Citation Nr: 1751466 Decision Date: 11/09/17 Archive Date: 11/17/17 DOCKET NO. 17-02 809 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for residual scars, first degree burns of the face. 2. Entitlement to service connection for Reiter's syndrome/reactive arthritis (claimed as joint pain). 3. Entitlement to service connection for ischemic heart disease. 4. Entitlement to service connection for aortic insufficiency. 5. Entitlement to service connection for mitral valve regurgitation. 6. Entitlement to service connection for pulmonary hypertension. 7. Entitlement to service connection for hypertension. 8. Entitlement to service connection for a back disability. 9. Entitlement to service connection for an acquired psychiatric disorder, to include depression. 10. Entitlement to an initial compensable disability rating for a bilateral hearing loss disability. REPRESENTATION Veteran represented by: Stacey Penn Clark, Attorney at Law ATTORNEY FOR THE BOARD Arif Syed, Counsel INTRODUCTION The Veteran had active service from August 1961 to August 1964. These matters come before the Board of Veterans' Appeals (Board) on appeal from October 2013 and July 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. With regard to the Veteran's acquired psychiatric disorder claim, the Board acknowledges that the United States Court of Appeals for Veterans Claims (Court) has held that the scope of a mental health disability claim includes any psychiatric disability that may reasonably be encompassed by a veteran's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). A review of the record reveals that the Veteran has been diagnosed with depression. In light of the Court's holding in Clemons, the Board has recharacterized the Veteran's claim as entitlement to service connection for an acquired psychiatric disorder, to include depression. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issue of entitlement to an increased disability rating for a bilateral hearing loss disability is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In an unappealed November 2010 rating decision, the RO denied the Veteran's claim of entitlement to service connection for residual scars, first degree burns of the face. 2. Evidence submitted since the November 2010 rating decision is cumulative or redundant of the evidence of record at the time of the prior final denial of the claim, and does not raise a reasonable possibility of substantiating the claim of service connection for residual scars, first degree burns of the face. 3. The Veteran's currently diagnosed ischemic heart disease did not manifest in or is otherwise attributable to active service nor may it be presumed so. 4. The Veteran's currently diagnosed aortic insufficiency did not manifest in or is otherwise attributable to active service. 5. The Veteran's currently diagnosed mitral valve regurgitation did not manifest in or is otherwise attributable to active service. 6. The Veteran's currently diagnosed pulmonary hypertension did not manifest in or is otherwise attributable to active service. 7. The Veteran's currently diagnosed hypertension did not manifest in or is otherwise attributable to active service nor may it be presumed so. 8. The Veteran's current acquired psychiatric disorder diagnosed as depression did not manifest in or is otherwise attributable to active service. 9. The Veteran's currently diagnosed back disability did not manifest in or is otherwise attributable to active service nor may it be presumed so. 10. The Veteran's currently diagnosed Reiter's syndrome/reactive arthritis did not manifest in or is otherwise attributable to active service. CONCLUSIONS OF LAW 1. The November 2010 rating decision denying service connection for residual scars, first degree burns of the face is final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2016). 2. Since the November 2010 rating decision, new and material evidence has not been received, and the claim of entitlement to service connection for residual scars, first degree burns of the face is not reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2016). 3. Ischemic heart disease was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2016). 4. Aortic insufficiency was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2016). 5. Mitral valve regurgitation was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2016). 6. Pulmonary hypertension was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2016). 7. Hypertension was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2016). 8. An acquired psychiatric disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2016). 9. A back disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2016). 10. Reiter's syndrome was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks entitlement to service connection for residual scars, first degree burns of the face, Reiter's syndrome/reactive arthritis, ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, a back disability, and an acquired psychiatric disorder. Implicit in the residual scars, first degree burns of the face claim is the contention that new and material evidence which is sufficient to reopen the previously-denied claim has been received. In the interest of clarity, the Board will discuss certain preliminary matters. The issues on appeal will then be analyzed and a decision rendered. Duties to Notify and Assist VA has a duty to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. This notice must specifically inform the claimant of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2016). With regard to new and material evidence claims, VA must also notify a claimant of the evidence and information that is necessary to reopen the claim generally, i.e. the definition of new and material evidence. Kent v. Nicholson, 20 Vet. App. 1 (2006). The Board notes VAOPGCPREC 6-2014 however which states that the plain language of 38 U.S.C.A. § 5103(a)(1) does not require VA, upon receipt of a previously denied claim, to provide notice of the information and evidence necessary to substantiate the element or elements that were found insufficient in the previous denial of the claim. In other words, the opinion holds that Kent is no longer controlling insofar as it construed the former § 5103(a) to require that VA provide case-specific notice to a claimant in a claim to reopen. The Veteran was provided with the required notice, to include notice with respect to the disability rating and effective-date elements of the claims as well as what is required generally to substantiate new and material evidence sufficient to reopen a previously denied claim, by a letter mailed in March 2013, prior to the initial adjudication of his claims. VA also has a duty to assist a claimant in the development of his claims. See 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c) (2016). In the instant case, the Board finds reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claims. There is no reasonable possibility that further assistance would aid in substantiating the claims. The pertinent evidence of record includes statements from the Veteran, service treatment records, medical articles, as well as VA and private treatment records. The Board notes that the Veteran was not provided examinations and nexus opinions for his ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and acquired psychiatric disorder claims. Under 38 C.F.R. § 3.159(c)(4) (2016), VA will provide a medical examination or opinion if the information and evidence of record does not contain sufficient medical evidence for VA to make a decision on the claim but: (1) contains competent lay or medical evidence that the claimant has a current diagnosed disability, or persistent or recurring symptoms of disability; (2) establishes that the Veteran suffered an event, injury, or disease in service; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service. See 38 U.S.C.A. § 5103A(d) (West 2014); 38 C.F.R. § 3.159(c)(4) (2016); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board further finds that there is sufficient evidence to decide these claims, and that further medical examination or opinion is not necessary to decide the claims for service connection for ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and an acquired psychiatric disorder. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). In the present case, as discussed in further detail below, the competent and probative evidence does not show or indicate that the Veteran sustained an in-service disease or injury resulting in his current ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and acquired psychiatric disorder. Accordingly, VA examinations for these claims are not warranted. The facts of this case are different than the facts in Charles v. Principi, 16 Vet. App. 370 (2002), in which the Court held that VA erred in failing to obtain a medical nexus opinion where evidence showed acoustic trauma in service and a current diagnosis of tinnitus. Significantly, in this case, there is no competent and probative evidence which supports evidence of in-service disease or injury resulting in current ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and acquired psychiatric disorder. With respect to the Veteran's residual scars, first degree burns of the face claim, since no new and material evidence has been submitted, a VA examination and an opinion are not required. Neither the Veteran nor his attorney has identified any shortcomings in fulfilling VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Board finds that under the circumstances of this case, VA has satisfied the notification and duty to assist provisions of the law and that no further action pursuant to the VCAA need be undertaken on the Veteran's behalf. Service connection for residual scars, first degree burns of the face The Veteran seeks service connection for residual scars, first degree burns of the face. A claim of service connection for this disability was previously denied in a November 2010 rating decision. The Veteran did not appeal the decision. It is incumbent on the Board, therefore, to adjudicate the new and material issue before considering the claim on the merits. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996) [before considering a previously adjudicated claim, the Board must determine that new and material evidence was presented or secured for the claim, making RO determination in that regard irrelevant]. Pertinent Legal Criteria Veterans are entitled to compensation from VA if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C.A. § 1110 (wartime service), 1131 (peacetime service). To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). In general, rating decisions that are not timely appealed are final. See 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. § 20.1103 (2016). Pursuant to 38 U.S.C.A. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. New evidence is defined as evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156(a) (2016). In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). In Shade v. Shinseki, 24 Vet. App. 110 (2010), the Court held that once new and material evidence has been presented as to an unestablished fact from a previously denied claim for service connection, the claimant will be entitled to the full benefits of the Secretary's duty to assist, including a medical nexus examination, if one is warranted; it does not require new and material evidence as to each previously unproven element of a claim. Application to reopen In the November 2010 rating decision, the RO denied the Veteran's claim of entitlement to service connection for residual scars, first degree burns of the face on the basis that there was no evidence of a current disability manifested by residual scarring of the face that began in or was caused by service. The Veteran did not appeal the rating decision and new and material evidence was not associated within one year of the rating decision. The decision therefore became final. At the time of the prior final rating decision in November 2010, the record included the Veteran's service treatment records, a VA examination dated October 2010, and the Veteran's statements. The Veteran's service treatment records document treatment in January 1962 for first degree burn to the lower half of the face. The Veteran submitted a statement dated July 2010 noting that he sustained the in-service burn to his face when a powder trail ignited from a rocket launcher. However, in a VA examination report dated November 2010, the examiner noted that the Veteran had a pending claim for service connection for scars of the face and summarized the service treatment record entries for treatment for burns of the face in January 1962. The examiner also noted that a January 1964 examination noted no facial scars, and "The Veteran says he does not have residual scarring of the face." The examiner performed a skin examination and reported observations of scarring of the hands and wrist but did not observe any residual scarring of the face. In December 2012, the Veteran applied to reopen his claim of entitlement to service connection for residual scars, first degree burns of the face. In order to reopen the previously denied claims, the evidence submitted since the last final denial (November 2010) must be new and material. After a thorough review of the entire record, and for the reasons expressed immediately below, the Board concludes that new and material evidence sufficient to reopen the claim of entitlement to service connection for residual scars, first degree burns of the face has not been submitted. In the present case, the unestablished fact is whether the Veteran has a current disability manifested by residual scars, first degree burns of the face that manifested in service. The newly added evidence, in pertinent part, consists of postservice VA and private treatment records, the results of an October 2013 skin examination, and statements from the Veteran. In the October 2015 examination, a different examiner observed scars of the hands and wrist but noted no scars or disfigurement of the head, face, or neck. The newly associated postservice medical evidence does not document any treatment for residual scars of the face. As such, the newly associated postservice medical evidence does not establish or suggest that the Veteran has residual scars related to first degree burns of the face. Furthermore, with regard to recent statements from the Veteran to the extent that he has residual scars of the face, such evidence is cumulative and redundant of similar statements made prior to the November 2010 rating decision. Accordingly, such statements are not new. See Reid v. Derwinski, 2 Vet. App. 312, 315 (1992). Moreover, while the Veteran is entirely competent to report his symptoms both current and past, the Board finds that to the extent he contends that he has residuals scars of the face, this lay evidence is outweighed by the objective evidence which is absent a finding of such. Moreover, the Veteran had the opportunity to describe and display any facial scarring on two occasions and on one occasion denied any facial scaring and on two occasions none was noted by two different examiners. Therefore, the statements offered by the Veteran in support of reopening his previously denied claim are inconsistent and not probative evidence of a current disability. In short, there is no competent evidence that the Veteran has residual scars, first degree burns of the face that manifested in service. In reaching this conclusion, the Board observes that the Veteran was provided a VA examination for his scars in October 2013. After examination of the Veteran, the VA examiner declined to report that the Veteran currently has residual scars of the face. As such, the October 2013 VA examination report raises no reasonable possibility of substantiating the claim and thus is not material within the meaning of 38 C.F.R. § 3.156(a). In this regard, evidence that is unfavorable to the appellant's case and which supports the previous denial cannot trigger a reopening of the claim. See Villalobos v. Principi, 3 Vet. App. 450, 452 (1992). The Veteran has been accorded ample opportunity to submit new and material evidence, to include competent medical evidence and information specifically indicating that he has residual scars, first degree burns of the face that is related to service. He has not done so. See 38 U.S.C.A. § 5107(a) (finding that it is a claimant's responsibility to submit evidence in support of his claim). In summary, the element which was missing at the time of the November 2010 denial of service connection remains lacking. New and material evidence has not been received, and the Veteran's claim of entitlement to service connection for residual scars, first degree burns of the face may not be reopened. The benefit sought on appeal remains denied. Service connection for ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, an acquired psychiatric disorder For the sake of economy, the Board will analyze the Veteran's ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and acquired psychiatric disorder claims together, as they involve the application of similar law. The law and regulations pertaining generally to service connection claims have been set forth above and will not be repeated here. For certain chronic disorders, such as ischemic heart disease and hypertension, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2016). In order to show 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, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact or chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2016). The Veteran contends that he has ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and an acquired psychiatric disorder that are related to his service. With regard to the Veteran's ischemic heart disease and hypertension, the record does not reflect medical evidence showing any manifestations of either of these disabilities during the one-year presumptive period after the Veteran's separation from service. On the contrary, the record does not reflect any complaints or findings consistent with either of these disabilities until August 1994 (more than 25 years after his separation from active service). See a private treatment record from C.Q., M.D. Accordingly, service connection is not warranted on a presumptive basis as to these claims. 38 C.F.R. §§ 3.307, 3.309. Having determined that presumptive service connection is not warranted, the Board's inquiry turns to whether service connection on a direct basis is warranted. As to a current disability, the competent and probative evidence of record documents diagnoses of ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and an acquired psychiatric disorder, in particular depression. See, e.g., private treatment records from V.P., M.D. dated November 2009 and March 2012; see also a private treatment record from K.Y., M.D., dated October 2013. Turning to in-service incurrence of an injury or disease, to the extent that the Veteran contends that his ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and depression are related to his service, the Board finds that the competent and probative evidence of record outweigh these contentions. Crucially, his service treatment records indicate no suggestion of treatment for any of these disabilities. While a July 1963 treatment record notes a complaint of chest pain, this complaint was related to a left shoulder strain. Further, although the Veteran was assessed with a blood pressure of 152/92 mm/Hg in August 1962, this is the only blood pressure reading in the service treatment records with a diastolic reading of over 90. Indeed, his June 1964 separation examination revealed normal findings with respect to his blood pressure (108/70 mm/Hg) and heart as well as a normal mental health evaluation. Moreover, the earliest document showing a history of a diagnosis or symptoms of any of these disabilities dating back to service is in August 1994. This is more than 25 years after his separation from service. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) [contemporaneous evidence has greater probative value than history as reported by the veteran]; see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) [noting that it was proper to consider the veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised]. The Board observes that lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person (e.g. any evidence not requiring that the proponent has specialized education, training, or experience). 38 C.F.R. § 3.159(a)(2). As such, the Veteran can competently testify about symptoms he experienced in service. However, competency must be distinguished from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Layno v. Brown, 6 Vet. App. 465, 469 (1994). In the present case, the Board finds that the Veteran's history of ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and an acquired psychiatric disorder since service is outweighed by the objective evidence of record in light of both the lack of any post service treatment or complaints of any of these disabilities until 1994. Accordingly, to the extent that the Veteran contends that his ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and acquired psychiatric disorder manifested during service, this contention is at odds with the remainder of the record, which is devoid any indication that any injury or disease occurred during service or for more than 25 years thereafter. The Board places low probative weight on his contentions not only because of the absence of records of treatment for any relevant manifestations but also because the June 1964 discharge physical examination noted no relevant chronic manifestations or symptoms at a time when the Veteran could have identified them. As such, the Veteran's statements are lacking probative value. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) [VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence]. In short, there is no objective indication of an in-service manifestation of ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, or an acquired psychiatric disorder. The Veteran's claims fail on this basis. The Board further notes that there is no competent evidence of record that establishes a causal relationship between the Veteran's currently diagnosed ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and depression and his service. In the absence of in-service disease or injury, it would seem that such nexus opinion would be impossible. VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Board observes that the Veteran has submitted medical articles pertaining to the development of aortic insufficiency as well as depression. The Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38 C.F.R. § 3.159(a)(1) [competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses]. However, the articles submitted by the Veteran are of a general nature and do not contain any information or analysis specific to the Veteran's case. The articles are also not particularly supportive because they report that residuals of Reiter's syndrome (addressed below) may cause certain symptoms but that they resolved over months in most cases. Additionally, the Court has held that medical evidence which is speculative, general, or inconclusive in nature cannot support a claim. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). As discussed in detail above, the Board has evaluated the medical evidence of record, to include the June 1964 separation examination which revealed normal blood pressure reading, chest examination, and mental health examination as well as the remainder of evidence which does not indicate complaint of or treatment following service for many years for the disabilities discussed herein. The Board has therefore placed great probative value on the service treatment records in particular. As such, the medical articles submitted by the Veteran are of little probative value, and, to the extent that there is any probative value, is greatly outweighed by the remainder of objective evidence. In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). "Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). The Board notes that the Veteran, while entirely competent to report his symptoms both current and past, has presented no clinical evidence of a nexus between his ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and acquired psychiatric disorder and his service. The Board finds that the Veteran as a lay person is not competent to associate any of his claimed symptoms to his service. That is, the Veteran is not competent to opine on matters such as the etiology of his current ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and depression. Such opinion requires specific medical training in the fields of cardiology and mental health and is beyond the competency of the Veteran or any other lay person. In the absence of evidence indicating that the Veteran has this medical training sufficient to render medical opinions, the Board must find that his contention with regard to a nexus between his ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and acquired psychiatric disorder and service to be of minimal probative value and outweighed by the objective evidence which is absent a finding of such. See 38 C.F.R. § 3.159(a)(1) (2016) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. Accordingly, the statements offered by the Veteran in support of his own claims are not competent evidence of a nexus. The Board is aware of the provisions of 38 C.F.R. § 3.303(b), discussed above, relating to chronicity and continuity of symptomatology. With respect to the Veteran's ischemic heart disease and hypertension, to the extent that the Veteran contends that he has had these disabilities continually since service, as mentioned above, the first postservice evidence of complaint of, or treatment for either of these disabilities is in August 1994. See a private treatment record dated August 1994 from Dr. C.Q. This was more than 25 years after the Veteran left service in August 1964. The Board finds that the probative value of the Veteran's current statements regarding a continuity of ischemic heart disease and hypertension symptomatology since service is outweighed by the remainder of the evidence of record. In particular, the Board reiterates that neither of these disabilities or residuals thereof were diagnosed at the time of his service discharge. His normal findings documented on the June 1964 separation examination from service as well as the medical evidence of record outweigh any current assertion that his current hypertension and ischemic heart disease were manifested during service. There is no competent medical evidence that the Veteran complained of or was treated for either of these disabilities for many years after his separation from service. The Board accordingly places no probative value on the assertions of the Veteran that there has been a continuity of symptomatology dating to service. Therefore, continuity of symptomatology after service is not demonstrated as to both claims. For the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for ischemic heart disease, aortic insufficiency, mitral valve regurgitation, pulmonary hypertension, hypertension, and an acquired psychiatric disorder. The benefits sought on appeal are accordingly denied. Service connection for Reiter's syndrome/reactive arthritis and a back disability For the sake of economy, the Board will analyze the Veteran's Reiter's syndrome/reactive arthritis and back disability claims together, as they involve the application of similar law. The law and regulations pertaining to service connection claims have been set forth above and will not be repeated here. The record does not reflect medical evidence showing any manifestations of arthritis of the lumbar spine or other joint related to Reiter's syndrome at the time of discharge from active duty or during the one-year presumptive period after the Veteran's separation from service. On the contrary, the record does not reflect any complaints or findings consistent with arthritis until 1994 (more than 25 years after his separation from active service). Accordingly, service connection is not warranted on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309. Having determined that presumptive service connection is not warranted, the Board's inquiry turns to whether service connection on a direct basis is warranted. As to current disability, the competent and probative evidence of record documents diagnoses of degenerative joint disease of the lumbar spine and Reiter's syndrome. See, e.g., the October 2013 VA examination report. Turning to in-service incurrence of an injury or disease, the Board notes that the Veteran's service treatment records document treatment for a back ache as well as Reiter's syndrome in August 1962. The Veteran was hospitalized for treatment for 6 days and then discharged with the disorder resolved. The Veteran successfully completed the remainder of his obligated service, and the service treatment records are absent complaints of or treatment for his back or Reiter's syndrome. Turning to nexus, the Board has carefully evaluated the evidence and, for reasons stated immediately below, finds that a preponderance of the competent and probative evidence of record is against a finding that the Veteran's current back disability and Reiter's syndrome/reactive arthritis are related to his service. Specifically, the Veteran was afforded a VA examination in October 2013. The VA examiner considered the Veteran's in-service treatment for a back ache and Reiter's syndrome. After examination of the Veteran and review of his claims folder, the VA examiner diagnosed the Veteran with degenerative joint disease of the lumbar spine and Reiter's syndrome and concluded that it is less likely than not that these disabilities are related to the Veteran's service. With regard to the Veteran's lumbar spine disability, the examiner's rationale for his conclusion was based on his finding that the Veteran's in-service back pain was not chronic and had resolved prior to his discharge from service as evidenced by normal findings on his June 1964 separation examination and no findings of postservice back pain until 1994. With respect to the Veteran's Reiter's syndrome, the examiner's rationale for his conclusion was based on his finding that there were no residuals from the in-service treatment for Reiter's syndrome as also evidenced by the normal separation examination for the Veteran's joints. The Veteran also submitted records of private care for a low back disorder. The private practitioner made no mention of activities in service or a previous episode of Reiter's syndrome. Moreover, in a December 2013 private rheumatologist's record, the physician asked the Veteran about his "HLA-B27" status (a test for autoimmune disorders such as reactive arthritis) and the Veteran declined further testing explaining that he no longer had interest in the matter. The October 2013 VA examination report was based upon thorough examination of the Veteran and analysis of the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) [the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"]. Additionally, the VA examiner's opinion is consistent with the Veteran's documented medical history, which is absent any report of symptomatology consistent with a back disability or Reiter's syndrome/reactive arthritis for more than 25 years after active service. The examiner also noted the Veteran's in-service treatment for back pain and Reiter's syndrome which he determined to be less likely as not related to the current degenerative joint disease of the lumbar spine and Reiter's syndrome. The Board observes that the Veteran has submitted medical articles pertaining to the development of arthritis and Reiter's syndrome. As discussed above, medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin, supra; see also 38 C.F.R. § 3.159(a)(1), supra. However, the articles submitted by the Veteran are of a general nature, do not contain any information or analysis specific to the Veteran's case, and are substantially not supportive as they report that Reiter's syndrome resolves in most cases in several months. Additionally, the Court has held that medical evidence which is speculative, general, or inconclusive in nature cannot support a claim. See Jones, Beausoleil, and Libertine, all supra. As discussed in detail above, the Board has evaluated the medical evidence of record, to include the June 1964 separation examination which revealed normal orthopedic findings as well as the remainder of evidence which does not indicate complaint of or treatment following service for many years for the disabilities discussed herein. The Board has therefore placed great probative value on the October 2013 VA examination in particular. As such, the medical articles submitted by the Veteran are of little or no probative value, and, to the extent that there is any probative value, is greatly outweighed by the VA examination report. The Board notes that the Veteran, while entirely competent to report his symptoms both current and past, such as pain, has presented no clinical evidence of a nexus between his current back disability and Reiter's syndrome/reactive arthritis and service. The Board finds that the Veteran as a lay person is not competent to associate any of his claimed symptoms to his service. That is, the Veteran is not competent to opine on matters such as the etiology of his current back disability and Reiter's syndrome/reactive arthritis. Such opinion requires specific medical training in the field of orthopedics and is beyond the competency of the Veteran or any other lay person. In the absence of evidence indicating that the Veteran has this medical training required to render medical opinions, the Board must find that his contention with regard to a nexus between his back disability and Reiter's syndrome/reactive arthritis and service to be of minimal probative value and outweighed by the objective evidence of record which does not support such a finding. See 38 C.F.R. § 3.159(a)(1) (2016) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. Accordingly, the statements offered by the Veteran in support of his own claims are not competent evidence of a nexus. The Board is aware of the provisions of 38 C.F.R. § 3.303(b), discussed above, relating to chronicity and continuity of symptomatology. To the extent that the Veteran contends that he has had a back disability or other joint symptoms continually since service, as mentioned above, the first postservice evidence of complaint of, or treatment for this disability is more than 25 years after the Veteran left service in August 1964. The Board finds that the probative value of the Veteran's current statements regarding a continuity of back and joint symptomatology since service are outweighed by the remainder of the evidence of record. In particular, the Veteran's June 1964 separation examination which revealed a normal spine and joints examination as well as the October 2013 VA examination outweigh any assertion that his current back disability in particular was manifested during service. There is no competent medical evidence that the Veteran complained of or was treated for a back or joint disability for more than 25 years after his separation from service. The Board accordingly places no probative value on the assertions of the Veteran that there has been a continuity of symptomatology dating to service. Therefore, continuity of symptomatology after service is not demonstrated. For the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for a back disability and Reiter's syndrome/reactive arthritis. The benefits sought on appeal are accordingly denied. ORDER The application to reopen the claim for service connection for residual scars, first degree burns of the face is denied. Entitlement to service connection for Reiter's syndrome/reactive arthritis (claimed as joint pain) is denied. Entitlement to service connection for ischemic heart disease is denied. Entitlement to service connection for aortic insufficiency is denied. Entitlement to service connection for mitral valve regurgitation is denied. Entitlement to service connection for pulmonary hypertension is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for a back disability is denied. Entitlement to service connection for an acquired psychiatric disorder, to include depression is denied. REMAND With respect to the Veteran's claim of entitlement to an initial compensable disability rating for a bilateral hearing loss disability, he was most recently provided a VA examination for this disability in October 2010. The Veteran subsequently submitted VA audiology reports dated January 2015 and October 2015 and test results obtained in August 2012 from a private audiologist which indicated a worsening of the bilateral hearing loss disability. Indeed, the private testing did not clearly indicate speech discrimination testing was by the specified Maryland CNC method but did suggest worsening acuity. The October 2015 VA treatment record in particular documents the Veteran's report of a reduced benefit of his hearing aids, and a review of audiometric testing conducted at that time reveals worse hearing compared to the October 2010 VA examination. In light of the foregoing, the Board finds that the Veteran should be provided a VA audiological examination on remand in order to determine the current severity of his bilateral hearing loss disability. See Snuffer v. Gober, 10 Vet. App. 400 (1997) [a veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination]. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Schedule the Veteran for a VA audiological examination in order to assist in determining the current level of severity of his bilateral hearing loss disability. Any and all studies, tests, and evaluations deemed necessary by the examiner, including the Maryland CNC test and a puretone audiometry test, should be performed. The examiner is requested to review all pertinent records associated with the claims file and to comment on the severity of the Veteran's service-connected bilateral hearing loss to include a description of the effects of the Veteran's bilateral hearing loss on his occupational functioning and daily activities. 2. When the development requested has been completed, the case should be reviewed on the basis of additional evidence. If the benefit sought is not granted, the Veteran and his attorney should be furnished a supplemental statement of the case (SSOC) and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. See 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 2014). ______________________________________________ J.W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs