Citation Nr: 20074122 Decision Date: 11/18/20 Archive Date: 11/18/20 DOCKET NO. 16-39 025 DATE: November 18, 2020 ORDER Entitlement to compensation under 38 U.S.C. § 1151 for prostate cancer is denied. Entitlement to compensation under 38 U.S.C. § 1151 for a bladder disability is denied. Entitlement to compensation under 38 U.S.C. § 1151 for a kidney disability is denied. Entitlement to compensation under 38 U.S.C. § 1151 for residuals of a heart attack is denied. Entitlement to compensation under 38 U.S.C. § 1151 for a heart valve replacement and bypass is denied. FINDINGS OF FACT 1. The most probative evidence indicates that the appellant’s prostate cancer was not due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance on fault on the part of VA, or an event not reasonably foreseeable. 2. The most probative evidence indicates that a bladder disability was not due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance on fault on the part of VA, or an event not reasonably foreseeable. 3. The most probative evidence indicates that a kidney disability was not due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance on fault on the part of VA, or an event not reasonably foreseeable. 4. The most probative evidence indicates that residuals of heart attack were not due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance on fault on the part of VA, or an event not reasonably foreseeable. 5. The most probative evidence indicates that a heart valve replacement and bypass were not due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance on fault on the part of VA, or an event not reasonably foreseeable. CONCLUSIONS OF LAW 1. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for prostate cancer have not been met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 3.361. 2. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for a bladder disability have not been met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 3.361. 3. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for a kidney disability have not been met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 3.361. 4. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for residuals of a heart attack have not been met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 3.361. 5. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for a heart valve replacement and bypass have not been met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 3.361. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty in the U.S. Army from February 1961 to February 1964. This matter comes before the Board of Veterans’ Appeals (Board) from a May 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The appellant was afforded a hearing by videoconference before the undersigned in March 2018. A transcript is of record. In a May 2018 decision, the Board, inter alia, denied entitlement to compensation under 38 U.S.C. § 1151 for prostate cancer, bladder disability, kidney disability, residuals of heart attack, and heart valve replacement and bypass. The appellant appealed the Board’s decision to the U.S Court of Appeals for Veterans Claims (Court). While the matter was pending before the Court, in April 2019, the appellant’s then-representative and a representative of VA’s General Counsel filed a Joint Motion for Partial Remand. Later that month, the Court granted the Joint Motion, vacated that portion of the Board’s May 2018 decision which denied compensation under 38 U.S.C. § 1151 for prostate cancer, bladder disability, kidney disability, residuals of heart attack, and heart valve replacement and bypass, and remanded the case to the Board for readjudication consistent with the Joint Motion. The Board remanded the matter in October 2019. A Supplemental Statement of the Case (SSOC) was issued in August 2020. Compensation under 38 U.S.C. § 1151 In February 2005, the appellant’s VA primary care physician referred him to a VA urologist for a consultation based upon a gradually rising PSA (prostate-specific antigen) and low percent of FPSA (free prostate-specific antigen). The VA physician opined that such values indicated perhaps a 25 percent chance of prostate cancer. However, the VA urologist determined that the appellant’s PSA level was normal for his age and that the changes observed by the physician were inconsequential. Thus, the urologist decided that the appellant did not need to be seen. The appellant was ultimately diagnosed with prostate cancer by biopsy in May 2009, which resulted in radical prostatectomy performed in August 2009. The appellant contends that, had he been seen by the VA urologist in 2005 as requested by his primary care physician, his prostate cancer would have been detected earlier and the treatment for such would thus not have needed to be so invasive. He further contends that he developed bladder, kidney, and heart problems as a result of such prostatectomy, which would have been avoidable had he been seen by the VA urologist in 2005. The issue of informed consent was not raised by the appellant, nor is it reasonably raised by the record. Veterans who sustain an additional disability as the result of VA hospitalization, medical or surgical treatment, vocational rehabilitation, or examination shall receive disability compensation in the same manner as if such disability or death were service connected. 38 U.S.C. § 1151. A disability is a qualifying additional disability if 1) it was not the result of the veteran’s willful misconduct and the disability was caused by hospital care, medical or surgical treatment; or examination furnished to the veteran under any law administered by VA, and 2) the proximate cause of the disability was a) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or b) an event not reasonably foreseeable. Id. In determining whether a veteran has an additional disability, VA compares the veteran’s condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the veteran’s condition after such care or treatment. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the veteran’s additional disability. Merely showing that a veteran received care or treatment and that the veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361(c) (1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease or injury for which the care or treatment was furnished unless VA’s failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA’s part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran’s additional disability or death, it must be shown that the hospital care or medical or surgical treatment caused the veteran’s additional disability or death; and 1) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or 2) VA furnished the hospital care or medical or surgical treatment without the veteran’s informed consent. 38 C.F.R. § 3.361(d). When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Court has held that claims file review, as it pertains to obtaining an overview of a claimant’s medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. “It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion.” Analysis Applying the facts to the criteria set forth above, the Board finds that entitlement to compensation under 38 U.S.C. § 1151 is not warranted. As a preliminary matter, the Board observes that the appellant underwent radical prostatectomy at a VA facility in August 2009 and subsequently underwent radiation therapy at a private facility, Rogue Valley Medical Center, in 2009 and 2010. To the extent that the appellant’s § 1151 claims are related to his radiation therapy, rather than the VA-performed radical prostatectomy, such claims must be denied as benefits under 38 U.S.C. § 1151 cannot be awarded for additional disability resulting from procedures performed at a private facility, even if those procedures were performed under contract with VA. The Board acknowledges that a Community Care Referral was made by VA because the appellant did not live in close proximity to VA facilities where such radiation therapy could be performed and it was not feasible to move closer during such treatment; however, such care is specifically excluded from consideration under 38 U.S.C. § 1151 for claims filed after October 1, 1997. See 38 C.F.R. § 3.361(f)(1). There is no evidence, nor is it contended, that VA had any jurisdiction or supervision over Rogue Valley Medical Center. Therefore, the type of treatment received by the appellant at Rogue Valley Medical Center is specifically excluded from consideration under 38 U.S.C. § 1151, as the treatment was not in a VA facility or by a VA employee. See Loving v. Nicholson, 19 Vet. App. 96, 100 (2005). Because the postoperative radiation therapy was not conducted by a VA employee or in a VA facility under the regulatory definition, compensation under 38 U.S.C. § 1151 (a) is unavailable for any additional disability caused by the procedure whether or not it was proximately due to fault or negligence of the care providers, or by an event not reasonably foreseeable. However, the appellant’s theory that it was VA care, or lack thereof, which caused additional disability, which then resulted in the need for the private treatment, is addressed below. The appellant’s prostate cancer did not develop as a result of the March 2005 denial of a urology referral, nor did it worsen or progress further due to the referral denial. The Board finds no indication that failure on the part of VA to timely diagnose or properly treat caused the appellant’s prostate cancer. The VA prostatectomy itself did not cause or worsen the appellant’s prostate cancer or cause or worsen any residuals, save for erectile dysfunction and urinary incontinence. As discussed below, erectile dysfunction and urinary incontinence are reasonably foreseeable residuals of prostatectomy. March 2005 Denial of Urology Referral First, the Board will address the denial of a urology referral in March 2005. The Board finds that the most probative evidence establishes that the appellant did not incur additional disability as a result of such denial. While Dr. T.C., the appellant’s primary care physician, expressed concern about the appellant’s PSA and FPSA levels, the estimate that such indicated a 25 percent chance of prostate cancer was expressed in a speculative matter. Indeed, Dr. T.C. stated that the results were “indicating perhaps a 25 percent chance of prostate cancer.” It is well established that medical opinions that are inconclusive in nature do not provide a sufficient basis upon which to support a claim. See e.g. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (finding doctor’s opinion that “it is possible” and “it is within the realm of medical possibility” too speculative to establish medical nexus); Goss v. Brown, 9 Vet. App. 109, 114 (1996) (using the words “could not rule out” was too speculative to establish medical nexus); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (holding that a physician’s statement that a service-connected disorder “may or may not” have prevented medical personnel from averting a Veteran’s death was not sufficient). After the VA urologist declined Dr. T.C.’s referral for a consultation in March 2005 because the urologist stated that the appellant’s PSA was normal for his age and that the change was inconsequential, Dr. T.C. informed the appellant and requested that a PSA test be again performed in July 2005 in order to continue monitoring the level. Records indicate that the appellant’s PSA had decreased to 3.9 by July 2005. Notably, Dr. T.C. did not challenge the opinion of the VA urologist and also did not recommend the appellant seek a second opinion elsewhere. The Board also observes that the appellant himself did not seek a second opinion. VA clinicians continued to monitor the appellant’s PSA level, which fluctuated between 3.3 and 4.6 from January 2006 to March 2008. A January 2007 VA clinical note from Dr. T.C. states that the appellant has had a slight elevation of PSA for several years and that such had been slowly rising for somewhat more than 10 years. The appellant was clinically asymptomatic, however; and the appellant stated that he would not elect for active intervention under any circumstances, at least for the time being. Monitoring would continue every six months. The January 2020 physician’s medical opinion explains that urinary incontinence and erectile dysfunction can, and often do, occur for patients undergoing prostatectomy, regardless of bladder neck involvement. As such, even if the March 2005 urology referral had not been denied, and even assuming that would have led to earlier detection of and treatment for prostate cancer, there is no competent evidence that a March 2005 urology referral would have led to earlier detection of prostate cancer such that a prostatectomy would have been prevented. Again, the appellant’s PSA level, measured as 4.1 in December 2004 and 4.5 in January 2005, was lower by July 2005, when measured as 3.9. Such then fluctuated between 3.3 and 4.6 from January 2006 to March 2008. It was not until 2009 that digital rectal examination revealed an abnormality and the PSA level was 6.3. Questions of competency notwithstanding, and even assuming arguendo that the appellant indeed incurred additional disability in the form of more malignancy which had to be removed in 2009, less invasive treatment options no longer being available, and/or urinary incontinence and erectile dysfunction, because the March 2005 urology referral was denied, any such disability was not the result of carelessness, negligence, lack of proper skill or judgment, or similar instance of fault, or an event not reasonably foreseeable. The Board affords great probative weight to the opinion of the January 2020 contracted physician that the appellant did not incur any additional disability due to carelessness, negligence, lack of proper skill or judgment, or similar instance of fault, or an event not reasonably foreseeable as a result of the March 2005 denial of a urology referral. As delineated above, based upon the appellant’s age, the VA urologist felt that the appellant’s PSA values, 4.1 in December 2004 and 4.5 in January 2005, were appropriate. The January 2020 physician noted that the appellant’s PSA level was again tested in July 2005, as directed by the urologist, and that the appellant’s PSA value had decreased to 3.9. The appellant’s PSA level then fluctuated between 3.3 and 4.6 from January 2006 to March 2008. The January 2020 physician explained that the VA medical providers had acted appropriately, in accordance with guidelines from the American Urological Association, with respect to early detection of prostate cancer. When a 2009 digital rectal examination was notable for an abnormality, and the appellant’s PSA level was 6.3 in March 2009 and 5.8 in August 2009, it was determined that a biopsy was needed. The biopsy was taken, which led to detection of and treatment for prostate cancer. Crucially, the Board finds the January 2020 medical opinion to be probative as to the questions of additional disability, etiology, foreseeability, and standard of care, as the opinion is based upon a thorough review of the record and upon the appellant’s entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support his opinion”). Here, the January 2020 physician provided a detailed rationale to support his conclusions. Significantly, the conclusions set forth by the January 2020 physician were rendered based upon review of the entire claims file, discussion of the clinical record, and thorough analyses of pertinent medical treatise evidence. See Prejean, supra. The rationale set forth in the January 2020 opinion was substantial, thorough, and based on the overall record. The appellant has not submitted a medical opinion to contradict these conclusions. See 38 U.S.C. § 5107(a) (it is the claimant’s responsibility to support a claim for VA benefits). As noted in the April 2019 Joint Motion, the March 2010 opinion is not adequate because it did not provide an opinion as to whether the appellant had additional disability resulting from either the August 2009 radical prostatectomy or the March 2005 denial of a urology referral. As such, the Board affords it minimal probative weight in this respect. Thus, the only competent and probative opinion of record addressing the standard of care provided by VA comes from the January 2020 physician, and is against the claim. The Board has considered the lay statements and testimony of the appellant and P.D. To this end, the Board recognizes that lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran’s particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011). In this case, the assertions of the appellant and P.D. as to etiology concern an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Cf. Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with 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”); 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); Jandreau, 492 F.3d at 1377, n. 4 (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir.2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). Significantly, the appellant and P.D. do not possess the requisite medical expertise to determine whether the appellant incurred additional disability due to the March 2005 denial of a urology referral, such as more of the prostate needing to be removed, and if any additional disability had resulted, whether such was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or an event not reasonably foreseeable. Indeed, the appellant and P.D. are not competent to determine that, had a urology referral occurred in 2005, cancer would have been detected earlier or that, following a urology consultation, any further testing would have been indicated. As such, these assertions by the appellant and P.D. are not competent medical evidence and are, therefore, afforded little probative weight. Moreover, the lay theory of the appellant is contradicted by the conclusions of the January 2020 examiner who specifically considered these lay contentions, as well as the appellant’s medical history, in rendering his negative opinion. The Board finds the specific, reasoned opinion of the trained health care provider who conducted the January 2020 examination and rendered the medical opinion to be of greater probative weight than the more general lay assertions of the appellant and P.D. The Board emphasizes that the appellant himself told Dr. T.C. in January 2007 that he would not elect for active intervention under any circumstances, at least for the time being. Rather, the preponderance of the evidence establishes that the continuance or natural progress of the appellant’s prostate cancer was not the result of a failure on VA’s part to timely diagnose and properly treat such. 38 C.F.R. § 3.361(c). Rather, as detailed above, VA continued to monitor the appellant, including by checking his PSA levels, after March 2005. This monitoring met the standard of care, as noted by the January 2020 contracted physician. Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease or injury for which the care or treatment was furnished unless VA’s failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c). The Board emphasizes that, although a urology referral was denied in March 2005, VA still monitored the appellant for indicia of prostate cancer, in accordance with the appropriate standard of care, from March 2005 until it was finally diagnosed in 2009, including checking his PSA level on numerous occasions. In sum, based on the evidence above, including the competent and persuasive opinion provided by the January 2020 physician, the Board finds that the March 2005 denial of a urology referral was not the proximate cause of any additional disability, and that, even if such was, the additional disability was not the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA, or an event not reasonably foreseeable. August 2009 Radical Prostatectomy The Board now turns to whether the appellant incurred any additional disability as the result of the August 2009 radical prostatectomy performed by VA and, if so, whether such was due to carelessness, negligence, lack of proper skill or judgment, or similar instance of fault, or an event not reasonably foreseeable. Urinary incontinence and erectile dysfunction The appellant’s urinary incontinence and erectile dysfunction are the result of the August 2009 radical prostatectomy performed by VA and constitute additional disability. Indeed, as noted by the January 2020 physician, such are known consequences of prostate surgery. Thus, the analysis turns to whether either or both were due to carelessness, negligence, lack of proper skill or judgment, or similar instance of fault, or an event not reasonably foreseeable. Following the appellant’s radical prostatectomy performed by VA in August 2009, there was a positive bladder neck periurethral margin. To the extent that this indicates that some portion of the bladder neck may have been removed in the prostatectomy leaving a positive margin behind on the remaining neck, and any removal of the bladder neck itself constitutes additional disability, such was not the result of carelessness, negligence, lack of proper skill or judgment, or similar instance of fault, or an event not reasonably foreseeable. Rather, the presence of a positive margin on the bladder neck following the prostatectomy indicates that any portion of the bladder neck which was removed had cancerous cells. Indeed, a margin is the edge or border of the tissue removed in cancer surgery. Such is described as positive when the pathologist finds cancer cells at the edge of the tissue, suggesting that all of the cancer has not been removed. See e.g. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/margin (last accessed 22 October 2020). The January 2020 physician explained that the ability to spare nerves during prostatectomy is variable depending on the margins of prostate cancer. The positive margin at the urethra was a technical issue of the surgery and unrelated to when the prostate cancer had been diagnosed. Anyone with a positive margin would require additional therapy, regardless of the location or progression of the cancer at the time of surgery. With respect to the performance of the August 2009 radical prostatectomy itself, the January 2020 physician explained that urinary incontinence and erectile dysfunction are known consequences of prostate surgery. Medical research reveals that, regardless of bladder neck involvement, incontinence and erectile dysfunction can, and often do, occur for patients undergoing prostatectomy. As such, the appellant’s current urinary incontinence and erectile dysfunction are not indicia of carelessness, negligence, lack of proper skill or judgment, or similar instance of fault, or an event not reasonably foreseeable. Again, the existence of a positive margin is a technical issue of surgery. As such, it is not the result of carelessness, negligence, lack of proper skill or judgment, or similar instance of fault, or an event not reasonably foreseeable. Crucially, the Board finds the January 2020 medical opinion to be probative as to the questions at issue, as the opinion is based upon a thorough review of the record and upon the appellant’s entire history. See Bloom, supra. Here, the January 2020 physician provided a detailed rationale to support his conclusions. Significantly, the conclusions set forth by the January 2020 physician were rendered based upon review of the entire claims file, discussion of the clinical record, and thorough analyses of pertinent medical treatise evidence. See Prejean, supra. The rationale set forth in the January 2020 opinion was substantial, thorough, and based on the overall record. The Board observes that the appellant and P.D. contended that the VA surgeon “butchered” him, in addition to at least three or four other veterans who underwent the same procedure. However, for the reasons discussed above, the appellant and P.D. not competent to opine on whether his prostatectomy was properly performed as there is no adequate foundation in the record to establish that either has the education, training, or clinical experience to offer a medical opinion relative to such. Layno, supra. Bladder disability Turning to the appellant’s August 2012 bladder perforation, the evidence of record reveals that the appellant sought emergent care in March 2012 for gross hematuria and urinary retention with renal failure. A catheter was inserted and bladder irrigation was performed. The appellant became hypoxemic and was admitted for a chronic obstructive pulmonary disease (COPD) exacerbation and possible pneumonia. See e.g. April 2012 Urology Associates of Southern Oregon clinical note. The appellant was admitted at Rogue Valley Medical Center in early July 2012 for a return of significant hematuria with urinary retention. After transfusion, catheter irrigation, and silver nitrate installation, the appellant did well for about two weeks. Then, in late July 2012, the appellant had an abnormal EKG and was assessed with new onset congestive heart failure (acute diastolic heart failure). The final assessment at discharge, however, was myocardial infarction versus heart strain. See July 2012 Rogue Valley Medical Center clinical notes, October 2012 Urology Associates of Southern Oregon note. While admitted for congestive heart failure in late July 2012, the appellant also experienced mild hematuria. He underwent cystoscopy and cauterization, in addition to blood transfusion and silver nitrate instillation. He did well for about a week, but again presented to the emergency room in early August 2012 for hematuria and retention. Clots in the bladder were irrigated. Due to continuing hematuria, bladder pain, and urinary retention, the appellant was admitted to the Providence Emergency Department. A bladder perforation was found with apparent intraperitoneal extravasation of urine. Bladder repair was performed. Bilateral nephrostomy drains were placed. The appellant underwent cardiac evaluation in anticipation of cystectomy. During this evaluation, he was found to have critical aortic stenosis and was treated surgically for such. The appellant’s post-operative course was mildly complicated. Nephrostomy drainage became clear bilaterally and suprapubic and urethral catheters were maintained on irrigation. However, though the urethral catheter was removed and he was discharged to a rehab facility, the appellant was readmitted later that day due to bloody urine drainage around the suprapubic catheter. Irrigation and reinstallation of the urethral catheter improved this and the appellant was discharged the next morning. Ultimately, a cystectomy (removal of the bladder) was not performed. During an October 2012 follow-up visit at Urology Associates of Southern Oregon, it was noted that the appellant’s urine had cleared to yellow, but he still experienced intermittent hematuria. The suprapubic catheter site had healed and clots had not been a problem. The appellant’s recurring gross hematuria was noted to be related to radiation cystitis/urethritis. Bladder was diverted with bilateral nephrostomy drains. There was minimal bleeding and the clot had resolved. Suprapubic and urethral catheters had been removed. The appellant was planning to be discharged from Medford Rehabilitation that day. During his January 2020 examination, the appellant endorsed urinary incontinence and past hematuria. However, he indicated that he had not experienced hematuria since approximately 2016. Following examination of the appellant and review of the evidence of record, the January 2020 physician identified urinary incontinence as the only diagnosis of the bladder or urethra of the urinary tract. The physician noted that he was unable to measure a bladder repair scar as such was superimposed onto the pre-existing prostatectomy scar. A November 2012 clinical note from Ashland Community Hospital explains that efforts to remove blood clots resulted in a bladder perforation. Such also explains that these clots were the results of radiation cystitis, a known side effect of radiation therapy. The appellant indeed had a bladder perforation in 2012, which was surgically repaired. But there is no competent evidence that the appellant has any additional bladder disability during the period on appeal. The Board affords great probative weight to the opinion of the January 2020 examiner that the only current residuals of the appellant’s prostate cancer are urinary incontinence and erectile dysfunction. Even assuming that the appellant indeed has additional disability in the form of bladder repair residuals, such was not due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance on fault on the part of VA, or an event not reasonably foreseeable. The need for radiation therapy after prostatectomy is not an indication that the prostatectomy was not performed pursuant to the standard of care. In June 2009, the appellant was informed of the risks, benefits, and alternatives of radical prostatectomy with nerve sparing. He provided informed consent for the procedure in August 2009. An August 2009 post-prostatectomy microscopic examination revealed that the bladder neck periurethral margin was positive for malignancy. In September 2009, the appellant stated that he had recovered from his surgery without any problems whatsoever. Incontinence was endorsed and he thus used pads/diapers. Nocturia was three to six times nightly. The appellant reported an inability to achieve an erection since the prostatectomy. Salvage radiation therapy was recommended. Notably, recent studies indicated that, although quality of life worsens initially following radiotherapy, the procedure does result in statistically significant increase in metastasis-free survival. It was recommended that salvage radiation therapy begin 16 weeks after the prostatectomy. The fact that radiation therapy was required following the VA-performed radical prostatectomy does not establish that there was any instance of fault in the performance of the prostatectomy. Rather, as explained by the January 2020 physician, the presence of positive margins, potentially cancerous cells left behind at the edges of the prostatectomy, is reasonably foreseeable. The radiation therapy was performed privately. In any event, as explained in the November 2012 clinical note from Ashland Community Hospital, radiation cystitis is a reasonably foreseeable consequence of salvage radiation therapy. There is no competent evidence to the contrary. With respect to the appellant’s contentions that the back-flushing of his bladder to remove clots resulted in additional disability, there is no competent evidence that he has any current residuals of such. The January 2020 medical opinion stands unchallenged on the critical question of whether the appellant has any additional bladder disability due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance on fault on the part of VA, or an event not reasonably foreseeable. Kidney disability The Board affords great probative weight to the January 2020 contracted examiner’s opinion that the appellant did not incur any additional kidney disability as the result of 2009 radical prostatectomy. The January 2020 examiner provided a well-reasoned explanation that the appellant’s episode of kidney failure was acute and had fully resolved without residual in 2012, prior to the period on appeal. Indeed, during the January 2020 examination, the appellant reported that he had been told his kidneys were bad following his coronary artery bypass graft. He had received dialysis in the hospital, but such was no longer needed. The appellant denied any procedure such as kidney biopsy or drainage. Rather, he reported an intermittent history of his bladder plugging up with blood clots requiring catheters and drainage in the past, but none in the recent last several years. Following examination of the appellant and review of the evidence of record, the contracted physician determined that there was no pathology upon which to render a diagnosis regarding the kidneys. There is no competent evidence to the contrary. The January 2020 medical opinion stands unchallenged on the critical question of whether the appellant has any additional kidney disability due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance on fault on the part of VA, or an event not reasonably foreseeable. Heart attack Heart valve replacement and bypass The Board finds that the most probative evidence establishes that the appellant did not incur additional heart disability, to include a heart attack and/or heart valve replacement and bypass, as the result of the 2009 VA-performed prostatectomy. As delineated above, the need for radiation therapy following the VA-performed prostatectomy does not indicate that the appellant incurred additional disability due to VA care. Rather, radiation therapy was recommended and performed privately to ensure that all of the appellant’s prostate malignancy had been removed. As noted above, there was a positive margin following the prostatectomy. Even assuming arguendo that this positive margin may indeed constitute additional disability as a result of VA care, in that, had VA not performed the prostatectomy, there would not be a positive margin on the bladder neck, but rather a malignant prostate with malignancy spreading to the bladder neck, the January 2020 contracted physician explained that the VA-performed 2009 radical prostatectomy met the standard of care and that there was no carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA. The January 2020 physician also thoroughly explained that the appellant’s bicuspid aortic valve, critical aortic stenosis, valve replacement, and coronary artery disease are not related to his radical prostatectomy or other treatment or complications for his prostate cancer. Rather, the physician explained that the appellant’s long-standing history of tobacco use and high blood pressure were clear risk factors for coronary artery disease. A heart or valve disorder would not be anticipated as a result of prostate cancer or its treatment, including surgery and radiation. The appellant’s bicuspid aortic valve was congenital and completely unrelated to prostate cancer or treatment for such. The appellant’s critical aortic stenosis, which required valve replacement, too, was unrelated to the treatment for his prostate cancer. As the evidence of record establishes, in anticipation of a possible cystectomy (bladder removal) by private clinicians, a cardiac workup was performed, which revealed the appellant’s bicuspid aortic valve. Essentially, this was an incidental finding made during due preparation for possible major surgery. Valve replacement was duly performed by private clinicians. Following examination of the appellant and consideration of the medical and lay evidence of record, the January 2020 physician opined that the appellant did not incur additional heart disability as a result of the VA-performed 2009 radical prostatectomy. The physician explained that the appellant’s acute myocardial infarction, coronary artery disease, and coronary artery bypass graft (CABG) were the result of the appellant’s hypertension and tobacco use. The appellant’s valvular heart disease and bicuspid aortic valve were congenital and treated by porcine replacement. The appellant’s congestive heart failure (CHF) was the result of acute volume overload and acute renal failure. Indeed, the physician stated that the appellant’s long-standing history of tobacco use and high blood pressure are clear risk factors for coronary artery disease. A heart or valve condition will not be anticipated as a result of prostate cancer or its treatment, including surgery and radiation. Rather, the appellant’s bicuspid aortic valve was congenital and completely unrelated to prostate cancer or any treatments for prostate cancer. The appellant’s critical aortic stenosis resulted in a need for valve replacement. However, such is also unrelated to prostate cancer or treatment, or residuals of prostate cancer or treatment for said residuals. The Board notes that there may be confusion regarding the January 2020 examiner’s statement that the appellant’s reports of being hospitalized for a heart attack after bladder irrigation not being supported by the record. The appellant reported during his January 2020 examination that, during a bladder irrigation procedure, he suffered a heart attack. He became confused and could not recall specifics. He felt his bladder blew up and that he was taken right in for a heart operation. Following examination of the appellant and review of the claims file, the January 2020 physician observed that the appellant experienced a COPD exacerbation and possible pneumonia, which resulted in a subsequent hospitalization. The Board notes that this statement by the January 2020 physician relates to the April 2012 episode of bladder irrigation with the COPD exacerbation and possible pneumonia. Such is consistent with the competent evidence of record. See e.g. April 2012 Urology Associates of Southern Oregon clinical note. However, later in 2012, records reveal that the appellant experienced cardiac symptoms. In late July 2012, the appellant had an abnormal EKG and was assessed with new onset congestive heart failure (acute diastolic heart failure). The final assessment at discharge, however, was myocardial infarction versus heart strain. See July 2012 Rogue Valley Medical Center clinical notes, October 2012 Urology Associates of Southern Oregon note. During his admission for congestive heart failure in late July 2012, the appellant also experienced mild hematuria. He underwent cystoscopy and cauterization, in addition to blood transfusion and silver nitrate instillation. He did well for about a week, but again presented to the emergency room in early August 2012 for hematuria and retention. Clots in the bladder were irrigated. Due to continuing hematuria, bladder pain, and urinary retention, the appellant was admitted to the Providence Emergency Department. A bladder perforation was found with apparent intraperitoneal extravasation of urine. Bladder repair was performed. Bilateral nephrostomy drains were placed. The appellant underwent cardiac evaluation in anticipation of cystectomy. During this evaluation, he was found to have critical aortic stenosis and was treated surgically for such. Ultimately, a cystectomy was not performed. In any event, the January 2020 physician provided a thorough, well-reasoned rationale as to the opinion that the appellant did not incur any additional heart disability caused by VA. Rather, the physician explained the causes for each heart disability. The Board finds the examiner’s opinion highly probative because it was based on a clinical examination of the appellant, a review of the claims file, consideration of the relevant medical history, and the opinion was accompanied by a detailed rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). There is no competent evidence to the contrary. As discussed above, the appellant is not competent to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the appellant in this case, who has not been shown by the evidence of record to have medical training or skills. Layno, supra. As there is no competent evidence to the contrary, the January 2020 medical opinion stands unchallenged on the critical question of whether the appellant incurred any additional heart disability as the result of VA treatment. A causal connection must be shown before the question of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault, or whether an event not reasonably foreseeable was the proximate cause of additional disability. Thus, the Board’s analysis ends with the conclusion that no additional heart disability was caused by VA. As the evidence preponderates against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Behlen, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.