Citation Nr: 1807121 Decision Date: 02/02/18 Archive Date: 02/14/18 DOCKET NO. 12-35 239 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), to include as secondary to residuals of a cerebrovascular accident (CVA) and to service-connected Non-Hodgkins lymphoma. 2. Entitlement to service connection for residuals of a cerebrovascular accident. REPRESENTATION Veteran represented by: National Association of County Veterans Service Officers ATTORNEY FOR THE BOARD Jacquelynn M. Jordan, Associate Counsel INTRODUCTION The Veteran served in the U.S. Navy from September 1966 to June 1970. For his meritorious service, the Veteran was awarded (among many other decorations) the Meritorious Unit Commendation Ribbon and Armed Forces Expeditionary Medal Korea). This matter is before the Board of Veterans' Appeals (Board) on appeal from June 2011 and August 2011 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. The June 2011 rating decision denied service connection for residuals of a cerebrovascular accident. The August 2011 rating decision denied service connection for PTSD. The Board notes, that on a December 2012 VA Form 9, the Veteran requested a hearing before the Board. A hearing was scheduled for July 2014; however, the Veteran withdrew his request in a July 2014 statement. He has not requested that the hearing be rescheduled. Therefore, there is no outstanding hearing request. In February 2015, the Board expanded the issue of service connection for PTSD to include all psychiatric disorders. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In that same decision, the Board remanded the issues of entitlement to service connection for an acquired psychiatric disorder and residuals of a CVA for further development. In September 2015, the Board remanded these issues for additional development, to include obtaining an addendum opinion regarding the issue of entitlement to service connection for residuals of a CVA and a VA examination regarding the issue of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, to include as secondary to residuals of a cerebrovascular accident (CVA) and to service-connected Non-Hodgkins lymphoma. In January 2016, the Board again remanded these issues for additional development, to include a medical opinion to determine the nature and etiology of any residuals of a CVA and a VA examination, if deemed necessary and to secure any records to determine whether the Veteran actually set foot in the Republic of Vietnam during his service, as well as a VA examination to determine the nature and etiology of any acquired psychiatric disorder. All necessary development has been accomplished. The matter is now before the Board. FINDINGS OF FACT 1. The Veteran does not have an acquired psychiatric disorder, to include PTSD, that is otherwise etiologically related to service, or is caused or aggravated by his service-connected disabilities, to include as secondary to residuals of a cerebrovascular accident and service-connected Non-Hodgkin's lymphoma neuropathy. 2. The more probative evidence demonstrates that the Veteran's cerebrovascular accident is not related to any event in service, to include exposure to herbicide agents, and it was not present to a compensable degree within one year of separation from service. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, to include PTSD, to include as secondary to residuals of a cerebrovascular accident and to service-connected Non-Hodgkin's lymphoma have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1116, 1131, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for service connection for residuals of a cerebrovascular accident have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1116, 1131, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSION Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the Veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Service Connection Generally, to prevail on a claim of service connection on the merits, there must be competent evidence of (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence or other competent evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). 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. With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). PTSD Generally, service connection for PTSD requires medical evidence establishing a diagnosis of the disorder, credible supporting evidence that the claimed in-service stressor(s) occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor(s). 38 C.F.R. § 3.304 (f) (2015). With regard to the second PTSD element as set forth in 38 C.F.R. § 3.304 (f), evidence of an in-service stressor, the evidence necessary to establish that the claimed stressor actually varies depending on the circumstances of the stressor and the nature of a Veteran's service. The DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)) provides two requirements as to the sufficiency of a stressor: (1) A person must have been "exposed to a traumatic event" in which "the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others" and (2) "the person's response [must have] involved intense fear, helplessness, or horror." DSM-IV at 427-28. These criteria are no longer based solely on usual experience and response but are individualized (geared to the specific individual's actual experience and response). Hence, under the DSM-IV, the mental illness of PTSD would be treated the same as a physical illness for purposes of VA disability compensation in terms of a predisposition toward development of that condition. Cohen v. Brown, 10 Vet. App. 128, 141 (1997). In Zarycki v. Brown, 6 Vet. App. 91 (1993), the United States Court of Appeals for Veterans Claims (Court) held that the presence of a recognizable stressor is the essential prerequisite to support the diagnosis of PTSD. Merits of the Claim The Veteran seeks service connection for an acquired psychiatric disorder, to include PTSD, to include as secondary to residuals of a cerebrovascular accident and to service-connected Non-Hodgkin's lymphoma. The Veteran has reported that he experienced multiple stressors during service. The Board notes that in September 2010, a VA examiner diagnosed the Veteran with PTSD. However, the Board also notes that a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. Cohen v. Brown, 10 Vet. App. 128, 142 (1997); Moreau v. Brown, 9 Vet. App. 389, 395-96 (1996). If the evidence establishes that a Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of a Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304 (f)(1). See also 38 U.S.C. § 1154 (b). The ordinary meaning of the phrase "engaged in combat with the enemy," as used in 38 U.S.C. § 1154 (b), requires that a Veteran have participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. The issue of whether any particular set of circumstances constitutes engagement in combat with the enemy for purposes of section 1154(b) must be resolved on a case-by-case basis. See VAOPGCPREC 12-99 (October 18, 1999). Where a veteran did not "engage in combat with the enemy," or the claimed stressor is not related to combat, a veteran's lay testimony alone will not be enough to establish the occurrence of the alleged stressor. See Moreau v. Brown, 9 Vet. App. 389, 395 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In these situations, the record must contain service records or other corroborative evidence that substantiates or verifies his testimony or statements as to the occurrence of the claimed stressor. See West (Carlton) v. Brown, 7 Vet. App. 70, 76 (1994); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). Moreover, a medical opinion diagnosing PTSD after the fact does not suffice to verify the occurrence of the claimed in- service stressor. See Moreau v. Brown, 9 Vet. App. 389, 395 - 396 (1996); Cohen v. Brown, 10 Vet. App. 128, 142 (1997). If there is no combat experience, or if there is a determination that a Veteran engaged in combat but the claimed stressor is not related to such combat, there must be independent evidence to corroborate the Veteran's statement as to the occurrence of the claimed stressor. Doran v. Brown, 9 Vet. App. 163, 166 (1996). Here, the Veteran's DD-214 fails to confirm that he was exposed to combat during military service. Further, while the evidence of record reflects that the Veteran served aboard the U.S.S. Hancock and had service during the Vietnam Era, there is no indication the Veteran had combat experience. Therefore, the law requires that the Veteran's claimed stressors be independently corroborated by evidence other than his lay testimony or the post-service diagnosis of PTSD. As noted above, the Veteran reports that he suffered a number of traumatic stressors, involving accidents and close calls during active duty service and suffers the effects to this day. He listed a number of stressors including: witnessing a crew member get cut in half by the propeller of a plane, seeing a crewman get sucked into an out take valve and drown, seeing a crewman swept overboard by the exhaust from a plane taking off and after, the boat circled back to the area, they found the crewman alive and rescued him and finally, he asserts that he witnessed a plane take off, then the plane exploded, killing all on board. The Veteran asserts that he remembers seeing the pilot smiling as he pulled up, and then seeing him ejected from the explosion. In February 2015, the Board remanded the claim to allow the Veteran to provide an updated stressor statement. The Veteran did not respond. In September 2015, the Board determined that the claimed stressors had not been verified; however, under 38 C.F.R. 3.304(f)(3), if an in-service stressor involves fear of hostile military or terrorist activity, service connection for PTSD may be established, if a VA psychiatrist or psychologist, or contract equivalent, confirms that the claimed stressor is adequate to support a diagnosis of PTSD; the claimed stressor is consistent with the places and circumstances of the Veteran's service; and the Veteran's symptoms are related to the claimed stressor. Accordingly, the claim was again remanded for a VA examination to determine whether the Veteran's PTSD is related to any fear of hostile military or terrorist activity while on active duty. In September 2015, the Veteran was provided a VA examination. The VA examiner determined that the Veteran did not have a diagnosis of PTSD that conforms to DSM-5 criteria. The examiner noted his disagreement with the original combat PTSD diagnosis, noting that the Veteran was not involved in combat during active duty service. The September 2015 VA examiner diagnosed the Veteran with adjustment disorder, with depressed mood. The examiner concluded that the Veteran was exposed to shipboard trauma onboard the U.S.S. Hancock; however, he concluded that the Veteran's symptoms did not meet the full diagnostic criteria for PTSD. She further opined, that the Veteran appeared to meet the criteria for an adjustment disorder with depressed mood, secondary to his most recent hospitalization for a subdural hematoma. She concluded that his depressed mood appeared to be due to his physical limitations. In January 2016, the Board determined that September 2015 VA examiner did not provide a specific opinion as to whether the Veteran's adjustment disorder, with depressed mood, manifested during or is otherwise related to service related to his military service. Additionally, the Board noted, that the examiner did not address the September 2010 diagnosis of generalized anxiety disorder. Accordingly, in January 2016, the Board remanded the claim for an additional examination and opinion. In August 2017, the Veteran was afforded an additional VA examination. The VA examiner concluded that the Veteran does not have a diagnosis of PTSD that conforms to DSM-5 criteria. Further, the examiner determined that the Veteran does not have a mental disorder that conforms to DSM-5 criteria. The examiner asserted, to a reasonable medical certainty, that the Veteran is not currently experiencing any mental disorder. The Veteran was questioned at length about a variety of mental health symptoms, and the examiner concluded that the Veteran endorsed only a few mental health symptoms. She further opined, that the symptoms the Veteran did endorse, did not rise to the level of severity or number sufficient to warrant a mental disorder diagnosis. Finally, the examiner noted that, the Veteran specifically indicated that he does not experience social or occupational impairment due to mental health symptoms. The examiner stated that there was no evidence of impairment elicited, despite in-depth questioning. She concluded that any prior diagnoses of record are currently in remission. The examiner was asked to provide a nexus opinion for each diagnosis other than PTSD. As there was no mental diagnosis found, the examiner provided no such opinion. Based on the above, as will be explained in detail below, the Board finds that the evidence of record is conflicting with regard to a diagnosis of PTSD. The Board acknowledges, however, that even if a PTSD diagnosis was conceded, to date there has been no corroboration of the Veteran's alleged in-service stressors. The Board is not required to accept a Veteran's uncorroborated account of his active service experiences. See Swann v. Brown, 5 Vet. App. 229, 233 (1993) and Wood v. Derwinski, 1 Vet. App. 190, 192 (1991). A June 2017 formal finding noted that there was a lack of information required to corroborate the Veteran's allegation of PTSD. The letter concluded that no further action can be taken to attempt to verify the Veteran's alleged PTSD stressors and that the stressors identified by the Veteran cannot be conceded. They concluded that any further development would be futile. As such, the VA's duty to assist the Veteran in verifying the PTSD stressors have been met and service connection must be denied. The preponderance of the evidence shows that the Veteran does not have a PTSD diagnosis that has been related to a credible or verified stressor event. 38 C.F.R. §§ 3.304 (f), 4.125(a); Cohen v. Brown, 10 Vet. App. 128, 139 (1997). As such, service connection for PTSD is not warranted. Id.; 38 C.F.R. § 3.303. Acquired Psychiatric Disorder The Board will now discuss whether the Veteran is entitled to service connection for any acquired psychiatric disorders, other than PTSD. The Veteran has also been diagnosed with adjustment disorder with depressed mood and generalized anxiety disorder. As noted above, the September 2015 VA examiner diagnosed the Veteran with adjustment disorder, with depressed mood. The examiner opined that the diagnosis was secondary to his multiple medical problems and recent hospitalization for a subdural hematoma. Service connection may be established on a secondary basis for a current disability which is proximately due to or the result of a service-connected disease or injury; or for a current disability which has been aggravated or made chronically worse beyond its natural progression by a previously service-connected disability. 38 C.F.R. § 3.310; See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Wallin v. West, 11 Vet. App. 509 (1998). In January 2016, the claim was remanded because the September 2015 examiner did not specify which medical problems the Veteran's psychiatric disorder was secondarily diagnosed to, other than the subdural hematoma and physical conditions. The Veteran is service-connected for Non-Hodgkin's lymphoma. In the medical examination report section labelled, "Medical diagnoses relevant to the understanding or management of the Mental Health Disorder", the examiner listed the following conditions: stroke, history of heart transplants, history of Non-Hodgkin's lymphoma and history of subdural hematoma. In January 2016, the Board remanded this issue for further development, to include a new VA examination to determine the etiology of any acquired psychiatric disorder that may be present. The August 2017 VA examiner was asked to identify all current psychiatric disorders and/or whether the Veteran has PTSD, generalized anxiety disorder, major depression and/or adjustment disorder, with depressed mood. The examiner was asked to provide a nexus opinion for each identified diagnosis, as well as whether any diagnosed psychiatric conditions were caused by or aggravated by his Non-Hodgkin's lymphoma or his residuals of a cerebrovascular accident. The August 2017 examiner determined, that the Veteran does not have a mental disorder diagnosis that conforms to DSM-5 criteria. As the examiner did not find a current diagnosis, she did not need to provide a nexus opinion because no psychiatric condition was identified. Further, in addressing the Veteran's prior diagnoses, the examiner determined that any prior diagnoses of record are currently in remission. The examiner noted, that she questioned the Veteran at length regarding a variety of mental health symptoms and only endorsed a few of them; however, the symptoms he did endorse, did not rise to a level of severity or number sufficient to warrant a mental health disorder diagnosis. Additionally, the Veteran specifically indicated that he does not experience social or occupational impairment due to mental health symptoms. The examiner found no evidence of impairment was elicited, despite in-depth questioning. The Board must also consider the Veteran's lay statements indicating that he has a psychiatric disorder as a result of service. As stated previously, the Veteran is competent to testify as to his observations. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). In addition, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, unlike disabilities that may be observable as to both their incurrence and their cause, such as a dislocated shoulder, the cause of a psychiatric disability is not readily apparent to lay observation, and the Court has held that psychiatric diagnoses are generally the province of medical professionals. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"). See also Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). Moreover, even if credible and competent, the Veteran's general lay assertions are outweighed by specific evidence of record - such as the service records which indicate the Veteran himself denied psychiatric problems upon separation from service. See June 1970 Report of Medical Examination. As a result, to date, there is no competent evidence that the Veteran has an acquired psychiatric disorder, to include as secondary to residuals of a cerebrovascular accident and service-connected Non-Hodgkin's lymphoma neuropathy that is causally or etiologically due to service. As the more probative evidence indicates that the Veteran does not have a diagnosed psychiatric disorder that is due to service, the claim for service connection for an acquired psychiatric disorder, acquired psychiatric disorder, to include as secondary to residuals of a cerebrovascular accident and service-connected Non-Hodgkin's lymphoma neuropathy and must therefore be denied. See 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102; see also Ortiz v. Principi, 274 F.3d 1361, 1366 (Fed. Cir. 2001). Additionally, for these reasons stated, the evidence in this case is not so evenly balance so as to allow application of the benefit-of-the-doubt rule, and as such the Board concludes that the preponderance of the evidence is against a diagnosis for an acquired psychiatric disorder, to include PTSD, to include as secondary to residuals of cerebrovascular accident and to service-connected Non-Hodgkin's lymphoma. See 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). As a consequence, the claim for service connection for an acquired psychiatric disorder, to include PTSD, to include as secondary to residuals of a cerebrovascular accident and service-connected Non-Hodgkin's lymphoma neuropathy is denied. Service Connection for Residuals of Cerebrovascular accident The Veteran asserts that the residuals of his CVA (stroke) are a result of his active duty military service. Specifically, he asserts that while aboard the U.S.S Hancock, he flew off the ship and went in land to Da Nang and then to Chu-Li, Vietnam. He notes that after separating from the Navy in 1970, he began to have health problems. The Veteran speculates that working on the flight deck, handling jet fuel and "sucking in the exhaust from the aircraft" caused his medical issues. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). 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, or nexus, between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, or results from, another disease or injury for which service connection has been granted shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a) (2016). Secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310 (b), and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability and not due to the natural progress of the nonservice-connected disease. Allen v. Brown, 7 Vet. App. 439 (1995). A Veteran who served in the Republic of Vietnam between January 9, 1962, and May 7, 1975, is presumed to have been exposed to certain herbicide agents (e.g., Agent Orange) during such service, absent affirmative evidence to the contrary. 38 U.S.C.A. § 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii). Service connection based on herbicide agent exposure will be presumed for certain specified diseases that become manifest to a compensable degree within a specified period of time in the case of certain diseases. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. In some cases, service connection may also be established under 38 C.F.R. § 3.303 (b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307 ) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology. However, the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303 (b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The governing law provides that a "veteran 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." 38 U.S.C.A. § 1116 (f). Furthermore, VA regulations provide that, if a veteran was exposed to an herbicide agent during active service, presumptive service connection is warranted for certain disorders. 38 C.F.R. § 3.309 (e). Generally speaking, service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307 (a)(6)(iii) (2016). Service on a deep-water naval vessel off the shores of Vietnam may not be considered service in the Republic of Vietnam for purposes of 38 U.S.C. § 101 (29)(A)(2012). Service offshore of the Republic of Vietnam is inconsistent with the definition of service in the Republic of Vietnam. 38 C.F.R. § 3.307 (a)(6)(iii)(2016); VAOPGCPREC 27-97 (1997), 72 Fed. Reg. 63604 (1997). A Veteran must demonstrate actual duty or visitation in the Republic of Vietnam to have qualifying service. 38 C.F.R. §3.307 (a)(6)(iii)(2016); VAOPGCPREC 27-97 (1997), 72 Fed. Reg. 63604 (1997). Service in deep-water naval vessels offshore of Vietnam, as opposed to service aboard vessels in inland waterways of Vietnam, is not included as service in the Republic of Vietnam for purposes of presumptive service connection for diseases related to herbicide exposure. 66 Fed. Reg. 23166 (2001); 38 U.S.C. §1116 (a)(1)(A)(2012); 38 C.F.R. § 3.307 (a)(6)(iii)(2016); Haas v. Peake, 525 F. 3d 1168 (Fed. Cir. 2008). For claims based on service in the Republic of Vietnam, the presumptive provisions require visitation in Vietnam pursuant to 38 C.F.R. § 3.307 (a) (2016), or service in the inland waterways of Vietnam. VAOPGCPREC 27-97 (July 23, 1997); Haas v. Peake, 525 F. 3d 1168 (Fed. Cir. 2008). What constitutes inland waterways is not defined in VA regulations. Thus, the Board has historically referred to the VA Adjudication Procedure Manual M21 (Manual) for interpretive guidance. The manual maintained that inland waterways included rivers, canals, estuaries, and delta areas, such as those on which the Vietnam "brown water" Navy operated. The Manual clearly stated that service aboard a ship that merely anchored in an open deep-water harbor along the Vietnam coast did not constitute inland waterway service to establish presumptive exposure to herbicide agents. Any such anchorage was considered to be in "blue water" which did not provide for a presumption of herbicide exposure. VA Adjudication Procedure Manual M21-1MR, pt. IV, sub. Pt. ii, ch. 2, § C.10.k. However, in April 2015, the United States Court of Appeals for Veterans Claims found VA's definition of inland waterways, specifically that it excluded Da Nang harbor, to be irrational and not entitled to deference. Gray v. McDonald, 27 Vet. App. 313 (2015). The Board notes that, while the decision in Gray found the definition of brown water versus blue water in Da Nang Harbor to be irrational, it rejected the appellant's argument that it should adopt the definition of inland waterways espoused by the United States Convention on the Territorial and Contiguous Zone, which would include the entirety of Da Nang Harbor. Specifically, it found that discretion to interpret the scope of the regulations applicable to brown water versus blue water lies with VA, not with the Court. It also noted that there was no indication that in using the term inland waterways VA intended to adopt a conventional definition, and the Secretary expressly denied any intent to do so at oral argument in that matter. Gray v. McDonald, 27 Vet. App. 313 (2015). A recent amendment to the VA's Adjudication Procedure Manual classifies inland waterways as fresh water rivers, streams, and canals, and similar waterways. Because those waterways are distinct from ocean waters and related coastal features, service on those waterways is considered service in the Republic of Vietnam. VA considers inland waterways to end at their mouth or junction to other offshore water features. For rivers and other waterways ending on the coastline, the end of the inland waterway will be determined by drawing straight lines across the opening in the landmass leading to the open ocean or other offshore water feature, such as a bay or inlet. For the Mekong and other rivers with prominent deltas, the end of the inland waterway will be determined by drawing a straight line across each opening in the landmass leading to the open ocean. VBA Manual M21-1, IV.ii.1.H.2.a.; VBA Manual M21-1, IV.ii.2.C.3.m. Offshore waters are the high seas and any coastal or other water feature, such as a bay, inlet, or harbor, containing salty or brackish water and subject to regular tidal influence. This includes salty and brackish waters situated between rivers and the open ocean. VBA Manual M21-1, IV.ii.1.H.2.b. The competence, credibility, and probative (relative) weight of evidence, including lay evidence must be assessed. See generally 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the unique and readily identifiable features of a medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994); and 38 C.F.R. § 3.159 (a)(2). However, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). See 38 C.F.R. § 3.159 (a)(1). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F. 3d 1274, 1278 (2010). Any competent lay evidence must be weighed to make a credibility determination as to whether it supports a finding of service incurrence; or, if applicable, continuity of symptomatology; or both. See Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Layno v. Brown, 6 Vet. App. 465 (1994). The credibility of lay evidence may not be refuted solely by the absence of corroborating contemporaneous medical evidence, but it is a factor. Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009). VA may rely on an absence of an entry in a record as evidence that the event did not occur, but only if the matter is of the kind that ordinarily would have been recorded. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); see Maxson v. Gober, 230 F. 3d 1330, 1333 (Fed. Cir. 2000) ("Evidence of a prolonged period without medical complaint can be considered"); Gagan v. Shinseki, 573 F.3d 1282, 1289 (Fed. Cir. 2009) (taking into account the lack of treatment or complaints of the condition for an extensive period of time); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 305 (2008) (more probative weight to VA opinions which relied, inter alia, on a record showing disability symptoms did not begin until decades after service). Reasonable doubt will be favorably resolved and it exists when there is an approximate balance of positive and negative evidence. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz v. Principi, 274 F. 3d 1361, 1365 (Fed. Cir. 2001). While the Board must provide reasons and bases supporting a decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on behalf of the Veteran. Gonzalez v. West, 218 F. 3d 1378 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence of record. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed. Timberlake v. Gober, 14 Vet. App. 122 (2000). Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Merits of the Claim The Veteran's service treatment records are silent for a treatment or a diagnosis of CVA or stroke. However, private treatment records show the Veteran had a CVA in August 1985. In February 2015, the Board remanded the issue of residuals of a cerebrovascular accident, in order to obtain a clarifying medical opinion, in order to determine whether the Veteran's stroke was caused by ischemic heart disease. In September 2015, the Board noted that in the prior remand, the record includes the report of an August 1985 EKG, which was interpreted as showing old myocardial infarction. As per VA regulations, it meets the definition of ischemic heart disease. Accordingly, the Board determined that the May 2015 opinion was inadequate and the Board again remanded this claim for an addendum opinion that considered the correct factual basis; specifically, an opinion that considered that there was evidence of ischemic heart disease prior to the Veteran's first heart replacement in 1988. In the January 2016 remand, the Board noted that the September 2015 remand directives instructed the VA examiner to address whether the Veteran's residuals of a cerebrovascular accident were secondary to ischemic heart disease. However, the Board noted that the Veteran is not service-connected for that disorder. The June 2011 rating decision denied service connection for ischemic heart disease, and the Veteran did not perfect an appeal of that issue. The Board also notes, that following the September 2015 Board remand, the Veteran was provided an examination in September 2015. The examiner stated, that it is less likely than not that the Veteran's CVA is caused by or manifested during service. However, the examiner did not provide any rationale for the opinion. Further, the VA examiner did not address whether the Veteran's residuals of a cerebrovascular accident were related to any herbicide exposure in service. Accordingly, the Board again remanded the issue for another VA medical opinion. In February 2017, the VA examiner provided a medical opinion that it is less likely as not that the Veteran's residuals of a cerebrovascular accident was manifested in service or otherwise related to his military service, to include any herbicide exposure therein. The examiner added, herbicide exposure and serving in the military have not been known as causes for CVA. In April 2017, the RO issued a deferred rating decision noting, that the February 2017 opinion did not express the requirements of the remand. Specifically, the examiner did not discuss the facts and medical principles involved as stated in remand directive #5. See January 2016 Board Remand. In August 2017, the examiner provided the requested addendum medical opinion. In that opinion, the examiner stated that, it is less likely as not that the Veteran's residuals of a cerebrovascular accident was manifested in service or otherwise related to his military service, to include herbicide exposure. The examiner opined, that the Veteran did not have CVA while in service and developed it in 1985, several years after service. The examiner reported reviewing the Veteran's service treatment records and stated that the STRs do not indicate any risk factors that would cause CVA. The examiner further opined, that there is no clear scientific or medical evidence showing that exposure to Agent Orange later causes CVA; explain, that studies are not persuasive to show that Agent Orange can cause CVA. The examiner acknowledged the Veteran has a history of hypertension and hyperlipidemia, which are risk factors that can lead to CVA. The Veteran is not service-connected for either medical condition. The examiner concluded that it is more likely that the Veteran's CVA is due to underlying medical risk factors and less likely than not due to exposure to Agent Orange during military service. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert, denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. In weighing lay evidence, the Board must render a finding with regard to both competency and credibility. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). In addition, as noted above, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that lay evidence is one type of evidence that must be considered, and competent lay evidence can be sufficient in and of itself. The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). This would include weighing the absence of contemporary medical evidence against lay statements. In addition, the U.S. Court of Appeals for Veterans Claims (Court) held that the credibility of lay evidence can be affected and even impeached by factors such as inconsistent statements, internal inconsistency of statements, and inconsistency with other evidence of record. See Macarubbo v. Gober, 10 Vet. App. 388 (1997). In this case, the evidence fails to demonstrate the Veteran's residuals of CVA warrants service connection on a direct or secondary basis. In this regard, the Board notes, that while the Veteran has a current disability, he did not have CVA during active duty service, there is no credible objective evidence linking the Veteran's CVA to active duty service and there is no credible, objective evidence that the Veteran's CVA is proximately due to or the result of a service-connected disease or injury or that a service-connected disease or injury has worsened the disability for which service connection is sought. 38 C.F.R. § 3.310 (a) (2014); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Additionally, in October 2017, the Department of Veterans Affairs Appeals Management Center issued a formal finding that there was a lack of information necessary to corroborate the Veteran's assertion of exposure to herbicides while stationed aboard U.S.S Hancock from February 1967 to March 1970. The Board finds that the medical evidence is more probative than the Veteran's lay and buddy statements. Whether the Veteran's CVA was caused by his active duty service or caused by aggravated by his service-connected non-Hodgkin's lymphoma cannot not be determined by mere observation alone. The Board finds that determining the exact cause of the Veteran's CVA is not within the realm of knowledge of a non-expert given the above facts. As the evidence does not show that the Veteran has expertise in medical matters, the Board concludes that his nexus opinion in this regard is not competent evidence and therefore is not probative of whether the Veteran's active duty service caused or aggravated his the residuals of a CVA. Thus, the Veteran's statements are afforded less probative value with respect to the medical question of whether his CVA is directly related to his active duty service or is secondarily related to his service-connected disabilities. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The examiner provided a full and complete rationale for the opinions. As held by the Court, "the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches". Guerrieri v. Brown, 4 Vet. App. 467, 470 (1993). The credibility and weight to be attached to these opinions is within the province of the Board. Id. Thus, in this case, the Board finds that the VA examiners' opinions are entitled to the most probative weight regarding the etiology of the Veteran's residuals of CVA. Therefore, given the records before it, the Board finds that the evidence against the claim is more probative than the evidence in favor of the claim. Therefore, the Veteran's claim for service connection for residuals of a cerebrovascular accident must be denied and the doctrine of reasonable doubt is not for application. See 38 U.S.C.A.§ 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Service connection for an acquired psychiatric disorder, to include PTSD, to include as secondary to residuals of cerebrovascular accident and to service-connected Non-Hodgkin's lymphoma is denied. Service connection for residuals of a cerebrovascular accident is denied. ____________________________________________ Cynthia M. Bruce Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs