Citation Nr: 1453527 Decision Date: 12/04/14 Archive Date: 12/10/14 DOCKET NO. 08-09 848A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for vision impairment, to include as secondary to diabetes mellitus. 2. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as a result of exposure to herbicides or as secondary to service-connected diabetes mellitus. 3. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as a result of exposure to herbicides or as secondary to service-connected diabetes mellitus. 4. Entitlement to service connection for radiculopathy of the left lower extremity, claimed as secondary to service-connected degenerative disc disease status post lumbar hemilaminectomy. 5. Entitlement to service connection for radiculopathy of the right lower extremity, claimed as secondary to service-connected degenerative disc disease status post lumbar hemilaminectomy. 6. Entitlement to service connection for acute cardiovascular accident (CVA) and transient ischemic accident (TIA), claimed as secondary to service-connected ischemic heart disease and/or diabetes mellitus. 7. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESS AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD John Kitlas, Counsel INTRODUCTION The Veteran served on active duty from June 1970 to October 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions promulgated in October 2006, June 2007 and October 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran provided testimony at a hearing before the undersigned Veterans Law Judge (VLJ) in May 2010. A transcript of this hearing is of record. This case was previously before the Board in May 2011 and January 2014, at which time it was remanded for further development to include VA medical examinations. Such examinations were accomplished in October 2012 and February 2014; and, as detailed below, the Board finds that the 2014 examinations are adequate for resolution of the vision impairment, radiculopathy, CVA and TIA claims. All other development directed with respect to these claims appears to have been substantially accomplished. Accordingly, a new remand is not required to comply with the holding of Stegall v. West, 11 Vet. App. 268 (1998). See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (Remand not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). For the reasons addressed in the REMAND portion of the decision below, the Board finds that further development is still required regarding the peripheral neuropathy and TDIU claims. Accordingly, these claims are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. All notification and development necessary for the equitable disposition of the issues adjudicated by this decision have been completed. 2. The preponderance of the competent medical and other evidence of record is against a finding the Veteran has a chronic disability manifested by vision impairment that was incurred in or otherwise the result of active service, or as secondary to a service-connected disability. 3. The preponderance of the competent medical and other evidence of record is against a finding the Veteran has radiculopathy of the lower extremities. Rather, such complaints are actually due to peripheral neuropathy. 4. The record reflects the Veteran's CVA and TIA occurred years after her separation from active service; and the preponderance of the competent medical and other evidence of record is against a finding either were secondary to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for a grant of service connection for vision impairment, to include as secondary to diabetes mellitus, are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2013). 2. The criteria for a grant of service connection for radiculopathy of the left lower extremity, claimed as secondary to service-connected degenerative disc disease status post lumbar hemilaminectomy, are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2013). 3. The criteria for a grant of service connection for radiculopathy of the right lower extremity, claimed as secondary to service-connected degenerative disc disease status post lumbar hemilaminectomy, are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2013). 4. The criteria for a grant of service connection for acute CVA and TIA, claimed as secondary to service-connected ischemic heart disease and/or diabetes mellitus, are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters The Board notes at the outset that VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). In this case, the Veteran was sent notification via letters dated in August 2006, January 2007, February 2008, May 2008, September 2008, January 2012, and September 2012. Although all of these letters were clearly not received prior to the initial adjudication of the appellate claims as required by Pelegrini v. Principi, 18 Vet. App. 112 (2004), they were all received prior to the most recent readjudication below via a May 2014 Supplemental Statement of the Case (SSOC). Such development "cures" the timing problem associated with inadequate notice or the lack of notice prior to the initial adjudication. Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (Mayfield III), citing Mayfield II, 444 F.3d at 1333-34. These letters, in pertinent part, informed the Veteran of what was necessary to substantiate her current appellate claims, what information and evidence she must submit, what information and evidence will be obtained by VA, as well as the information and evidence used by VA to determine disability rating(s) and effective date(s) should service connection be established. All the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (harmless error). In view of the foregoing, the Board finds that the Veteran was notified and aware of the evidence needed to substantiate her claims and the avenues through which she might obtain such evidence, and of the allocation of responsibilities between herself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. In any event, the Veteran has not demonstrated any prejudice with regard to the content or timing of any notice. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). In addition, the Board finds that the duty to assist a claimant in the development of his or her case has been satisfied regarding the vision impairment, radiculopathy, and CVA and TIA claims. The Veteran's service treatment records are on file, as are various post-service medical records. Further, the Veteran has had the opportunity to present evidence and argument in support of her claims, to include at the May 2010 Board hearing. Nothing indicates she has identified the existence of any relevant evidence that has not been obtained or requested. Moreover, she was accorded VA medical examinations in October 2012 and February 2014 which included findings and opinions relevant to the resolution of these claims. VA examiners are presumed qualified to render competent medical opinion(s). See Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009). As these opinions were based upon both a medical evaluation of the Veteran, and an accurate understanding of her medical history based upon review of her VA claims folder, the Board finds they are supported by an adequate foundation. Although the Board previously found the October 2012 VA examinations to be inadequate, as detailed below the deficiencies noted on these examinations were corrected in February 2014. No prejudice is demonstrated with respect to the February 2014 examinations, nor is there a competent medical opinion which explicitly refutes the findings and opinions expressed therein. Accordingly, the Board finds that these examinations are adequate for resolution of these claims. Consequently, the Board finds that the duty to assist the Veteran has been satisfied in this case. With respect to the aforementioned May 2010 hearing, the Board is cognizant that Bryant v. Shinseki, 23 Vet. App. 488 (2010), held that 38 C.F.R. 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ accurately noted the nature of the appellate claims, and asked questions to clarify the Veteran's contentions. Moreover, the Veteran, through her testimony and other statements of record, has demonstrated that she had actual knowledge of the elements necessary to substantiate her claims. Finally, neither the Veteran nor her representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor has she identified any prejudice in the conduct of this hearing. As such, the Board finds that, consistent with Bryant, the duties set forth in 38 C.F.R. 3.103(c)(2) have been satisfied. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (The Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (Noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). Legal Criteria Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Further, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). Analysis - Vision Impairment The Veteran, in her statements and hearing testimony, has contended that she suffered head trauma during service, which resulted in her vision impairment. She also contends that she currently has vision impairment and peripheral neuropathy of the bilateral lower extremities as a result of her service-connected diabetes mellitus. The Board acknowledges that the Veteran's service treatment records reflect that she was treated for myopia throughout service and had a prescription as a result thereof. Further, her service treatment records reflect that she had head trauma during service in July 1970 when she suffered a contusion of the face as a result of an assault by a training leader. Additionally, in September 1975, the Veteran was treated for a blow to the right side of the head and, in February 1980, she was seen for a laceration on the top of her head and received five stitches. It was noted that there was no loss of consciousness, blurring on diplopia. Also, in March 1980, the Veteran was treated for viral gastritis and complained of blurry vision at that time. The record also shows post-service treatment for vision problems. For example, in March 1995, it was noted that the Veteran's visual problems started in November 1994. Such records show continued treatment for legal blindness and macular degeneration, which were diagnosed in 1997. Additionally, the Veteran was treated for a corneal abrasion in October 2001and a March 2004 record shows a diagnosis of myopia bilaterally. A June 2006 record that shows a visual evoked potential (VEP) test was positive, which was consistent with damage along the neural pathway from the brain to the optic nerve to the eye. Such was also noted to be consistent with the Veteran's poor vision. The physician concluded that the Veteran's loss of vision in each eye is directly attributable to damage along the neural pathway from the brain to the optic nerve to the eye. The Board notes, however, that refractive error of the eye is not eligible for service connection, as it is not considered a disease or injury for VA compensation purposes. See 38 C.F.R. § 3.303(c). Such condition may be service-connected if it is subject to, or aggravated by, a superimposed disease or injury during service which results in additional disability. See VAOPGCPREC 82-90 (July 18, 1990), published at 56 Fed. Reg. 45,711 (1990); see also Winn v. Brown, 8 Vet. App. 510, 516 (1996); Natali v. Principi, 375 F.3d 1375, 1380 (Fed. Cir. 2004). Moreover, the Veteran has claimed that her vision impairment is caused or aggravated by her service-connected diabetes mellitus. The affect one disability has upon another involves complex medical issues that generally requires competent medical evidence to resolve. This finding is supported by Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) in which the Federal Circuit held in the context of a claimant contending secondary service connection that the claimant's own conclusory generalized statement that his service illness caused his present medical problems was not enough to entitle him to a medical examination. If such a contention is not sufficient to warrant a medical examination, it is clear that it is not sufficient to warrant a grant of service connection. Here, nothing on file shows that the Veteran has the requisite knowledge, skill, experience, training, or education to render a medical opinion. Consequently, her contentions cannot constitute competent medical evidence. 38 C.F.R. § 3.159(a)(1) . In view of the foregoing, the Board remanded this case to accord the Veteran a competent medical examination and opinion to address the nature and etiology of her current vision loss. She was afforded a VA eye examination in October 2012, but the Board previously found it to be inadequate because no rationale was provided as to why the Veteran's diabetes mellitus does not aggravate any current eye disorder manifested by vision impairment. Additionally, while an in-service injury from a grenade explosion was considered, other potential causes from head injuries during service were not expressly addressed. Moreover, the October 2012 VA examiner indicated that there was no optic nerve damage, but did not appear to consider or reconcile the June 2006 record which stated that VEP test was positive and that it was consistent with damage along the neural pathway from the brain to the optic nerve of the eye. The more recent February 2014 VA examination noted the Veteran had previously been diagnosed with age-related cataract, and traumatic optic neuropathy. Further, the examiner opined that the vision impairment was not permanently aggravated by the service-connected diabetes mellitus, and noted that no diabetes-related eye conditions were noted on the examination. Additionally, the examiner opined that vision impairment was not caused by in-service head trauma from grenade explosion or other head injuries. The examiner noted prior vision tests, to include the findings of traumatic optic neuropathy, but stated that tests conducted as part of the VA examination demonstrated no optic nerve atrophic changes, excluding a diagnosis of optic nerve atrophy/neuropathy/trauma. The examiner also stated that given the grenade trauma occurred in 1970, and had trauma affected the visual pathways there would have been clear evidence shortly thereafter of reduced visual acuity or evidence of trauma to the optic nerve, but there was no such evidence on eye examinations conducted in November 1980 or December 1991. Also, the examiner stated the attenuated VEP may have been reduced due to problems with the cortical visual pathways, but stated that this would be mere speculation; and relating this to trauma incurred during service would be difficult to prove given the prior normal exams and exams after June 2006 to include the VA examination itself. The examiner acknowledged that further testing would be necessary to rule out specific cortical injuries/pathology given moderately reduced acuity on the VA examination, but the evidence clearly showed in-service events did not cause the vision impairment. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The Board has already noted that the VA examiner is presumed qualified to render a competent medical opinion, and was familiar with the Veteran's documented medical history from review of the VA claims folder. Further, the examiner referenced relevant findings regarding the Veteran's eyes as part of the examination report itself. The examiner's opinion was not expressed in speculative or equivocal language. Moreover, the examiner supported this opinion by stated rationale with reference to documented medical findings in the record, as well as from the VA examination itself. The examiner also noted the Veteran had other in-service head trauma besides the grenade, and addressed the findings of the June 2006 VEP test. As such, it corrected the prior deficiencies noted of the October 2012 VA examination. In addition, the Board reiterates that no competent medical opinion is of record which explicitly refutes the findings of the February 2014 VA examiner in this case. Consequently, the Board concludes this opinion is adequate, persuasive, and entitled to significant probative value in the instant case. For these reasons, the Board finds that the preponderance of the competent medical and other evidence of record is against a finding the Veteran has a chronic disability manifested by vision impairment that was incurred in or otherwise the result of active service, or as secondary to a service-connected disability. No other basis for establishing service connection for the claimed disability is demonstrated by the record. Accordingly, this claim must be denied. Analysis - Radiculopathy As already noted, the Veteran has contended that she has peripheral neuropathy either as a result of in-service exposure to herbicides, or as secondary to her diabetes mellitus. She has also contended that she has radiculopathy of the lower extremities secondary to her service-connected degenerative disc disease status post lumbar hemilaminectomy. The Board notes that the Veteran is presumed to have been exposed to herbicides while on active duty, and service connection has been established for diabetes mellitus and ischemic heart disease on the basis of such exposure. However, the Board notes that radiculopathy is not one of the conditions presumptively associated with such exposure. See 38 C.F.R. § 3.309(e). Further, while the Veteran contended that she has peripheral neuropathy secondary to such exposure, it does not appear she has contended such is the case with the radiculopathy. The Board also notes that there was no indication of any neurologic impairment of the lower extremities during service, or for years thereafter. For example, an August 1990 VA examination found the Veteran's neurologic system to be within normal limits. The Court has indicated that the normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service is probative evidence against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board where it found that veteran failed to account for the lengthy time period after service for which there was no clinical documentation of low back condition); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (A prolonged period without medical complaint can be considered, along with other factors concerning a claimant'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.). The Board further notes that there has been some confusion in the record as to whether the Veteran has peripheral neuropathy as a result of diabetes mellitus, radiculopathy due to her lumbar spine disability, and/or neuropathy due to a vitamin B12 deficiency. For example, a July 2001 VA treatment record reflects mild left lower extremity sensory and poor gait ? secondary to lumbar radiculopathy. In a September 2003 record, the assessment included lower back pain with possible radiculopathy. A September 2006 private treatment record reflects diagnoses of severe, acute exacerbation of back pain and right lower extremity radiculopathy. In November 2006, a VA treatment record indicated that that the Veteran's paresthesia of the lower extremities was secondary to her recent L4-L5 disc herniation and status post laminectomy. A January 2007 VA treatment record reflects diagnoses of lumbar degenerative disc disease and lumbar spinal stenosis, but the physician indicated that there was no definitive evidence of myelopathy or radiculopathy on examination. In March 2007, the Veteran was diagnosed with left L4-5 lumbar radiculopathy. A May 2007 VA treatment record reflects an assessment of radiculopathy at the cervical and lumbar spines. At a June 2007 VA spine examination, the Veteran's complaints of paresthesias, leg/foot weakness, and falls were noted and the examiner indicated that that the etiology of such were not unrelated to her back disability. In a January 2008 VA treatment record, it was indicated that the Veteran may have radiculopathy/muscular strain at the lumbar spine. In a June 2008 statement, Dr. Liebowitz indicated that EMG/NCS of the lower extremities revealed mild left peroneal neuropathy. He indicated that such appeared to be related to the Veteran's service-connected degenerative disc disease/status post lumbar hemilaminectomy. Pertinent to the Veteran's claimed peripheral neuropathy, in September 2006, an impression of neuropathy was provided. A January 2007 VA record reflects that the Veteran's sensory changes and generalized numbness/tingling could be to polyneuropathy. A March 2007 private treatment record reflects an impression of diabetic neuropathy. A March 2009 record reflects a history of diabetes with neuropathy and a December 2009 treatment record reflects a diagnosis of diabetic peripheral neuropathy. As relevant to the etiology of the Veteran's lower extremity complaints, in September 2007, a neurology note reflects that NCS revealed a mild left peroneal neuropathy, which may be a focal compression neuropathy. It was further observed that she did not have evidence of polyneuropathy on NCS. EMG, CK, and a lumbar spine MRI were normal. The physician observed that the Veteran had multiple risk factors for polyneuropathy include diabetes mellitus type II, hypertriglyceridemia, and B12 deficiency. She was given a prescription for oral B12 supplementation in order to treat the underlying disease to prevent the development of polyneuropathy. The physician indicated that she was unable to find any neurological cause of the Veteran's reported sensory loss and weakness in her legs. Additionally, an October 2007 neurological consultation following the Veteran's CVA reflects that her past medical history was significant for peripheral neuropathy assumed to be due to diabetes. The physician noted that the Veteran's neuropathy was thought to be secondary to diabetes mellitus and her low back pain radiating to the leg was thought to be due to a radiculopathy in the lumbosacral spine. Due to the confusion as to the nature and etiology of the Veteran's complaints regarding her bilateral lower extremities, she was provided with a VA examination in October 2008 in order to determine the nature and etiology of such claimed disorder. Following a review of the record, an interview with the Veteran, and a physical examination, the examiner diagnosed subjective complaints of bilateral peripheral neuropathy of the lower extremities. He also noted that, based on the neurology consultation, her condition was mild peroneal neuropathy of the left lower extremity. The examiner then opined that it was less likely as not secondary to the Veteran's diabetes mellitus. He indicated that the Veteran's complaints of peripheral neuropathy, which started in 2002, pre-dated her diagnosis of diabetes mellitus in 2004. The examiner further indicated that there were significant risk factors for the Veteran's neuropathy other than diabetes, to include vitamin B12 deficiency and crossing her legs. He also opined that he could not resolve the issue of whether the Veteran's complaints of lumbar radiculopathy of the lower extremities is secondary to her service-connected degenerative disc disease status post lumbar hemilaminectomy without resorting to speculation. In this regard, the examiner stated that there was no clinical findings to support radiculopathy and the Veteran's subjective description was so inconsistent, but did not fit the pathology of radiculopathy, He indicated that there was a possibility that neuropathy and radiculopathy superimposed each condition. Given the confusion as to the nature of the Veteran's complaints of the lower extremities, the Board finds that competent medical evidence is required to diagnose the cause of these complaints, and whether such is related to service. As already noted, the Board has found that the Veteran's contentions do not constitute competent medical evidence. The Board further notes that it previously found the October 2012 VA examination to be inadequate because, among other things, it discussed the peripheral neuropathy claim but did not address the radiculopathy claims. The February 2014 VA examination, in essence, attributed the Veteran's impairment of the lower extremities to peripheral neuropathy. Moreover, the examiner explicitly stated that there were no findings to support a diagnosis of radiculopathy; that history and examination were not consistent with radiculopathy. In regard to Dr. Liebowitz's June 2008 statement, the VA examiner stated that mild isolated peroneal neuropathy is more likely due to compression of nerve in the leg rather than lumbar degenerative disc disease. In short, the February 2014 VA examiner concluded that the Veteran did not have radiculopathy of the lower extremities; and that such complaints were due to peripheral neuropathy. The Board has already noted that the examiner is presumed qualified to render a competent medical opinion, was familiar with the Veteran's medical history from review of the claims folder, and that no competent medical opinion is of record which explicitly refutes the findings/opinions on this matter. Moreover, the finding that the Veteran's complaints are due to peripheral neuropathy and not radiculopathy is consistent with those of the October 2008 VA examiner. As such, the Board finds this opinion to be adequate, persuasive, and entitled to significant probative value in the instant case. The Board acknowledges that the Court held in McLain v. Nicholson, 21 Vet. App. 319 (2007) 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. However, as detailed above there was confusion as to whether the Veteran's complaints were due to radiculopathy or peripheral neuropathy. As detailed above, the preponderance of the competent medical evidence reflects these complaints were due to peripheral neuropathy and not radiculopathy. In other words, the Board does not dispute the Veteran has a disability of the lower extremities, but notes she has separate claims for what has been determined to be the disability that causes these complaints. The Court has previously indicated that a claimant may not be compensated twice (or more) for the same symptomatology; such a result would overcompensate the claimant for the actual impairment of his earning capacity and would constitute pyramiding of disabilities, which is cautioned against in 38 C.F.R. § 4.14. In Esteban, the Court found that the critical element was that none of the symptomatology for any of the conditions was duplicative of or overlapping with the symptomatology of the other conditions. Here, the same symptomatology was in question as to whether the Veteran had peripheral neuropathy or radiculopathy. In view of the foregoing, the Board finds that the preponderance of the evidence is against the Veteran's radiculopathy claims, and they must be denied. Analysis - CVA and TIA Initially, the Board observes that there is no indication of a CVA or TIA in the Veteran's service treatment records. Rather, they occurred years after her separation from service. See Mense, supra. Further, it does not appear the Veteran contends either is directly related to service, but as secondary to her service-connected ischemic heart disease and/or diabetes mellitus. As already noted, the Board has found the affect one disability has upon another generally requires competent medical evidence to resolve, and that the Veteran's contentions do not constitute competent medical evidence. The Veteran was afforded a VA examination in October 2012 in connection with the claim. The examiner provided a negative opinion on the matter by determining that the Veteran's CVA and TIA were not caused, or aggravated, by ischemic heart disease or diabetes mellitus. In a November 2013 brief, the Veteran's representative cited to two pieces of medical literature: (1) Diabetes, Heart Disease and Stroke, by the U.S. Department of Health and Human Services, National Diabetes Information Clearinghouse (NDIC); and (2) The Significant Effects of Diabetes on Coronary Heart Disease Mortality: The Framingham Heart Study, by Fox, Sullivan, D'Agostino and Wilson. The Board previously found that this medical treatise information does not apply directly to the case of the Veteran, but that the literature may better inform a medical expert in providing an opinion as to the Veteran's claim. Thus, the Board remanded the claim for another VA examination and medical opinion with consideration of the submitted medical treatise evidence. The subsequent February 2014 VA examiner opined that the Veteran's CVA and TIA were not caused or aggravated by her service-connected ischemic heart disease or diabetes. In support of this opinion, the examiner stated the Veteran had no evidence of abnormal heart rhythm or embolic activity related to ischemic heart disease that would cause or aggravate a stroke or TIA. Further, the examiner found the Veteran's diabetes to be very well controlled, and could not cause or aggravate a CVA, TIA. The examiner also noted the Veteran had other risk factors for stroke such as long term use of estrogen, obesity and hyperlipidemia. The Board has previously determined that the VA examiners' are presumed qualified to render a competent medical opinion, and were familiar with the Veteran's history from review of the VA claims folder. Although the October 2012 VA examination did not have the benefit of reviewing the medical treatise evidence from the representative's November 2013 brief, such was part of the record at the time of the February 2014 VA examination. Granted, it does not appear the examiner explicitly referred to this treatise evidence in the stated rationale. Nevertheless, the Board previously found that it did not apply directly to this case, but that consideration of such may better inform an opinion. Since the February 2014 VA examiner indicated the claims folder was reviewed, and the folder included this treatise evidence, it would appear that the examiner did consider this evidence. This is further supported by the fact that the examination instructions which were part of the examination report explicitly stated that this treatise evidence should be considered. Moreover, the Board notes that the opinions expressed by this VA examiner were not in speculative or equivocal language, nor is there a competent medical opinion of record which explicitly refutes the findings/opinions of this examiner. Therefore, the Board finds that this opinion is adequate, persuasive, and entitled to significant probative value in this case. In view of the foregoing, the Board finds that the preponderance of the competent medical and other evidence of record is against a finding either the Veteran's CVA or TIA were secondary to a service-connected disability. No other basis for establishing service connection for these conditions is demonstrated by the evidence of record. Thus, the claim must be denied. Conclusion For the reasons stated above, the Board has found that the preponderance of the evidence is against the Veteran's claims of service connection for vision impairment, radiculopathy, CVA and TIA. As the preponderance of the evidence is against these claims, the benefit of the doubt doctrine is not for application in the instant case. See generally Gilbert, supra; see also Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Consequently, the benefit sought on appeal with respect to these claims must be denied. ORDER Entitlement to service connection for vision impairment, to include as secondary to diabetes mellitus, is denied. Entitlement to service connection for radiculopathy of the left lower extremity, claimed as secondary to service-connected degenerative disc disease status post lumbar hemilaminectomy, is denied. Entitlement to service connection for radiculopathy of the right lower extremity, claimed as secondary to service-connected degenerative disc disease status post lumbar hemilaminectomy, is denied. Entitlement to service connection for acute CVA and transient TIA, claimed as secondary to service-connected ischemic heart disease and/or diabetes mellitus, is denied. REMAND The Board previously remanded the Veteran's peripheral neuropathy claims, in part, to obtain a competent medical opinion which addressed whether the claimed conditions were secondary to the service-connected diabetes mellitus. Although the February 2014 VA examiner found that the peripheral neuropathy was not secondary to the diabetes on the basis the neuropathy pre-dated the diagnosis of diabetes, no opinion appears to have been promulgated which explicitly addressed whether the neuropathy was aggravated by the diabetes. Without such an opinion, the Board must find that this examination is not adequate for resolution of these claims. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, even though the Board regrets the additional delay, these claims must once again be remanded to obtain clarification as to the issue of secondary aggravation. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (When the medical evidence of record is insufficient, in the opinion of the Board, or of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion, ordering a medical examination, or citing recognized medical treatises that clearly support its ultimate conclusions.). Inasmuch as resolution of the peripheral neuropathy claims may affect whether the Veteran is entitled to a TDIU, they are inextricably intertwined. Therefore, the Board must defer adjudication of the TDIU claim until the development deemed necessary for the peripheral neuropathy claims have been completed. The Board also notes that as part of the January 2014 remand it directed that after all of the individual examinations have been completed, the Veteran's claims folder should be forwarded to an appropriate medical professional to offer an opinion regarding whether the Veteran's service-connected disabilities have the "combined effects" of precluding the Veteran from securing or following gainful occupation. Although the February 2014 VA examiner did offer a negative opinion on this matter, the examiner explicitly stated she was not a psychiatrist and could not comment on the effect of the service-connected PTSD on employment. No other opinion is of record which addresses the combined effects of the Veteran's service-connected disabilities to include her PTSD. Therefore, this opinion is inadequate for resolution of the TDIU claim, and the case must be remanded for a new opinion that does take into account the service-connected PTSD with the other service-connected disabilities. Since the Board has determined that a new examination is necessary in the instant case, the Veteran is hereby informed that 38 C.F.R. § 3.326(a) provides that individuals for whom examinations have been authorized and scheduled are required to report for such examinations. The provisions of 38 C.F.R. § 3.655 addresses the consequences of a veteran's failure to attend scheduled medical examinations. That regulation at (a) provides that, when entitlement to a benefit cannot be established or confirmed without a current VA examination and a claimant, without "good cause," fails to report for such examination, action shall be taken. At (b) it is provided that when a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. However, when the examination is scheduled in conjunction with any other original claim, a reopened claim for a benefit which was previously disallowed, or a claim for increase, the claim shall be denied. Accordingly, the case is REMANDED for the following action: 1. Request the names and addresses of all medical care providers who have treated the Veteran for her peripheral neuropathy and service-connected disabilities since February 2014. After securing any necessary release, obtain those records not on file. 2. After obtaining any additional records to the extent possible, the Veteran's claims folder should be made available to the February 2014 VA examiner for review and clarification of the opinion expressed therein. Specifically, whether it is at least as likely as not the Veteran's peripheral neuropathy has been aggravated by the service-connected diabetes mellitus. By aggravation, the Board means a permanent increase in severity that is beyond natural progression. If the original examiner is unavailable, then the requested opinion should be obtained from another appropriately qualified clinician. If a new examination is deemed necessary, then one should be conducted. A complete rationale for any opinion expressed must be provided. An examiner's report that he or she cannot provide an opinion without resort to speculation is inadequate unless the examiner provides a rationale for that statement. See Jones v. Shinseki, 23 Vet. App. 382 (2010). As such, if the examiner is unable to offer an opinion, it is essential that the examiner provide a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. The Veteran should also be afforded a new examination by an appropriate medical professional to offer an opinion regarding whether the Veteran's service-connected disabilities have the "combined effects" of precluding the Veteran from securing or following gainful occupation which includes her service-connected PTSD. In proffering an opinion, the examiner should review the claims file, to include the medical and lay evidence of record, taking into consideration the level of education, special training, and previous work experience, but not age or any impairment caused by nonservice-connected disabilities. A complete rationale for any opinion expressed must be provided. 4. Thereafter, review the claims folder to ensure that the foregoing requested development has been completed. In particular, review the examination reports to ensure that they are responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 5. After completing any additional development deemed necessary, readjudicate the issues on appeal in light of any additional evidence added to the records assembled for appellate review. If the benefits requested on appeal are not granted to the Veteran's satisfaction, the Veteran and her representative should be furnished a SSOC, which addresses all of the evidence obtained after the issuance of the last SSOC in May 2014, and provides an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if in order. By this remand, the Board intimates no opinion as to any final outcome warranted. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2014). ______________________________________________ JOAQUIN AGUAYO-PERELES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs