Citation Nr: 1306967 Decision Date: 02/28/13 Archive Date: 03/01/13 DOCKET NO. 03-23 057 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD) and/or coronary artery disease. 2. Entitlement to service connection for varicose veins, to include as secondary to hypertension and/or service-connected coronary artery disease and/or PTSD. 3. Entitlement to an effective date earlier than July 16, 2003, for the award of service connection for tinnitus. [The issues of service connection for a metabolic disorder manifested by fatigue; service connection for a genitourinary disorder with bladder discomfort; service connection for a respiratory disorder, to include as due to herbicides as secondary to service-connected coronary artery disease; whether new and material evidence has been received to reopen a previously denied claim of service connection for a nerve disorder (claimed as peripheral neuropathy), to include as due to exposure to herbicides or as secondary to service-connected degenerative disc disease of the lumbar spine; entitlement to service connection for a disability manifested by incoordination of the legs, to include as secondary to service-connected degenerative disc disease of the lumbar spine; service connection for a gastrointestinal disorder, to include as a result of exposure to herbicides or as secondary to service-connected PTSD; entitlement to a rating in excess of 40 percent for residuals of prostate cancer, status post radiation therapy, from February 6, 2012; and entitlement to an effective date earlier than April 14, 2005, for the award of service connection for coronary artery disease are the subject of a separate decision by the Veterans Law Judge who conducted a hearing in those matters in October 2012.] REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel INTRODUCTION The Veteran had active service from December 1967 to July 1969. He also had service with the Navy Reserves from August 1989 to August 1994, the Army Reserves from August 1994 to August 1999, and the Army National Guard from August 1999 to August 2001, with unverified periods of active duty for training and inactive duty for training. There is a verified period of active duty for training from April 30, 1995, to June 9, 1995. This matter comes before the Board of Veterans' Appeals (Board) from a May 2006 rating decision of the VARO in St. Louis, Missouri, which denied the claims at issue. The RO in New Orleans, Louisiana, currently has jurisdiction of the claims file. In July 2008, a hearing was held before the undersigned Veterans Law Judge. In December 2008, the Board remanded the matter to the RO for the purpose of obtaining additional evidence and providing the Veteran with VA examinations for his cardiovascular disorders, varicose veins, and lumbar spine. In an October 2010 rating decision, the RO granted service connection for degenerative disc disease of the lumbar spine with left side radiculopathy. The remaining issues were returned to the Board in November 2010. By decision dated in November 2011, the Board granted service connection for coronary artery disease due to the Veteran's exposure to herbicides during his active service in Vietnam. The issues of service connection for hypertension, service connection for varicose veins, and entitlement to an earlier effective date for service-connected tinnitus were remanded for further development. For reasons which will be set forth in a remand at the end of the decision below, the issue of entitlement to an earlier effective date for the award of service connection for tinnitus is once again REMANDED to the RO by way of the Appeals Management Center, in Washington, D.C. VA will notify the Veteran should further action be required on his part. The Board notes that service connection is currently in effect for: coronary artery disease, rated as 100 percent disabling; PTSD, rated as 70 percent disabling; residuals of prostate cancer, status post radiation therapy, rated as 40 percent disabling; tinnitus, rated as 10 percent disabling; degenerative disc disease of the lumbar spine with left side radiculopathy, rated as 10 percent disabling; hearing loss of the left ear, rated as noncompensably disabling; and erectile dysfunction associated with PTSD, rated as noncompensably disabling. A combined 100 percent rating has been in effect since August 4, 2010. The Veteran has been in receipt of a total rating based on unemployability due to the severity of his service-connected disorders from April 3, 2004. He is also entitled to special monthly compensation under 38 U.S.C. § 1114(k) on account of loss of use of a creative organ from August 20, 2007, and to special monthly compensation under 38 U.S.C. § 1114(s) on account of coronary artery disease rated as 100 percent disabling and additional service-connected disabilities independently ratable as 60 percent or more from August 4, 2010. FINDINGS OF FACT 1. Hypertension did not have its onset during service and is not related to disease, injury, or event of service origin or to a service-connected disability. 2. Varicose veins did not have their onset during service and are not related to disease, injury, or event of service origin or to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for varicose veins are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002)) defines VA's duty to assist a Veteran in the development of a claim. VA regulations for the implementation of the VCAA are codified as amended at 38 C.F.R. §§ 3.102, 3.156, 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice 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. VCAA notice should be provided to a claimant before the initial RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has held the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those elements are: 1) Veteran status; 2) existence of a current disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability award. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). A review of the evidence discloses the Veteran has received all required notice, has had a meaningful opportunity to present evidence that would help him develop his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1,369 (Fed. Cir. 2004). He was sent appropriate VCAA letters in March 2005, May 2005, and June 2008. The claim was most recently readjudicated in May 2012 supplemental statement of the case. See Prickett v. Nicholson, 20 Vet App. 370, 376 (2006) (holding that the issuance of fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). Regarding the duty to assist, VA has also satisfied its obligation in terms of obtaining all potentially relevant evidence concerning the claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records, VA medical records, and identified private medical records have been obtained. Also, the Social Security Administration was contacted and provided records in its possession with regard to a favorable determination granting the Veteran Social Security disability benefits. The Veteran also has been provided VA compensation examinations, including the obtaining of medical nexus opinions, concerning the etiology of hypertension and varicose veins and any potential relationship with military service or service-connected disability, as it was directed when it remanded the claim previously. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. See also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The medical nexus opinions obtained, particularly in April 2012, are responsive to the determinative issue of causation, so additional examinations and opinions are not needed. 38 C.F.R. § 4.2. See also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that once VA undertakes the effort to obtain an examination for a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). See also Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (VA's duty to assist includes providing an adequate examination when such an examination is indicated). The medical evidence of record is adequate to address all pertinent concerns, as the claims file has been reviewed for all relevant medical and other history, the Veteran has been examined, the findings have been reported in sufficient detail, and there has been discussion of the underlying medical rationale, which is where most of the probative value of an opinion is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The VA examination reports of record are thorough and supported by the record. The Veteran had the opportunity to provide testimony in his own behalf with regard to hypertension and varicose veins before the undersigned Veterans Law Judge conducting a travel board hearing at the VARO in New Orleans in July 2008. A transcript of the hearing proceedings is in the claims file. In view of the foregoing, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board finds, "It is difficult to discern what additional guidance the VA could have provided to the Veteran regarding what further evidence he should submit to substantiate his claim." See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (observing certain circumstances as to when a remand would not result in any significant benefit to the Veteran). Pertinent Law and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.203(a). Establishing service connection generally requires competent evidence of three things: 1) A current disability; 2) inservice incurrence or aggravation of a disease or injury; and 3) a causal relationship, that is, a nexus, between a claimed inservice disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a) (2012). In addition, hypertension will be presumed to have been incurred in service if manifest to a degree of 10 percent or more within one year following separation from service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. § 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the 2nd or 3rd elements is through a demonstration of continuity of symptomatology. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). A claimant can establish continuity of symptomatology with competent evidence showing: 1) That a condition was "noted" during service; 2) post-service continuity of the same symptomatology; and 3) a nexus between the current disability and the post service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-96 (1997); 38 C.F.R. § 3.303(b). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Pursuant to 38 C.F.R. § 3.310(a), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. See Evans v. West, 12 Vet. App. 22, 29 (1998) (noting requirements for establishing service connection on a secondary basis). In order to establish a secondary service connection claim, the claimant must show: 1) The existence of a current secondary disability; 2) the existence of a service-connected disability; and 3) evidence that the service-connected disability proximately caused the secondary disability. 38 C.F.R. § 3.310(a). A claimant may also establish secondary service connection by demonstrating that his current secondary disability was aggravated or worsened by the already service-connected disorder. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (when aggravation of a Veteran's nonservice-connected [secondary] condition is proximately due to or the result of a service-connected condition, such Veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability as shown prior to the aggravation); Libertine v. Brown, 9 Vet. App. 521, 522 (1996). (Additional disability resulting from aggravation of a nonservice-connected [secondary] condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a)). If the claimant succeeds in establishing service connection for a secondary condition, "the secondary condition shall be considered a part of the original condition." 38 C.F.R. § 3.310(a). The Board notes that 38 C.F.R. § 3.310 was amended on September 7, 2006 (effective October 10, 2006). The amendment is to provide prospectively as it is more restrictive; it is not for application in the instant claim since the Veteran filed his claim prior to the amendment of 38 C.F.R. § 3.310. The term "active military, naval, or air service" includes: (1) active duty; (2) any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty. 38 U.S.C.A. § 101(2), (24); 38 C.F.R. § 3.6(a). The claimant in this case is a "veteran" based on his active duty service from December 1967 to July 1969. Therefore, he is entitled to "veteran" status and the full benefit of VA resources for any compensation claim based on that period of active service. However, in order for the appellant to achieve "veteran" status and be eligible for service connection for disability claimed during his inactive service, the record must establish that he was disabled during active duty for training due to a disease or injury incurred or aggravated in the line of duty or he was disabled from an injury incurred or aggravated during inactive duty training. See Mercado- Martinez v. West, 11 Vet. App. 415, 419 (1998); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Factual Background and Analysis The Board has thoroughly reviewed all the evidence in the numerous claims folders. While the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence, and on what this evidence shows, or fails to show, on the claim. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board discuss its reasons for rejecting evidence favorable to the Veteran). The Veteran's service treatment records are negative for any complaints or findings of hypertension. On separation examination in July 1969, he denied a history of high blood pressure. His blood pressure reading was 120/80. He again denied a history of high blood pressure on Naval Reserve examinations in August 1989, August 1991, and November 1991. Blood pressure readings were also normal at the time of those examinations. The Veteran has testified that he was first diagnosed with hypertension in the mid-1990's. The record shows that at the time of a March 1999 periodic examination a blood pressure reading was recorded of 140/90. There was no history of high blood pressure recorded. At the time of a November 2000 medical evaluation, the Veteran was given a diagnosis of hypertension. At the time of a March 2001 periodic examination, a blood pressure reading was recorded of 138/82. History of high blood pressure was noted. It was indicated this was first diagnosed in 1996 and was well controlled with medication. A VA treatment record dated in August 2003 showed that the Veteran gave a history of hypertension since 1995. The Veteran was afforded a VA hypertension examination in March 2006. He reported that his hypertension was diagnosed in 1996. The examiner stated that the contention that the Veteran's hypertension is due to PTSD is difficult to assess but is somewhat doubtful. He explained that most forms of hypertension have no underlying cause and these are essential hypertension or primary hypertension. He stated that in 5% of cases, there is a known case, including chronic kidney disease, thyroid dysfunction, etc. The examiner stated the issue of stress is a concern here, but that the problem with this is that stress, such as emotional stress, can cause in the short term elevation of blood pressure. However, it does not seem to cause a persistent elevation in blood pressure and therefore would probably not be the true cause of hypertension. He states that: "The conclusion is that the chronic stress of PTSD may, at time with episodes of acute stress, cause temporary elevation of blood pressure but it seems unlikely that it was the significant cause of hypertension itself and most likely the hypertension is essential hypertension which is the situation in the majority of cases. I would therefore conclude that the PTSD or chronic stress is unlikely the cause of the veteran's hypertension." With regard to the varicose veins, the Veteran asserts that they were first present during his active service. He testified in July 2008 that they had been present since he left Vietnam and that they were caused by his heart condition. He testified that his varicose veins were present during service, but that he did not pay any attention or seek medical treatment. He stated, "I just thought it was just, you know, I was an infantryman carrying a lot of weight on my back." The service treatment records are negative for any complaints or findings of varicose veins. On separation examination in July 1969, the examiner noted that the Veteran's vascular system (varicosities, etc.) and lower extremities were normal. Naval Reserve examination reports revealed consistent findings in August 1989, August 1991, November 1991, March 1999, and March 2001. A review of the medical evidence of record reflects at the time of an August 2003 VA examination, it was stated there were no varicose veins present. VA treatment records dated in October 2003 reflect no varicose veins being present. It was not until VA medical records dated in August 2004 that there was documentation of the presence of varicose veins. At that time they were noted on the left lower extremity only. In February 2005, varicosities were visualized on the posterior and lateral calf area and compression hose was ordered. The presence of superficial varicose veins was noted at the time of the March 2005 Agent Orange exposure examination. In September 2005, the Veteran had bilateral post thigh varicosities involving the knees and hips. Orthopedic prosthetics were ordered. In December 2008, the Board remanded the issues in order that the Veteran might be accorded a VA examination for the purpose of opining as to the nature and etiology of any current hypertension and/or varicose veins. The examiner was asked to determine whether hypertension had its onset in service or was related to any inservice event, disease, or injury. The examiner was also to address whether hypertension was caused by the Veteran's service-connected PTSD, whether it was aggravated by the PTSD, and whether varicose veins, if present, were caused or aggravated by coronary artery disease or hypertension. At the time of an August 2010 examination the Veteran was given a diagnosis of essential hypertension. However, the examiner did not provide the requested opinions. In September 2010, the examiner provided an addendum with the opinion that it was not likely that the Veteran's PTSD caused his hypertension and it was not clinically possible to differentiate between the natural course of the Veteran's hypertension and any aggravation that might have been caused by PTSD. In a second addendum dated that same month, the examiner determined that it was not likely that the Veteran's varicose veins were caused or aggravated by either his coronary artery disease or hypertension, but were more likely due to venous hypertension caused by valve incompetence. The examiner did not provide an opinion as to whether hypertension had its onset in service or was related to any inservice disease, event, or injury and did not provide any reasons or bases for opining that the varicose veins were not aggravated by coronary artery disease or hypertension. Subsequent thereto, additional VA medical records and the Veteran's Navy personnel file, to include records pertaining to periods of active duty for training and inactive duty for training between 1989 and 1994, were received. The Veteran was afforded a hypertension examination by VA in April 2012. The examiner noted that review of the claims file disclosed that the Veteran reported he had headaches and nosebleeds while in the service and was discovered to have hypertension and was placed on medication "at that time." Notation was made, however, that the Veteran's blood pressure readings were mostly in the 140/86 range. A reading was made in December 1967 of 120/78, while a reading of 120/80 was made at the time of separation examination in July 1969. The examiner opined following review of the claims file that, "It is not at least as likely as not (50 percent or greater probability) that the Veteran's hypertension had the clinical onset during active service or is related to any inservice disease, event, or injury." The examiner gave as his rationale that hypertension was documented in March 2001 with a statement that the Veteran "has HTN since 1996 and is well controlled on medication." Blood pressure at that time was noted to be 138/82. The examiner stated that he did not find any notation of elevated blood pressure readings during the Veteran's active service from 1967 to 1969. The examiner added that, "It is not at least as likely as not that hypertension was (i) caused by or (ii) aggravated by coronary artery disease. The examiner gave as his rationale that hypertension started in 1996 and coronary artery disease was not noted until 2006. He stated this made it unlikely that hypertension was caused by the coronary artery disease. With regard to aggravation, reference was made to review of the literature. The examiner stated that, "Uncontrolled HTN can lead to stroke and failure of the heart and/or kidneys. Uncontrolled HTN can lead to hypertrophy of the heart and this can lead to heart failure. Uncontrolled HTN can lead to hypertensive nephrosclerosis and this can lead to renal failure. Uncontrolled HTN can lead to intracerebral hemorrhage and stroke. Hypertension is the most prevalent major risk factor for premature cardiovascular disease (CVD), being more common than cigarette smoking, dyslipidemia, and diabetes, the other major risk factors. In the INTERHEART study of patients from 52 countries, hypertension accounted for 18 percent of the population-attributable risk of a first myocardial infarction (MI). Coronary artery disease can be aggravated by HTN. However, a review of the literature did not find evidence of coronary artery disease aggravating HTN. It is not possible to clearly separate the effects of similar disease states on an organ such as the heart because the body is an integrated system." With regard to a relationship between the service-connected PTSD and hypertension, the examiner opined that, "It is not at least as likely as not that hypertension was (i) caused by or (ii) aggravated by PTSD. As for rationale, the examiner stated that, "PTSD is not listed as a cause or risk factor for HTN. Some small research studies (30 persons) 5/29/09 have noted associations between PTSD and elevated B/P in blacks. The authors note that the hypothesis needs to be confirmed by direct evaluation and further research. There is at this time a lack of specific information commonly associated with HTN and PTSD to directly link PTSD as a cause or aggravating factor for HTN." The Veteran was also evaluated in April 2012 by the same VA health-care provider with regard to varicose veins. It was noted that he had varicose veins of the left lower extremity. Review of the file reflected that reported varicose veins involved that extremity in 2004. Following examination and review of the claims file, the examiner opined that the Veteran's varicose veins developed in 2004, a time when he was not on active duty service. She stated that the current varicose veins involving the left lower extremity were not caused by or aggravated by coronary artery disease, hypertension, or PTSD. As for rationale, she stated, "Varicose veins are not caused by coronary artery disease or PTSD or HTN. Varicose veins are veins that have become enlarged and tortuous. The term commonly refers to the veins of the leg. It is usually a problem of the veins in the legs, though varicosities can occur (sic) other places. The causes of varicose veins are listed as heredity, obesity, aging, prolonged standing, leg injury, abdominal straining, crossing the legs or ankles, post phlebitic obstruction, incontinence, venous and arteriovenous malformations." The examiner opined that the varicose veins were not aggravated by coronary artery disease, hypertension, and/or PTSD. She stated they were the "result of leaky valves and veins of the legs. Progression or worsening of varicose veins is related to incompetence of the valves in the veins. In a review of the literature no information was found which linked worsening of varicosities to coronary artery disease, HTN or PTSD." As noted above, in order to prevail on the issue of entitlement to secondary service connection, there must be 1) evidence of a current disability; 2) evidence of service-connected disability; and 3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran has current diagnoses of hypertension and varicose veins. Additionally, he is service connected for several disabilities, including PTSD and CAD. Thus the first two requirements in Wallin have been satisfied. At the outset, the Board acknowledges the Veteran was engaged in combat with the enemy. If an injury or disease was alleged to have been incurred or aggravated in combat, such incurrence or aggravation may be shown by satisfactory lay evidence, if consistent with the circumstances, conditions, or hardships of service, even if there is no official record of the incident. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). In-service incurrence by way of the combat presumption may also be rebutted by clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b). However, 38 U.S.C.A. § 1154(b) does not eliminate the need for evidence of a nexus; it merely reduces, for Veterans who have engaged in combat, the burden of presenting evidence of incurrence or aggravation of an injury or disease in service, and the Veteran's claim is not being denied based on the absence of in-service incurrence or aggravation or injury. See Collette v. Brown, 82 F.3d 389, 392 (Fed. Cir. 1996) (Section 1154(b) does not create a statutory presumption that a combat Veteran's alleged disease or injury is service connected). Here, the Veteran stated on one occasion in April 2012 that he was discovered to have hypertension during service. With respect to varicose veins, he stated that these were present during service either as a result of heart disease and/or carrying heavy packs. However, there is clear and convincing evidence to the contrary. See 38 U.S.C.A. § 1154(b). While the Veteran stated on VA examination in April 2012 that he was discovered to have hypertension during service, on every other instance in the record he has reported that his hypertension was diagnosed in 1995 or 1996. See August 2010 VA examination report, April 2008 VA examination report, March 2006 VA examination report, February 2004 VA treatment records, June 2004 Social Security Administration (SSA) disability determination examination report, August 2003 VA treatment records, March 2002 VA treatment records, December 2001 VA treatment records, and March 2001 National Guard periodic examination report. And subsequently, in June 2012, he stated that, "Hypertension was not claimed as a presumptive basis, but as a secondary condition of heart disease due to Agent Orange." Also, on separation examination in July 1969, the Veteran specifically denied a history of high or low blood pressure. His blood pressure reading was 120/80. He again denied a history of high or low blood pressure on Naval Reserve examinations in August 1989, August 1991, and November 1991. Blood pressure readings were also normal at the time of those examinations. The contemporaneous examination made at the time of service discharge, as well as the three examinations after service, all refute the Veteran's statement that he had hypertension during (and since) service. This is not a situation where there is a lack of medical evidence. To the contrary, the service separation examination and treatment records in the years following service specifically show that hypertension was not present. Thus, the Board finds that clear and convincing evidence shows that the Veteran did not have hypertension during service and that his single statement that he was diagnosed with hypertension during service is not credible. Likewise, with respect to varicose veins, the Veteran's lower extremities and vascular system (varicosities, etc.) were specifically examined at the time of his separation from service in July 1969, and the examiner noted that the Veteran's vascular system and lower extremities were normal. Naval Reserve examination reports revealed consistent findings in August 1989, August 1991, November 1991, March 1999, and March 2001. At the time of an August 2003 VA examination, it was stated there were no varicose veins present. VA treatment records dated in October 2003 reflect no varicose veins being present. It was not until VA medical records dated in August 2004 that varicose veins were diagnosed. In sum, the Veteran's lower extremities were examined upon separation from service and on numerous occasions thereafter; however, it was specifically noted that varicose veins were not present until August 2004. This contemporaneous examination made at the time of service discharge, as well as the seven examinations after service, all refute the Veteran's statement that he had varicose veins during (and since) service. Again, this is not a situation where there is a lack of medical evidence. To the contrary, the service separation examination and treatment records in the years following service specifically show that varicose veins were not present. Thus, the Board finds that clear and convincing evidence shows that the Veteran did not have varicose veins during service and that his statements that varicose veins were present during service, while competent, are not credible. There is no competent and credible evidence of record showing that the Veteran's hypertension and varicose veins had their onset during service or any period of ACDUTRA or are related to any in-service disease, event, or injury. As noted above, the Veteran's statements that these disabilities were present during service from 1967 to 1969 are not found to be credible. In addition, the VA examiner in April 2012 provided a reasoned opinion that hypertension and varicose veins did not have their onset in service. She stated that hypertension was less likely than not to have had its clinical onset during the Veteran's active service because the medical records for the Veteran's active service did not reveal any elevated blood pressure readings. She noted that review of the claims file failed to show that the Veteran had varicose veins that began in or were caused by his active duty service. There is no medical opinion to the contrary. Neither hypertension nor varicose veins is among the list of diseases that will be presumptively service connected if the Veteran was exposed to herbicides during active service, and hypertension was not diagnosed within one year of the Veteran's separation from active duty in July 1969. See 38 C.F.R. §§ 3.307, 3.309(e). Because the evidence of record does not establish that the Veteran was disabled from any injury or disease during active duty training, presumptive service connection for hypertension during any period of ACDUTRA is not possible. 38 U.S.C. § 1110; Acciola v. Peake, 22 Vet.App. 320, 324 (2008) (citing Mercado-Martinez v. West, 11 Vet.App. 415, 419 (1998)); Paulson v. Brown, 7 Vet.App. 466, 470 (1995). Therefore, service connection for varicose veins and hypertension is not warranted on a direct/presumptive basis. The remaining question is whether the record contains nexus evidence establishing a connection between the service-connected PTSD and/or coronary artery disease on the one hand and hypertension and varicose veins on the other hand. To this end, the April 2012 VA examiner referred to review of the entire claims file and opined that any current hypertension was not likely caused by the Veteran's service-connected coronary artery disease since the hypertension began in the mid-1990's and the coronary artery disease was not noted until many years later in 2006. She referred to medical literature pertaining to hypertension and coronary artery disease showing no evidence that coronary artery disease aggravates hypertension. She further stated that the hypertension was not caused by or aggravated by the Veteran's service-connected PTSD since she stated PTSD was not a known cause or risk factor for hypertension and she noted there was currently insufficient specific medical information to directly link PTSD as a causal or aggravating factor. With regard to varicose veins, the medical evidence is also against the claim. The April 2012 VA examiner gave reasons for her opinion by indicating that varicose veins are veins that have become enlarged and tortuous because of leaky or incompetent valves in the veins and a review of the medical literature provided no evidence indicating a causal relationship or aggravation of varicose veins to either coronary artery disease or PTSD. There is no medical evidence of record in the Veteran's favor. The March 2006 VA examiner concluded that the PTSD or chronic stress is unlikely the cause of the Veteran's hypertension. An addendum statement in September 2010 by a VA physician opining that it was not likely that the Veteran's PTSD causes hypertension. That examiner stated that it was not clinically possible to differentiate between the natural course of hypertension and any aggravation that might have been caused by PTSD. The examiner also stated that same month that it was not likely that the Veteran's varicose veins were caused or aggravated by his coronary artery disease but were more likely due to venous hypertension caused by valvular incompetence. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as to any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). In this case, the Board finds the April 2012 VA examiner's opinion is of great probative weight. The examiner gave detailed reasons for her opinion that neither varicose veins nor hypertension had any causal relationship to service or to any service-connected disability. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (probative value of a medical opinion comes from its reasoning). In this case, while the Veteran believes that his currently diagnosed hypertension and varicose veins are related to his service-connected PTSD and/or coronary artery disease, his opinion establishing the etiology of the disabilities and establishing a medical nexus between those disabilities and the service-connected disorders is not a simple matter capable of lay observation. Rather, these matters require medical knowledge. The Veteran does not assert any such medical knowledge. As the April 2012 opinion is competent, conclusively stated, and consistent with the record, the Board assigns that opinion the greatest probative weight regarding etiology. As a result, the Board finds the persuasive evidence regarding nexus weighs against a relationship between hypertension and varicose veins on the one hand and the Veteran's service-connected PTSD and coronary artery disease, on the other hand. As such, service connection for hypertension and varicose veins under any theory is not warranted. The Board has considered the applicability of the benefit of the doubt doctrine. However, as a preponderance of the evidence is against the claim, that doctrine is not for application. 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). ORDER Service connection for hypertension, to include as secondary to service-connected PTSD and/or coronary artery disease, is denied. Service connection for varicose veins, to include as secondary to service-connected PTSD and/or coronary artery disease, is denied. REMAND In November 2011, the Board remanded the question of the Veteran's entitlement to an effective date earlier than July 16, 2003, for the award of service connection for tinnitus in order that the Veteran might be accorded a statement of the case with regard to this matter. The statement of the case was issued by the RO in January 2012. In February 2012, the Veteran submitted a statement in support of claim in which he specifically stated he was filing a formal appeal with regard to this issue. Also received in February 2012 was a VA Form 9 dated January 30, 2012, in which the Veteran stated that he wanted a BVA hearing by live video conference and he wanted to appeal all issues listed on the statement of the case that was provided him. A communication of record dated in June 2012 reflects that service connection had been granted for tinnitus effective July 16, 2007. The following notation was made- "issue earlier effective date." It was indicated on the form that a video conference hearing with the Board was requested. The Veteran has not been afforded a video conference hearing in connection with his claim for an earlier effective date for service connection for tinnitus. Accordingly, the Board finds that the Veteran should be accorded such a hearing and the case is REMANDED for the following action: The Veteran should be scheduled for a video- conference hearing at the earliest available opportunity for the purpose of addressing his claim of entitlement to an earlier effective date for his award of service connection for tinnitus. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs