Citation Nr: 1400499 Decision Date: 01/07/14 Archive Date: 01/23/14 DOCKET NO. 08-20 244 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for sinus problems. 2. Entitlement to service connection for status post bilateral mandible sagital osteotomy. 3. Entitlement to service connection for anosmia. 4. Entitlement to service connection for ageusia. 5. Entitlement to service connection for dysfunction of the salivary and lacrimal glands, claimed as Sjogren's syndrome. 6. Entitlement to service connection for nasal allergies. REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs WITNESSES AT HEARING ON APPEAL The Veteran and Dr. J.A.G. ATTORNEY FOR THE BOARD J. Andrew Ahlberg, Counsel INTRODUCTION The Veteran served on active duty from July 1980 to May 1987 and from March 1990 to May 1991. This matter was originally before the Board of Veterans' Appeals (Board) in October 2011, on appeal from November 2006 and October 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. In November 2006, the RO, in pertinent part, denied the claims for service connection for sinus problems, status post bilateral mandible sagital osteotomy and nasal allergies. In October 2008, the RO denied service connection for anosmia, ageusia, and Sjogren's syndrome. In October 2011 and February 2013, the Board remanded these claims for additional development. Following the February 2013 remand, a March 2013 granted the Veteran's claim for service connection for hearing loss in the right ear that had previously been on appeal to the Board. As such, the only issues reaming on appeal are as listed on the Title Page. The Veteran testified before a Decision Review Officer (DRO) at the RO in September 2008. A transcript of that hearing has been prepared and associated with the claims file. In its March 2013 Board remand, the undersigned found that that the issue of entitlement to service connection for left ear hearing loss had been raised by the record, but has not been adjudicated by the RO. From review of the record subsequent to the March 2013 Remand, it does not appear that any development or other action has been undertaken with respect to this issue. As such, and because the Board does not have jurisdiction over the claim for service connection for left ear hearing loss, this matter is referred to the RO for appropriate action. An additional issue that requires the attention of the RO is entitlement to service connection for a psychiatric disability, an issue raised by the Veteran in a September 2008 statement that as not been addressed by the RO. As the Board also does not have jurisdiction over the claim for service connection for psychiatric disability, this matter is also referred to the RO for appropriate action. (With regard to this matter, the attention of the RO is directed to a September 2007 VA Fee Basis examiner's statement linking major depression to the in-service jaw surgery). FINDINGS OF FACT 1. The in-service bilateral mandible sagital osteotomy was performed for congenital defects that were not subject to a superimposed disease or injury during service. 2. The Veteran has not presented credible testimony as to the existence of continuity of symptomatology from service to the present time associated with sinus problems, residuals of a bilateral mandible sagital osteotomy, anosmia, ageusia, dysfunction of the salivary and lacrimal glands claimed as Sjogren's syndrome, or nasal allergies. 3. The weight of the competent evidence is against a conclusion that the Veteran has a current disability due to sinus problems, residuals of a bilateral mandible sagital osteotomy, anosmia, ageusia, dysfunction of the salivary and lacrimal glands claimed as Sjogren's syndrome, or nasal allergies that is etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for sinus problems are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 2. The criteria for service connection for residuals of a bilateral mandible sagital osteotomy are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 4.9 (2013). 3. The criteria for service connection for anosmia are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 4. The criteria for service connection for ageusia are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 5. The criteria for service connection for dysfunction of the salivary and lacrimal glands, claimed as Sjogren's syndrome, are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 6. The criteria for service connection for nasal allergies are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to notify and Assist Under the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). This notice must be provided prior to an initial RO decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication, such as where (1) the claimant demonstrates actual knowledge of the content of the required notice; (2) a reasonable person could be expected to understand from the notice what was needed; or (3) a benefit could not have been awarded as a matter of law. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. 396 (2009). Defective timing may be cured by a fully compliant notice letter followed by a readjudication of the claim. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, VA's duty to notify has been satisfied. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). An April 2006 letter issued prior to the initial adjudication of the claims for service connection for sinus problems, status post bilateral mandible sagital osteotomy, and nasal allergies in November 2006 contained the content of notice required with respect to the information and evidence necessary for the Veteran to prevail with respect the claims for service connection for the claimed disabilities. In addition, an October 2008 letter issued prior to the initial adjudication of the claims for service connection for service connection for anosmia, ageusia, and Sjogren's syndrome in October 2008 contained the content of notice required with respect to the information and evidence necessary for the Veteran to prevail with respect to the claims for service connection for these disabilities. Accordingly, VA's duty to notify has either has been satisfied or any deficiency has caused no prejudice to the Veteran. VA's duty to assist the Veteran has also been satisfied in this case. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(1)-(3). The Veteran's service treatment records (STRs), VA medical records, private medical records, and Social Security Administration (SSA) records have been obtained. The Veteran was also afforded VA examinations in November 2011, December 2011, and October 2012 that were adequate because the reports from these examinations reflect a review of the claims file and the relevant history contained therein, consideration of a history provided by the Veteran, thorough clinical findings, and, to the extent indicated, relevant opinions supported by adequate rationale. As such, these examinations were substantially compliant with the instructions of the October 2011 remand. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). The record also reflects substantial compliance with the instructions of the February 2013 because the RO, as direct therein, obtained additional reports of VA treatment prior to February 8, 2012, and after February 22, 2006; issued the Veteran a letter in March 2013 providing him an opportunity to submit additional evidence and forms authorizing the release of any private treatment records, to include from treatment provided at the Caguas Internal Medicine Group by a Dr. V. (additional private clinical reports, preceded by a waiver of initial consideration of these reports by the RO, were received in May 2013 after the issuance of the April 2013 supplemental statement of the case); and obtained additional SSA records in March 2013. In short, there is no indication in the record that additional evidence relevant to the issues decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. at 121-22. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 542-43 (2006), aff'd, Mayfield v. Nicholson, 499 F.3d 1317 (2007); see also Dingess/Hartman, 19 Vet. App. at 486. As such, the Board finds it proper to proceed with an adjudication of the Veteran's case. II. Legal Criteria, Factual Background, and Analysis To establish direct service connection, the record must contain: (1) medical evidence of a current disorder; (2) medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease; and, (3) medical evidence of a nexus between the current disorder and the in-service disease or injury. In other words, entitlement to service connection for a particular disorder requires evidence of the existence of a current disorder and evidence that the disorder resulted from a disease or injury incurred in or aggravated during service. 38 U.S.C.A. § 1110, 1131. Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 C.F.R. § 3.303(d). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is questioned. When the fact of chronicity in service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit clarified that the provisions of 8 C.F.R. § 3.303(b) pertaining to the award of service connection on the basis of continuity of symptomatology apply to chronic diseases as defined in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331(Fed. Cir. 2013). Congenital and developmental defects are not disabilities within the meaning of applicable regulations providing for payment of VA disability compensation benefits. 38 C.F.R. §§ 3.303, 4.9. Therefore, such disorders require more than an increase in severity during service in order to warrant a grant of service connection. The evidence must show that the congenital or developmental defect was subject to a superimposed disease or injury during military service that resulted in increased disability. VAOPGCPREC 82-90 (July 18, 1990), published at 56 Fed. Reg. 45,711 (1990) (a reissue of General Counsel Opinion 01-85 (March 5, 1985). The VA General Counsel explained there is a distinction under the law between a congenital or developmental "disease" and a congenital "defect" for service connection purposes in that congenital diseases may be recognized as service connected if the evidence as a whole shows aggravation in service within the meaning of VA regulations. A congenital or developmental defect, on the other hand, because of 38 C.F.R. § 3.303(c), is not service connectable in its own right, though service connection may be granted for additional disability due to disease or injury superimposed upon such defect during service. VAOPGCPREC 82-90. A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (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 v. Nicholson, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009. A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App 370, 374 (2002). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, a layperson is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). [*Notwithstanding the above precedent with respect to the statement of lay persons, the Board notes that the STRs and post service evidence document that the Veteran has worked as a nurse; as such his statements may constitute competent medical evidence if he has specialized knowledge regarding the area of medicine at issue. See Black v. Brown, 10 Vet. App. 279, 284 (1997).] When there is an approximate balance in the 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. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the U. S. Court of Appeals for Veterans Claims (Court) held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. The Board notes at the outset that it has reviewed all of the evidence of record, to include in the Veteran's claims file and the Virtual VA file with an emphasis on the evidence relevant to this appeal. (The Virtual VA file reflects VA clinical records dated from June 1992 through March 2013 that are documented to have been considered in the April 2013 supplemental statement of the case.) Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Summarizing the pertinent evidence with the above criteria in mind, the STRs in pertinent part reflect that in April 1985, the Veteran underwent surgery, (Le Forte I ostectomy, maxillary with two parasagittal splits and widening of the posterior maxillary arch and bilateral sagittal osteotomy of ramus of mandible with 8mm advancement and fixation with compression bone screws) for congenital/developmental defects, as characterized by a VA dentist who reviewed the records of this treatment and examined the Veteran in December 2011, in the maxilla and mandibular areas. The contemporaneous reports from this surgery indicated that the Veteran desired this surgery as an elective surgical correction, and the surgery was also described as "elective" by the VA dentist who examined the Veteran in December 2011. These contemporaneous reports also indicated that the Veteran complained about the inability to chew food properly, and described the defects that necessitated the surgery as a maxillary vertical excess with mandibular retrognathia. Review of the STRs does not reflect that the defects that necessitated the in-service surgery were subject to a superimposed disease or injury during military service, and are otherwise negative for sinus problems, anosmia (loss of smell), ageusia (loss of taste), Sjogren's syndrome (a systemic autoimmune disease causing dry eyes, a dry mouth, and fatigue), or nasal allergies. Moreover, an examination and medical history completed for Reserve duty purposes in July 1992 did not reference any of the conditions for which service connection is claimed. The Veteran's essential contention, to include in sworn testimony presented to the DRO at the RO in September 2008, is that each condition for which service connection is claimed is a complication of, or is otherwise the result of, the in-service jaw surgery. General support for this assertion has been submitted in the form of a September 2007 statement from a Fee Basis physician and a psychiatrist who testified on the Veteran's behalf at the September 2008 hearing. There is evidence of record contradicting the Veteran's assertions as to the in-service onset of the conditions at issue however in the form of VA outpatient treatment reports that reflect the Veteran reporting that at least some of the conditions at issue only began after a Bell's palsy episode in December 2005. (See eg. March 1, 2006, VA outpatient treatment report in which the Veteran reported loss of gustatory sensation since he developed Bells palsy two month prior; see also October 20, 2006, VA outpatient treatment report noting an onset of unspecified symptoms after the Veteran developed Bell's palsy). There is also medical evidence weighing against the Veteran's assertions as to the in-service onset of the conditions at issue in the form of the opinions of VA examiners (all medical physicians) following examinations as set forth below. A November 2011 VA examination to assess the nature and etiology of the asserted loss of the senses of taste and smell (with a January 2012 addendum noting that the claims file had been reviewed by the physician and that it was less likely than not that the conditions were related to service) noted that there were no complications from the 1985 bilateral mandible osteotomy shown in the STRs and that the loss of the sense of smell or taste was not shown in the STRs. The examiner attributed the Veteran's loss of the sense of smell to a sinus infection and tobacco use. With respect to the loss of taste, in describing the pathological basis of this condition, the examiner noted that that Veteran had Bell's palsy and that the Veteran complained afterward about having the loss of taste. The examiner concluded by stating that the complaints about the loss of the senses of taste and smell "certainly in my opinion [are] not related to [the in-service] bilateral mandible osteotomy due to the time elapsed." The Veteran was afforded a VA examination in October 2012 to assess the Veteran's asserted sinus/nasal allergy problems. The physician noted that the claims file and treatment reports were thoroughly reviewed and that the claims file showed no evidence of sinus pathology in the past or at the present time. In this regard, reference was made to x-rays in November 2011 and October 2012 noting that the paranasal sinuses were clear. A December 2011 VA examination to assess the Sjogren's syndrome, the reports from which document that the claims file and electronic medical records were reviewed, reflect a history reported by the Veteran of right facial paralysis (Bell's palsy) and parotid enlargement in 2005 or 2006, at which time he was told about the possibility of his having Sjogren's syndrome. Current complaints in this regard were said to be a dry mouth and dry eyes that require the constant use of artificial saliva and tears. The examiner, whose practice area included internal medicine, noted that upon review of the claims file and medical record, there was evidence that the Veteran's primary care physician recorded a diagnosis of Sjogren's syndrome "based only [on a] history given by the [V]eteran, but as per medical evaluation by expert/sub-specialist/rheumatologist found that the [V]eteran did not fulfill [the] criteria for [a] Sjogren's diagnosis." The VA examiner also found that the reviewed laboratory results were not consistent with Sjogren's and that the clinical picture was not consistent with systemic inflammatory disease. The physician who conducted the December 2011 VA examination made the determination that there was no evidence of Sjogren's syndrome, explaining that this condition was associated with elevated acute phase reactants and hypergammagloulinemia, both of which were within normal values for the Veteran. She also emphasized that even if the Veteran had Sjogren's syndrome, as the condition was an autoimmune disorder resulting from chronic dysfunction of exocrine glands, it would have not relating to the in-service surgery. The examiner also commented in this regard that, as per the Veteran's statements, the first complaints describing problems with a dry mouth and eyes were rendered in 2005 or 2006, a gap of approximately twenty years from active service. Applying the pertinent criteria to the facts set forth above, given the contemporaneous evidence from the surgery in question and the December 2011 VA dental examination discussing this surgery, the Board finds that the bilateral mandible sagital osteotomy performed in service was for congenital defects, and not an acquired disease, and as there is no contention or evidence that these conditions were subject to a superimposed disease or injury during service, the claim for service connection for status post bilateral mandible sagital osteotomy must be denied as a matter of law. 38 C.F.R. §§ 3.303, 4.9; VAOPGCPREC 82-90. With respect to the remaining claims on appeal, "it is the duty of the [Board] as the factfinder to determine credibility of the testimony and other lay evidence." Culver v. Derwinski, 3 Vet. App. 292, 297 (1992). In the instant case, the Board finds that the Veteran has not credibly reported the existence of relevant in-service symptoms or continuity of relevant symptoms from service to the present time. The Board makes this determination for multiple reasons, the first being the lack of any relevant evidence in the STRs. Secondly, in his original application for VA benefits following his second and final period of active service, he made no reference to anosmia, ageusia, or Sjogren's syndrome-the Veteran's silence regarding these conditions-when otherwise speaking affirmatively-constitutes negative evidence as to his credibility. Thirdly, and as detailed above, there are clinical records that reflect the Veteran relating problems with some of the conditions at issue; in particular, the loss of sense of taste, not to service but to his Bell's palsy in 2005. Such contemporaneous documents have much greater probative value than those made by the Veteran to VA adjudicators asserting an in service onset of his disability, both because of their contemporaneous nature and because they were prepared by medical personnel for neutral (treatment/evaluation) purposes rather than in contemplation of the receipt of monetary benefits. Also in this regard, it was only after the Veteran suffered from Bell's palsy in September 2008 that the Veteran filed claims for service connection for the loss of senses of smell and taste and absence of tear and saliva. Finally weighing against the Veteran's credibility is the fact that it was not for over 20 years that service connection for anosmia, ageusia, or Sjogren's syndrome was claimed, or that any manifestations of these symptoms were clinically demonstrated. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). The Board finds that given the credibility concerns with respect to the claims for service connection for anosmia, ageusia, or Sjogren's syndrome, the Board also finds reason to doubt the credibility of his statements asserting continuity of sinus problems or nasal allergies from service to the present time, particularly given the silent STRs for these conditions. Also weighing against the Veteran's credibility is the fact that he VA examiner in October 2012 noted that a review of the post-service clinical record did not reveal any evidence of a sinus disability, a conclusion largely confirmed by the undersigned's review of the record. In this regard, multiple problems lists contained in the VA outpatient treatment reports not include a sinus condition, and while some of these reports refer to allergies, a problem list set forth on a February 4, 2013, VA clinical record reviewed in the Virtual VA file specifically noted that the Veteran had no allergies. Nonetheless, given the length of the appeal period, the reference in the clinical record to allergies, and the attribution of loss of sense of smell by the VA examiner in November 2011 to, in part, a "sinus disorder," the undersigned does not find that service connection must be denied on the basis of the "first prong" (the necessity of a current disability to warrant a grant of service connection) not being demonstrated. See McLain v. Nicholson, 21 Vet. App. 319 (2007)(holding that the requirement that a claimant have a current disability before service connection may be awarded for that disability is also satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if no disability is present at the time of the claim's adjudication). Instead, and as explained in further detail below, the claims for service connection for sinus problems and nasal allergies will be denied on the basis of the third element (nexus to service) not being demonstrated. Notwithstanding any credibility issues, the Board acknowledges some conflict in the medical record to the extent that while the VA examinations described herein resulted in negative opinions regarding the in-service onset of the conditions at issue, there is positive evidence in this regard represented by the September 2007 statement from a Fee Basis physician and a psychiatrist who testified on the Veteran's behalf at the September 2008 hearing. In this regard, the adjudication of the Board includes the responsibility of determining the weight to be given to the evidence of record, and this responsibility includes the authority to favor one medical opinion over another. See Cathell v. Brown, 8 Vet. App. 539, 543 (1996); Owens v. Brown, 7 Vet. App. 429, 433 (1995). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. See Guerrieri v. Brown, 4 Vet. App. 467 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). The Court has held, for example, that a post-service reference to injuries sustained in service, without a review of service medical records, is not competent medical evidence. Grover v. West, 12 Vet. App. 109, 112 (1999). A medical opinion based upon speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the claimant's history, and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Further, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). A medical opinion based on an inaccurate history provided by the Veteran is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). A bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Weighing against the probative value, particularly in contrast to the opinions by VA physician that are supported by rationale and clinical findings, of the September 2007 Fee Basis physician's opinion is that it is supported by little, if any, rationale or reference to clinical findings. Bloom, supra. In short, the opinion is a merely "bare conclusion" that is not supported by a factual predicate in the record. Miller, supra. While some rationale (although not clearly stated) was provided by the VA psychiatrist who testified on the Veteran's behalf at the September 2008 hearing, as a psychiatrist, the Board notes that a medical doctor (such as the VA examiners in the instant case) would be required to render a probative opinion as to whether any of the conditions at issue were related to service; in particular, the in-service jaw surgery. See Cox v. Nicholson, 20 Vet. App. 563, 568-69 (2007). Finally, and while not dispositive of the matter, the positive opinions, unlike the negative opinions rendered by the VA physicians, did not have the benefit of the entire clinical history contained in the claims file and electronic medical record. Prejean, supra. From the above, the Board finds that the weight of the negative medical evidence exceeds that of the positive. To the extent that the Veteran's assertions linking current disability to service are considered competent given his training as a nurse, the Board finds the probative value of these statements, given the questions as to his credibility highlighted above, to be overcome by that of the negative opinions contained in the VA examination reports set forth above. In sum, the Board finds that the third element of service connection has not been demonstrated with respect to any of the disabilities for which service connection has been claimed given the silent STRs for any acquired relevant disability; the fact that the probative weight of the negative competent post service medical evidence exceeds that of the positive; and the fact that the Veteran has not presented credible testimony as to continuity of relevant symptomatology from service to the present time. For the foregoing reasons, the Board concludes that the claims for service connection for with sinus problems, residuals of a bilateral mandible sagital osteotomy, anosmia, ageusia, dysfunction of the salivary and lacrimal glands claimed as Sjogren's syndrome, and nasal allergies must be denied. In reaching the decision to deny these claims, the Board has carefully considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for sinus problems is denied. Service connection for status post bilateral mandible sagital osteotomy is denied. Service connection for anosmia is denied. Service connection for ageusia is denied. Service connection for dysfunction of the salivary and lacrimal glands, claimed as Sjogren's syndrome, is denied. Service connection for nasal allergies is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs