Citation Nr: 1802745 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 13-06 620A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) 2. Entitlement to an initial rating in excess of 30 percent for service-connected coronary artery disease (CAD). 3. Entitlement to service connection for a right lower extremity disability, to include as secondary to service-connected CAD and as a result of herbicide exposure. 4. Entitlement to service connection for a left lower extremity disability, to include as secondary to service-connected CAD and as a result of herbicide exposure. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A.M. Clark, Counsel INTRODUCTION The Veteran served on active duty from October 1966 to October 1968, including confirmed service in the Republic of Vietnam. This case comes before the Board of Veterans' Appeals (Board) on appeal from September 2011 (lower extremities) and August 2013 (CAD) rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. This case was previously before the Board in July 2016, when the claims listed above were remanded for further development. Additional claims concerning entitlement to service connection for peripheral neuropathy of the bilateral upper extremities and tinnitus, and entitlement to an increased rating for service-connected posttraumatic stress disorder (PTSD) were adjudicated at that time. The Veteran subsequently filed an appeal to the United States Court of Appeals for Veterans Claims (Court) with respect to his increased rating claim for PTSD. A Joint Motion was granted and the Board readjudicated the PTSD claim in August 2017. With respect to his claims listed on the title page above, an October 2017 supplemental statement of the case was most recently issued, and the case is once again before the Board. A review of the evidence reflects that the issue of a TDIU has been raised by the record. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a TDIU claim is part of an increased rating claim when such claim is reasonably raised by the record. In light of evidence associated with the Veteran's claims file during the appeal period, the Board finds that the issue of entitlement to a TDIU is reasonably raised by the record and considered to be part of the Veteran's appeal for an increased rating for his service-connected disability, as is reflected on the title page of this decision. The issue of entitlement to service connection for an implantable cardiac pacemaker has been raised by the record in a July 2013 Ischemic Heart Disease Disability Benefits Questionnaire, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2017). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. The Veteran's service-connected disabilities preclude him from securing or following a substantially gainful occupation. 2. Throughout the rating period on appeal, the Veteran's CAD did not result in one episode of acute congestive heart failure, or more nearly approximate a workload greater than 3 metabolic equivalents (METs) but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope or reflect evidence of left ventricular dysfunction with ejection fraction of 30 to 50 percent. 3. The Veteran served in the Republic of Vietnam during the Vietnam War and is presumed to have been exposed to certain herbicide agents. 4. Peripheral neuropathy of the lower extremities did not manifest during service or within one year of separation or within a year after the date of his last exposure to herbicide agents. The competent and credible evidence of record fails to establish an etiological relationship between the Veteran's bilateral lower extremity disability and his active service or his service-connected CAD. CONCLUSIONS OF LAW 1. The criteria for a total disability rating based on individual unemployability have been met. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). 2. The criteria for an initial rating in excess of 30 percent for CAD have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.10, 4.104, Diagnostic Code (DC) 7005 (2017). 3. A right lower extremity disability was not incurred in or aggravated by active service, and an organic disease of the nervous system may not be presumed to have been incurred therein, nor is it due to the presumed exposure to herbicides in the Republic of Vietnam or proximately due to or the result of the Veteran's service-connected CAD. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1154 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 4. A left lower extremity disability was not incurred in or aggravated by active service, and an organic disease of the nervous system may not be presumed to have been incurred therein, nor is it due to the presumed exposure to herbicides in the Republic of Vietnam or proximately due to or the result of the Veteran's service-connected CAD. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1154 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Assist and Notify As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). There is no indication in this record of a failure to notify. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Pursuant to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities. 38 U.S.C. § 5103A(c)(2). All records pertaining to the conditions at issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the Veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159(c)(3)). In this case, the Veteran has referenced no such records, and all pertinent records have been obtained. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service treatment records, VA examination reports, and private examination reports. Next, the Veteran was afforded VA examinations for his CAD in October 2010, June 2012, July 2013, and May 2017, and an addendum opinion was obtained in October 2017. The duty to assist does not require that a claim be remanded solely because of the passage of time as an otherwise adequate examination was conducted. VAOPGCPREC 11-95. Here, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's CAD since the most recent examinations. The Board finds the examinations already of record to be thorough and adequate upon which to base a decision with regard to the Veteran's claim. The examiners personally interviewed and examined the Veteran (including eliciting a history from him), and provided the information necessary to evaluate his disability under the applicable rating criteria. The Veteran was also afforded VA examinations in May 2017 with an addendum opinion in October 2017 with respect to his claims for service connection for a right lower extremity disability and for a left lower extremity disability. For the reasons discussed below, the examinations are adequate because the advanced practice nurse who conducted the examinations and provided opinions as to the etiology of the Veteran's right and left lower extremity disabilities supported her conclusions with an analysis that is adequate for the Board to consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). In a December 2017 post-remand brief, the Veteran's representative argued that that the examinations were inadequate because the VA examiner is an advance practice nurse and not a doctor. In essence, it is argued that the Veteran should have been examined by a vascular surgeon and a cardiologist. While the Veteran's representative is correct that an advance practice nurse conducted the most recent examinations of record, this does not render the examinations inadequate, for several reasons. First, the Veteran's representative has made no specific argument as to why an advanced practice nurse does not have appropriate expertise to conduct an examination to determine whether a current right and left lower extremity disability is related to CAD and/or service. The Veteran's representative has therefore not met his burden of rebutting the presumption that the advance practice nurse was competent. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (explaining that "the Board is entitled to assume the competence of a VA examiner," and the appellant bears the burden of rebutting the Board's presumption of competence). Moreover, the Court has specifically held that a trained health care professional may provide competent medical evidence as long as the examination and opinions themselves are not incomplete or otherwise insufficient. Id. Finally in this regard, the discussion below reflects that the advance practice nurse prepared examination reports that discussed the Veteran's medical history, included relevant examination findings, and indicated the reasons for the opinions given based on an accurate characterization of the evidence of record. The Board therefore finds that the advance practice nurse had appropriate expertise as instructed by the Board to answer the medical questions at issue in this case, and a remand for new VA examinations is not warranted. A Court or Board remand confers upon the Appellant the right to compliance with that order. Stegall v. West, 11 Vet. App. 268, 271 (1998). As already noted, the matter was most recently remanded in July 2016. These actions were accomplished, and there has been substantial compliance with the July 2016 remand. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). The Board concludes that all the available records and medical evidence have been obtained in order to make an adequate determination as to these claims. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. TDIU Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1). TDIU is granted where a Veteran's service-connected disabilities are rated less than total, but prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16 (2017). Evidence of record reflects that the Veteran last engaged in substantially gainful employment in March 1998. See VA Form 21-8940. The evidence reflects that the Veteran suffers from service-connected posttraumatic stress disorder (PTSD), rated as 70 percent disabling from October 19, 2010; coronary artery disease (CAD), rated as 30 percent diabling from August 21, 2010, and tinnitus, rated as 10 percent disabling from August 24, 2011. The Veteran's service-connected disabilities meet the threshold schedular criteria for consideration of TDIU since October 19, 2010. 38 C.F.R. § 4.16(a). The Veteran has submitted an October 2017 evaluation by Dr. W. She noted that the Veteran was her patient and she had taken over the care of the Veteran from his previous physician who followed him for 30 years. She noted that he had been treated for a variety of chronic medical problems including CAD and PTSD. She indicated that the Veteran had been unable to work since March 1998. The treating physician stated at the time the Veteran was last working he was suffering a great deal from PTSD and having recurrent chest pains that would not allow him to work. She stated that it was later determined that the chest pains were related to his CAD. She opined that the Veteran would not be able to return to work. In light of the Veteran's occupational background and functional limitations, and giving him the benefit of the doubt, the Board finds that the Veteran's service-connected disabilities, when considered together, are sufficient to render him unable to obtain and maintain any form of substantially gainful employment in accordance with his occupational background and education level throughout the period on appeal, and specifically, since October 19, 2010 when he first met the schedular criteria. Accordingly, based on all of the foregoing, the Board finds that entitlement to a TDIU is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. III. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). The Board should consider only those factors contained in the rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2017). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran is currently assigned a 30 percent disability rating for coronary artery disease pursuant to DC 7005. Diagnostic Code 7005 provides ratings for arteriosclerotic heart disease (coronary artery disease), and requires documented coronary artery disease. Arteriosclerotic heart disease resulting in workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray, is rated 30 percent disabling. Arteriosclerotic heart disease resulting in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent, is rated 60 percent disabling. Arteriosclerotic heart disease resulting in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent, is rated 100 percent disabling. 38 C.F.R. § 4.104, DC 7005 (2017). A Note to Diagnostic Code 7005 provides that, if non-service-connected arteriosclerotic heart disease is superimposed on service-connected valvular or other non-arteriosclerotic heart disease, the adjudicator is to request a medical opinion as to which condition is causing the current signs and symptoms. 38 C.F.R. § 4.104. The Veteran underwent a VA examination in October 2010. The Veteran reported at least a mild degree of orthopnea or difficulty breathing in the supine position. He stated that he is easily fatigued and his activities of daily living are generally confined to just walking slowly, weather permitting, and avoiding stairs. It was noted that he did have nocturia rather often at night. The VA examiner noted that the Veteran had not had a coronary artery bypass grafting/surgery. A physical examination revealed that his lungs were clear and his heart had normal sinus rhythm. A firm circular object in the left infraclavicular area consistent with his implanted pacemaker was noted. The VA examiner estimated that the Veteran would function at the 1-3 MET level only, given his extensive history of myocardial necrosis and related stenting times seven. The Veteran underwent an additional examination in June 2012. It was noted that there was at least one hospitalization for chest pain which resulted in a normal cardiac work up on April 15, 2010. The VA examiner noted no congestive heart failure. The VA examiner indicated that an echocardiogram was being ordered. The Veteran underwent an additional examination in July 2013. The VA examiner noted that the Veteran did not have congestive heart failure. The VA examiner estimated that the Veteran's METs were greater than 5 but not greater than 7. It was noted that this METs level would be consistent with activities such as golfing (without a cart), mowing lawn (push mower), heavy yard work (digging). The examiner report reflects there was no evidence of cardiac hypertrophy or dilatation. The VA examiner noted that in his medical opinion the estimated METs workload reflects only cardiac function without regard to other limiting medical problems. He noted that the Veteran is unable to exercise due to neck and back and knee arthritis and morbid obesity. He noted that there has been no medical indication for a repeat Echo or stress cardiac imaging since 2010 and symptoms and medications have been stable (angina free). The VA examiner noted that the Veteran sees his community internist and cardiologist regularly. The Veteran attended an additional VA examination in May 2017. It was noted that the Veteran was on continuous medication for his heart condition. The VA examiner noted that the Veteran did not have congestive heart failure. It was noted that the Veteran had an implanted cardiac pacemaker. The VA examiner noted that she had contacted the Veteran's cardiologist and no testing had been done since the last VA examination. The VA examiner was asked to reconcile METs obtained in April 2010 (10.1- cardiac stress test), October 2010 (1-3 based on Veteran interview), and July 2013 (5-7 based on Veteran interview). The VA examiner noted that it was more likely than not that the Veteran's METs per stress test are more accurate in April 2010 as this test allows the separation of other factors impacting METs and is objective. The VA examiner noted that it is unlikely that the Veteran continues to have the 2010 complaints as he continues to see the same cardiologist who has not recommended any additional testing since 2010 and notes do not support ongoing shortness of breath or chest pain. An October 2017 addendum opinion was obtained. The VA examiner noted a June 2017 METs-Stress Test. A left ventricular ejection fraction (LVEF) of 51% was noted. Peak METs were noted to be 3.9. The VA examiner noted that she was unable to fully evaluate METs as the Veteran stopped the procedure due to back pain. She noted that with normal LVEF it is less likely that 3.9 METs reflect cardiac function alone. She stated that the Veteran is obese and deconditioned and that his ability to have sexual relations indicates a METs level of 5.25 which corresponds with the Veteran's interview. The VA examiner determined that cardiac METs at 5.25 are more consistent with the Veteran's interview and 3.9 METs additionally reflects obesity and lack of exercise. While the Board has considered that some of the testing completed in the VA examinations throughout the period on appeal may meet the 60 percent and 100 percent disability ratings based on the METs recorded, the evidence clearly reflects that these findings were reached not only because of the Veteran's service-connected CAD, but also took into consideration his non-service-connected obesity and lack of exercise. As thoroughly explained in the October 2017 VA addendum opinion, the Veteran's METs most consistent with the record are commensurate with 5.25, which is appropriately rated at the 30 percent disability rating. The Board thus finds that the Veteran's CAD does not meet the criteria for an increased rating under DC 7005. See 38 C.F.R. § 4.104. The evidence does not show symptoms that manifested in more than one episode of acute congestive heart failure in the past year, or workload of greater than 3 METs but not greater than 5 (solely due to his service-connected CAD), nor has he been found to have left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The preponderance of the evidence is against the claim. The benefit-of-the-doubt rule does not apply, and entitlement to a schedular rating for CAD in excess of 30 percent is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102; 4.3 (2017); Gilbert, 1 Vet. App. at 55. IV. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110 (2012). Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/ Caluza element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). In addition to the regulations cited above, service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2017). Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. Finally, 38 U.S.C. § 1154(a) 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). Specifically, "[l]ay 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). Additionally, Veterans who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. The last date on which such a Veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 C.F.R. § 3.307(a)(6)(iii). Service personnel records confirm that the Veteran served in the Republic of Vietnam during this time frame. In addition to the presumption of herbicide exposure, noted above, certain diseases are deemed to be associated with herbicide exposure. These diseases include early onset peripheral neuropathy. 38 C.F.R. § 3.309(e). The regulations formerly referred to acute and subacute peripheral neuropathy; however, effective September 6, 2013, VA adopted a proposed rule to amend its adjudication regulations regarding presumptive service connection for acute and subacute peripheral neuropathy associated with exposure to certain herbicide agents. Specifically, based on findings from a September 2010 National Academy of Sciences (NAS) report that concluded that early-onset peripheral neuropathy associated with herbicide exposure is not necessarily a transient condition, the amendment replaced the terms "acute and subacute" in 38 CFR 3.307(a)(6)(ii) and 38 CFR 3.309(e) with the term "early-onset" and removed the Note to 38 CFR 3.309(e) requiring that the neuropathy be "transient." This change effectively removed the requirement that acute and subacute peripheral neuropathy appear "within weeks or months" after exposure and that the condition resolve within two years of the date of onset in order for the presumption to apply. This amendment clarified that VA will not deny presumptive service connection for early-onset peripheral neuropathy solely because the condition persisted for more than two years after the date of the last herbicide exposure. However, it did not change the requirement that peripheral neuropathy must have become manifest to a degree of ten percent or more within one year after the Veteran's last in-service exposure in order to qualify for the presumption of service connection. In the 2010 report, NAS found that evidence did not support an association between herbicide exposure and delayed-onset peripheral neuropathy, which NAS defined as having its onset more than one year after exposure. See 78 Fed. Reg. 54,763-01. Indeed, VA has published a list of specific conditions for which a presumption of service connection based on exposure to herbicides used in Vietnam during the Vietnam era is not warranted. These include chronic peripheral nervous system disorders. See Notice, 75 Fed. Reg. 32,540-03 (2010). As a result, to qualify for presumptive service connection, early onset peripheral neuropathy must have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a). The Veteran initially claims service connection for a bilateral lower extremity disability secondary to his service-connected CAD. The Board will first consider this claim on a secondary service connection basis. May 2017 VA examinations and opinions address these questions. The VA examiner opined that the Veteran's peripheral neuropathy was not related in any way to CAD. She noted that, according to research, polyneuropathy has a wide variety of causes, ranging from the common, such as diabetes mellitus, alcohol abuse, and HIV infection, to hypothyroidism, vitamin deficiencies, and Lyme disease. She additionally noted that the Veteran's disorder had not been aggravated by CAD as CAD does not cause peripheral neuropathy in any way and such a relationship is not supported in the current medical literature. In a May 2017 Artery and Vein Conditions examination it was noted that the Veteran had chronic venous insufficiency and varicose veins. The VA examiner noted that the Veteran's disability was not due to CAD. She noted that risk factors for chronic venous disease included advancing age, family history of venous disease, ligamentous laxity, prolonged standing, increased body mass index, smoking, sedentary lifestyle, lower-extremity trauma, prior venous thrombosis, the presence of an arteriovenous shunt, some hereditary conditions, high estrogen states, and pregnancy. The VA examiner stated that current literature does not support CAD as a risk factor for venous insufficiency or varicose veins or peripheral neuropathy. She additionally noted that it is not at least as likely as not that the disorder had been aggravated by CAD. She stated that these were two separate entities and not related to each other. In an October 2017 addendum opinion, the VA examiner noted that heavy lifting is not a risk factor for varicose veins. There are no contradictory medical opinions of record. The Board finds that the VA opinions are adequate for evaluation purposes. Significantly, the VA examiner considered the Veteran's history and provided sufficient rationale for the opinions stated. These opinions provide evidence against this claim, making it less than likely such a connection exists. The Board further finds compelling the fact that, as noted above, no medical evidence is of record to support a conclusion that the Veteran's current bilateral lower extremity disability has been caused or aggravated by his service-connected CAD. The Board has also considered the statements made by the Veteran relating his bilateral lower extremity disability to his service-connected CAD. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), the specific issue in this case, the etiology of a bilateral lower extremity disability, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Therefore, after weighing the pertinent evidence of record, the Board concludes that the preponderance of the evidence is against entitlement to service connection for a bilateral lower extremity disability, as secondary to service-connected CAD. The Board also considers the theory of entitlement to service connection for a bilateral lower extremity disability, on a direct basis. Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). The Veteran contends that he developed neuropathy of the bilateral lower extremities due to exposure to Agent Orange during his service in Vietnam. Service treatment records do not reflect treatment for neuropathy of the lower extremities. An August 1968 separation examination reflects a normal clinical evaluation of the Veteran's lower extremities and neurologic system. Post-service treatment records first reflect complaints of tingling in the legs in August 2011. The Veteran was diagnosed with signs of sensory impairment in both feet. Records additionally show diagnosis of chronic venous insufficiency and varicose veins around 2001. The Veteran underwent a May 2017 VA Examination of Peripheral Nerves Conditions. The VA examiner diagnosed the Veteran with peripheral neuropathy with a diagnosis date of 2016. She noted the Veteran's reports of numbness and tingling of his feet and fingers that had been present for many years. He reported that most recently a podiatrist had told him he has neuropathy in his feet. The Veteran reported moderate symptoms of paresthesias and/or dysesthesias and numbness in his bilateral lower extremities. A sensory examination of his lower extremities revealed decreased sensation. Trophic changes of the bilateral lower legs were noted. The VA examiner noted that the Veteran was a very poor historian. She stated that the examination was based on his subjective claims only and that he had not been evaluated by his primary care physician for these complaints in his lower extremities. The VA examiner noted that an August 2016 VA treatment record supported a diagnosis of lower extremity neuropathy and the Veteran was given diabetic shoes. She also indicated that medical records did support chronic left leg vascular insufficiency. She opined that the Veteran's peripheral neuropathy and peripheral vascular disease were not related to herbicide exposure, reasoning that neither of these problems had presented until at least 40 years post military service. An additional opinion was provided in the Veteran's May 2017 Artery and Vein Conditions examination. A diagnosis of chronic venous insufficiency and varicose veins, diagnosed in 2001, was provided. The VA examiner stated that it was not at least as likely as not that any current peripheral neuropathy or peripheral vascular disease of the lower extremities arose during service or was due to exposure to herbicides. She noted that at this time peripheral neuropathy would need to be at least 10 percent disabling within one year of herbicide exposure and the Veteran did not report symptoms within the first year post Vietnam. In an October 2017 addendum opinion, the VA examiner noted the Veteran's assertions that his varicose veins had started in Vietnam carrying heavy equipment. She opined, however, that the Veteran's varicose veins were not at least as likely as not related to carrying heavy equipment during service. She stated that medical records indicate that the Veteran was not seen or treated for varicose veins until around 2001, almost 50 years post service, and that there is no medical evidence that the Veteran was seen or treated for varicose veins during service or shortly thereafter. She additionally noted that heavy lifting is not a risk factor for varicose veins. Simply stated, the examiner indicated that the Veteran's bilateral lower extremity disability was not associated with herbicides or service, providing highly probative evidence against this claim. Upon review of the record, the Board finds that Veteran's neuropathy of the lower extremities is not related to his herbicide exposure during service. The neuropathy of the lower extremities did not manifest to a compensable degree within a year after the date of his last exposure to herbicide agents. Additionally, there is no evidence of neuropathy, an organic disease of the nervous system, shown in service. To determine that a chronic disease was shown in service, the disease identity must be established. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Characteristic manifestations sufficient to identify the disease (neuropathy, an organic disease of the nervous system) entity were not noted. Additionally, there is no evidence of neuropathy within one year of separation from service. 38 U.S.C. § 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. § 3.303(b), 3.307, 3.309. The only other evidence of record supporting this claim is the Veteran's general lay assertions. In this case, the Board finds that the Veteran is competent to state that his neuropathy is a result of service (in part because of the Agent Orange regulation). See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). However, in this case, the Board finds the opinions of the VA examiner in May and October 2017 be more probative than the Veteran's lay statements concerning the etiology of his lower extremity disability. The VA examiner reviewed the claims file and considered the Veteran's reported history. She additionally used her expertise in reviewing the facts of this case and determined that the Veteran's bilateral lower extremity disability is unrelated to his period of service, including presumed exposure to herbicides therein. It is clear that the VA examiner fully understood the basis for the claim yet still determined, after reviewing the facts of the case, that the Veteran's bilateral lower extremity neuropathy was not at least as likely related to service. For the foregoing reasons, the Board finds that the claim of entitlement to service connection for a right and left lower extremity disability, to include as a result of in-service exposure to herbicide agents, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990) ORDER Entitlement to a TDIU is granted. An initial rating in excess of 30 percent for service-connected CAD is denied. Service connection for a right lower extremity disability, to include as secondary to service-connected CAD and as a result of herbicide exposure, is denied. Service connection for a left lower extremity disability, to include as secondary to service-connected CAD and as a result of herbicide exposure, is denied. ______________________________________________ CAROLINE B. FLEMING Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs