Citation Nr: 21066277 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 13-12 560 DATE: October 29, 2021 ORDER Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), prior to May 11, 2011, for purposes of accrued benefits and/ or substitution, is denied. Entitlement to an increased rating higher than 50 percent for posttraumatic stress disorder (PTSD) prior to May 11, 2011, for purposes of accrued benefits and/ or substitution, is denied. Entitlement to service connection for ischemic heart disease (claimed as mildly prominent aorta and abdominal aortic aneurysm (AAA)), for purposes of accrued benefits and/ or substitution, is denied. FINDINGS OF FACT 1. Effective prior to May 11, 2011, the Veteran's service-connected disabilities did not prevent him from obtaining or maintaining substantially gainful employment. 2. Effective prior to May 11, 2011, the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. 3. The preponderance of the evidence is against finding that ischemic heart disease (claimed as mildly prominent aorta and abdominal aortic aneurysm (AAA)), began during active service, or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for a TDIU prior to May 11, 2011, for purposes of accrued benefits and/ or substitution, are not met. 38 U.S.C. §§ 5110, 7105; 38 C.F.R. §§ 3.400, 4.16(b). 2. The criteria for a disability rating in excess of 50 percent for PTSD, prior to May 11, 2011, for purposes of accrued benefits and/ or substitution, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 3. The criteria for service connection for ischemic heart disease (claimed as mildly prominent aorta and abdominal aortic aneurysm (AAA)), for purposes of accrued benefits and/ or substitution, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS This case is on appeal to the Board of Veterans' Appeals (Board) from Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) rating decisions dated in February 2011 and June 2011. The Veteran testified before the undersigned Veterans Law Judge at a Board hearing at the AOJ in April 2014. Unfortunately, the Veteran died in December 2017 during the pendency of his appeal. In September 2018, the appellant was substituted as the claimant for the purposes of proceeding with the Veteran's pending appeal. In January 2020, the Board, in pertinent part, for purposes of accrued benefits and/ or substitution, denied service connection for ischemic heart disease; denied an increased rating higher than 50 percent for PTSD, effective prior to May 11, 2011; granted an increased rating of 70 percent, for PTSD, effective May 11, 2011, and 100 percent, effective July 2, 2012; and granted a 70 percent rating for PTSD, effective August 7, 2014. The appellant appealed the Board's January 2020 decision to the U.S. Court of Appeals for Veterans Claims (Court); and pursuant to a joint motion for partial remand (JMPR), in December 2020, the Court vacated the Board's decision insofar as the Board denied service connection for ischemic heart disease; denied higher ratings for the PTSD prior to July 2, 2012, and effective August 7, 2014; and did not address the issue of entitlement to a TDIU. In May 2021, the Board granted a 100 percent rating for PTSD, effective May 11, 2011 and Board remanded the remaining issues on appeal, pursuant to the JMPR. Specifically, the remand directives noted that efforts should be made to obtain the Veteran's Social Security Administration (SSA) records; and medical opinions should be provided as to whether the Veteran's degeneration of the muscularis of the abdomen was related to his exposure to herbicide agents in service, and how the Veteran's PTSD impacted his ability to work prior to May 11, 2011. The AOJ contacted SSA for medical records and was notified in May 2021 that the Veteran's SSA records had been destroyed. The medical opinions addressing the degeneration of the muscularis of the abdomen and employability due to PTSD also were provided in May 2021. The directives of the Board's remand having been substantially complied with the case is now returned for appellate review. 1. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), prior to May 11, 2011, for purposes of accrued benefits and/ or substitution The November 2020 JMPR found that the Board should have addressed entitlement to a TDIU as being on appeal as part of the increased rating claim for PTSD, pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). See November 2020 JMPR, p. 7-8. The JMPR also noted that the Board should consider whether a new opinion regarding the Veteran's ability to obtain and maintain substantially gainful employment is warranted, given that a November 2015 VA medical opinion did not address whether the Veteran was unable to work due to his PTSD in combination with all of his other service-connected disabilities. Id. at 8. Given that the Veteran has been assigned a 100 percent rating for PTSD, effective May 11, 2011, the issue of entitlement to a TDIU, as of that date, is moot. The Veteran reportedly had not worked at any time during the appeal. See also June 2017 VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability). He testified at the April 2014 Board hearing that he was medically disabled since 2000 and that he had to have back surgery for the job that he was doing. See April 2014 Board hearing transcript, p. 10. As noted in the introduction, an attempt was made to retrieve copies of the Veteran's SSA records but the AOJ was notified that the records had been destroyed. Total disability is considered to exist when there is any impairment in mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (a)(1). A total disability rating for compensation purposes may be assigned on the basis of individual unemployability, that is, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16 (a). The term "unable to secure and follow a substantially gainful occupation" is defined as having two components: one economic and one non-economic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of: the Veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. Ray v. Wilkie, 31Vet. App.58, 73 (2019). If there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Id. Individual unemployability must be determined without regard to any non-service-connected disabilities or the Veteran's advancing age. 38 C.F.R. §§ 3.341 (a), 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In reaching a determination of TDIU, it is necessary that the record reflect some factor which takes the Veteran's case outside the norm with respect to a similar level of disability under the rating schedule. 38 C.F.R. §§ 4.1, 4.15; Van Hoose, 4 Vet. App. at 363. The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The question is whether or not the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Beaty v. Brown, 6 Vet. App. 532, 538 (1994). Prior to May 11, 2011, the Veteran did not meet the percentage requirements for consideration of a total evaluation under 38 C.F.R. § 4.16 (a), as his combined disability rating for his service-connected PTSD and tinnitus disabilities was 60 percent, effective August 2, 2010, and 40 percent, effective July 8, 2010. He had two service-connected disabilities at that time. Nevertheless, for the period prior to May 11, 2011, the Veteran may be entitled to a TDIU on an extraschedular basis if it is established that he is unable to secure or follow substantially gainful employment as a result of the effect of his service-connected disabilities. 38 C.F.R. § 4.16 (b). A May 2021 retrospective opinion found that prior to May 11, 2011, after a review of the Veteran's medical records, including past PTSD evaluations, the Veteran's PTSD symptoms were not severe enough to interfere with his ability to perform occupational activities. The examiner noted that the Veteran had earned a GED in 1979 and had not worked since 2000 when he had a back surgery. He had worked for a garage door company and also had worked at factories in the past. The examiner noted that the Veteran's ability to work was mostly impacted by his physical health, particularly his back. As noted, the ultimate question is whether the Veteran, because of service-connected disabilities, is incapable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). This is so because a disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. Id. In making its determination, VA considers such factors as the extent of the service-connected disability, and employment and educational background. See 38 C.F.R. §§ 3.340, 3.341, 4.16(b), 4.19. While there is some evidence the Veteran's employment activities would be limited by his PTSD, none of the medical evidence establishes that the Veteran is prevented from working as a result of his service-connected disabilities prior to May 11, 2011. In consideration of the evidence of record, the Board finds that the Veteran's service-connected disabilities did not preclude him from securing and following a substantially gainful occupation prior to May 11, 2011. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the appellant's claim for purposes of accrued benefits and/ or substitution, that doctrine is not applicable. See 38 U.S.C.A. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Entitlement to an increased rating higher than 50 percent for posttraumatic stress disorder (PTSD) prior to May 11, 2011, for purposes of accrued benefits and/ or substitution, The appellant seeks, for purposes of accrued benefits and/or substitution, a rating higher than 50 percent for the Veteran's PTSD for the period prior to May 11, 2011. For the period from May 11, 2011, the Veteran was assigned a 100 percent rating for his PTSD. This is the highest schedular rating available. Thus, the timeframe for the 100 percent rating for PTSD from May 11, 2011, is not on appeal. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher prior to May 11, 2011. The Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 70 percent or higher. The Veteran's symptoms more closely approximated the symptoms associated with a 50 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for 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 or place; or memory loss for names of close relatives, own occupation or own name. Turning to the relevant evidence in this case, the Board notes that the Veteran's outpatient records reflect that he consistently participated in a PTSD peer support group, approximately monthly since 2010. He participated appropriately in all group sessions. The Veteran had a mental health outpatient appointment in July 2010. The Veteran was not interested in medication management at the time. He reported feeling hopeless about the future, but he did not have suicidal ideation. In September 2010, the Veteran submitted a statement in support of his claim. He reported nightmares, depression, losing his temper easily, and outbursts. The Veteran underwent a VA examination for PTSD in September 2010. The Veteran reported feeling down and stressed, though he was coping with help from other Vietnam veterans. The Veteran reported that he had nightmares every night, and intrusive memories each day. He was assessed as having mild depression. The Veteran reported marital discord, loss of interest in activities, and a sense of a foreshortened future. He had chronic sleep difficulty, and difficulty controlling his temper. The Veteran had feelings of worthlessness, and anxiety regarding finances. The Veteran had excellent relationships with his children and grandchildren and had social support. He did not endorse any violence or assaultive behavior, and there was no evidence of delusions or hallucinations. The Veteran denied suicidal ideation, plan, or intent. In March 2011, the Veteran's daughter-in-law wrote a statement on his behalf. She explained that the Veteran slept on the floor, and not next to his wife, because of his nightmares. The Veteran's daughter-in-law described mood swings, and lack of control of his anger. The appellant also wrote a statement in March 2011. She reported that the Veteran was jumpy and irritable, and lost his temper over nothing. The appellant said that the Veteran yelled and got upset over little things. In April 2011, VA received a letter from the Veteran's daughter. She explained that the Veteran's moods were like a "rollercoaster." The Veteran was avoidant and had a short temper. He also had flashbacks and nightmares. VA also received a letter from the Veteran's brother in April 2011. He reported that the Veteran used to enjoy hunting, but no longer could. The Veteran had another appointment in May 2011. The Veteran reported feeling sad, irritable, being easily upset by others, and emotional. He had suicidal ideation, but no plans or attempts. It was noted that he had endorsed suicidal ideation in the past and had thoughts of taking his life "years ago." A retrospective medical opinion was provided in May 2021. The Veteran's medical records were reviewed. The examiner found that prior to May 11, 2011, the evidence did not show that the Veteran had deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. For example, at the September 2010 VA examination, the Veteran reported having excellent relationships with his children and grandchildren, and he had social support from other Vietnam veterans. The examiner noted that while the Veteran reported marital discord, the relationship was stable, and the Veteran had remained married for over 30 years. Additionally, the examiner indicated that the Veteran submitted statements from supportive family members, including his daughter-in-law, daughter, brother, and wife. The examiner found that the evidence showed some deficiencies in mood, as the Veteran reported feeling down and losing his temper easily in September 2010. However, the evidence did not show near continuous panic or depression, impaired impulse control, inability to establish and maintain effective relationships, or difficulty adapting to stressful circumstances. As such, the examiner found that there was no evidence of deficiencies in judgment, thinking, or work. The examiner found that prior to May 11, 2011, the Veteran's functional impairment associated with his PTSD included mood and motivation disturbances, irritability, sleep disturbances, and lack of interest/pleasure. The examiner noted that the above information was gathered after reviewing the Veteran's records, including his PTSD reviews and mental health notes. The examiner commented that it was important to note that any mental health symptoms can fluctuate and change. Therefore, it was evident the Veteran's symptoms and limitations changed over time and as it related to other situations at the time he was evaluated. The Board finds that prior to May 11, 2011, the level of impairment caused by the Veteran's symptoms more closely approximates the level associated with a 50 percent rating. The Veteran experienced occupational and social impairment with reduced reliability and productivity. Mental status examinations in VA treatment records and the September 2010 VA examination and May 2021 retrospective medical opinion indicate that the Veteran had difficulty controlling his temper, feelings of worthlessness, and anxiety regarding finances, depression, marital discord, loss of interest in activities, and a sense of a foreshortened future, as well as sleep impairment. As noted in May 2011, he also had suicidal ideation, but no plans or attempts. It was noted that he had endorsed suicidal ideation in the past and had thoughts of taking his life "years ago." These findings do not rise to the level of occupational and social impairment with deficiencies in most areas. The Board notes that the Veteran expressed suicidal ideation, which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). Suicidal ideation also is contemplated for a 70 percent rating. However, the severity, frequency, and duration of the Veteran's suicidal ideation has not risen to the level contemplated by the 100 percent disability rating, nor the 70 percent rating. The Veteran regularly denied thoughts, intent, or a plan involving self-harm in existing treatment records. See, e.g., July 2010 VA mental health outpatient note; and September 2010 VA examination. While the Veteran did experience symptoms contemplated by a 70 percent ratingincluding one note of suicidal ideation for the past few years in May 2011 and also angry outbursts, which could be akin to impaired impulse controlthe evidence overall does not demonstrate the level of impairment associated with a 70 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 50 percent rating, including disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. Further, while the Veteran's PTSD would impact his ability to work, the record shows that the Veteran had not worked since a back surgery in 2000, which is unrelated to his service-connected PTSD. The May 2021 retrospective opinion also found that prior to May 11, 2011, the Veteran's PTSD symptoms were not severe enough to interfere with his ability to perform occupational activities. Therefore, based on the evidence of a record, a rating higher than 50 percent is not warranted for the Veteran's PTSD, prior to May 11, 2011, for purposes of accrued benefits and/ or substitution. 3. Entitlement to service connection for ischemic heart disease (claimed as mildly prominent aorta and abdominal aortic aneurysm (AAA), for purposes of accrued benefits and/ or substitution, The appellant seeks, for purposes of accrued benefits and/or substitution, service connection for ischemic heart disease (claimed as mildly prominent aorta and abdominal aortic aneurysm). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain specified diseases may be presumptively service connected. 38 C.F.R. § 3.309. If a veteran was exposed to an herbicide agent during active military, naval or air service, diseases including ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease, including coronary artery disease, coronary spasm, and coronary bypass surgery; and stable, unstable, and Prinzmetal's angina) shall be service connected if the requirements of 38 C.F.R. § 3.307 (a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 (d) are also satisfied. 38 C.F.R. § 3.309 (e). 38 C.F.R. § 3.309 (e) provides that ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. See Note 2. The Veteran was awarded a Vietnam Campaign Medal and a Vietnam Service Medal, in addition to the Vietnamese Cross of Gallantry for Valor with Palm. As he had service in the Republic of Vietnam, the Veteran is presumed to have been exposed to herbicide agents during service. However, neither mildly prominent aorta nor abdominal aortic aneurysm is a disease for which presumptive service connection based on exposure to herbicides may be granted. 38 C.F.R. § 3.309 (e). Therefore, a nexus linking such a disorder and military service cannot be presumed under the law, regardless of the Veteran's exposure to herbicides during service. Id. The question for the Board is whether the Veteran had a disability that began during service or was at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran had a current diagnosis of degeneration of the muscularis of the abdomen and mildly prominent aorta, and evidence shows that exposure to herbicides in service occurred, the preponderance of the evidence weighs against finding that the Veteran's diagnosis of degeneration of the muscularis of the abdomen and mildly prominent aorta began during service or was otherwise related to an in-service injury, event, or disease. The Veteran did not have a diagnosis of a heart disability during service. At an enlistment examination in May 1967, clinical evaluation of the Veteran's chest, heart, vascular system, and abdomen was normal. Similarly, at a separation examination in November 1969, there were no heart, chest, or abdominal problems noted. The Veteran's outpatient records reveal that in May 2005, the Veteran had a chest X-ray. The cardiomediastinal silhouette was within normal limits, though the aorta was mildly prominent. A July 2005 note reflects that an aortic aneurysm was an incidental finding on the lumbar spine film, and follow-up with a primary care physician was recommended. The Veteran underwent a VA examination in January 2011, which included an EKG. He was not diagnosed with ischemic heart disease. The Veteran had an ultrasound in April 2011. The impression was aneurysm of the distal abdominal aorta. In July 2014, the Veteran had a CT scan. It revealed that the abdominal aortic aneurysm was larger. The Veteran was referred to vascular surgery for further evaluation. In October 2015, the Veteran had an endovascular abdominal aortic aneurysm repair. The Veteran underwent a nuclear stress test prior to surgery, which showed no evidence of myocardial ischemia or infarction. The Veteran denied chest pain, palpitations, syncope, or orthopnea. The Veteran underwent another VA examination in November 2015. He denied having ischemic heart disease and denied filing a claim for such. The AOJ obtained a supplemental opinion in June 2016. The examiner reviewed the Veteran's outpatient records, which revealed he had imaging completed earlier that month. The Veteran was status post vascular surgery with a known type II endoleak, though he was asymptomatic from his aneurysm. There was a mild increase in the size of his endoleak, and a surveillance plan was implemented. In August 2016, a VA examination report notes that the examiner concluded that the Veteran was not diagnosed with a heart disability, including ischemic heart disease. The examiner opined that that the Veteran's aneurysm was not related to his military service, including exposure to herbicides. The rationale was that AAA is caused by degeneration of the muscularis of the aortic wall and is aggravated by hypertension. The Veteran's outpatient records do not reflect a diagnosis of ischemic heart disease, nor any care by a cardiologist. The Board initially denied the Veteran's claim on the basis of this evidence in January 2020. However, the Board's decision was vacated, as noted. The JMPR noted that the Board should obtain a new medical opinion addressing whether the Veteran's herbicide exposure caused degeneration of the muscularis of the abdomen, which was noted by a 2016 VA examiner as the cause of the Veteran's AAA. See November 2020 JMPR, p. 3. The JMPR further noted that a VA examiner should state whether the Veteran's mildly prominent aorta, as noted on a February 6, 2007 VA outpatient treatment record, is a condition that is related to exposure to herbicides. Id. A May 2021 VA medical opinion was provided that there was no medical evidence here or in the medical literature that proves that herbicide exposure causes a prominent aorta or degeneration of the muscularis abdomen or abdominal aortic aneurism. Based on the medical evidence of record, the preponderance of evidence is against the appellant's claim, for purposes of accrued benefits and/or substitution. The medical evidence does not show a diagnosis of ischemic heart disease. There also is no probative medical evidence that the Veteran's mildly prominent aorta and abdominal aortic aneurysm was related to his military service, including his exposure to herbicide agents in service. While the appellant asserts that the Veteran's mildly prominent aorta and abdominal aortic aneurysm is related to an in-service injury, event, or disease, including exposure to herbicides in Vietnam, the appellant is not competent to provide a nexus opinion in this case. This issue is medically complex, as it requires specialized medical education, knowledge of the interaction between multiple organ systems in the body, and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. (Continued on the next page) Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. S. L. Kennedy Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sarah B. Richmond, 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.