Citation Nr: 1416569 Decision Date: 04/14/14 Archive Date: 04/24/14 DOCKET NO. 07-36 623 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a heart condition. 2. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD N. Sangster, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1976 to July 1978. This appeal to the Board of Veterans' Appeals (Board) is from a November 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In September 2011, the Board remanded this claim for further development that included obtaining outstanding medical treatment records since 2006 and providing VA Compensation and Pension examinations for medical nexus opinions regarding the etiologies of these claimed disabilities. The Board again remanded these claims in October 2013 for still further development that included an addendum opinion from those January 2012 VA compensation examiners. In light of the Board's October 2013 decision denying the Veteran's claim for an acquired psychiatric disorder, his claim for service connection for a heart condition, including as secondary to a psychiatric disorder, has been recharacterized to reflect the fact that service connection now is only permissible, at best, for this claimed heart condition if shown that it alternatively was directly or presumptively incurred during his service. The Board's denial of service connection for his claimed psychiatric disorder necessarily precludes him from establishing entitlement to service connection for his heart condition as secondarily related to his service by way of this disability, inasmuch as it is not service connected. Also note that this appeal was processed electronically using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. Indeed, the Board is in the process of transitioning to an even newer, and presumably better, electronic claims processing system known as the Veterans Benefits Management System (VBMS). FINDINGS OF FACT 1. The most probative evidence indicates the Veteran does not have a heart condition, including ischemic heart disease (IHD) or coronary artery disease (CAD), but even if accepting he does it has not been attributed to his military service and did not first develop until many years after the conclusion of his service. 2. His tinnitus also was not manifested during his service and is not the result of it. CONCLUSIONS OF LAW 1. It is not shown he has IHD, CAD or other heart condition, but even to the extent he may not as a result of disease or injury incurred in or aggravated by his military service or that may be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306, 3.307, 3.309 (2013). 2. His tinnitus also was not incurred in or aggravated by his service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Standard of Review In deciding these claims, the Board has reviewed all of the evidence in the claims file, which as mentioned here consist entirely of an electronic file (meaning paperless file), and has an obligation to provide an adequate statement of reasons or bases supporting this decision. See 38 U.S.C.A. § 7104 (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). But while the Board must review the entire record, it need not discuss each and every piece of evidence, certainly not in exhaustive detail. See id. The analysis below therefore focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, concerning the claims. Timberlake v. Gober, 14 Vet. App. 122 (2000). The Board must assess the credibility and weight of all evidence, both the medical and lay evidence, to determine its probative value, accounting for evidence that it finds persuasive or unpersuasive and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. When the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must weigh against a claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). II. The Duties to Notify and Assist As provided by the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating claims for VA benefits upon receipt of a complete or substantially complete application. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 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 claims; (2) that VA will obtain and assist the claimant in obtaining; and (3) that the claimant 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). Ideally, VCAA notice should be provided prior to an initial unfavorable decision on claims by the RO as the Agency of Original Jurisdiction (AOJ). Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate or incomplete, this timing error can be effectively "cured" by providing any necessary VCAA notice and then readjudicating the claims - including in a statement of the case (SOC) or supplemental SOC (SSOC) - such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claims. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Supreme Court has made clear that VCAA notice errors, even when shown to have occurred, are not presumptively prejudicial, rather, must be judged on a case-by-case basis, and that, as the pleading party attacking the agency's decision, the Veteran, not VA, bears this burden of proof of not only establishing there is a VCAA notice error but also, above and beyond that, showing the error is unduly prejudicial, meaning outcome determinative of the claims. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Here, prior to initially adjudicating the Veteran's claims, so in the preferred sequence, a July 2006 letter was sent to him in accordance with the duty to notify provisions of the VCAA. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). He was duly notified of the evidence that was needed to substantiate his claims, of information and evidence that VA would obtain, and of the information and evidence he was expected to provide, and told that VA would assist him in obtaining supporting evidence, but that it was his ultimate responsibility to provide VA any evidence pertaining to his claims. He was also notified of the criteria for establishing a "downstream" disability rating and effective date, as required by Dingess, in the eventuality service connection is ultimately granted. Therefore, he has received all required notice concerning his claims. VA also has made the required reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate these claims. 38 U.S.C.A. § 5103A. To this end, his service treatment records (STRs) and VA medical treatment records have been associated with his claims file for consideration. He also had VA compensation examinations concerning his claims, including for medical nexus opinions regarding the etiologies of his claimed conditions and their posited relationship with his military service. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examinations obtained concerning these claims are adequate as they are predicated on a review of the claims file, contain a description of the history of his disabilities, document and consider the relevant medical facts and principles, and provide opinions regarding the etiologies of these disabilities, particularly in terms of whether they are related or attributable to his military service. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations or opinions for these claims has been met. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran has indicated that he is receiving Social Security Administration (SSA) benefits. See a statement by him to this effect during a January 2006 VA substance abuse program consultation. Neither a copy of the administrative decision from the SSA awarding benefits nor the medical records considered have been requested by the RO or provided by the Veteran. Normally, VA has a duty to attempt to obtain SSA records in this circumstance, when it has notice of their existence. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992). In Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2009), however, the U. S. Court of Appeals for the Federal Circuit clarified that VA's duty to assist was limited to obtaining "relevant" SSA records. The Federal Circuit Court rejected the appellant's argument in Golz that SSA records are always relevant and that VA always is required to obtain them. The Federal Circuit Court defined relevant records as "those records that relate to the injury for which the claimant is seeking benefits and have a reasonable possibility of helping to substantiate the Veteran's claim." Id. at 1321. The Federal Circuit Court made clear that, "[n]ot all medical records for a Veteran will have a reasonable possibility of aiding in the substantiation of a VA disability claim." Id. The Federal Circuit Court therefore concluded in Golz, "[t]here must be specific reason to believe these records may give rise to pertinent information to conclude that they are relevant." Id. at 1323. Here, the simple fact of the matter is that the Veteran has not reported that he is receiving SSA benefits because of either of his disabilities at issue in this appeal. Pertinently, he indicated during that consultation mentioned that he was receiving SSA benefits for conditions involving his hip and eye. So the specific conditions he mentioned have no relevance to this VA appeal. Moreover, neither he nor his representative has contended that the medical records considered in connection with his SSA claim have any bearing on these VA claims currently on appeal Accordingly, the Board finds that obtaining the Veteran's SSA records would not aid in substantiating his claims because they would not "give rise to pertinent information" concerning his heart condition or tinnitus. Further, because there is no reasonable possibility that his SSA records would assist in substantiating these currently-appealed claims, although VA is on notice that he is in receipt of SSA disability benefits, the Board finds that there is no duty to obtain these records. The Veteran has received all required notice and assistance with these claims, has had a meaningful opportunity to participate effectively in their development, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). VA has provided him opportunity to submit evidence and argument in support of these claims. He has not made the Board aware of any additional evidence needing to be obtained prior to appellate review of these claims, and no further action must be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. III. Governing Statutes, Regulations, and Case Law for Service Connection In order to establish entitlement to service connection for a claimed disability, the facts must demonstrate that a disease or an injury resulting in current disability was incurred in active military service in the line of duty or, if pre-existing service, was aggravated during service beyond its natural progression. 38 U.S.C.A. § 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) (2013). Service connection on a direct-incurrence basis requires competent and credible evidence showing: (1) the Veteran has the alleged disability or, at the very least, indicating he has at some point since the filing of his claim; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002). With regards to the medical evidence, a diagnosis or opinion by a health care professional is not conclusive and is not entitled to absolute deference. Indeed, the Court has provided guidance for weighing medical evidence. The Court has held, for example, that in meeting our responsibility to weigh the credibility and probative value of the evidence, we may accept one medical opinion and reject others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). However, the Board is mindful that it cannot make its own independent medical determinations, and that it must have plausible reasons based on medical evidence in the record for favoring one medical opinion over another. Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (citing Colvin v. Derwinksi, 1 Vet. Appl. 171 (1991)). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence and not necessarily by its quantity or source. The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is "credible", or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Baldwin v. West, 13 Vet. App. 1, 8 (1999). In determining the probative value to be assigned to a medical opinion, in particular, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303 -04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In deciding claims it is often necessary to characterize it as lay versus medical. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). 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. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). Competent medical evidence, in comparison, is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza at 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see also Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997). Indeed, even if lay testimony is competent, should VA find it to be mistaken or lacking credibility, the Board may reject it as unpersuasive and, thus, not ultimately probative. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board may find a lack of credibility in, for example, conflicting medical statements or witness biases. Buchanan at 1337. The lack of contemporaneous medical evidence is also relevant; however, the mere lack of such evidence may not constitute the sole basis for discrediting the lay evidence. Id. A. Heart Condition The Veteran claims he has a heart condition as a result of his active military service. Specifically, he claims he has CAD, IHD, and angina and consequently has had two stents placed in his heart's arteries. Considering however the pertinent statutes, regulations and cases in conjunction with the evidence of record, the Board concludes that his claim for a heart condition must be denied. A review of his STRs is unremarkable for any evidence of complaints, symptoms, diagnosis or treatment for a heart condition. He has received ongoing treatment for various conditions at VA medical centers (VAMCs). He sought treatment for depression and relapse of drug abuse in July 2000. Upon physical examination, there was no cardiopulmonary abnormality. A previous chest X-ray from April 2000 showed no infiltrates but that he had a small calcified left hilar node. He was diagnosed with polysubstance abuse, substance-induced mood disorder and pharyngitis. In June 2001 he went to the Montgomery, Alabama, VAMC with complaints of chest pains. He was evaluated and his troponin was negative. He was treated with non-steroidal anti-inflammatory drugs (NSAIDs) and told to follow up with his primary care physician. Psychiatric Resident Notes from April 2006 show he had an abnormal cardiomegaly and received a diagnosis of congestive heart failure (CHF) after he had a drug relapse. Upon further evaluation, however, there were no carotid bruits and his heart was normal. See Tuskogee VAMC Physician Note-Primary Care dated April 6, 2006. In November 2008 he was seen in a VA emergency room (ER) for pain in his abdomen and chest. It was noted his pain was atypical for myocardial infarction (meaning heart attack) and ischemia with cardiac enzymes (CE) and EKG. His symptoms were attributed instead to gastroesphageal reflux disease (GERD). Again, in April/May 2012, he presented to a VA ER with chest pains. At that time, he reported that in January of that year he had undergone a left heart catherization (LHC) and a percutaneous coronary intervention (PCI). His history was questioned because he had not been taking Plavix since that time. It was once again noted that his pain was atypical for chest pains and negative for a cardiac source. He had a normal MIBI stress test, and his CE and troponin were also negative. His previous records from the Huntsville Hospital, where he reported having the LHC, were reviewed and revealed that he did have an LHC in December 2011, which showed all coronary arteries were intact and no diagnosis of CAD. Further, the Huntsville Hospital records show that in March 2012 he had normal carotid doplers. Consequently, the examiner determined that the reported history of CAD was inaccurate. See Birmingham VAMC History and Physical note dated in May 2012. In February 2013, the Veteran reported a history of PCI in January 2012 in Huntsville, Alabama, and in May 2009 in Dothan, Alabama. A review of his chest X-ray from April 2012 showed it was negative for any abnormalities. See Birmingham VAMC Addendum dated in February 2013. In a January 2012 Disability Benefits Questionnaire (DBQ), the examiner diagnosed the Veteran with IHD with stenting. It was noted that he had a PCI, but no myocardial infarction, CHF, coronary bypass surgery or heart transplant. He opined that the Veteran's claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by his military service. In explanation, the examiner indicated there was no evidence in service of any heart condition and that it, instead, had started well after service. He determined that the Veteran's IHD was due to genetics, hypertension, hyperlipidemia dietary factors and cocaine/crack use. So he completely disassociated the Veteran's heart ailments from his service, even to the extent he has them. In compliance with the Board's October 2013 election to remand this claim, rather than immediately decide it, this VA examiner provided an addendum opinion in December 2013. Based on a review of the claims file, particularly the Veteran's medical records from the Huntsville Hospital, he opined that the Veteran did not have CAD, IHD or any other current heart condition. The examiner pointed out that the records from Huntsville Hospital showed the Veteran had normal coronary arteries in 2012, and his stress test and EKGs revealed no defect consistent with past myocardial infarction or current IHD. A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the Veteran). So as the Court made clear in Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008), the probative value of a medical opinion comes from when there is factually accurate, fully articulated, and sound reasoning for the conclusion, not just from mere review of the claims file). See also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[a] medical opinion...must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Board, then, may conversely reject a medical opinion that was based on an inaccurate factual premise. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). As the Court explained in Coburn v. Nicholson, 19 Vet. App. 427 (2006), reliance on a Veteran's statements renders a medical report not credible if the Board rejects the statements of the Veteran as lacking credibility. Here, while the Veteran's medical treatment records showed a reported history of a heart condition, they have been proven to be inaccurate by his medical records from the Huntsville Hospital. See Birmingham VAMC History and Physical note dated May 2012. In addition, upon review of those medical treatment records, the VA examiner's December 2013 addendum opinion adequately and competently opined that the Veteran did not have any current heart condition. The most fundamental requirement for any claim for service connection is that the Veteran must have proof he has the condition claimed. See Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328 (1997) (indicating VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability); but see, too, McClain v. Nicholson, 21 Vet. App. 319 (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). Congress has specifically limited entitlement for service-connected disease or injury to cases where such incidents have resulted in actual disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998). A current disability means a disability shown by competent and credible evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). Here, at least arguably, the Veteran has not met this threshold preliminary pleading requirement. In the absence of competent and credible evidence showing he has had a heart condition at some point since the filing of his claim for this condition, service connection cannot be granted for this disorder. See Shedden, 381 F.3d at 1166-67 (holding that service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). But even if the Board resolves this doubt in the Veteran's favor, as required by 38 C.F.R. § 3.102, and accepts or concedes that he has a heart disorder of some sort, service connection still would not be warranted because there is not also the required attribution of this disorder to his military service, either in terms of showing it incepted during his service or within the one-year presumptive period following the conclusion of his service or that it is otherwise related or attributable to his 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."). As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and this claim of entitlement to service connection for a heart condition resultantly must be denied. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Tinnitus The Veteran also claims that his tinnitus is a result of his active military service. A review of his STRs shows that, during his entrance examination in April 1976, he had some hearing loss bilaterally. At his separation examination in June 1978, he again had some hearing loss in both ears in the 500 Hz and 1000 Hz frequencies. Nevertheless, a review of his STRs in their entirety shows there were no complaints of hearing loss, tinnitus or ear infections at any time while he was in service. A review of his post-service medical treatment records shows that he was treated in February 2006 for a foreign object stuck in his right ear. In April 2006 he complained of hearing problems. A review of the record shows he failed to report for a November 2006 Ear, Nose and Throat (ENT) Clinic appointment. Otherwise, his medical treatment records are unremarkable for treatment or diagnosis of tinnitus. He had an audiological evaluation in February 2012. He reported constant tinnitus since December 2011. The examiner noted that the Veteran had normal hearing sensitivity for VA purposes evidenced bilaterally with excellent word recognition. She reviewed his claim file and documented that he had normal hearing sensitivity for VA purposes evidenced for both ears in 1976, 1977 and 1978, although there was a decrease in thresholds evidenced for the right ear at high frequencies. She did not provide any opinion at that time regarding the etiology of this claimed tinnitus. That examiner resultantly provided an addendum opinion in December 2013. She opined that it was less likely than not that impaired hearing and tinnitus were caused by or the result of noise exposure in the military. She noted again that the Veteran had normal hearing sensitivity for VA purposes with excellent word recognition ability. It was documented that he had a significant decrease in thresholds for both ears within normal range of hearing during active service as evidenced by his April 1976 and June 1978 audiological evaluations. She also noted there were no records of complaint or treatment of hearing loss and/or tinnitus in his STRs. She commented that The Institute of Medicine (IOM) (2006) had determined in a study that there was insufficient scientific basis to conclude that permanent hearing loss directly attributable to noise exposure will develop long after noise exposure (in other words, there is no such thing as "delayed-onset" hearing loss or tinnitus). She further explained that the IOM panel had concluded that, based on their current understanding of auditory physiology, a prolonged delay in the onset of noise-induced hearing loss was "unlikely". In any event, she concluded that the Veteran's reported onset time of tinnitus was not relevant to his time in service since he had reported an onset of tinnitus in 2011. Tinnitus is "a noise in the ear, such as ringing, buzzing, roaring, or clicking." See Dorland's Illustrated Medical Dictionary 1714 (28th ed. 1994). It is often subjective in nature; indeed, because of its inherently subjective nature, even a layman such as the Veteran is considered competent to report the observable manifestations of tinnitus like this ringing, buzzing, roaring, or clicking sound. He is competent to provide evidence regarding tinnitus, as it is a condition readily apparent through the senses. See Charles v. Principi, 16 Vet. App. 370 (2002) (holding that tinnitus is subjective and the kind of condition lay testimony is competent to describe); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (a Veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses). But there still has to be attribution of his tinnitus to his 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."). And there simply is not this required correlation in this instance. There is no credible evidence supporting the Veteran's claim for tinnitus. There were no reports of tinnitus during his service. Indeed, a review of his medical treatment records shows an absence of complaints or treatment for tinnitus. He acknowledged during his February 2012 audiological evaluation that his tinnitus had only started in 2011, so some 33 years after his discharge from active service. Additionally, and most importantly, the December 2013 audiological addendum opinion provided a detailed explanatory rationale for disassociating the Veteran's tinnitus from his service, concluding it was not caused or related to his service. See Neives-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (Most of the probative value of an opinion comes from its underlying reasoning or rationale, not merely from reviewing the claims file, although that, too, has significance if it would reveal facts or evidence that might affect the underlying basis of the opinion.) Accordingly, the preponderance of the evidence weighs against finding that the Veteran's tinnitus was caused by or is otherwise related or attributable to his service. There is no reasonable doubt concerning this determinative issue, only instead a preponderance of evidence against the claim, in turn meaning it must be denied. ORDER The claim of entitlement to service connection for a heart condition is denied. The claim of entitlement to service connection for tinnitus also is denied. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs