Citation Nr: 1301063 Decision Date: 01/10/13 Archive Date: 01/16/13 DOCKET NO. 08-06 280 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for erectile dysfunction. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Schechter, Counsel INTRODUCTION The Veteran served on active military duty from May 1968 to May 1970. He is a recipient of the Bronze Star Medal. The appeal comes before the Board of Veterans' Appeals (Board) from a June 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Board remanded the case in December 2009, December 2010, and November 2011 for additional development, and the case now returns to the Board for further review. The Veteran testified before the undersigned at a Travel Board hearing conducted at the RO in June 2010. A transcript of that hearing is contained in the claims file. FINDINGS OF FACT 1. The evidence preponderates against erectile dysfunction having developed in service or otherwise being causally related to service. 2. The evidence preponderates against diabetes mellitus having caused or aggravated the Veteran's erectile dysfunction. CONCLUSION OF LAW The criteria for service connection for erectile dysfunction are not met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the decision of the U.S. Court of Appeals for Veterans Claims (Court) in Dingess v. Nicholson, 19 Vet. App. 473 (2006) requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date. If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a Statement of the Case (SOC) or Supplemental Statement of the Case (SSOC). Where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Supreme Court has held that an error in VCAA notice should not be presumed prejudicial, and that the burden of showing harmful error rests with the party raising the issue, to be determined on a case-by-case basis. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). In this case, the appellant has not demonstrated any prejudicial or harmful error in VCAA notice and, as discussed herein, the Board has not identified any. VA has fulfilled the above requirements with regard to the claim of entitlement to service connection for erectile dysfunction. By August 2005 and November 2005 VCAA letters, the Veteran was informed of the evidence need to establish entitlement to service connection for erectile dysfunction, on both direct and secondary bases. 38 C.F.R. § 3.303, 3.310. The letters also appropriately informed of the relative duties of the Veteran and VA in obtaining evidence in furtherance of the claim. This included informing that it was ultimately the Veteran's responsibility to see that evidence required to sustain the claim is obtained. This notice was followed by the appealed June 2006 rating action, as well as by subsequent readjudications, including most recently by a SSOC in June 2012. The Veteran was afforded an additional notice letter in March 2006 informing how VA determines disability ratings and effective dates for ratings, in general compliance with the requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA's duty to assist the Veteran in the development of the claim includes assisting him in the procurement of service medical records and pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that the RO appropriately assisted the Veteran in obtaining indicated treatment and evaluation records, including both VA and private records. Service records were also associated with the claims file. The RO also informed the Veteran, including in the appealed rating action, subsequent rating actions, and by a SOC and SSOCs, of records obtained, and thus by implication of records not obtained, in furtherance of his claim. VA's duty to assist the Veteran by providing examinations when necessary was also adequately fulfilled. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. As delineated in 38 C.F.R. § 3.159(c)(4), a VA examination to address the question of etiology as related to service is required when the Veteran presents a claim for service connection and meets the low threshold requirements there is an event, injury, or disease in service; there is evidence of current disability; the medical evidence of record does not contain sufficient competent medical evidence to decide the claim; and the Veteran indicates that the claimed disability or symptoms may be associated with service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Similar requirements are implicated in claims for secondary service connection. 38 C.F.R. § 3.310. The Board finds that the VA examinations afforded the Veteran addressing his claimed erectile dysfunction in January 2011 and December 2011, and their findings and analysis, as discussed infra, taken together with the balance of the evidence of record, are adequate for the Board's adjudication herein. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The examinations provided sufficient detail, and supported their conclusions with analyses fully supported by review of the evidence presented, which analyses are readily weighed against contrary evidence. Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). Further, the evidence so considered by the examination reports was sufficient and encompassed the evidence of record. Id. The Board accordingly concludes that no further examination is required to support the Board's adjudication of the claim for service connection for erectile dysfunction including as secondary to service-connected diabetes mellitus. 38 C.F.R. § 3.159(c)(4). These examinations were appropriately followed by review of the claim by the RO, including most recently with issuance of the June 2012 SSOC. These examinations, taken together with records of VA and private treatment or evaluation, as well as service treatment records, examination reports, and lay statements including statements by the Veteran and his spouse, as well as other evidence of record, are adequate for the Board's adjudication herein. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The examinations in January 2011 and December 2011, taken as a whole, addressed both the medical findings upon current examination and the Veteran's history. The examination reports presented findings and conclusions reasonably consistent with the Veteran's medical history and the balance of contemporaneous medical records, and sufficiently addressed the medical criteria underlying the erectile dysfunction service connection claim to allow the Board to adjudicate the claim based on informed medical findings and medical judgment. Further examination would constitute unreasonable delay and expenditure of scarce VA resources. See 38 C.F.R. § 3.303; Counts v. Brown, 6 Vet. App. 473, 478- 9 (1994); and Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992) (VA's statutory duty to assist is not a license for a "fishing expedition."). Based on the evidence presented, the Board finds no reasonable likelihood that further evaluation would produce findings supporting a more beneficial outcome for the appealed claim for service connection for erectile dysfunction. Ultimately, in the absence of credible evidence that the evidence obtained, including VA examination evidence, is materially incomplete or inadequate for the Board's adjudication of the appealed claim, the burden must shift to the Veteran to produce evidence which has not been found upon VA examination or otherwise shown by the evidence of record. The claimant bears the burden of presenting and supporting his claims for benefits. 38 U.S.C.A. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). The Board also finds that requirements of the Board's prior remands in December 2009, December 2010, and November 2011 have been substantially fulfilled with regard to the service connection claim adjudicated herein. The December 2009 remand was to afford the Veteran a Travel Board hearing, which was conducted before the undersigned in June 2010. By the December 2010 and November 2011 remands the Board required a VA examiner to adequately address questions of both causation and aggravation of erectile dysfunction by diabetes mellitus, with due consideration of glucose levels or other indication of diabetes mellitus prior to the record of initial diagnosis of diabetes mellitus in 2005. By the December 2010 remand, the Board also required that unobtained VA treatment records be obtained for association with the claims file. These issues were adequately addressed by the RO or Appeals Management Center (AMC), by VA treatment records obtained, and by the VA examinations obtained in January and December of 2011, as discussed further infra. Only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998). D'Aries v. Peake, 22 Vet. App. 97 (2008). The Veteran has not indicated the existence of additional pertinent evidence. The case presents no reasonable possibility that additional evidentiary requests would further the appealed claim. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio, supra. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) recently held that 38 C.F.R. 3.103(c)(2) (2010) requires that any Veterans Law Judge who chairs a hearing fulfill two duties to comply with the VCAA. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant, 23 Vet. App. at 488. The Board finds that these duties were adequately fulfilled at the June 2010 hearing, with the undersigned sufficiently addressing the issues and suggesting the submission of additional evidence. At that hearing, as well as elsewhere in the record, the Veteran and his authorized representative demonstrated adequate knowledge of the issue of erectile dysfunction and claims for service connection on direct and secondary bases, and of the need to submit relevant evidence. This was also reflected in their request for additional time to submit relevant evidence, and the undersigned's agreement at the hearing to keep the record open for an additional 30 days expressly for this purpose. Thus no prejudice could have reasonably resulted from any deficiency in the undersigned's fulfillment of the requirements of Bryant v. Shinseki. In short, in this case, with regard to the service connection claim herein adjudicated, the Board finds that any error in notice and development assistance cannot "reasonably affect the outcome of the case," and hence will not affect "the essential fairness of the [adjudication]" for the rating assigned for the rating period in question, for the appealed claim. ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998); Mayfield v. Nicholson, 19 Vet. App. 103 (2005). The Veteran was duly afforded the opportunity to produce additional evidence to support his claim. Thus, the Board determines that the evidentiary record is adequate, and the only significant medical questions remaining pertaining to the Veteran's claim for service connection for erectile dysfunction, based on development already undertaken, the responsibility of the Veteran. See 38 C.F.R. §§ 3.303, Part 4. In view of the foregoing, the Board finds that all notification and development actions needed to render a decision on the Veteran's claim on appeal herein adjudicated have been accomplished. II. Evidentiary Considerations Relevantly, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Although medical evidence may be required to support a claim in instances were specialized knowledge is required, lay statements may serve to support a claim by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (a lay persons is competent to testify to pain and visible flatness of the feet). The Federal Circuit Court has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a disability when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical profession." Jandreau, 492 F.3d at 1377; see also Buchanan v. Nicholson, supra ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). It is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in doing so, the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998). The Board cannot make its own independent medical determination, and it must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans; Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994), distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). In determining the weight to be assigned to evidence, credibility can be affected by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self- interest, malingering, desire for monetary gain, and witness demeanor. Caluza v. Brown, 7 Vet. App. 498, 511, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) ; 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court of Appeals for Veterans Claims held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. III. Claim for Service Connection for Erectile Dysfunction, Including as Secondary to Diabetes Mellitus Status The Veteran contends, in effect, that his erectile dysfunction was caused or aggravated by his service-connected diabetes mellitus. Service connection may be granted for a disability resulting from injury or disease incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Id. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993). Service connection may be granted, on a secondary basis for a disability which is proximately due to or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Similarly, any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice- connected disease, will be service connected. Allen v. Brown, 7 Vet. App. 439 (1995). In the latter instance, the nonservice-connected disease or injury is said to have been aggravated by the service-connected disease or injury. 38 C.F.R. § 3.310. In a November 2011 statement the Veteran asserted that he had diabetes mellitus for years prior to his diagnosis of erectile dysfunction. He further asserted that his medication for hypertension and diabetes mellitus were causing his erectile dysfunction. The difficulty with the latter assertion is that the Veteran is not service connected for hypertension. The Veteran submitted an August 2006 letter from Dr. S.D., a private physician, informing that the physician had seen the Veteran beginning in May 2005. The physician noted that the Veteran had self-reported a history of diabetes mellitus "dating back more than five years but never had anything follow-up on this specifically until a couple of years ago." The examiner noted that the Veteran also had a history of erectile dysfunction "about the same time." The physician then provided the following analysis and opinion: It is well known that diabetes is a frequent cause of erectile dysfunction. It would be difficult to not impossible (sic) to know exactly what the connection was in [the Veteran], but from my understanding, this evaluation by urology, there is no other explanation for his erectile dysfunction. The Veteran was afforded a VA examination for compensation purposes in December 2011 to address his claimed erectile dysfunction and its etiology, including whether diabetes mellitus had caused or aggravated the condition. The examiner noted that the Veteran's erectile dysfunction was shown to be treated as early as April 2000, with laboratory findings from April 2000 and over the years thereafter showing low testosterone levels. The April 2000 note informed that the Veteran himself felt that his libido was satisfactory, and he reported satisfactory erections, causing the physician then not to prescribe exogenous testosterone. However, by July 2000 the Veteran was noted to being taking Viagra, reportedly with good results. A March 2005 treatment record noted obstructive benign prostatic hypertrophy (BPH). A May 2005 treatment record noted that since the last prior treatment by that physician (which was not earlier than March 2005 based on the March 2005 record of treatment by that physician) the Veteran was first diagnosed with diabetes mellitus. The examiner also noted the above-detailed August 2006 letter of Dr. S.D. However, having reviewed the clinical record and the objectively supported medical history as well as the Veteran's assertions, the December 2011 VA examiner arrived at an opposite conclusion to Dr. S.D., with findings contradicting the factual premise of Dr. S.D. Specifically, while Dr. S.D. asserted that there was no other explanation for the Veteran's erectile dysfunction than diabetes mellitus, the VA examiner noted that the Veteran's erectile dysfunction was "very likely due to [a] chronically low level of [t]estosterone" and that other risk factors for the Veteran included hypertension, medications, and age. Thus, Dr. S.D.'s assertion of no other causal possibilities for the Veteran's erectile dysfunction than diabetes mellitus is effectively medically refuted by the VA examiner. (As noted infra, the prior VA examiner in January 2011 provided several additional medical causes of the Veteran's erectile dysfunction.) Additionally, the December 2011 VA examiner noted that the documented clinical history revealed that diabetes mellitus was not diagnosed prior to the middle of 2005, whereas erectile dysfunction was reflected as a clinical problem as early the middle of 2000. The examiner noted that prior blood glucose readings did not support diabetes mellitus prior to the middle of 2005, and A1c levels (test indicators for diabetes mellitus) were not obtained prior to 2005. The VA examiner thus effectively concluded that the recorded clinical history did not support a diagnosis of diabetes mellitus prior to its noted initial diagnosis in 2005. The December 2011 VA examiner thereby opined that it was not at least as likely as not that the Veteran's diabetes mellitus had caused or aggravated the Veteran's erectile dysfunction, based on other causes reflected in the clinical profile being more likely causal of the diabetes mellitus. The Veteran was afforded prior VA examinations for compensation purposes in March 2006 and January 2011 also addressing his claimed erectile dysfunction. The March 2006 examiner concluded that it was unlikely that the Veteran's diabetes mellitus had caused the Veteran's erectile dysfunction, based on the Veteran not having been diagnosed with diabetes mellitus until April 2005. The January 2011 examiner assessed that it was unlikely that the Veteran's diabetes mellitus had caused or aggravated his erectile dysfunction, concluding that other medical conditions were far more likely to have caused or aggravated the erectile dysfunction. The January 2011 examiner noted that blood sugar readings in 1996 and 2000 did not meet the criteria for diabetes mellitus, and that while a higher random blood sugar reading of 171 was obtained in 2005, this still did not meet the criteria for a diagnosis of diabetes mellitus. The January 2011 examiner noted age, low testosterone levels, hypertension diagnosed in 1990, a prostatectomy performed in March 2005, dyslipidemia diagnosed in 1996, a history of 22 years of alcohol use, and hypertriglyceridemia diagnosed in 2001 as factors in the development of the Veteran's erectile dysfunction which outweighed diabetes mellitus, diagnosed in April 2005, as a likely causal or aggravating of the erectile dysfunction. The Board finds that the consistent opinions of the March 2006, January 2011, and December 2011 VA examiner are supported by the clinical records and the medical knowledge of those examiner, and are uncontradicted by any competent, credible evidence bearing any significant weight. While Dr. S.D. is competent to provide an assessment of a causal link between the Veteran's diabetes mellitus and his erectile dysfunction, the supposition of no other causes shown in the record is contradicted by the clinical history with its findings of low testosterone levels on a chronic basis, and by the other causal factors as shown in the record and as identified by the January 2011 and December 2011 VA examiners. The Board accordingly finds that Dr. D.'s August 2006 opinion that diabetes mellitus was causal of the Veteran's erectile dysfunction is entitled to very little or no weight, because the overwhelming weight of the evidence is to the effect that the factual premise for the opinion is unsupported and in fact contradicted by the record. A medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Similarly, while the Veteran is competent to assert that his diabetes mellitus developed prior to his erectile dysfunction, this assertion appears contradicted by the clinical record, wherein the Veteran reported erectile dysfunction in 2000, years prior to the documented first diagnosis of diabetes mellitus in 2005. While the Veteran is competent to address his perception of past medical findings and may be credible to the extent such perceptions are not otherwise fatally contradicted, the Veteran's perceptions in this case - of past reporting of blood glucose levels or of past assertions of clinicians - are not found by the Board to warrant any significant weight as evidence supportive of the presence of diabetes mellitus prior to 2005, where, as here, the considerable weight of well-informed medical opinion in this case is against diabetes mellitus being present earlier than 2005. Layno; Caluza. With regard to the Veteran's assertions that his erectile dysfunction was aggravated by diabetes mellitus and medication for diabetes mellitus, the Board recognizes the possibility of such causation. As the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has emphasized in a recent case, past case law, including in Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); and Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006), has made clear that lay evidence may serve to support the presence of a medical condition both currently and in the past, and may support causation. King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). However, the Board nonetheless finds that the January 2011 and December 2011 VA medical examiners' opinions to the contrary, informed by medical knowledge and supported by the clinical record, are entitled to far greater weight than the Veteran's lay assertion of any such potential aggravation. The Veteran testified at his hearing that he was informed by his VA doctor that diabetes mellitus causes erectile dysfunction or impotency. That potential causal link is not reasonably in dispute in this case, as both the January 2011 and December 2011 VA examiners recognized such potential causation (particularly with regard to the erectile dysfunction, the subject of the present claim). However, they concluded that such causation was unlikely in this case due to the relative chronology of onset and progression of the Veteran's diabetes mellitus and erectile dysfunction, and due to the multiple other more likely causes and aggravating factors of the Veteran's erectile dysfunction in this case, as already noted. Accordingly, with the weight of the evidence being both supportive of and favoring the March 2006, January 2011, and December 2011 VA examiners' opinions both that diabetes mellitus did not cause the Veteran's erectile dysfunction and that the Veteran's diabetes mellitus did not aggravate the Veteran's erectile dysfunction, the Board finds that the preponderance of the evidence is against the Veteran's service-connected diabetes mellitus having caused or aggravated the Veteran's erectile dysfunction. 38 C.F.R. § 3.310. The Board has also considered direct service connection, but neither the Veteran's assertions nor the balance of the evidentiary record supports a direct link between service and current erectile dysfunction, either through onset in service or continuity of symptoms from service or by injury in service or any other direct causal means. 38 C.F.R. § 3.303. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for erectile dysfunction is denied. ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs