Citation Nr: 21001875 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 19-08 096 DATE: January 12, 2021 ORDER Entitlement to a rating of 100 percent for service-connected posttraumatic stress disorder (PTSD) is granted Entitlement to service connection for human immunodeficiency virus (HIV), claimed as due to military sexual trauma, is granted. New and material evidence having been received, the matter of entitlement to service connection for a heart disability is reopened. Entitlement to service connection for a heart disability, claimed as secondary to service-connected PTSD, is denied. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran’s service-connected PTSD more nearly approximated a disability picture that resulted in total occupational and social impairment. 2. The evidence is at least in equipoise that the Veteran’s diagnosed HIV was incurred during active service. 3. In a November 2014 rating decision, the RO denied the Veteran’s claim of entitlement to service connection for a heart disability. He did not appeal the decision nor was new and material evidence received within one year. 4. The evidence received since the November 2014 decision includes evidence which relates to unestablished facts necessary to substantiate the claim of entitlement to service connection a heart disability and, if presumed credible, raises a reasonable possibility of substantiating the claim. 5. A heart disability, to include coronary artery disease (CAD), is not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. Resolving doubt in the Veteran’s favor, the criteria for the assignment of a 100 percent disability rating for his service-connected PTSD are met throughout the appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. 2. The criteria for service connection for HIV are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. New and material evidence has been received to warrant reopening of the claim of service connection for a heart disability. 38 U.S.C. §§ 5107, 5108, 7104; 38 C.F.R. § 3.156. 4. A heart disability is not proximately due to, or aggravated by, a service-connected disability. 38 U.S.C. §§ 1131, 5017; 38 C.F.R. §§ 3.303, 3.310(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1971 to May 1979. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated April 2017, December 2017, and November 2018 of the Department of Veterans Affairs (VA) Regional Office (RO). The April 2017 rating decision denied a rating in excess of 50 percent for service-connected PTSD. The Veteran filed a notice of disagreement (NOD) in October 2017 and a statement of the case (SOC) was issued in March 2020. He perfected a timely appeal in April 2020. The December 2017 rating decision denied the Veteran’s claim of entitlement to service connection for HIV. A NOD was filed in October 2018; a SOC was issued in December 2018. The Veteran perfected a timely appeal in February 2019. The November 2018 rating decision declined to reopen the Veteran’s claim of entitlement to service connection for a heart disability. A December 2018 rating decision confirmed and continued the denial. The Veteran filed a NOD in February 2019. A SOC was issued in January 2020, which reopened and denied the claim of entitlement to service connection for a heart disability. He perfected a timely appeal in March 2020. Although the RO reopened the Veteran’s heart disability claim, the question of whether new and material evidence has been received is one that must be addressed by the Board, notwithstanding a decision favorable to the Veteran that may have been rendered by the RO. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996) (before considering a previously adjudicated claim, the Board must determine that new and material evidence was presented or secured for the claim, making RO determination in that regard irrelevant); see also Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001) (the Board has a jurisdictional responsibility to consider whether it was proper for the RO to reopen a previously denied claim). As such, the Board will first consider whether new and material evidence has been received sufficient to reopen the heart disability claim. In November 2020, the Veteran presented sworn testimony during a virtual hearing, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran’s VA claims file. 1. Entitlement to a rating in excess of 50 percent for service-connected PTSD. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. If two disability ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. §§ 3.102, 4.3. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claim. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. The Board must then determine if the evidence is credible, or worthy of belief. Barr, at 308 (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the “authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence”). The Board has considered all evidence of record as it bears on the issues before it. See 38 U.S.C. § 7104(a) (“Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record”); 38 U.S.C. § 5107(b) (“Secretary shall consider all information and lay and medical evidence of record in a case”). Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran’s appeal. PTSD is evaluated pursuant to 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. Under this formula, a 70 percent evaluation is contemplated for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411. A 100 percent evaluation is warranted when there is evidence of total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place; memory loss for names of close relatives, own occupation or name. Id. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Historically, the Veteran was granted service connection for anxiety neurosis in a February 1980 rating decision and a noncompensable (zero percent) rating was assigned from August 7, 1979. A May 2014 rating decision recharacterized the service-connected disability as PTSD and increased the assigned rating to 10 percent from August 18, 2000, 30 percent from December 21, 2011, and 50 percent from March 24, 2014. In December 2016, the Veteran filed a claim of entitlement to an increased rating for PTSD, which was denied in an April 2017 rating decision. As indicated above, the Veteran filed a NOD as to the denial in October 2017 and this appeal follows. For the following reasons, the Board finds that a rating of 100 percent is warranted under the schedular criteria throughout the appeal period. VA treatment records dated in December 2015 indicated that the Veteran had experienced a major panic attack. The Veteran denied suicidal and homicidal ideation. The treatment provider confirmed diagnoses of PTSD and panic disorder without agoraphobia. VA treatment records dated in December 2016 documented an exacerbation of the Veteran’s anxiety symptoms. The VA treatment provider stated, “[i]t is the opinion of these [behavioral health] practitioners that [the] Veteran’s anxiety which is related to PTSD has indeed worsened and at this time prevents him from socializing even with his family.” In a December 2016 statement, the Veteran reported that the frequency of his panic attacks has increased to two to three times (or more) a week. He reported that he lost social contact with his family out of fear caused by panic attacks. VA treatment records dated in February 2017 show that the Veteran experiences fecal incontinence during panic attacks. The Veteran was afforded a VA psychological examination in March 2017 at which time the examiner confirmed diagnoses of PTSD with secondary panic disorder. The Veteran reported nightmares, instructive daytime thoughts and flashbacks of military sexual trauma, anxious mood, sleep disturbance with insomnia, panic attacks, hypervigilance, exaggerated startle response, and avoidance behaviors. The Veteran has never been married and has no children. His closest relationship is with his sister, who he now sees occasionally when she provides him rides. He also speaks with his sister by telephone. The Veteran is prescribed Diazepam and Ambien to treat his PTSD and panic disorder symptoms. He additionally reported reckless or self-destructive behavior, impaired concentration, anxiety, panic attacks more than once a week, chronic sleep impairment, and disturbance of motivation and mood. He exhibited clear speech. His thought process was logical, but he at times required redirection by the examiner. The Veteran described his isolated lifestyle as a ‘living hell.’ He has not worked since 1993. In a May 2017 statement, the Veteran’s sister, Ms. L.B., described the Veteran’s panic attacks as so severe that he loses control of his bowels. In a May 2017 statement, Mr. G.M. and Mrs. D.M. explained that the Veteran had trouble attending family gatherings and experienced anxiety attacks. They reported that, as a result of his panic and anxiety, the Veteran is mostly confined to his home the last couple of years. Mr. G.M. and Mrs. D.M. stated that the Veteran “barely leaves his home except for doctor’s appointments and [groceries]. At which time he has to arrange for someone to drive him.” VA treatment records dated in May 2017 noted that the Veteran’s “[a]nxiety persists to a degree that prohibits him from activities of daily living such as grocery shopping and leaving his home.” The treatment provider diagnosed the Veteran with treatment resistant anxiety, which renders him “[u]unable to perform activities such as shopping or visiting with family secondary to anxiety and panic.” The treatment provider stated, “[i]t is the opinion of these practitioners [that] any employment would render higher anxiety and further reduce his ability to perform even basic activities of daily living. The deleterious effects of anxiety and panic to sleep also decreased ability to concentrate and further prevent [the Veteran’s] ability for employment.” VA treatment records dated in October 2017 indicates that, since his last therapy session, the Veteran was able to go to lunch with a friend. However, he chose a time that there would be very few patrons at the establishment. It was noted that the Veteran “fears leaving his home because of irritable bowel and incontinence with same.” VA treatment records dated in September 2018 note that the “frequency of anxiety attacks ahs increased mildly, noting he has ‘small, medium and large’ attacks. Typically, has one ‘small’ attack nearly every day. Reports he has lost control of his bowels during large panic attacks in the past.” VA treatment records dated in October 2018 show that the Veteran continues to maintain a friendship with his new friend. VA treatment records dated in January 2020 documented the Veteran’s report of escalating “PTSD symptoms at times from vivid flashback dreams. One of them, he said, produced a ‘bad panic attack’ where he lost his bowels but made it to the bathroom in time.” The Veteran endorsed problems with sleep and focus. In a February 2020 report of a private psychiatric evaluation, Dr. E.S. noted that the Veteran “has difficulties completing activities of daily living due to his psychiatric symptoms. He reported chronic impairment in maintaining some personal hygiene due to PTSD and back pain. The Veteran stated that he has avoided bathing much in the last three to four years. He “limits his activities outside of the household and does not regularly engage in running errands due to symptoms of PTSD out of fear and ‘is trapped in [his] own home.’ He rarely leaves his house.” Dr. E.S. noted that the Veteran does not visit his family much anymore and is afraid of having panic attacks while driving. As such, his family and friends help with running errands. The Veteran reported that he is “always apologizing to people for being angry with them and my fuse is real short because [he is] so angry with [his] life situation.” He explained that he used to enjoy going out to eat with his family, but stopped because he was afraid of having a panic attack and losing control of his bowels. The Veteran also described chronic sleep impairments and nightmares, as well as hypervigilance and impaired memory and concentration. He reported that, when he was working, he was unable to remain focused on tasks. He described a low mood without any motivation. He reported chronic passive suicidal ideation, but denied any active suicidal ideation. The Veteran indicated that his sister recently died and “he doesn’t feel anything about it.” Dr. E.S. reported that the Veteran’s PTSD symptoms “effectively impair his ability to secure and follow gainful employment and to perform effectively in the workplace.” He explained that the Veteran “would be unable to tolerate average workplace stressors, which could have the potential to increase the frequency and intensity of suicidal ideation and psychiatric hospitalizations.” In a separate February 2020 disability benefits questionnaire (DBQ), Dr. E.S. indicated that the Veteran’s PTSD symptoms manifest in total occupational and social impairment. The Veteran endorsed avoidance, difficulty in falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, depressed mood, anxiety, suspiciousness, mild memory loss, and flattened affect. He additionally reported disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a work-like setting, suicidal ideation, and neglect of personal appearance and hygiene. The Board has thoroughly reviewed the record and has given full consideration to 38 C.F.R. § 4.7 (where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned) and 38 C.F.R. § 3.102 (when there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the veteran). In determining whether the Veteran meets the schedular criteria for an increased disability rating, the Board’s inquiry is not necessarily limited to the criteria found in the VA rating schedule. See Mauerhan, supra. As summarized in detail above, the evidence shows that, throughout the appeal period, the Veteran’s service-connected PTSD has been manifested by symptoms such as severe panic attacks more than once a week, suicidal ideation, anxiety, irritability, nightmares, inability or difficulty adapting to stressful circumstances, depression, difficulty sleeping, intrusive thoughts, impaired impulse control, an inability or difficulty establishing and maintaining effective work and social relationships, impaired concentration and memory, exaggerated startle response, and hypervigilance. The evidence of record shows that the Veteran has socially isolated himself from others and has experienced debilitating panic attacks throughout the appeal period. In addition, the record shows that the Veteran has not worked during the appeal period. VA treatment providers and a private psychologist have opined that the Veteran is unable to work as a result of his service-connected PTSD. To this end, as described above, the Veteran’s VA behavioral health treatment team opined that the Veteran’s psychological symptoms render him unable to perform even basic activities of daily living and prevent the Veteran’s ability for employment. See the VA treatment records dated May 2017. Moreover, in February 2020, Dr. E.S. opined that the Veteran’s PTSD manifests in total occupational and social impairment. Additionally, the Veteran’s psychiatric symptoms have required him to maintain individual therapy throughout the appeal period. He has described outbursts of anger, irritability, impaired memory, impaired impulse control, irritability, and impaired thought processes. The Veteran’s debilitating panic attacks have significantly impaired his personal relationships. While the record shows that the Veteran has, at times, been able to maintain a friendship, he generally socially isolates to the point of feeling trapped in his own home. Applying the criteria set forth above to the facts in this case, and affording the Veteran the benefit of the doubt, the Board finds that his service-connected PTSD has been productive of symptomatology which more nearly approximates the criteria for 100 percent disability rating throughout the appeal period. While there may have been day-to-day fluctuations in the manifestations of the Veteran’s service-connected PTSD, the evidence shows no distinct periods of time during the appeal period, when the Veteran’s service-connected PTSD varied to such an extent that a rating less than the 100 percent assigned herein would be warranted. Hart v. Mansfield, 21 Vet. App. 505 (2007). Although the record does contain some evidence suggesting that the Veteran’s PTSD has not been consistently productive of total social and occupational impairment, in cases such as this, where there is a question as to which of two evaluations apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Affording the Veteran, the benefit of the doubt, the Board finds that his disability picture more nearly approximates the criteria for a 100 percent rating. Accordingly, the Board finds that a 100 percent rating is warranted for the Veteran’s service-connected PTSD for the entire period on appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102; 3.400(o)(2); Gilbert, 1 Vet. App. at 53-56. As detailed above, the record reflects that the Veteran is unable to obtain and maintain gainful employment as a result of his service-connected PTSD. Moreover, the Veteran asserted entitlement to a TDIU based upon his service-connected PTSD in his October 2017 NOD. As such, the Board has considered whether a TDIU is warranted during the appeal period. See Rice v. Shinseki, 22 Vet. App. 447 (2009). To this end, the Court has held that the receipt of a 100 percent schedular rating for a service-connected disability does not necessarily render moot any pending claim for a TDIU. Bradley v. Peake, 22 Vet. App. 280 (2008). Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, the Court’s decision in Bradley recognizes that a separate award of a TDIU predicated on a single disability may form the basis for an award of special monthly compensation. The Bradley case, however, is distinguishable from the instant case. In Bradley, the Court found that TDIU was warranted in addition to a schedular 100 percent evaluation where the TDIU had been granted for a disability other than the disability for which a 100 percent rating was in effect. Under those circumstances, there was no “duplicate counting of disabilities.” Bradley, 22 Vet. App. at 293. In this matter, the Veteran seeks entitlement to a TDIU based upon his service-connected PTSD. See the Veteran’s NOD dated October 2017. He has not asserted, nor does the record suggest, that he is entitled to a TDIU based upon his other service-connected disabilities. Accordingly, the issue of entitlement to a TDIU is rendered moot by the assignment of the 100 percent disability rating for PTSD in this decision. See 38 U.S.C. § 7105(d)(5). 2. Entitlement to service connection for HIV. In order to prevail on the issue of service connection for any particular disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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. Here, the Veteran contends that he developed HIV as a result of military sexual trauma (MST) during his active duty service. See, e.g., November 2020 Board hearing transcript. For the reasons set forth below, the Board finds that entitlement to service connection for HIV is warranted. As indicated above, the Veteran served on active duty from April 1971 to May 1979. The Board observes that MST during the Veteran’s active duty service has been conceded by the RO. See, e.g., the rating decision dated May 2014. To this end, service treatment records (STRs) dated in March 1979 document the Veteran’s in-service report of a sexual assault that took place at Keesler Air Force Base in 1972. The March 1979 STR documented the Veteran’s report that he engaged in additional homosexual encounters during his active duty dating from 1977 to 1978 when he was treated for rectal condylomata accuminata. He was separated from military service in April 1979 following a Physical Evaluation Board, which documented a diagnosis of depressive neurosis with moderate impairment. The Board recognizes that the Veteran now argues that he did not engage in any voluntary sexual encounters during his active duty service from 1977 to 1978. See, e.g., the November 2020 Board hearing transcript. However, the Veteran’s April 1979 report of engaging in such encounters was reiterated in an October 1979 VA psychological examination at which time he reported engaging in homosexual activity during his military service. To this end, the Board notes that engaging in unprotected sexual encounters during active service is not willful misconduct and the Veteran may be service connected for disabilities incurred as a result of such activities. 38 U.S.C. § 105; 38 C.F.R. § 3.301. Private treatment records dated in September 1989 document a continuing diagnosis of AIDS. Treatment records dated in May 1993 note that the Veteran has been HIV positive for about 12 years. Private treatment records dated in December 2014 indicated that the Veteran was diagnosed with HIV in 1987. The Veteran was afforded a VA medical opinion in December 2017 at which time the examiner noted that the Veteran is HIV positive and was a victim of military sexual trauma in 1971. The examiner stated that the Veteran voluntarily engaged in high risk behavior in 1977 and 1979. The examiner stated that there was no evidence of blood transfusion on active duty. The examiner further noted that HIV was first identified in the United States in 1981. The examiner therefore concluded that the Veteran’s “HIV infection is not at least as likely as not due to the assault he sustained on active duty.” In support of his claim, the Veteran submitted a May 2020 medical opinion from Dr. B.W., who determined “it is at least as likely as not that [the Veteran’s] HIV was contracted during his time in service.” Dr. B.W. explained, Although HIV and AIDS were not formally identified until 1981, there were earlier reports of clusters of disease, referred to as GRID, Gay-Related Infections Disease, Gay Bowel Disease, among other names. Prior to 1981, studies note the identification of Kaposi’s Sarcoma and Pneumocystis carinii pneumonia (both conditions significantly prevalent in patients with AIDS) in otherwise healthy young men that later became appreciated as suffering from HIV infection. In fact, as previously referenced, HIV was found in frozen blood samples that had been saved during the study of hepatitis B in the 1970s and available data indicates that, although cases were not labeled as HIV/AIDS, the current epidemic started in the mid-1970s, and sporadic AIDS cases in the USA may have even predat[ed] this. From a personal standpoint, I was in my internship and residency at University of Alabama Birmingham from June 1978 until July 1981 and I can distinctly remember seeing at least two patients who were in the categories described above. Therefore, the fact that HIV was not formally identified in US until 1981 has no bearing on the fact that HIV was present in USA prior to 1981. Based on the fact that [the Veteran] does not have history of drug abuse or blood transfusion prior to 1986, and I light of the lay statement evidence described above demonstrating that he did not have experience [in] any sexual contact apart from the sexual assaults he suffered in-service, and considering the vast medical research that supports high transmissibility of HIV in MSM, it is my medical opinion that it is at least as likely as not that [the Veteran’s] HIV was caused by sexual assaults during his military service. Accordingly, the Board has weighed the probative evidence of record including the Veteran’s STRs, his lay statements, the May 2020 private nexus opinion, and the December 2017 VA medical opinion and finds that the evidence is at least in equipoise as to whether the diagnosed HIV was incurred during the Veteran’s active military service. The benefit-of-the-doubt rule is therefore for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board will resolve the reasonable doubt in the Veteran’s favor and find that the evidence supports the grant of service connection for HIV. See 38 U.S.C. § 5107. 3. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a heart disability. In general, decisions of the RO that are not appealed in the prescribed time period are final. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. For claims filed on or after August 29, 2001, new evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the credibility of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary’s duty to assist. Id. at 118. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. 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(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In a May 2014 decision, the RO denied the Veteran’s original claim of entitlement to service connection for a heart disability. A November 2014 decision confirmed and continued the May 2014 denial. The Veteran did not appeal the November 2014 decision. As new and material evidence was not received within one year of the decision, it became final as to the identified claim. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1100; Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). Under these circumstances, the RO’s November 2014 rating decision denying entitlement to service connection for a heart disability is not subject to revision on the same factual basis. See 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.1103. The Veteran now seeks to reopen his claim of entitlement to service connection for a heart disability. As noted above, despite the finality of a prior adverse decision, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Thus, the Board has reviewed the entire record, with attention to the additional evidence received since the last final decision in November 2014. After reviewing the record, the Board finds that the additional evidence received is new and material within the meaning of 38 C.F.R. § 3.156 warranting reopening of the claim. Without the need to discuss every piece of newly received evidence in detail, the Board finds that new and material evidence has been received regarding the request to reopen the Veteran’s claim of entitlement to service connection for a heart disability. See Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). Namely, in a December 2016 statement, Dr. M.C. stated that, in addition to coronary artery disease (CAD), the Veteran suffers from anxiety attacks which have caused exacerbations of chest pain and elevated blood pressure. Dr. M.C. opined, “[o]ptimal control of his anxiety is desired for his overall cardiovascular health. Additionally, the Veteran and his attorney submitted multiple journal articles, which suggested a relationship exists between PTSD and heart disease. Critically, this evidence relates to the previously unestablished element of nexus as to the claim of entitlement to service connection for a heart disability. Accordingly, the standards under 3.156(a) have been met and the claim is reopened. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); Shade, supra. 4. Entitlement to service connection for a heart disability. Service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310(a); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board notes that there has been an amendment to the provisions of 38 C.F.R. § 3.310. See 71 Fed. Reg. 52,744 -47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. The Veteran has asserted entitlement to service connection for a heart disability, which he contends is secondary to his service-connected PTSD. See the Veteran’s NOD dated February 2019; see also the November 2020 Board hearing transcript. At the outset, the Board observes that the Veteran’s STRs are negative for any indication of an in-service heart disability nor does the record contain any indication that the current heat disability is causally related to an in-service disease or injury. The Veteran does not contend otherwise. Rather, the Veteran claims service connection on a secondary basis. For the reasons set forth below, the Board finds that the evidence of record does not support a finding that the Veteran’s heart disability is caused or aggravated by the service-connected PTSD. Private treatment records dated in September 200 note a well-documented history of CAD for the past 16 years. Private treatment records dated in March 2014 noted a diagnosis of stable CAD with a history of bypass surgery in 2005 and stenting of the coronary artery in November 1999. In a December 2016 statement, Dr. M.C. reported that the Veteran has a diagnosis of CAD for which he underwent stent placement in 1999 following a myocardial infarction. Dr. M.C. stated that the Veteran’s “other diagnosis of anxiety and his reports of subsequent anxiety attacks have cause[d] exacerbations of chest pain and elevated blood pressure, and he has been treated multiple times in the emergency room.” Dr. M.C. opined, “[o]ptimal control of his anxiety is desired for his overall cardiovascular health.” As indicated above, the Veteran has submitted multiple journal articles in support of an association between CAD and PTSD. A May 2019 DBQ from a private treatment provider documented diagnoses of CAD, ventricular tachycardia, congestive heart failure, ischemic cardiomyopathy, and valvular heart disease with a history of LV dysfunction, hyperlipidemia, and myocardial infarction. The Veteran was afforded a VA examination in December 2019 at which time the examiner confirmed a history of myocardial infarction in 1999 with continuing diagnoses of CAD, stable angina, congestive heart failure, ventricular arrhythmia, and cardiomyopathy. In a separate December 2019 VA medical opinion, the examiner determined that the diagnosed heart disability is less likely than not (less than 50 percent probability) proximately due to or the result of the Veterans’ service-connected PTSD. The examiner noted that the Veteran “has a long smoking history of two packs per day for 38 years, [he] quit in 2007. Strong family history of CAD, both mother and father deceased of heart disease.” The examiner explained that there is no causational relationship between PTSD and CAD. The examiner cited pertinent medical literature in support of his conclusion. The examiner further noted that the medical evidence of record does not support a finding that the Veteran’s CAD status-post coronary artery bypass graft (CABG) is aggravated by his service-connected PTSD. The examiner explained, “[t]he aggravation is related to his significant stenosis of the CAD . . . [and] [t]here was structural medical evidence of worsening heart disease, not [due to] the PTSD.” 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. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Significantly, the most probative evidence of record demonstrates that the Veteran’s diagnosed heart disability is not caused or aggravated by his service-connected PTSD. The findings of the December 2019 VA examiner were thoroughly explained and fully supported by the evidence of record. To this end, the Board notes that the VA examiner’s opinions were based on a review of the record as well as a thorough review of pertinent medical literature, and the examiner explained the reasons for his conclusions based on an accurate characterization of the evidence of record. The Board therefore places significant weight on the findings of the December 2019 VA examiner. 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”). Accordingly, the Board finds that the competent medical evidence demonstrating the absence of nexus between the claimed heart disability and the Veteran’s service-connected PTSD outweighs any medical evidence suggestive of a nexus or aggravation. (Continued on the next page)   The Board has carefully considered the contentions of the Veteran that the diagnosed heart disability is aggravated by his service-connected PTSD. 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, 24 Vet. App. at 433, n. 4. In this case, the Veteran’s assertions 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). Questions of competency notwithstanding, the Veteran’s lay theory regarding the etiology of his heart disability is contradicted by the conclusions of the December 2019 VA examiner who specifically considered the Veteran’s lay statements and pertinent medical literature in rendering the negative opinion. The Board finds the specific, reasoned opinion of the trained health care provider who conducted the December 2019 VA opinion to be of greater probative weight than the more general lay assertions of the Veteran. Thus, the preponderance of the evidence is against the Veteran’s contention that he suffers from a heart disability, which is related to or aggravated by his service-connected PTSD. Thus, the benefit-of-the-doubt rule is not applicable to the claim. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. K. Buckley, 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.