Citation Nr: 1755036 Decision Date: 11/30/17 Archive Date: 12/07/17 DOCKET NO. 10-25 670 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Whether the rating reduction from 60 percent to 10 percent for residuals of prostate cancer, post-operative radical prostatectomy, from August 1, 2013, to November 20, 2013, was proper. 2. Entitlement to a disability rating in excess of 60 percent prior to August 1, 2013, and in excess of 10 percent from August 1, 2013, to November 20, 2013. 3. Entitlement to a disability rating in excess of 40 percent from November 21, 2013. 4. Entitlement to service connection for headaches. 5. Entitlement to service connection for congestive heart failure, to include as due to herbicide exposure. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD Saudiee Brown, Associate Counsel INTRODUCTION The Veteran had active duty service from September 1967 until September 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from July 2009 and May 2013 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Board previously remanded the claims for service connection for headaches and congestive heart failure in May 2016. The Board did not adjudicate the Veteran's increased rating claims based on the fact that the Veteran was scheduled for a hearing on those claims. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in July 2017. The Board notes that the Veteran testified only to his increased rating claims. The Board also notes that the Veteran's wife, C.M., was present as a witness at that hearing. A transcript of the hearing is of record. The Board notes that the Veteran mentioned in his July 2017 Board hearing that he had depression that he felt was secondary to his service-connected residuals of prostate cancer, post-operative radical prostatectomy. Thus, the Board requests the RO to contact the Veteran and provide the information necessary to file a claim if he wishes to do so. FINDINGS OF FACT 1. The reduction in the disability rating assigned to the residuals of prostate cancer, post-operative radical prostatectomy effective August 1, 2013, was not supported by evidence demonstrating improvement in the disorder. 2. Throughout the current appeal period, the Veteran's residuals of prostate cancer, post-operative radical prostatectomy required use of an appliance. 3. The Veteran's headaches are not shown to be causally or etiologically related to any disease, injury, or incident during service. 4. The Veteran's congestive heart failure is not included in the herbicide presumption list and is otherwise not shown by the evidence to be related to service. CONCLUSIONS OF LAW 1. The reduction from 60 percent to 10 percent for residuals of prostate cancer, post-operative radical prostatectomy, from August 1, 2013, to November 20, 2013, is void, and the 60 percent rating is restored. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.105, 3.344 (2017). 2. The Veteran's residuals of prostate cancer, post-operative radical prostatectomy meet the criteria for a 60 percent rating (but no higher) throughout the appeal period. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321 (b)(1), 4.1, 4.21, 4.115a, 4.115b, Diagnostic Code 7527 (2017). 3. The Veteran's headaches were not incurred in or aggravated by the Veteran's active duty military service. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2016). 4. The Veteran's congestive heart failure was not incurred in or aggravated by the Veteran's active duty military service. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). II. Reductions With regard to rating reduction matters, VA regulations provide that where the reduction in the rating of a service-connected disability is considered warranted and the lower rating would result in a reduction or discontinuance of compensation payments currently being made, a rating action will be taken. A veteran will be notified of the proposed reduction and that he or she has 60 days in which to present evidence showing why the reduction should not be implemented and to request a hearing. The reduction will be made effective the last day of the month during which the 60-day period expires. 38 U.S.C.A. § 5112 (b) (6); 38 C.F.R. § 3.105 (2016). In this case, the Veteran's compensation payments were reduced; therefore, the procedural requirements were for application. The Board notes that the RO fully complied with the procedural requirements. In addition, the provisions of 38 C.F.R. § 3.344 (a) and (b), which apply to evaluations in effect for five years or more, are not for application. The Veteran's 60 percent disability rating was in effect for less than five years. Rather, the provisions of 38 C.F.R. § 3.344 (c) apply in this case, which provide that, with respect to a disability rating in effect for less than five years, re-examinations disclosing improvement will warrant a rating reduction. The May 2013 rating decision reduced the Veteran's assigned disability rating for residuals of prostate cancer, post-operative radical prostatectomy from 60 percent to 10 percent on the basis that the August 2012 VA examination showed residuals of voiding dysfunction that did not require the wearing of absorbent material and a voiding dysfunction that caused increased urinary frequency of daytime voiding intervals between 2 and 3 hours. The issue in this case is whether the rating reduction was proper due to improvement of the service-connected disability. VA regulations require that each disability be viewed in relation to its history. 38 C.F.R. § 4.1 (2016). The provisions of 38 C.F.R. § 4.2 establish that it is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. Furthermore, 38 C.F.R. § 4.13 provides that the rating agency should assure itself that there has been an actual change in the condition, for better or worse, and not merely a difference in the thoroughness of the examination or in use of descriptive terms. In any rating reduction case, not only must it be determined that an improvement in a disability has actually occurred, but that such improvement reflects improvement in ability to function under ordinary conditions of life and work. See Brown v. Brown, 5 Vet. App. 413, 420-421 (1993). In December 2010, the Veteran underwent surgery for the placement of an artificial urinary sphincter appliance. There was an additional surgery performed January 2011 due to exposed tubing from the previous surgery and a possible infection with an incompletely healed surgical wound, which called for the removal of the artificial urinary sphincter and penile implant with secondary infection. After healing, the Veteran reported continued urinary incontinence requiring about 3 pads per day and was open to replacement of artificial urinary sphincter. In November 2011, a second artificial urinary sphincter replacement surgery was performed. A December 2011 follow up showed a well healed incision with the activation of the artificial urinary sphincter appliance. In the Veteran's July 2017 Board hearing, the Veteran's wife, C.M., testified that the Veteran has used an appliance since his second surgery installation. In addition, the Veteran continued to change a pad over 4 times per day. In this case, based on the history of the Veteran's residuals of prostate cancer, post-operative radical prostatectomy, clinical findings and the Veteran's reported symptoms and functional impairment, the Board finds that the Veteran's disability rating should not have been reduced. The purpose behind the provisions of 38 C.F.R. § 3.344 is to ensure there is actual improvement in a disability before reduction. Again, in all rating reduction cases, the Board must consider the recorded history of the disability, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. See 38 C.F.R. § 4.2; see also Brown, 5 Vet. App. 413 (1993). The Board must also consider whether the evidence reflects actual improvements in the ability to function under ordinary conditions of life and work. See Brown, id. While the August 2012 examination showed a lack of need for using absorbent material, this is not necessarily indicative of improvement under ordinary conditions of life and work. Specifically, the Veteran still used an appliance. Since his original rating assignment, the Veteran continues to assert that his disability has worsened and not improved over time. In reviewing all of the evidence and resolving the benefit of the doubt in favor of the Veteran, the Board does not find improvement in the Veteran's disability. Accordingly, the 60 percent rating is restored effective August 1, 2013, the date the reduction took place. 38 U.S.C.A. § 5107 (b); see Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). III. Increased Rating Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2016). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1999). In Fenderson v. West, 12 Vet. App. 119 (1999), however, the Court of Appeals for Veterans Claims (Court) held that the rule does not apply where the Veteran has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson, 12 Vet. App. at 126. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Analysis The Veteran's residuals of prostate cancer, post-operative radical prostatectomy is currently assigned an initial 40 percent evaluation from September 29, 2008, 100 percent evaluation from December 8, 2010, 40 percent evaluation from February 1, 2011, a temporary total evaluation from November 21, 2011, 60 percent evaluation from January 1, 2012, 10 percent evaluation from August 1, 2013, and 40 percent from November 21, 2013. The disability is rated pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7527 for prostate gland injuries, infections, hypertrophy, and postoperative residuals. Diagnostic Code 7527 indicates that these disabilities are to be rated as voiding dysfunction or urinary tract infections, whichever is predominant. Voiding dysfunction is rated under the three subcategories of urine leakage, urinary frequency, and obstructed voiding. 38 C.F.R. § 4.115a. For urine leakage, a 20 percent evaluation is assigned for continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence requiring the wearing of absorbent material which must be changed less than 2 times per day. A 40 percent rating is assigned where the wearing of absorbent materials must be changed 2 to 4 times per day. The maximum rating of 60 percent is warranted when there is urinary leakage requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day. For urinary frequency, a 20 percent rating is assigned for daytime voiding intervals between one and two hours, or; awakening to void three to four times per night. A maximum 40 percent evaluation is assigned for daytime voiding intervals less than one hour, or; awakening to void 5 or more times per night. For obstructed voiding, a 30 percent rating requires urinary retention requiring intermittent or continuous catheterization. 38 C.F.R. § 4.115a (2016). For urinary tract infection, a 10 percent evaluation is warranted when there is long-term drug therapy, one to two hospitalizations per year, and/or intermittent intensive management is required. A 30 percent evaluation is warranted when there is recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or continuous intensive management. If urinary tract infections result in poor renal function, the disorder is rated as renal dysfunction. Id. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that a 60 percent evaluation is warranted for the Veteran's residuals of prostate cancer, post-operative radical prostatectomy for the time period beginning prior to August 1, 2013, from August 1, 2013 to November 20, 2013, and from November 21, 2013. In January 2008, a VA treatment discharge summary note showed a diagnosis of prostate cancer and multiple blood antibodies. The Veteran underwent a radical retropubic prostatectomy with bilateral lymph node dissection. In September 2008, a VA treatment note showed that the Veteran was voiding well but used 2 to 3 pads per day. In November 2008, the Veteran was afforded a VA examination for his claim. The Veteran had no frequency, dysuria, or hematuria. He reported occasional urgency and had leakage every day all the time. He averaged 3 pads per day but always took extra pads with him. He wore 1 pad at night. The Veteran was diagnosed with prostate cancer status post retropubic radical prostatectomy with residuals of leakage, stress incontinency and erectile dysfunction. In a January 2009 VA treatment note, the Veteran stated he was voiding well and had some leakage. He used 2-3 pads per day. In January 2010, a VA treatment note showed that the Veteran denied dysuria, hematuria and new bone pain. The Veteran took Ditropan for his stress urinary incontinence and used 5 pads per day. In December 2010, a VA treatment note showed that the Veteran underwent an artificial urinary sphincter placement and inflatable penile prosthesis placement. In January 2011, a VA treatment note showed an infected artificial urinary sphincter and inflatable penile prosthesis. The Veteran underwent an explantation of artificial urinary sphincter implantable penile prosthesis. In November 2011, a VA treatment note showed that the Veteran underwent another placement of artificial urinary sphincter. In a June 2011 private treatment note, the Veteran reported difficulty with urination and requiring 4 pads per day. An appliance was needed intermittently. There was no dysuria, straining or hematuria. The Veteran denied recurrent urinary tract infections and obstructed voiding. There was no history of renal dysfunction or renal failure. There was no acute nephritis or any history of hydronephrosis. The private physician diagnosed the Veteran with prostate cancer, in remission, status post prostatectomy status post prostate surgery with residual erectile dysfunction, urinary incontinence, bilateral testicle tenderness and well-healed scar. The private physician stated that the Veteran could not walk long distances because he needed a nearby restroom for urination and could not lift over 20 to 25 pounds. In September 2013, a disability benefits questionnaire was completed regarding the Veteran's claim. The examining physician noted the Veteran underwent a procedure for placement of an artificial sphincter and penile prosthesis. It was also noted that the Veteran required the use of an appliance but still had voiding dysfunction that caused urine leakage despite the artificial sphincter. The Veteran required absorbent material which was changed 2 to 4 times per day. In November 2013, the Veteran testified at an RO hearing that he changed his absorbent material about 4 times per day and used an appliance to help with his voiding dysfunction. The Veteran reported that he worked two days a week about four hours per day due to his voiding dysfunction. He said that he spent more time in the restroom than actually working. He denied urinary tract infections. In November 2013, the Veteran was afforded another VA examination regarding his claim. The examiner noted that the Veteran underwent placement of both a penile prosthesis and artificial urinary sphincter and found that the Veteran had worsening urinary incontinence. He had to wear absorbent pads and wore two pairs of underwear. The Veteran reported requiring absorbent material that had to be changed 2 to 4 times per day. The Veteran did not have a history of recurrent symptomatic urinary tract or kidney infections. Examination of the external genitalia revealed that the penile prosthesis was in place, the testicles were normal, and he was truly incontinent of urine - when he stood up, urine flowed freely from the urethral meatus which the Veteran could not control. The examiner stated that the Veteran had significant urinary incontinence requiring absorbent pads and extra underwear as well as daily Oxybutynin. The artificial urinary sphincter did not work well and he continued to suffer from erectile dysfunction despite placement of the penile prosthesis in 2011. He also could not tolerate oral medications due to his heart problems. The examiner opined that the Veteran's residuals from his prostate cancer surgery remained considerable, and despite two surgical procedures, he remained quite symptomatic and uncomfortable. In July 2017, the Veteran testified at his Board hearing that he continued to have leakage despite the appliance he used. He asserted that the appliance overflowed his leakage and he used the restroom regularly to relieve the overflow. He also used pads. The Veteran's wife, C.M., testified that the Veteran started wearing black pants because of his constant leakage. C.M. stated that before implementing the appliance the Veteran changed pads about 8 times per day, and since the implement about 2 to 3 times during the day and 1 to 2 times at night. She also stated that he saw the doctor every 3 months and recently had Botox injections which somewhat helped. The Veteran denied any urinary tract infections. Overall, the evidence of record shows that the Veteran has consistently needed an appliance since December 2010. Thus, the Veteran has been shown to meet the criteria for a 60 percent evaluation for urinary leakage. The Board has also considered whether an evaluation in excess of 60 percent is warranted. However, a 60 percent evaluation is the maximum schedular evaluation available for urine leakage. Similarly, the maximum rating for urinary frequency is 40 percent, and the maximum evaluation for obstructed voiding is 30 percent. Moreover, the Veteran denied urinary tract infections where the maximum evaluation for this disability is 30 percent. In addition, there is no indication that the Veteran has renal dysfunction. As such, there is no basis to award an evaluation in excess of 60 percent for any of the periods on appeal. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Total Disability Rating Based on Individual Unemployability The record reveals that the Veteran testified to work limited hours as a janitor based on his residuals prostate disability at his November 2013 RO hearing; however, the record does not reveal that the Veteran is claiming to be rendered unemployable by virtue of his disabilities, and the Board finds that the record has not raised an implied claim for a total disability rating based on individual unemployability due to service-connected disabilities pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). IV. Service Connection Service connection may be granted 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 (a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Direct service connection may be granted with evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303 (b) by evidence of (i) the existence of a chronic disease in service during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or evidence of continuity of symptomatology. If the disability claimed is not considered to be a chronic disease under 38 C.F.R. § 3.307, credible lay evidence of continuous symptoms may establish service connection. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In addition, under 38 C.F.R. sections 3.307 (a)(6) and 3.309(e), certain diseases may be presumed to be related to exposure to herbicides, absent affirmative evidence to the contrary. Id. In this regard, the Board notes that ischemic heart disease includes, but is not limited to, "acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina." 38 C.F.R. § 3.309 (e); see also 75 Fed. Reg. 53,202, 53,216 (Aug. 31, 2010). However, Note 3 provides that for purposes of this section, the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. Headaches The Veteran asserts that his headaches disability is due to his active duty service. Service treatment records show that the Veteran was treated during service in February 1968 for reported frontal headaches that had been ongoing since he was struck in the head and lost consciousness in December 1967. Subsequent service treatment records dated August 1968 note complaints of ongoing frontal headaches. In September 2010, the Veteran was afforded a VA examination for his claim. The Veteran reported to the examiner that he had been experiencing on and off headaches since 1968. He described, however, that his headaches had become essentially constant over the past six or seven years. Based on reported and noted history and findings from the examination, the VA examiner diagnosed tension headaches. The examiner opined that it was less likely as not that the tension headaches were related to the Veteran's active duty service because the Veteran did not report or demonstrate headaches during his September 1970 separation examination. In the May 2016 Board remand, the Board found this opinion to be inadequate as the examiner rested his decision entirely on the lack of headaches on the Veteran's separation examination, and did not address the Veteran's lay statements or explanation as to why he distinguished the Veteran's current tension headaches from the headaches treated during service. In September 2016, the Veteran was afforded another VA examination for his claim. The examiner diagnosed the Veteran with tension headaches. The Veteran stated the onset of his headaches was in 2014 which was gradual. He described throbbing headaches occurred 2 to 3 times per week. The examiner opined that the Veteran's claimed headaches were less likely than not due to the Veteran's active duty service. The examiner reasoned that the Veteran's service records showed that the Veteran was seen in the emergency room in February 1968 for complaint of headache from a blow on head with transient loss of consciousness. He was diagnosed with post concussive headache. The Veteran was seen again in August 1968 for complaint of frontal headache unrelieved by Anacin. The remainder of the Veteran's in-service medical records was silent for complaints of headaches. The Veteran's separation physical in September 1970 showed no complaints of headache. Review of the Veteran's interval medical record from 2001 to 2011 showed that he consistently denied headaches in the review of systems. The examiner stated that there was a 30 year interval before the Veteran complained of headaches as shown in an August 2011 nursing note in which the Veteran complained of ringing in his ears and intermittent headaches and requested an audiology consult. Given the long interval between the initial injury in service and the recent complaints it was less likely than not that the two were related. The Veteran has offered his own opinion on etiology, stating that he currently has a headache condition that is causally related to his active service. The Board acknowledges that the Veteran is competent to describe his symptoms without any specialized knowledge or training. Layno v. Brown, 6 Vet. App. 465 (1994). However, as a layperson, the Veteran is not competent to diagnose his symptoms as a specific disease, nor is he competent to render a nexus opinion regarding the etiology of any current disorder; both of these determinations require medical expertise. Jandreau v. Nicholson, 492 F.3d at 1372 (Fed. Cir. 2007). Therefore, the Board affords more probative weight to the VA examiners' opinions as a whole than the Veteran's own contentions, and there are no medical opinions to the contrary. The Board has considered the doctrine of giving the benefit of the doubt to the Veteran, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert, 1 Vet. App. at 54-56. Therefore, the preponderance of the evidence is against the claim for service connection; there is no doubt to be resolved. Service connection for headaches is not warranted. Congestive Heart Failure The Veteran asserts that his congestive heart failure is due to service to include as due to herbicide exposure. The Veteran's DD 214 shows that the Veteran served in Vietnam from October 26, 1969 to September 3, 1970. Therefore, the Board concedes exposure to herbicides during service. Preliminary, the Board notes that the Veteran is not entitled to service connection for congestive heart failure on a presumptive basis. Service treatment records are absent for complaints, treatment or diagnosis of a heart condition. In addition, there is no note of treatment for congestive heart failure within one year of service. Finally, congestive heart failure does not fall under the list of presumptive diseases and there is no diagnosis of ischemic heart disease as shown below. The evidence shows that an echocardiogram in December 1990 indicated possible inferior infarct, abnormal. In July 2001 the Veteran was treated for congestive heart failure with malignant hypertension. In a January 2002 VA treatment record, the VA physician indicated cardiomyopathy most likely secondary to graves and hypertension. Echocardiogram showed diastolic dysfunction and the stress test was negative for ischemia. A December 2002 VA treatment note mentioned ischemic cardiomyopathy but gave a diagnosis of dilated cardiomyopathy caused by hypertension or hyperthyroidism. In November 2007, a VA treatment note diagnosed the Veteran with congestive heart failure with medication. In May 2009, a VA treatment note indicated a history of congestive heart failure and no definite history of coronary artery disease. Records for subsequent VA treatment received by the Veteran through January 2014 reflect that the Veteran has been followed medically for this heart condition. Nonetheless, those records provide no opinion as to the cause or origin of the Veteran's heart condition. In February 2013, the Veteran was afforded a VA examination. The VA examiner noted the Veteran's medical history, including previous echocardiogram, radiological, and exercise stress test results and diagnosed the Veteran with congestive heart failure. The examiner opined that the Veteran's congestive heart failure was secondary to his hypertension. In the May 2016 Board remand, the Board found that the examiner did not provide an adequate reasoning or rationale for this opinion and thus the expressed diagnosis and opinion were considered incomplete. In September 2016, the Veteran was afforded another VA examination for his claim. The examiner noted a diagnosis of congestive heart failure in 2001. The examiner also noted that the Veteran's functional limitation of condition was reduced capacity for tasks that required strenuous physical activity. The examiner stated that the Veteran's congestive heart failure was related to the his hypertension. The examiner opined that the Veteran's claimed heart condition to include congestive heart failure was less likely than not incurred during active duty service. The examiner reasoned that there was no evidence in the Veteran's available service treatment record of complaint or treatment for a heart condition. Further, the examiner opined that the Veteran's congestive heart failure was less likely than not the result of an injury or even to include herbicide exposure, which occurred during active duty service. The examiner reasoned that there was no evidence of treatment or complaint of heart condition during service. In addition, under the authority granted by the Agent Orange Act of 1991, VA determined that presumption of service connection based on exposure to herbicides used in Vietnam was not warranted for any conditions other than those for which VA found a positive association between the condition and such exposure. VA determined that a positive association existed between exposure to herbicides and ischemic heart disease. The Veteran's initial symptoms started in 2001. A discharge note dated July 2001 reported diagnosis as malignant hypertension with congestive heart failure and dilated cardiomyopathy due to hypertension. Although the Veteran was diagnosed with ischemic cardiomyopathy in 2002, which is a term used to describe patients show heart can no longer pump enough blood to the rest of their body due to coronary artery disease, no coronary artery disease was found. Further testing to include stress test completed September 2013 showed no ischemic changes. The examiner stated that the Veteran did not have ischemic heart disease. Accordingly, presumptive service connection based on the Veteran's in-service herbicide exposure is not established, as he does not have ischemic heart disease, and his diagnosed congestive heart failure is not included among the diseases qualifying for the presumption under § 3.309(e). In addition, there is no competent evidence suggesting that the Veteran's presumed exposure to herbicides during active service led to the development of his congestive heart failure many years later. This long period of time weighs against a relationship to service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that a proper consideration for the trier of fact is the amount of time that has elapsed since military service in terms of whether a condition was incurred therein). Because the Veteran's congestive heart failure did not manifest during service or until many years after separation, service connection may not be established based on a chronicity in service or a continuity of symptoms after service, or on a presumptive basis for a chronic disease that manifests to a compensable degree within one year of separation. See 38 C.F.R. §§ 3.303 (b), 3.307(a), 3.309(a). In addition, evidence shows that the Veteran's congestive heart failure is not directly related to service. The Veteran has offered his own opinion on etiology, stating that he currently has congestive heart failure that is causally related to his active service. The Board acknowledges that the Veteran is competent to describe his symptoms without any specialized knowledge or training. Layno, 6 Vet. App. 465. However, as a layperson, the Veteran is not competent to diagnose his symptoms as a specific disease, nor is he competent to render a nexus opinion regarding the etiology of any current disorder; both of these determinations require medical expertise. Jandreau, 492 F.3d at 1372. Therefore, the Board affords more probative weight to the VA examiners' opinions as a whole than the Veteran's own contentions, and there are no medical opinions to the contrary. The Board has considered the doctrine of giving the benefit of the doubt to the Veteran, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert, 1 Vet. App. at 54-56. Therefore, the preponderance of the evidence is against the claim for service connection; there is no doubt to be resolved. Service connection for congestive heart failure is not warranted. ORDER 1. The reduction of the evaluation from 60 percent to 10 percent for residuals of prostate cancer, post-operative radical prostatectomy, from August 1, 2013, to November 20, 2013, was improper; the 60 percent evaluation is restored, effective August 1, 2013. 2. Entitlement to a 60 percent rating (but no higher) for residuals of prostate cancer, post-operative radical prostatectomy throughout the appeal period is granted. 3. Entitlement to service connection for headaches is denied. 4. Entitlement to service connection for congestive heart failure, to include as due to herbicide exposure is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs