Citation Nr: 22010577 Decision Date: 02/24/22 Archive Date: 02/24/22 DOCKET NO. 18-09 419 DATE: February 24, 2022 ORDER New and material evidence has been received to reopen a service connection claim for hearing loss. Service connection for hearing loss is denied. Service connection for a left knee disability, to include as secondary to right knee degenerative joint disease is denied. Service connection for left hand arthritis is denied. REMANDED Service connection for loss of balance is remanded. FINDINGS OF FACT 1. In February 2015, the RO denied the Veteran's claim for service connection for hearing loss. The Veteran failed to file a timely notice of disagreement; and no new and material evidence was received within a year of the rating decision's issuance. Certain evidence received since the February 2015 decision is neither cumulative nor redundant of the evidence of record at the time of the February 2015 denial and, by itself or in conjunction with the evidence previously assembled, relates to an unestablished fact necessary to substantiate the claim of service connection. 2. The evidence of record persuasively weighs against finding that a hearing loss disability began during active service, or is otherwise related to an in-service injury or disease. 3. The Veteran's left knee disability is not secondary to his service-connected right knee disability, and is not otherwise related to an in-service injury or disease. 4. The evidence of record persuasively weighs against finding that a left hand disability began during active service, or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The February 2015 RO rating decision, which denied service connection for hearing loss is final. 38 U.S.C. § 7105. Evidence received since the February 2015 RO rating decision is new and material; accordingly, the claim for service connection for is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. The criteria for service connection for hearing loss are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. 3. The criteria for service connection for a left knee disability are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for a left hand disability are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1976 to August 1980. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2016 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran testified before the undersigned Veterans Law Judge at a hearing held in October 2021. A transcript is of record. New and material evidence has been received to reopen a service connection claim for hearing loss. The Veteran's service connection claim for hearing loss was originally denied by way of a February 2015 rating decision. The Veteran did not file a timely notice of disagreement; and the decision became final and is not subject to revision except on the receipt of new and material evidence. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. When a claim to reopen is presented, a two-step analysis is performed. The first step of which is a determination of whether the evidence presented or secured since the last final disallowance of the claim is "new and material." See Elkins v. West, 12 Vet. App. 209, 218-19 (1999) (en banc). The provisions of 38 C.F.R. § 3.156 (which defines "new and material evidence") provides as follows: New evidence means existing evidence not previously submitted to agency decisionmakers. 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(a). Second, if VA determines that the evidence is new and material, the VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist has been fulfilled. See Winters v. West, 12 Vet. App. 203, 206 (1999) (en banc) (discussing the analysis set forth in Elkins), overruled on other grounds sub nom. Winters v. Gober, 219 F.3d 1375, 1378 (Fed. Cir. 2000); Elkins, supra. The second step becomes applicable only when the preceding step is satisfied. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 325 (1999). In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). In Evans v. Brown, 9 Vet. App. 273 (1996), the Court held that to reopen a previously and finally disallowed claim, there must be new and material evidence presented or secured since the time that the claim was finally denied on any basis. Additionally, evidence considered to be new and material sufficient to reopen a claim should be evidence that tends to prove the merits of the claim that was the specified basis for the last final disallowance of the claim. In Justus v. Principi, 3 Vet. App. 510 (1992), the Court held that for new and material evidence purposes only, new evidence is presumed to be credible. The only exception would be where evidence presented is either (1) beyond the competence of the individual making the assertion or (2) inherently incredible. If new and material evidence has been received with respect to a claim that has become final, then the claim is reopened and decided on a de novo basis. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. The evidence on record at the time of the February 2015 denial included the service treatment records, a VA examination dated June 2014, and VA opinions dated June 2014 and January 2015. The claim was denied because the service treatment records did not reflect evidence of a hearing loss disability, and the VA examiners opined that his current hearing loss was less likely than not due to service. The RO, in its March 2016 rating decision reopened the claim and decided the issue on the merits. Evidence received since the February 2015 rating decision includes testimony from the Veteran, and a November 2021 opinion from Dr. Y.W. in which she stated that it was possible that the Veteran's hearing loss is related to service. In determining whether the submitted evidence is new and material, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). Thus, pursuant to Shade, evidence is new if it has not been previously submitted to agency decisionmakers and is material if, when considered with the evidence of record, would at least trigger VA's duty to assist by providing a medical opinion, which might raise a reasonable possibility of substantiating the claim. Id. The Board finds that the Veteran's testimony, coupled with a private medical opinion, constitutes new and material evidence. As new and material evidence has been received to reopen the claim, the claim for entitlement to service connection is reopened. Service Connection 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). Service connection for hearing loss is denied. The Veteran contends that his hearing loss began during service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of sensorineural hearing loss, and evidence shows that he was exposed to excessive noise during service, the evidence of record persuasively weighs against finding that the Veteran's diagnosis of hearing loss began during service or is otherwise related to an in-service injury, event, or disease. At his October 2021 Board hearing, the Veteran testified that his ears "popped" when he was 15-20 feet away from a plane and he was not wearing hearing protection. He also stated that he was exposed to excessive noise when one of his instructors threw a fake (or simulated) grenade. He stated that he has had difficulty hearing ever since he left service. Service treatment records reflect that upon enlistment, the Veteran's hearing was measured as follows: Hertz 500 1000 2000 3000 4000 6000* Right 10 10 0 0 0 25 Left 15 10 0 10 15 35 * 6000 Hz is not considered under 38 C.F.R. § 3.385. Upon separation from service, his hearing was measured as follows: Hertz 500 1000 2000 3000 4000 6000* Right 5 0 0 0 0 25 Left 5 5 0 10 15 35 The Veteran underwent a VA examination in June 2014. The examiner diagnosed the Veteran with bilateral sensorineural hearing loss. The examiner opined that the Veteran's hearing loss was less likely than not related to service. He explained that the Veteran's enlistment and separation exams both showed a mild high frequency hearing loss at 6000Hz (left worse than right). He noted that pre-existing hearing loss was not aggravated beyond normal progression of hearing loss. Instead, the pre-existing hearing loss was stable at separation with no significant shift in hearing bilaterally. Impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Since the VA examiner's opinion was focused largely on the Veteran's preexisting hearing loss at 6000 hertz (which is not considered as part of a hearing loss disability under 38 C.F.R. § 3.385), the RO obtained another opinion, dated January 2015. The examiner opined that the Veteran's hearing loss was less likely than not related to service. He noted that both the enlistment and separation examinations reflected hearing loss at 6000 Hz. The examiner correctly acknowledged that this is not relevant when determining service connection for a hearing loss disability. He found that the Veteran's separation examination showed essentially the same hearing thresholds as were found at enlistment. There was no significant shift in hearing identified at separation (greater than 10 dBHL). The Veteran submitted a November 2021 correspondence in which Dr. Y.W. opined that "while it is possible that Veteran's hearing loss and/or tinnitus are related to his/her military service it is speculative for this provider to give an opinion re: the relationship between Veteran's reported hearing loss and/or tinnitus and his/her military service. It is advised that Veteran should complete a claim for service connection re: these conditions and be scheduled for a full C&P exam with a qualified examiner who can review his full medical history, complete service medical records and determine the present status of his/her hearing loss and tinnitus." The Court has held that the Board must determine how much weight is to be attached to each medical opinion of record. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one medical professional's opinion over another, depending on factors such as reasoning employed by the medical professionals and whether or not, and the extent to which, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). Adequate reasons and bases, in short, must be presented if the Board adopts one medical opinion over another. In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. 444, 448-9 (2000). In some cases, the physician's special qualifications or expertise in the relevant medical specialty or lack thereof may be a factor. In every case, the Board must support its conclusion with an adequate statement of its reasoning of why it found one medical opinion more persuasive than the other. There are substantial and significant factors which favor the valuation of the VA medical opinion over the opinions of the private physician in this case. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. Nieves-Rodriguez, 22 Vet. App. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In this case, the opinions of the VA examiners are superior in regard to all three factors. Regarding the first factor, it is unclear whether or not Dr. Y.W. was aware of the Veteran's medical history. She stated that she reviewed VA medical records, but not the service treatment records, and she recommended that the Veteran be scheduled for a VA examination (apparently unaware that he had already undergone a VA examination, and that the claims file already contained two VA opinions). Regarding the second and third factors, Dr. Y.W. did not provide a fully articulated opinion. The opinion was equivocal in nature and did not provide the degree of certainty required for medical nexus evidence. It was not accompanied by any rationale. The VA examiners, on the other hand, reviewed the service treatment records and cited to them. They both acknowledged that the Veteran displayed a level of hearing loss at 6000 Hz (although this frequency is not considered by 38 C.F.R. § 3.385. when determining if the Veteran has a hearing loss disability). Both examiners noted that there was no hearing loss disability (as defined by 38 C.F.R. § 3.385) during service, and that there was no significant threshold shift during service (as documented by his entrance and separation examination, which are nearly identical). The Veteran believes his hearing loss disability was caused by service. However, he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of pathology. Therefore, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examiners. The evidence of record persuasively weighs against finding that the Veteran's hearing loss disability began during active service, or is otherwise related to an in-service injury or disease. Service connection for a left knee disability, to include as secondary to right knee degenerative joint disease is denied. The Board notes that the RO originally denied this claim by way of a November 2014 rating decision. Service connection was denied on a direct basis. The Veteran did not file a timely notice of disagreement. However, the RO issued a February 2015 rating decision in which it granted service connection for a right knee disability. This gave rise to a new theory upon which service connection could be based regarding the Veteran's left knee. Namely, it raised the possibility of service connection for a left knee disability as secondary to the Veteran's now service-connected right knee. The RO, in its March 2016 rating decision impliedly found that new and material evidence had been received within one year of the November 2014 denial. Thus, the November 2014 rating decision did not become final, and the RO decided the claim on a de novo basis. Likewise, the Board will decide the claim on a de novo basis. The Veteran contends that his left knee disability was either caused or aggravated by his service-connected right knee degenerative joint disease. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or was aggravated beyond its natural progress by his right knee degenerative joint disease. The Veteran submitted an October 2021 correspondence from Dr. Y.W. in which she stated, in toto, that "After reviewing of [the Veteran's] personal statement as well as my personal exam of this Veteran, it is my medical opinion that this Veteran's left knee condition is caused or contributory to his service connected right knee condition." The Veteran underwent a VA examination in March 2016. The Veteran complained of bilateral "dull" sub-patellar knee pain, reproducible with ascending stairs and arising from a seated position. He reported prior trauma to his right knee during active military service. He denied any left knee trauma. He reported occasional bilateral "pop" when rising from a seated position. He denied "locking" or "giving out." He used a brace for his left knee regularly. He denied flare-ups. The examiner diagnosed the Veteran with patellofemoral pain syndrome and osteoarthritis in each knee. The March 2016 VA examiner rendered an opinion in which he stated that the Veteran's left knee disability is less likely than not proximately due to or the result of the Veteran's service connected right knee disability. He explained that the Veteran has a current diagnosis of bilateral patello-femoral pain syndrome and osteoarthritis, with both conditions having a mild clinical severity. He stated that despite the Veteran's claims of worsened symptomology on the right, the appreciable radiographic and physical examination findings support an assessment of both conditions being of equal severity when comparing the left to the right. The examiner also addressed the issue of the right knee disability potentially aggravating the left knee disability. He explained that that it is commonly accepted medical knowledge that development of a painful condition in a unilateral weight bearing joint is a significant risk factor for the development of symptomology in the contralateral joint, as well as a potential for aggravation beyond natural progression of degenerative changes in said contralateral joint. He stated that this set of circumstances would most likely manifest with symptoms in the initial joint presenting first, then in the secondarily affected joint, with radiographic and physical exam findings supporting a more severe clinical picture in the originally affected joint. The examiner explained that as both diagnosed conditions appear of equal clinical and radiographic severity, it would not appear in this Veteran's case that his left knee conditions are due to his right knee conditions, as discussed above. Rather, it is most likely that his bilateral osteo-arthritis is age-related, and that his left knee patello-femoral syndrome is due to de-conditioning. There are substantial and significant factors which favor the valuation of the VA medical opinion over the opinions of the private physician in this case. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. Nieves-Rodriguez, 22 Vet. App. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Regarding the first two factors, the probative value of the opinions is in equipoise. Both examiners reviewed the claims file and were familiar with the pertinent medical history. Moreover, both gave fully articulated and unequivocal opinions. However, regarding the third factor, the opinion of the VA examiner is far more probative. The private examiner (Dr. Y.W.) failed to provide any reasoned analysis to support her opinion. The opinion is entirely conclusory. The VA examiner, on the other hand, acknowledged that there is commonly accepted medical knowledge that development of a painful condition in a unilateral weight bearing joint is a significant risk factor for the development of symptomology in the contralateral joint, as well as a potential for aggravation beyond natural progression of degenerative changes in said contralateral joint. However, based on the evidence in this case, namely the fact that the disability in each knee is mild (rather than one knee disability being more severe than the other), the examiner concluded that the right knee disability did not cause or aggravate the left knee disability. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. The Veteran believes his knee hand disability was caused or is aggravated by his service-connected right knee disability. However, he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of internal joint pathology. Therefore, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the March 2016 VA examiner. Regarding service connection on a direct basis, at the Veteran's Board hearing, he testified that he had left knee symptoms during service, but not as much as in the right knee. He also stated, in a June 2014 correspondence, that he injured both knees during boot camp. Service treatment records reflect complaints of bilateral calf muscle spasms, and cramps in both legs in June 1978. However, they fail to reflect any findings attributed to a left knee disability. The Veteran's separation examination yielded normal findings, and the Veteran failed to report a left knee injury or symptoms when he completed a Report of Medical History upon separation from service. To the contrary, he specifically denied having a "trick" or locked knee; bone, joint, or other deformity; and arthritis, rheumatism, or bursitis. The Veteran underwent a VA examination in June 2014. The findings did not result in a diagnosis of any left knee disability. When he underwent a VA examination in March 2016, he denied any trauma to the left knee. The VA did not obtain an opinion regarding direct service connection for the Veteran's left knee disability. In light of the holding in McLendon v. Nicholson, 20 Vet. App. 79 (2006), the Board feels that such an opinion is not required. McLendon provides that in disability compensation (service connection) claims, VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. The standards of McLendon are not met in this case as the evidence of records fails to suggest that a left knee disability, first reported many years post service, had its onset in service or is otherwise related thereto. In conclusion, the evidence of record persuasively weighs against finding that a left knee disability was caused or aggravated by his service-connected right knee disability, or is otherwise related to an in-service injury or disease. Service connection for a left knee disability is denied. Service connection for left hand arthritis is denied. The Veteran contends that he has a left hand disability that is due to an in-service injury. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of left arthritis, and evidence shows that he made a single report of pain during service, the evidence of record persuasively weighs against finding that the Veteran's current disability began during service or is otherwise related to an in-service injury, event, or disease. Service treatment records reflect that the Veteran reported (in June 1978) that joints in his hands began aching the previous day. There was no diagnosis or treatment. There were no similar complaints made throughout the Veteran's remaining two years of service. His April 1980 separation examination yielded normal findings. He completed a Report of Medical History in conjunction with his separation examination. He denied arthritis and rheumatism. He denied any bone, joint, or other deformity. He reported broken bones, which was a reference to a broken nose sustained during childhood. At his October 2021 Board hearing, the Veteran testified that he was climbing down a missile silo and he slipped. When he grabbed onto something to break his fall, he sustained a strain injury. He stated that he told a doctor about it but that he never received any in-service treatment. He stated that he began having problems with his left wrist when he was in his 40s. The Veteran submitted an October 2021 correspondence from Dr. Y.W. in which she stated that "After reviewing of [the Veteran's] service treatment records as well as my personal exam of this Veteran, it is my medical opinion that this Veteran's left hand condition started while in the service and continues to be a problem today." The Veteran underwent a VA examination in March 2016. The Veteran reported bilateral multi-joint hand pains. The examiner diagnosed the Veteran with degenerative arthritis. In a March 2016 opinion, the examiner opined that it was less likely than not that the Veteran's current left hand disability was incurred during service or caused by his in-service injury. He explained that the Veteran has a current diagnosis of bilateral arthritis of multiple joints of the hands, of a mild clinical severity. He noted that the service treatment records reflect a single complaint of "aching" during a physical therapy consult. He also noted that there was an unremarkable separation history and physical exam, without record of hand-related complaints, diagnoses, or findings. He opined that given the lack of recorded hand symptomology, to include at the time of discharge from the active military and within 1 year thereafter, it is not possible to appreciate a cause-and-effect relationship between the Veteran's current condition and the in-service single recorded complaint. The examiner also noted that there is no evidence available (either in the available records or the medical literature) that suggests that the Veteran's hand condition is due to or caused by his other service-connected conditions, or that his hand condition existed prior to active military service. He stated that there exists a likely alternative etiology, in the form of age-related changes, which is supported by the mild, symmetric nature of the Veteran's complaints and radiographic findings. There are substantial and significant factors which favor the valuation of the VA medical opinion over the opinions of the private physician in this case. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. Nieves-Rodriguez, 22 Vet. App. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Regarding the first two factors, the probative value of the opinions is in equipoise. Both examiners reviewed the claims file and were familiar with the pertinent medical history. Moreover, both gave fully articulated and unequivocal opinions. However, regarding the third factor, the opinion of the VA examiner is far more probative. The private examiner (Dr. Y.W.) failed to provide any reasoned analysis to support her opinion. The opinion is entirely conclusory. It fails to address the fact that the separation examination yielded normal findings or the fact that symptoms began many years after service. The Veteran testified that his symptoms began when he was in his 40s. Given that the Veteran was born in 1958, his symptoms would not have begun until (at the earliest) 1998, which is 18 years after service. The VA examiner provided a thorough analysis which cited the service treatment records, including the single complaint of "aching" and the normal separation examination and Report of Medical History. The Veteran believes his left hand disability is related to an in-service injury, event, or disease. However, he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of pathology. Therefore, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the March 2016 VA examiner. The evidence of record persuasively weighs against finding that a left hand disability began during active service, or is otherwise related to an in-service injury or disease. Service connection for a left hand disability is denied. REASONS FOR REMAND Service connection for loss of balance is remanded. VA treatment records dated August 2017 reflect that the Veteran's dizziness and loss of balance could be caused by multiple factors, including his history of orthopedic issues (right knee). Consequently, a VA opinion is necessary to determine whether the Veteran's loss of balance is at least as likely as not caused by, or aggravated by, his service connected disabilities. The same August 2017 treatment report reflects that the Veteran's symptoms do not appear to be inner ear related. However, in light of the fact that the Veteran attributes his loss of balance to hearing loss, and the fact that he is service connected for tinnitus, the VA examiner's opinion should include consideration of whether the Veteran's loss of balance is caused or aggravated by his service connected tinnitus. The matter is REMANDED for the following action: Schedule the Veteran for a VA examination for his reported dizziness/loss of balance. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the Veteran's dizziness/loss of balance at least as likely as not proximately due to either his service-connected right knee or tinnitus disability? Is the Veteran's dizziness/loss of balance at least as likely as not aggravated by either his service-connected right knee disability or tinnitus? Provide rationale to support the opinions expressed in response to each question. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Prem, 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.