a medical report incredible only if the Board rejects the statements of the veteran). As detailed above, the private physician has a reputation of exaggerating his reports such that they are unbelievable. Finally, and of great significance, the VA opinion was rendered by a doctor of psychology licensed in clinical psychology, whereas the private opinion was provided by a doctor of education, who was a "consulting psychologist." Therefore, the Board finds the VA opinion to be more probative than the opinion of the Veteran's private physician. Having reviewed the aforementioned medical opinions and reports, the Board finds that there is insufficient medical evidence to establish an etiological link between the Veteran's major depressive disorder and his active service, to include as secondary to service-connected bilateral hearing loss and tinnitus. As noted above, the August 2008 private did relate the Veteran's major depressive disorder to his active service and his service-connected bilateral hearing loss and tinnitus. However, as was discussed above with regard to the Veteran's PTSD claim, this opinion contains factual inaccuracies and is not based on a review of the Veteran's records. Thus, this opinion is overshadowed by the September 2008 VA opinion that clearly indicated that the Veteran's major depressive disorder was due to a general medical condition, as opposed to some other factor such as his bilateral hearing loss or tinnitus. Indeed, this opinion was based on a complete review of the entire claims file, which included the August 2008 private opinion, and provided sound reasoning to support the conclusion, including medical research. The Board acknowledges the assertions by the Veteran and the appellant in support of the claim. They are competent to testify as to observable symptoms during and after active duty. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds that any such assertions are credible. However, the contentions that the Veteran directly incurred major depressive disorder during active duty, or that his service-connected bilateral hearing loss and tinnitus proximately caused or aggravated his major depressive disorder, do not constitute medical evidence in support of the claim. Although lay persons are competent to provide opinions on some medical issues, the specific issues in this case (whether the Veteran's major depressive disorder was related to active duty, and whether his service-connected bilateral hearing loss and tinnitus proximately caused or aggravated his major depressive disorder) fall outside the realm of common knowledge of a lay person. See Kahana, supra; Jandreau, supra. As a result, the assertions by the Veteran and the appellant cannot constitute competent medical evidence in support of the claim. The Board is aware that lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno, supra. Additionally, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Further, 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, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, supra. The Veteran and appellant are competent to state that they observed the claimed major depressive disorder symptoms during or after service. The Board finds them to be credible in this regard. However, neither the Veteran nor the appellant is competent to attribute the coincidence of symptoms occurring during or after service, or before or after the development of the service-connected bilateral hearing loss and tinnitus, as establishing the diagnosis and etiology of his major depressive disorder. As such, the Board finds that the assertions by the Veteran and the appellant are outweighed by the September 2008 VA medical opinion addressed above. In summary, the Board finds that major depressive disorder was not diagnosed in service or for many years thereafter, and the medical evidence of record shows that the Veteran's major depressive disorder was not causally related to or aggravated by his service-connected bilateral hearing loss or tinnitus. For the reasons and bases discussed above, the Board has concluded that the negative evidence in this case outweighs the evidence in favor of the claim. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for major depressive disorder, to include as secondary to service-connected bilateral hearing loss and tinnitus. Because the preponderance of the evidence is against the claim, the benefit of the doubt provision does not apply. Therefore, the Board concludes that service connection for major depressive disorder is not warranted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. New and Material Evidence When the Board disallows a claim, the disallowance becomes final unless the Chairman determines that reconsideration is warranted, an appeal is made, or another exception to finality applies. 38 U.S.C.A. §§ 7103, 7104; 38 C.F.R. § 20.1100. If a claim has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C.A. § 5108. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). VA must review all of the evidence submitted since the last final decision in order to determine whether the claim may be reopened. See Hickson v. West, 12 Vet. App. 247, 251 (1999). For purposes of determining whether new and material evidence has been received to reopen a finally adjudicated claim, the recently submitted evidence will be presumed credible. Kutscherousky v. West, 12 Vet. App. 369, 371 (1999). The Court has interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." Shade v. Shinseki, 24 Vet. App. 110 (2010) (noting that evidence "raises a reasonable possibility of substantiating the claim," if it would trigger VA's duty to provide an examination in adjudicating a non-final claim); see also Evans v. Brown, 9 Vet. App. 273, 284 (1996) (finding that the newly presented evidence need not be probative of all the elements required to award the claim, but only need to be probative in regard to each element that was a specified basis for the last disallowance). The February 2009 Board decision denied service connection for a dental disorder, claimed as chipped front teeth. The Board found that the Veteran did not have a dental condition resulting from a combat wound or other service trauma. The Board observed that the Veteran's September 1956 separation examination found his mouth to be clinically normal. It noted that in an August 2006 statement the Veteran stated that he was treated for his chipped front teeth shortly after service, having a partial plate put in. However, the Veteran also stated that these records were unavailable, as he had previously tried to obtain them. The Board found that the record did not contain any other medical evidence noting that the Veteran chipped his teeth as a result of the claimed incident during service. Evidence of record at that time included the Veteran's service treatment records, post-service VA and private medical records, and the Veteran's own contentions. Evidence received since the February 2009 Board decision includes VA outpatient treatment reports dated from 2006 to 2009. At least some of these records are dated after the Board's February 2009 decision. None of the additional VA medical records show that the Veteran had a dental condition resulting from a combat wound or other service trauma. They simply do not relate to an unestablished fact necessary to substantiate the claim for service connection for a dental disorder, claimed as chipped front teeth. They do not raise a reasonable possibility of substantiating that claim. See Shade, supra, at p. 17 (explaining that the language of 38 C.F.R. § 3.156(a) "suggests a standard that would require reopening if newly submitted evidence, combined with VA assistance and considering other evidence of record, raises a reasonable possibility of substantiating the claim"). Thus, the additional VA medical records are not material within the meaning of 38 C.F.R. § 3.156(a). Subsequent to the February 2009 Board decision, the Veteran and the appellant offered additional written and oral contentions that during active duty he incurred a dental disorder, claimed as chipped front teeth. The Board finds that these assertions are redundant of the prior contentions that were already considered and rejected by the February 2009 Board decision. See Reid v. Derwinski, 2 Vet. App. 312, 315 (1992). In addition, although lay persons are competent to provide opinions on some medical issues, see Kahana, supra, the specific issue in this case of whether the Veteran had a dental disorder, claimed as chipped front teeth, due to active duty, falls outside the realm of common knowledge of a lay person. See Jandreau, supra. Thus, the assertions by the Veteran and the appellant do not raise a reasonable possibility of substantiating the claim, and are not material within the meaning of 38 C.F.R. § 3.156(a). In sum, the evidence received raises no reasonable possibility of substantiating the claim for service connection for a dental disorder, claimed as chipped front teeth. Thus, it is not material within the meaning of 38 C.F.R. § 3.156(a) and the claim is not reopened. ORDER Entitlement to service connection for PTSD is denied. Entitlement to service connection for major depressive disorder, to include as secondary to service-connected bilateral hearing loss and tinnitus, is denied. New and material evidence not having been received, the application to reopen a claim for service connection for a dental disorder, claimed as chipped front teeth, is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs