Citation Nr: 1553025 Decision Date: 12/18/15 Archive Date: 12/23/15 DOCKET NO. 04-31 269 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUE Entitlement to service connection for rheumatoid disease. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. G. Mazzucchelli, Counsel INTRODUCTION The Veteran served on active duty from July 1976 to July 1996. This case comes before the Board of Veterans' Appeals (Board) from an August 2003 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which denied the benefits sought on appeal. In May 2007, the Veteran was afforded a videoconference hearing before the undersigned Veterans Law Judge. Thereafter, in July 2007, the Board remanded the Veteran's claim for additional development. Once that development was complete, the Board issued a March 2010 decision denying service connection. The Veteran then appealed that Board decision to the United States Court of Appeals for Veterans Claims (Court). An October 2010 Court Order remanded the claim to the Board for readjudication in accordance with a Joint Motion for Remand (JMR). The Board remanded the claim to the RO in September 2011 for development in compliance with the Court's instructions. In September 2012, the Board issued a new decision denying service connection. The Veteran appealed that Board decision to the Court, and a May 2013 Court Order remanded the claim to the Board for readjudication consistent with the JMR. The Board remanded the claim to the RO in September 2014 for development in compliance with the Court's instructions. The Board acknowledges that the Veteran's claim was initially characterized as service connection for a pleural effusion requiring thoracotomy, decortication, and chest tube placement, claimed as lung surgery secondary to a connective tissue disorder. However, the Veteran has subsequently submitted numerous lay statements and clinical evidence indicating that the disability at issue is, in fact, rheumatoid disease. When determining the scope of an issue on appeal, the Board has an obligation to broadly consider the claimant's description of the claim, the symptoms the claimant describes, and the information the claimant submits in support of that claim. Brokowski v. Shinseki, 23 Vet. App. 79 (2009). Accordingly, the Board finds that the Veteran's claim is most appropriately characterized as reflected on the title page of this decision. FINDING OF FACT Rheumatoid disease is not shown to be causally or etiologically related to any disease, injury, or incident in service. CONCLUSION OF LAW Rheumatoid disease was not incurred in or aggravated by the Veteran's active duty military service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Proper VCAA notice must inform the claimant of any information and 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, letters dated April 2003 and May 2003, sent prior to the initial August 2003 rating decision, as well as letters dated April 2005, September 2006, August 2007, and October 2014, advised the Veteran of the evidence and information necessary to substantiate his service connection claim as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, the September 2006 letter informed the Veteran of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. While the April 2005, September 2006, August 2007, and October 2014 letters were issued after the initial August 2003 rating decision, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that VA could cure such a timing problem by readjudicating the Veteran's claim following a compliant VCAA notification letter. Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Court clarified that the issuance of a statement of the case could constitute a readjudication of the Veteran's claim. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In the instant case, after the April 2005, September 2006, August 2007, and October 2014 letters were issued, the Veteran's claim was readjudicated in supplemental statements of the case issued in April 2005, December 2005, March 2006, July 2006, May 2008, March 2012, and June 2015. Therefore, any defect with respect to the timing of the VCAA notice has been cured. Relevant to the duty to assist, the Veteran's service treatment records, as well as VA and private treatment records, have been obtained and considered. Additionally, the Veteran has not reported, and neither does the evidence of record show, that he is in receipt of Social Security Administration (SSA) disability benefits for his claimed disabilities. Absent any evidence showing that the Veteran is in receipt of said benefits for his claimed disorders, VA need not attempt to obtain his SSA records. Golz v. Shinseki, 590 F.3d 1317, 1323 (2010). Pursuant to the terms of the May 2013 JMR and Court Order, the Board obtained the Veteran's treatment records from the Martinsburg, West Virginia VA Medical Center (VAMC), including specifically: 1) treatment records from J.B., MA, dated March 2009, 2) treatment records showing a follow-up for a rheumatoid disorder after October 2010 and June 2011, and 3) treatment by Dr. S. on or before July 2011. Those records were associated with the electronic file on June 27, 2013. The Veteran was notified in the September 2014 remand that the requested evidence had been developed, and that he had the opportunity to respond thereto and to submit additional argument and evidence. Additional argument was subsequently received from the Veteran. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. Therefore, the Board finds that VA has satisfied its duty to assist in obtaining all available records. Additionally, the Veteran was afforded a VA examination in September 2005 and VA obtained two independent medical expert reports in September 2009 in order to adjudicate his claim of entitlement to service connection for rheumatoid disease. An additional VA opinion was obtained in April 2015 after additional records were obtained. In this regard, the Board notes that the VA examiners and independent medical experts offered etiological opinions as to that disorder and based their conclusions on reviews of the record; the September 2005 VA examiner also based his conclusions on an interview with the Veteran and a full examination. Moreover, they offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); 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"). As such, the Board finds that the opinions proffered by the VA examiners and independent medical experts are sufficient to assist VA in deciding the claim. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101 , 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. 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 attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease," whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran contends that service connection is warranted for pleural effusion requiring thoracotomy, decortication, and chest tube placement. In pertinent part, it is contended that the recurrent pleural effusion for which the Veteran underwent thoracotomy and decortication with chest tube placement in March 2002 had its origin during his period or periods of active military service, at which time the Veteran received treatment for a connective tissue/rheumatoid disease process, as evidenced by various laboratory studies conducted at that time. The Veteran's service treatment records show that the Veteran received treatment for numerous orthopedic complaints from approximately the 1980's through separation from service. The reports show that the Veteran received treatment for numerous orthopedic complaints after being struck by a car, sustaining injuries after a lifting accident, playing baseball, and multiple ankle twisting injuries incurred during physical training. The reports also show diagnoses of herniated nucleus pulposus of the cervical spine. See STRs dated from 1980's through 1990's. Specifically, a June 1991 orthopedic report shows that the Veteran's knee and ankle complaints were the result of participating in a single Martial Arts tournament. The diagnoses were patella-femoral syndrome of the left knee and status post left ankle reconstruction with slightly restricted range of motion. The Veteran's low back pain was also mentioned in this report. In 1995, the Veteran's pain of the cervical spine and neurological impairment of the upper extremities were attributed to a car accident occurring approximately four years earlier. See July 1995 Naval Hospital Report. The Veteran's service treatment records also show that, on a number of occasions, he received treatment for what was variously described as atypical pneumonia, pleurisy, or viral syndrome/upper respiratory infections, as well as costochondritis, arthritis, and "migrating polyarthralgias." From October 1994 to April 1995, tests for antinuclear antibodies (ANA) and rheumatoid factor (RH) were for the most part negative, although on October 17, 1994, tests of ANA and ANA titer were described as positive. At service separation examination in February 1996, the Veteran received a diagnosis of nonspecific large and small joint arthritis (some aspects of which are already service connected), but no evidence of connective tissue/rheumatoid disease or any respiratory disorder was noted at that time. At the time of a VA general medical examination in September 1996, the Veteran stated that he had been in good health until approximately 1990, at which time he began to note the gradual onset of pain in his joints. Reportedly, the Veteran first noted problems in his shoulders, followed by his hips, feet, hands, fingers, jaw, and elbow. According to the Veteran, over the past five to six years, his pain had gradually increased in severity. Also noted was that the Veteran had apparently been told at one point in service that he had been evaluated for lupus and/or rheumatoid factor, which subsequently returned to normal. On physical examination, the Veteran's lungs were clear to percussion and auscultation. ANA and RH factor tests reported as part of the Veteran's VA general medical examination were described as negative. In correspondence of mid-May 2000, the Veteran's private rheumatologist wrote that the Veteran remained under his care for chronic rheumatoid disease whose onset "dated back to the 1970's." Treatment records from a naval hospital dated in January and February 2002 show treatment at that time for pneumonia. Records dated in February 2002 reveal that the Veteran was seen at that time for treatment of what was described as a left pleural effusion. The Veteran was subsequently transferred to a private medical facility, at which time it was noted that he had experienced the onset of mild shortness of breath approximately one month prior to admission. Reportedly, this was accompanied by some left-sided pleuritic pain, which was actually the dominant symptom. According to the Veteran, his symptoms had progressed over the past month despite a course of antibiotics. When his symptoms continued, the Veteran presented to the local naval hospital, where a follow-up chest film showed a more significant, free-flowing left-sided pleural effusion. The Veteran subsequently underwent an ultrasound-guided thoracentesis prior to admission. The results of that procedure showed a pleural fluid with a pH of 7.0, a lymphocyte predominant cellular mix, negative gram stain, negative culture, and negative AFB and fungal studies, consistent with an inflammatory process. The Veteran was given nonsteroidal anti-inflammatory medication, with the result that his pleuritic pain improved. However, the effusion did accumulate again to some extent. Noted at the time was that cytology of the Veteran's pleural fluid was negative. Other laboratory studies performed included a C-reactive protein (CRP) which was 22, an erythrocyte sedimentation rate (ESR) which was 50, and a rheumatoid factor which was positive, with a ratio of 1 to 8. Also noted was a negative ANA, negative antineutrophil cytoplasmic antibody (C-ANCA), and negative perinuclear-anti-neutrophil cytoplasmic antibodies (P-ANCA). Accordingly, at discharge, it was decided that the best course of action would be to treat the Veteran as an outpatient with nonsteroidal anti-inflammatory medication, and to follow his effusion over the next few weeks. The pertinent diagnoses noted at the time of discharge were inflammatory left pleural effusion; and positive rheumatoid factor. Private records of hospitalization dated in March 2002 reveal that the Veteran was rehospitalized at that time for what was described as recurrent left pleural effusion. At the time of admission, it was noted that the Veteran had been discharged from the hospital approximately two weeks earlier after being admitted for evaluation of a left pleural effusion. However, on March 11, 2002, the Veteran had reported to his primary care physician at the local Naval hospital that he continued to experience spiking fevers, and that his pleuritic pain had worsened. Reportedly, radiographic studies of the Veteran's chest showed a worsening pleural effusion, with tracking into the fissures suspicious for loculation. During hospitalization, the Veteran underwent a thoracotomy with decortication and chest tube placement. After a few days, the chest tubes were removed, and the Veteran's recovery from the procedure was largely uncomplicated. The composition of the pleural fluid was such that the "differential was high for bacterial or rheumatoid as his cultures had been on previous occasions and also from the thoracotomy were completely negative." Accordingly, there was a strong suspicion, at least initially, of a rheumatoid process, inasmuch as the Veteran did have a moderately elevated rheumatoid factor. However, he had no other stigmata of rheumatoid disease. The pertinent diagnosis noted at the time of discharge was empyema (a collection of pus in the pleural space). In correspondence of mid-March 2003, one of the Veteran's private physicians wrote that the Veteran had been bothered by pain secondary to an unspecified inflammatory process that had involved his lung, for which the Veteran had undergone a thoracotomy. VA radiographic studies of the Veteran's hands conducted in May 2003 showed no evidence of any fracture, dislocation, or arthropathy. The pertinent diagnosis noted was normal bilateral hands. Private radiographic studies of the Veteran's chest conducted in September 2003 showed evidence of a stable pleural thickening in the left costophrenic angle. The Veteran's lung fields were clear, and there was no evidence of any pneumothorax or pleural effusion. The pertinent diagnoses noted were "negative for acute pulmonary process," and stable left basilar pleural thickening. In correspondence of mid-April 2004, a private rheumatologist wrote that he had followed the Veteran since March of 2002 for rheumatoid arthritis complicated by pleural effusions. According to the Veteran's rheumatologist, he had reviewed the Veteran's old records, and found evidence going back "to at least 1979" of symptoms consistent with early inflammatory disease involving not only the Veteran's musculoskeletal system, but also his pleura. In the opinion of the Veteran's rheumatologist, his disease dated back "at least to 1979 if not before." The Veteran's physician noted that the Veteran had a pleuritis attack in 1984, which mirrored that which caused his surgery. While the 1984 episode was resolved without surgery, the attending physician was apparently not able to give an exact diagnosis of the cause of the Veteran's illness. According to the Veteran's physician, this was often the case until a trained specialist was consulted and the underlying rheumatoid disease discovered. The Veteran's rheumatologist further indicated that, in the early part of 1995, the Veteran had been given a series of blood tests which revealed his rheumatoid disease. However, no follow up was undertaken. Reportedly, these tests included at least one positive ANA screening as well as several tests which revealed an elevated Rheumatoid Factor and Sedimentation Rate. According to the Veteran's physician, he had "little doubt" that, had the Veteran been followed by a rheumatologist, as the aforementioned tests suggested he should have been, his underlying disease would have been diagnosed and treatment begun. In the opinion of the Veteran's rheumatologist, the aforementioned were just a few examples of medical record entries showing the progress of the Veteran's disease over an almost 30-year period. In his opinion, all of those events were clinically related to the Veteran's inflammatory arthritis or connective tissue disease. Following a review of the Veteran's records in January 2005, a VA physician noted that the Veteran had presented with a history of what initially appeared like pneumonia three years earlier, for which he had unsuccessfully been treated with antibiotics. Reportedly, this later led to the discovery of a pleural effusion, requiring drainage by way of a chest tube and subsequent open thoracotomy with abrasion of the pleural lining. Thereafter, the Veteran was referred to (the aforementioned private) rheumatologist, who reportedly diagnosed him with lupus. The rheumatologist submitted an opinion on August 11, 2004, to the effect that the Veteran's pulmonary difficulty was secondary to connective tissue disorder, as opposed to being related in any way to fibromyalgia. According to the VA physician, he agreed with the opinion of the private rheumatologist. That rheumatologist's letter also stated, however, that he believed that the Veteran's prior undiagnosed pulmonary episodes were early manifestations of his condition, and were "undiagnosed and unrecognized." The VA physician disagreed with this statement of the Veteran's private rheumatologist, inasmuch as, in service medical records, he found multiple entries of serologic testing for connective tissue disorders in the 1990's, with a negative testing for dsDNA (which is a serological test for lupus), as well as at least two negatives on both ANA and rheumatoid factor. According to the VA physician, these tests were performed in 1994 and 1995, making it clear that the Veteran's military physicians were suspicious of these conditions, but that their suspicions were unconfirmed by laboratory results. In the opinion of the VA physician, given that these tests were all negative in the mid-1990's, it seemed "very unlikely" that any of the Veteran's conditions would have been present in the mid-1980's or 1970's, and account for the minimum prior respiratory symptoms. In short, the VA physician agreed with the opinion of the Veteran's private rheumatologist that the thoracotomy and placement of a chest tube were the result of a rheumatologic condition. However, he could see no evidence to lead to the conclusion that this rheumatologic condition existed while in service. In fact, negative laboratory results proximal to the time of the Veteran's military discharge led the VA physician to the conclusion that it was "very unlikely" that such a condition could have been clinically apparent 10 to 20 years prior to the aforementioned negative testing. In correspondence of August 2004, the same private rheumatologist who had provided the April 2004 statement indicated that he had been following the Veteran since early 2002 "after being called in to consult after the Veteran had to have surgery for a severe attack of inflammatory connective tissue disorder of his left lung." According to the Veteran's physician, as part of his care of the Veteran for rheumatoid disease and fibromyalgia, he had reviewed his medical records, including "back from when he was on active duty in the United States Navy." Reportedly, from this review, the Veteran's physician could clearly see that the Veteran's disease had been an ongoing process which began manifesting itself in the 1970's with pleuritis. In correspondence of mid-June 2005, the same private rheumatologist who had submitted the aforementioned statements wrote that, in his opinion, the Veteran had "rheumatoid arthritis with rheumatoid disease as manifest by recurrent pleuritis as far back as the 1970's." Further noted was that there was "no doubt" in his mind that the Veteran's disease had begun in the 1970's, with the "initial onset of rheumatoid arthritis." Finally, in the opinion of the Veteran's rheumatologist, he suffered from neither systemic lupus nor any other systemic vasculitis. In September 2005, a VA examiner, following a review of the Veteran's claims file and an examination of the Veteran, wrote that, on examination, he could see no objective findings of rheumatoid disease, inasmuch as the joints of the Veteran's fingers and hands did not display any nodularity or ulnar deviation. Noted at the time was that prior radiographic studies of the hands, feet, elbows, and shoulders performed for a May 2003 VA examination were all normal, with the exception of a possible calcific tendinitis of the subscapularis of one of the Veteran's shoulders. Moreover, on reviewing the Veteran's service treatment records, the VA physician was able to locate only one report of rheumatoid factor and antinuclear antibody testing, both of which were negative. Subsequently, in September 1996, both rheumatoid factor and ANA were again tested, once again with negative results. While the Veteran's claims folder contained a letter from his private rheumatologist dated in August 2004, stating unequivocally that the Veteran had rheumatoid disease, the VA physician did not have the benefit of that rheumatologist's laboratory reports to confirm that opinion. Moreover, according to the VA examiner, this was in conflict with the negative results on both the VA computer and service treatment records. According to the VA examiner, were additional records from the Veteran's private rheumatologist to confirm that the Veteran did, in fact, have a positive rheumatoid factor and positive ANA, he would agree that the Veteran did have rheumatoid disease, which was an inherited condition. It was, however, the understanding of the VA examiner that, in such a situation, a rheumatoid factor test should always be positive, while the Veteran exhibited "two negatives from prior testing." Under the circumstances, the VA examiner could see no primary evidence on which to base a diagnosis of rheumatoid arthritis. However, were such evidence to be provided by current testing or from other sources, this would change his opinion. In correspondence of late May 2007, the Veteran's private rheumatologist wrote the following: I am...a rheumatologist with a practice in Charleston, South Carolina. A brief background on my qualifications and expertise in the field of rheumatology is as follows; I attended Hampden-Sydney College, and then moved on to earn my MD at the Medical University of South Carolina in 1970. I then pursued postgraduate training with an Internal Medicine Internship and Residency at the Medical College of Virginia, followed by a Fellowship in Immunology and Connective Tissue Diseases. I continue to regularly attend the National Meetings of the American Rheumatism Association, the South Carolina Rheumatism Society, and have participated in the Speakers Programs for Pfizer-Serle and Merck. I am a Diplomate in Internal Medicine and in Rheumatology of the American Board of Medical Examiners, Charter Member and Past President of the South Carolina Rheumatism Society, and a member of the American Rheumatism Association, the Dorchester County Medical Society, and the South Carolina Medical Association. I previously sat on the now defunct Board of Directors of the South Carolina Arthritis Foundation and held a position in the Alumni Association of the MUSC. In addition, I have been on the Board of Trustees of the Trident Regional Medical Center for seven years, and was Chairman in 1981, 1987, and 1988. I have been published in five different scientific sources, including the Southern Medical Journal, the MCV Quarterly Journal, and the Journal of Family Practice. I have participated in twenty-seven clinical research studies, and I am Board Certified in Internal Medicine and Rheumatology. I'm writing this letter on behalf of my patient (the Veteran), whom I have been treating for the past several years for rheumatoid disease. I first met (the Veteran) when I was called in to consult on his case after he underwent surgery to the left lung due to pleural effusion, and testing for the causes of the effusion including cancer and tuberculosis proved to be negative. The procedure performed on (the Veteran) required drainage of the lung using a chest tube and subsequent open thoracotomy with abrasion to the pleural lining. After the initial consult and further testing, I determined that the cause of the pleural effusions was rheumatoid disease. In the process of collecting information concerning (the Veteran's) medical history, I have reviewed his medical record that covered his active duty naval service from July 1976 to July 1996. From these records, I have been able to determine without a doubt that this disease began to manifest itself in the late 1970's. The following are key points in my determination of when the disease first manifested: (The Veteran's) induction physical indicates that he entered the Navy as a healthy young adult male. Subsequent annual physicals conducted over the course of his career including his retirement physical indicate that he later developed and complained of arthritic pain. This shows the development and progression of the disease occurred after his entry into and before his retirement from the Navy. Beginning in the late 1970's and throughout the remainder of his career, (the Veteran) was seen for a great number of upper respiratory infections. Rheumatoid disease is an autoimmune disease that causes inflammation of the joints and other organs of the body, and predisposes patients to common infections, such as upper respiratory and urinary tract infections. In 1984, (the Veteran) had an incident of pleural effusion the cause of which was never diagnosed. He was treated for pneumonia and chest pain without relief and was tested for a number of other ailments, which were all negative. After several weeks the pleural effusion and associated chest pains then self resolved and the cause was never definitely determined. This incident mirrored the symptoms and treatment (the Veteran) experienced in 2002 prior to the invasive procedures that relieved the effusion. In 1989, (the Veteran) underwent arthroscopic surgery of the right knee. Initially it was believed that he was suffering from a torn meniscus, during the surgery it was discovered that the meniscus was intact but the synovium that lines the patella was extremely inflamed. The surgeon removed the inflamed tissue but no pathology report is available. This incident further indicated the existence of rheumatoid disease because during flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis). A number of other entries relating to or suspicious of autoimmune/ rheumatologic diseases (such as bursitis, tendinitis, and painful joints) were noted but evaded proper diagnosis before (the Veteran's) retirement in 1996. This in no way reflects on the medical care (the Veteran) was given but in the difficulty diagnosing this disease can be for a practitioner who does not specialize in the field. In 1995, (the Veteran) was being seen by a rheumatologist who suspected possible rheumatoid disease but further diagnosis and treatment were deferred until the testing and treatment of a herniated cervical disc (the Veteran) was suffering from at the time was complete. Unfortunately, (the Veteran) retired before the rheumatologic evaluation was complete. Had this evaluation been completed, I have no doubt that (the Veteran's) underlying rheumatoid disease would have been discovered and treatment begun. In regards to the origin of the disease, the cause of rheumatoid diseases is unknown. Although infectious agents such as viruses, bacteria, and fungi are suspected, none has been proven as the definitive cause. It is also suspected that certain infections or factors in the environment might trigger the immune system to attack the body's own tissues, resulting in inflammation in various organs of the body such as the lungs. The exact cause of rheumatoid disease continues to be a very active area of medical research. However, the origin of this disease has so far remained elusive. While some scientists believe that the tendency to develop rheumatoid disease may be genetically inherited, this theory has not proved to be an absolute truth, as many individuals who develop the disease have no family history of it. As far as (the VA examiner's) concern over previously negative blood test results, some people have rheumatoid disease and have a normal level of RF (Rheumatoid Factor). The RF test must often be repeated later (sometimes over years) if rheumatoid disease is suspected and the RF level was normal in an initial test. The absence of an elevated RF level most certainly does not exclude a diagnosis of rheumatoid disease. Approximately 20 percent of all people with rheumatoid disease will have a negative rheumatoid factor test, and some people who do not have the disease will test positive. There (are) other serological indicators such as sedentary rate (which indicates an inflammatory condition) that can and must be taken into account when considering the diagnosis of rheumatoid disease. (The VA examiner) also bases his opinion on the negative results of serological testing for ANA and dsDNA...these tests are normally conducted when lupus is suspected. (The Veteran) has never been diagnosed as having lupus by me or anyone else. While ANA can be found in the blood of people suffering from other maladies, the rate of incidence for rheumatoid disease is only 25-30 percent, and, therefore, cannot be a definitive measure for excluding a diagnosis of rheumatoid disease. Let me again make it clear that (the Veteran's) condition is not a result of his persistent fibromyalgia, nor have I ever determined that he has lupus, as (the VA examiner) stated in his January 19, 2005 evaluation report. (The Veteran's) condition is a result of rheumatoid disease which I have no doubt has existed since the late 1970's. In an attempt to clarify the exact nature and etiology of the Veteran's rheumatoid disease, the Board, in June 2009, sought the opinion of two independent medical experts, specifically, in the fields of rheumatology and pulmonary medicine. In mid-September 2009, the independent expert in the field of pulmonary medicine (identified as the Chief of Medicine, University of Texas Southwestern University Hospital, James M. Collins Professor in Biomedical Research, and Professor and Vice Chairman, Department of Internal Medicine) wrote the following: I am a physician board certified in Internal Medicine, Pulmonary Diseases, and Critical Care Medicine. I frequently care for patients with a variety of collagen vascular diseases and am quite familiar with the diagnosis and management of these processes. I also have extensive experience in the evaluation of pleural disease. I have been asked to review (the Veteran's) extensive records from the 1970's to present regarding the etiology of his pleural effusion. I have been specifically requested to answer (a question) regarding the pleural effusion in 2002. I believe the effusion in 2002 was most likely a classic rheumatoid pleural effusion. (The Veteran) initially presented on January 15, 2002 to "SMC -ER" with cough and pleuritic pain. He was diagnosed with left sided pneumonia and given an antibiotic for 10 days (Biaxin). He was seen several times over the next month with intermittent chest pain. Evidently, on February 10, 2002, he again presented to the Summerville ER with chest pain. A clinic note on February 12, 2002 notes that (the Veteran) had a normal EKG, V/Q lung scan, and a normal CBC. It does apparently state that the patient had positive blood cultures-"BC- GBC in clusters." How many cultures were positive, and what the ultimate speciation of the gram positive cocci were is [sic] not found elsewhere in the chart. He was then given another 10-day course of antibiotics (Levaquin). On February 12, 2002, he was again seen in clinic, noted to be febrile, and had an enlarging left pleural effusion on chest X-ray. On February 23, 2002, he was admitted to a local hospital for a CT scan and thoracentesis. According to the chart, 900cc of fluid were removed; the chemistries are not mentioned when the patient is seen one week post discharge on March 6, 2002. Of note the patient was not on antibiotics, suggesting that the clinical impression was that his effusion was non-infectious. Indeed, he was felt to have an "inflammatory" effusion and was discharged home on nonsteroidals. The patient however continued to complain of chest pain, myalgias, (and) fatigue as well as low grade temperatures at home. (The Veteran) was readmitted with continued pain, fever, malaise, and an enlarging and now loculated left pleural effusion on March 11, 2002. He was not on antibiotics at the time. In the record, his pleural fluid is referred to as a "low Ph, low glucose" effusion and the patient subsequently underwent VATS thoracotomy and chest tube placement. Subsequent to this, he was placed on immunosuppressant therapy for his rheumatoid arthritis. The usual characteristics of a rheumatoid effusion are: (a) a unilateral effusion in a patient with rheumatoid arthritis, (b) low pleural pH and very low pleural glucose which can easily be confused with a bacterial empyema and (c) no evidence of infection to explain these findings. I might add a fourth which is what the pleura looks like at the time of surgery- empyemas produce characteristic "chicken fat" in the pleural space. This clearly was not present, his cultures were negative, and the clinical impression of all who treated him at the time was that this effusion was related to a collegian vascular disease. Thus in all probability the pleural effusion in 2002 was due to rheumatoid arthritis in (the Veteran). In late September 2009, the independent medical expert in the field of rheumatic diseases wrote the following: I am currently Associate Professor and Chief, Rheumatic Diseases Division, University of Texas Southwestern Medical Center, and Chief of Service for Rheumatology at the University Hospital of the University of Texas Southwestern, and Parkland Health Hospital System, serving Dallas County, Texas. I am Board Certified in Internal Medicine and Rheumatology. My inpatient and outpatient consultative practice includes many patients with rheumatoid arthritis, systemic lupus erythematosus, and fibromyalgia, as well as other, sometimes unclassifiable, autoimmune disorders. I have also published over 50 research articles, reviews, and textbook chapters relating to human immunology and rheumatology, including the prevalence of autoantibodies in the general population and incomplete or atypical forms of classical autoimmune diseases. I have been asked to offer an opinion as to the likelihood that (the Veteran's) currently diagnosed rheumatoid disease (manifested as a sterile pleural effusion) represents a continuation of rheumatoid arthritis/disease that began during his active military service or within the year following discharge. After reviewing the entire case file and Service Medical Records, I believe this is highly unlikely. Rheumatoid arthritis (RA) is a systemic autoimmune disease that primarily affects the joints, but can affect many organ systems, including the lungs. Like most autoimmune diseases, it affects women more commonly than men; it is seen at all ages beginning in early adulthood. The cardinal feature is synovitis, a condition where the lining of the joint becomes inflamed, producing joint swelling, tenderness, pain, and decreased range of motion. Untreated, the synovitis causes cartilage loss and erosions of bone. This leads to classical changes in the appearance of the joints. For example, fingers that become subluxed (shifted) or are pulled off to one side or the other. In most cases, there are radiographic changes of RA present within 1 to 2 years of the onset of the disease if not treated with aggressive immunosuppression. The laboratory features of RA include markers of inflammation, either an elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), a normochromic, normocytic anemia, and the presence of characteristic autoantibodies. The classical autoantibody test in RA is the rheumatoid factor, or RF. This protein is present in about 80 percent of patients with definite RA. In general, the level of RF tends to correlate with severity of disease, including the presence of extra- articular (non-joint) problems such as lung disease. A major problem with the RF test is the fact that it can be seen in a large number of other conditions, especially chronic infections such as hepatitis C, TB, syphilis, etc., as well as primary lung and liver diseases. A newer test for RA is the antibody to cyclic citrullinated peptide (anti-CCP), which is more specific for RA, but is also only seen in about 80 percent of patients with definite disease. Finally, patients with RA can have other autoantibodies, notably the anti-nuclear antibody (ANA), which can be seen in up to 40 percent of RA patients. The ANA is not specific for any one autoimmune disease. It can be seen at low levels (at titer of 1:160 or less) in 5 percent of the healthy population. It can be transiently induced by viral infections. The American Rheumatism Association (now the American College of Rheumatology) has published criteria for assigning the diagnosis of RA to persons with arthritis. They include the presence of significant morning stiffness, inflammatory arthritis in three or more joints observed by a physician, arthritis of the hands observed by a physician, symmetric arthritis observed by a physician, characteristic skin nodules, the presence of a significantly elevated rheumatoid factor, and the presence of characteristic changes on X-rays. The presence of four of these findings must be present. While these criteria were meant for clinical research purposes, they do describe the vast majority of patients seen in practice. Lung involvement in RA can take several forms, including inflammation of the pleura (lining). This can result in chest pain and shortness of breath, as well as the production of a plural effusion (fluid). As noted by the Pulmonary Consultant, the pleural effusion suffered by the appellant in February 2002 had the characteristics of a rheumatoid effusion (e.g., low pH, low glucose, numerous lymphocytes) and was sterile. The absence of a rheumatoid pleural effusion without preceding rheumatoid arthritis would be rare, but not impossible. While I agree with the appellant's private rheumatologist that RA can sometimes be difficult to diagnose, particularly early and mild cases, I base my opinion...on the repeated physical exams performed and laboratory data obtained by several physicians and medical corpsmen over the appellant's 20-year service and subsequent care. In many cases, autoimmune disorders such as RA or systemic lupus erythematosus were entertained as explanations for complaints of joint pain or chest pain. In each case, the Service Medical Record or VA documentation notes no swelling, tenderness, or abnormality of any joint except his knees, and his previously fractured ankle. Even his private rheumatologist described a normal joint exam (except for the left knee which had recently been operated on) when he saw the Veteran initially during his 2002 hospitalization. At no point would the Veteran meet criteria for RA outlined above. Throughout the service records, I found several instances where the appellant was tested for RF and/or ANA. In all cases, the RF values in the primary reports were negative. I was unable to find the cases of positive RF alluded to in correspondence. In [one] case (October 23, 1994), the ANA was positive at a low titer (1:160). Subsequent testing was negative. Repeated radiographs of his hands failed to reveal any changes consistent with RA. The only positive findings in the peripheral skeleton were mild degenerative joint disease of the knees, the old ankle fracture, and calcific tendinitis of the shoulders. (The Veteran's) record indicates an evaluation for chest pain in August 1979. The diagnosis of pleurisy was entertained. The chest X-ray was normal and the pain was noted to be reproduced with pressure on the chest wall consistent with costochondritis. Then in 1984, he was ill for several weeks with a febrile illness that included abdominal, flank, and chest pain, and an elevated white blood count. This illness resolved after receiving antibiotics. A sputum sample showed white blood cells and both many gram positive cocci in pairs and chains as well as other oral bacteria. This was felt to be consistent with an airway infection. One notation in the record indicates a possible small pleural effusion, but this was not commented on in the official chest X-ray report. (The Veteran) did seek care during active duty for a number of joint complaints felt to be bursitis or tendinitis. The history and physicals taken at the time seem to be consistent with those diagnoses and not anything more complicated. Towards the end of his service, however, his complaints of widespread joint and muscle pain are noted, along with normal examinations. These findings are consistent with the fibromyalgia that his private rheumatologists have confirmed. I note the finding of "reactive synovium" on the operative note of his right-knee arthroscopy in 1991. The surgeons did not biopsy this, did not describe it as "proliferative" or consistent with RA. I am not able to conclude anything about the cause of the synovial changes based on this report. In fact, they could be secondary to the mechanical instability that led to arthroscopy in the first place. The only consistent, objective finding in the medical record is a slightly elevated ESR that was obtained from time to time. This is a nonspecific test that measures inflammation from any cause-from a viral infection to cancer. As such, it does not confirm the presence of autoimmune disease itself, but could have been the result of sinusitis, upper respiratory infection, etc. At the time of his discharge (1996) the level had returned to near normal (13 versus 10 mm/hr). He was never seen to be anemic, a nonspecific marker for longstanding systemic inflammation. In summary, it is my opinion that the clinical onset of the disease resulting in the pleural effusion in early 2002 did not occur during the period of active [military] service or in the year thereafter. Each of the illnesses or conditions that were treated during his naval service had other, more plausible explanations. Moreover, clinical and laboratory evidence of rheumatic disease was sought and not found by navy medical personnel at the time and subsequently by VA physicians. The finding of a transiently positive ANA at low titer is not significant in making any diagnosis in this case. The positive rheumatoid factor seen in 2002 is supportive of the diagnosis of a rheumatoid pleural effusion. In the absence of other stigmata of RA, however, I would caution that other causes of RF (such as occult hepatitis C infection) should be entertained. Given this opinion...I agree with the pulmonary consultant's response... as it is phrased. It is likely that the pleural effusion that occurred in 2002 is a result of the currently diagnosed "rheumatoid disease." It is just that it is my opinion that such disease is of recent, not remote, onset. After obtaining additional VA treatment records of the Veteran, including an October 2011 VA physician's rheumatology note that reported the Veteran's history of present illness as involving rheumatoid arthritis "diagnosed in 2002, however most likely had symptoms since 1978 when he developed recurrent episodes of pleuritis/pericarditis," the RO obtained an opinion from a private physician at the Division of Rheumatology and Immunology at the University of Maryland School of Medicine. In an opinion dated in April 2015, this physician provided the following statement: VBMS reviewed in detail. VA CPRS reviewed in detail. It is less likely as not that Veteran's Rheumatoid disease had its clinical onset while in service, manifested to a compensable degree within a year after separation from service, or is at least as likely as not related to any symptoms, treatment or events in service. Rationale: I concur with the findings of [the September 2009 independent medical expert] in that the Veteran's rheumatological disease is of recent not remote onset i.e. during Veteran's [active duty] service time or within a year of separation. There has been no new and/or relevant information since the appeals hearing in September 2012. I am in total agreement with the 2012 decision of the appeals board i.e. his rheumatoid disease is not related to service, symptoms, or treatment while in the service. Competent medical evidence includes statements from a person qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). As the aforementioned clinicians are so qualified, their medical opinions constitute competent medical evidence. The Board finds that the Veteran is competent to report-as he did in his May 2007 hearing before the undersigned Veterans Law Judge-that he experienced pulmonary symptoms and joint pain during and after service. Similarly, the Veteran's spouse and colleagues are competent to observe the Veteran's pain, fatigue, and other symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) ("Competent lay evidence" is evidence provided by a person who has personal knowledge derived from his own senses); 38 C.F.R. § 3.159(a)(2) ("Competent lay evidence" is any evidence not requiring that the proponent have specialized education, training or experience, but 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). See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional); Clyburn v. West, 12 Vet. App. 296, 301 (1999) (Veteran is competent to report continuous pain since service). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that a service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination or to establish service connection. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Board finds that the Veteran, his spouse, and his colleagues are not competent to provide an opinion linking his claimed rheumatoid disease to service, because the disease is complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board accords their statements regarding the etiology of the Veteran's claimed rheumatoid disease no probative value, as they are not competent to opine on the complex medical question of etiology. In this regard, the Board observes that diagnosing rheumatoid disease requires specialized testing, and there is no indication that the Veteran or his spouse or colleagues are competent to administer such tests or interpret the results. Where, as here, conflicting medical opinions are of record, the Board can ascribe greater probative weight to one opinion over another provided that a rational basis is given. See Winsett v. West, 11 Vet. App. 420 (1998), aff'd 217 F.3d 854 (Fed. Cir. 1999). Greater weight may be placed on one clinician's opinion than another's based on the reasoning in the opinions, and whether and to what extent the clinicians reviewed the Veteran's prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). In this case, the Board finds that the September 2009 independent medical experts' opinions are entitled to greater probative weight than the opinions of the Veteran's private clinician. The Board finds the independent medical experts' discussion of the Veteran's medical history and test results during and after service, and their negative etiological opinions resulting therefrom, to be persuasive. Specifically, the Board adopts the independent medical experts' findings that the Veteran's test results during and after service demonstrate that his rheumatoid disease is not attributable to his military service. That is, the independent medical experts' opinions are consistent with the other objective evidence of record. The Board acknowledges the opinions of the Veteran's rheumatologist, wherein he opines that the Veteran's RA began in service. However, in his opinions, the private rheumatologist does not specifically address the negative evidence of record. He does not account for the in-service histories and physicals that attribute the Veteran's complaints and symptoms to other non-related diagnoses. The IME opinions do. The Board also finds that the October 2011 VA physician's rheumatology note that reported the Veteran's history of present illness as involving rheumatoid arthritis "diagnosed in 2002, however most likely had symptoms since 1978 when he developed recurrent episodes of pleuritis/pericarditis," to be less than probative. The statement is unsupported by any rationale, seems to reflect the history as reported by the Veteran, and does not reflect any review of the extensive record of the case. The Veteran's service treatment records along with the opinions of independent medical experts do not support the conclusion that the Veteran's RA began in service. Indeed, the service treatment records show that the Veteran's joint complaints were attributable to other events. The reports show that the Veteran received treatment for numerous orthopedic complaints after being struck by a car, sustaining injuries after a lifting accident, playing baseball, and multiple ankle twisting injuries incurred during physical training. The reports also show diagnoses of herniated nucleus pulposus of the cervical spine. For example, a June 1991 orthopedic report shows that the Veteran's knee and ankle complaints were the result of participating in a single Martial Arts tournament. The diagnoses were patella-femoral syndrome of the left knee and status post left ankle reconstruction with slightly restricted range of motion. The Veteran's low back pain was also mentioned in this report. In 1995, the Veteran's pain of the cervical spine and neurological impairment of the upper extremities were attributed to a car accident occurring approximately four years earlier. See July 1995 Naval Hospital Report. With regard to the Veteran's complaints of the joints, the service treatment records in the majority of instances set forth a reason, or reasons, for the Veteran's complaints along with recommended treatment. RA was not found. Additionally, as noted by the rheumatologist IME in 2009, the Veteran's service treatment records fail to illustrate the published criteria for assigning the diagnosis of RA to persons with arthritis. Rather, the IME either attributed the Veteran's specific joint problems to the plausible medical explanations provided contemporaneous with the treatment the Veteran received, or attributed his widespread joint and muscle pain to his service-connected fibromyalgia. Additionally, with regard to the Veteran's complaints of pleural effusion and chest pain, the IME explained why the Veteran's 1979 and 1984 diagnosis of pleurisy, as a result of costochondritis, and airway infections adequately accounted for the Veteran's symptoms at that time. The independent medical expert also meticulously accounted for the positive laboratory findings during service (the elevated ESR and ANA findings). With regard to the ANA findings, he noted that subsequent testing was negative and repeat radiographs of the hands failed to reveal any changes consistent with RA. He also noted that the elevated ESR could have resulted from several causes. Importantly, he added that at discharge the Veteran's levels had returned to normal, and the Veteran had never received treatment for anemia, a nonspecific maker for longstanding systemic inflammation. The IME found that clinical and laboratory evidence of rheumatic disease was sought and not found by navy medical personnel at the time, nor by subsequent VA physicians. The Veteran's RA was positively diagnosed in 2002 as supporting findings were present at that time. The IME's findings are consistent with the overall evidence of record, and corroborated by the pulmonologist IME, who also found RA present in 2002. These conclusions were further affirmed by another independent expert in April 2015 after review of the complete record. In this case, the Board has assessed the credibility and weight of the medical opinions provided. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). As noted above, the Board finds that the private rheumatologist as well as the independent medical experts are equally qualified. However, when weighing the medical opinions offered with the other objective evidence of record, the Board finds that the rheumatologist IME's opinion is of more probative value. Owens v. Brown, 7 Vet. App. 429 (1993). The IME opinion was based on the positive and negative facts and data; it was based on the actual service treatment records findings and data; and, the IME applied sound medical principles (the criteria for assigning the diagnosis of RA to persons with arthritis) to the case. Nieves-Rodriguez v. Peake, 22 Vet. App. 302. Moreover, another independent expert concurred with the IME's findings. Finally, the Board acknowledges that the private rheumatologist is the Veteran's treating physician. Nonetheless, the treating physician's opinion does not receive greater weight than that of a VA examiner or other doctor. See Winsett v. West, 11 Vet. App. 420 (1998). As noted above, the rheumatologist IME's report is more convincing and thereby more probative because he offered more comprehensive reasons and bases in support of his conclusions, while acknowledging both the positive and negative evidence of record and setting forth sound medical principles for assigning the diagnosis of RA. At this time, the Board notes that it is cognizant of the Veteran's honorable service and understands the Veteran's appellate contentions. Additionally, in reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, in this case the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for rheumatoid disease. As such, the benefit-of-the-doubt doctrine is not applicable. Therefore, the Board finds that service connection is not warranted for the Veteran's rheumatoid disease. The appeal must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for rheumatoid disease is denied. ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs