Citation Nr: 1309514 Decision Date: 03/20/13 Archive Date: 04/01/13 DOCKET NO. 06-17 960 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD) with anxiety and depressive disorders and coronary artery disease (CAD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Sherrard, Counsel INTRODUCTION The Appellant had active duty in the U.S. Army from July 1970 to April 1972. He also had service in the National Guard from April 1972 to September 1978, and from September 1980 to August 1996, with various periods of active duty for training (ADT) and inactive duty for training (IADT). This matter comes before the Board of Veterans' Appeals (BVA or Board) from a March 2005 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). The Appellant provided testimony at a May 2007 videoconference hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing is associated with the claims folder. In July 2009, the Board remanded the claim for further development. Once the requested development was completed, the case was returned to the Board, and the Board denied the benefits on appeal in a January 2011 decision. In a March 2012 Memorandum Decision, the United States Court of Appeals for Veterans Claims (Court) vacated the portion of the January 2011 Board decision that denied service connection for hypertension, and remanded the case for compliance with the Memorandum Decision. The Board subsequently remanded the claim for further development in August 2012. As discussed below, the development requested has been completed, and the claim is now appropriate for appellate review. The Board has not only reviewed the Appellant's physical claims file but also the Appellant's file on the "Virtual VA" system to insure a total review of the evidence. FINDING OF FACT The Appellant hypertension is not the result of an injury or disease incurred in or aggravated by active military service, nor is it causally related to or permanently worsened by any service-connected disability. CONCLUSION OF LAW The criteria for service connection for hypertension are not met. 38 U.S.C.A. §§ 101, 1101, 1110, 1112, 1113, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Service Connection for Hypertension Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). 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. With chronic disease 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. 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). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as cardiovascular-renal disease, including hypertension, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Active military service includes active duty, any period of ADT during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of IADT during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident (CVA) which occurred during such training. 38 U.S.C.A. § 101(21), (24); 38 C.F.R. § 3.6(a), (c), (d). ADT includes full-time duty performed for training purposes by members of the National Guard of any State. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c)(3). IADT includes duty (other than full-time duty) under sections 316, 502, 503, 504, or 505 of title 32 (32 U.S.C.S. §§ 316, 502, 503, 504, or 505), or the prior corresponding provisions of law. 38 U.S.C.A. § 101(23); 38 C.F.R. § 3.6(d)(4). Presumptive periods for service connection do not apply to ADT or IADT. Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). Thus, service connection may be granted for disability resulting from disease or injury incurred or aggravated while performing AD or ADT, from an injury incurred or aggravated while performing IADT, or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during a period of IADT. 38 U.S.C.A. §§ 101(24), 106, 1110 (2012). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). "Aggravation" is defined for this purpose as a chronic, permanent worsening of the underlying condition, beyond its natural progression, versus a temporary flare-up of symptoms. Id. To prevail on the theory of secondary service causation, generally, the record must show (1) medical evidence of a current disability, (2) a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Effective from October 10, 2006, 38 C.F.R. § 3.310 was amended. See 71 Fed. Reg. 52,744 (2006). The new regulation appears to place additional evidentiary burdens on claimants seeking service connection based on aggravation, specifically in terms of requiring the establishment of a baseline level of disability for the non-service-connected condition prior to the claimed aggravation. Regardless of whether the case is considered under the old or new regulation, based upon the facts in this case, neither version is more favorable, and the regulatory change does not affect the outcome herein. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno, 6 Vet. App. at 469; 38 C.F.R. § 3.159(a)(2). The Court has emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of a veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Appellant's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Board notes that the term hypertension refers to persistently high arterial blood pressure. Medical authorities have suggested various thresholds ranging from 140 millimeters of mercury (mm Hg) systolic and from 90 mm Hg diastolic. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 909 (31st Ed. 2007). Similarly, for VA rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mm or greater. The term isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Code 7101, Note 1 (2012). In this case, the Appellant contends that his hypertension was caused or aggravated by his service in the National Guard. In the alternative, he avers that his hypertension was caused or aggravated by his service-connected PTSD or CAD. The Appellant does not contend, and the medical evidence of record does not support, a finding that his hypertension is related to his period of active duty from July 1970 to April 1972. Service treatment records from that period are negative for any high blood pressure readings, or signs, symptoms, treatment, or diagnosis of hypertension. Neither the February 1970 enlistment nor the April 1972 separation examination report indicates a history or medical finding of high blood pressure. Indeed, the Appellant's blood pressure reading at separation examination was 130/84. Moreover, the Board also finds that the weight of the evidence demonstrates that hypertension did not manifest to a compensable degree within one year of service (active duty) separation. The weight of the evidence demonstrates no diagnosis or findings of hypertension of any severity during the one year post-service presumptive period. See 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). The evidence shows the first assessment or indication of hypertension 13 years after service separation in 1985. For these reasons, the Board finds that hypertension, first indicated in 1985 (and not formally diagnosed until 1988), did not manifest to a compensable degree within one year of service separation; therefore, the presumptive provisions for hypertension are not applicable in this case. 38 C.F.R. §§ 3.307, 3.309. As noted above, the Appellant avers that his hypertension was caused or aggravated by his periods of ADT and IADT in the National Guard. As an initial matter, the Board finds that the Appellant is not a "Veteran" for the purposes of the benefit he seeks, which is based on periods of ADT and IADT, because he did not become disabled due to an injury or disease incurred in or aggravated during a period of ADT or IADT. See Donellan v. Shinseki, 24 Vet. App. 167 (2010) (observing that the determination of "veteran" status is a predicate ruling prior to findings of service connection). As stated above, the law provides that service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Active military, naval, or air service includes any period of ADT during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of IADT during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a CVA which occurred during such training. See 38 U.S.C.A. § 101(21), (24); 38 C.F.R. § 3.6(a). Service connection for a person on IADT is permitted only for injuries, not diseases, incurred or aggravated in line of duty. See Brooks v. Brown, 5 Vet. App. 484, 485 (1993) (holding under then-applicable law that service connection for a myocardial infarction sustained during a period of IADT was not appropriate). VA's General Counsel has held that it was the intention of Congress when it defined active service in 38 U.S.C.A. § 101(24) to exclude inactive duty for training during which a member was disabled or died due to non-traumatic incurrence or aggravation of a disease process. VAOPGCPREC 86-90. As here pertaining to the Appellant's period of National Guard service subsequent to separation from active service in April 1972, the fact that a claimant has established status as a "Veteran" for purposes of other periods of service (e.g., the Appellant's period of active duty) does not obviate the need to establish that the claimant is also a "Veteran" for purposes of the period of ADT or IADT where the claim for benefits is premised on that period of ADT or IADT. See Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998). Here, to warrant service connection for hypertension (and to establish status as a "Veteran"), the Appellant must show that he became disabled, i.e., that he was diagnosed with hypertension or that hypertension manifested during a period of ADT. Because hypertension is classified as a disease rather than an injury, as discussed below, he cannot receive service connection for hypertension if it was diagnosed or manifested during a period of IADT. The Board finds that because the preponderance of the competent and probative evidence of record is against a finding that the Appellant's hypertension first manifested during a period of ADT, he is not a "Veteran" for the purpose of the hypertension claim. When the Appellant re-entered the National Guard in September 1980, his blood pressure was recorded at 126/70, well within the normal range, and the Appellant checked "no" next to "high blood pressure" on his medical history form. A periodic examination in April 1981 showed a blood pressure reading of 130/88, still within normal range. A private medical record recorded a blood pressure reading of 130/110 on December 24, 1985, demonstrating elevated diastolic pressure. A January 1986 private treatment record shows a blood pressure reading of 140/108, demonstrating borderline systolic pressure and elevated systolic pressure. A periodic March 1986 examination showed a blood pressure reading of 140/90, again demonstrating borderline systolic and elevated diastolic pressures. A March 1987 private treatment record indicates a blood pressure reading of 154/106, showing both elevated systolic and diastolic pressures. The first formal diagnosis of hypertension was recorded in 1988. In this regard, a May 1988 private treatment record notes that the Appellant's blood pressure was consistently staying up, and, thus, the Appellant required treatment. The private physician further noted that the Appellant had consistent off and on elevations of systolic and diastolic pressure. After the Appellant started taking medication, by October 1988, his blood pressure was considered stable. At a January 1990 National Guard examination, the Appellant stated on his report of medical history that his private physician had placed him on medication for his high blood pressure beginning in the summer of 1988. In 1992, the Appellant was hospitalized for four days for both a hypertension episode and anxiety. In a December 1993 Air Guard clinical note, the Appellant stated he had been treated for high blood pressure for about eight years. As noted above, presumptive periods for service connection do not apply to ADT or IADT. Biggins, 1 Vet. App. at 477-78. Thus, the fact that hypertension manifested within one year of multiple periods of ADT and IADT does not entitle the Appellant to service connection on a presumptive basis. The question is whether hypertension manifested during a period of ADT. The first documented abnormal blood pressure reading was recorded on December 24, 1985. According to the Appellant's National Guard records, the only period of ADT he had in 1985 was from March 16 to March 30, 1985, and in December 1985, his only period of IADT was from December 7 to December 8, 1985. Therefore, high blood pressure and/or hypertension (a disease) did not manifest during a period of ADT, or, for that matter, during a period of IADT. Even if it were shown that hypertension manifested during a period of IADT, hypertension is a disease and not an injury, and is thus not subject to service connection. A precedent opinion of VA's General Counsel analyzed the meaning of the term "injury" for purposes of active service and cited to previous General Counsel opinions which defined an "injury" as harm from an external trauma, meaning from the application of external force or violence, rather than from a degenerative process. See VAOPGCPREC 08-2001; published in 66 Fed. Reg. 33310 (2001). Based on the foregoing, the Board finds that hypertension is not an "injury" within the meaning of 38 U.S.C.A. § 101(24), as it is a condition resulting from internal, non-traumatic causes. Thus, the weight of the evidence indicates that the Appellant did not become disabled due to incurrence or aggravation of an injury during a period of IADT. The Board acknowledges the Appellant's contention that his hypertension was aggravated by his National Guard service. In particular, private treatment records seem to suggest that his National Guard service caused or contributed to spikes in his blood pressure in 1991 and 1992. Private treatment records show that on December 18, 1991, the Appellant reported that his blood pressure was currently down, but that he had experienced seven or eight "attacks" of high blood pressure lately. He was diagnosed with hypertension with an anxiety component in January 1992, and the clinician noted that his blood pressure was good when he was relaxed, but up when he was anxious. Later that month, the day following a period of IADT, a private clinician stated that the emergency room employees believed that the Appellant's high blood pressure and anxiety were both related to the Appellant being in the military Reserve (or National Guard), and that the Appellant always arrived at their clinic by ambulance from his Reserve drill weekends. In February 1992, it was noted that the Appellant's anxiety had made treatment and control of his hypertension difficult. Later that year, the Appellant's blood pressure stabilized with both a decrease in anxiety with medication and with blood pressure medication. Despite the indication in the private treatment records of a relationship between the Appellant's National Guard service and high blood pressure readings, the Board finds that the weight of the evidence is against a finding that such a relationship, either of causation or aggravation, exists. The Appellant was afforded a VA examination in August 2012. The VA examiner reviewed the Appellant's claims file, including his medical and service treatment records, and conducted a thorough physical examination. The examiner opined that a pure acute and transitory sympathetic nervous system response to anxiety or other psychologic issue with elevated blood pressure and pulse rate (such as those experienced by the Appellant in 1991 and 1992, as described above) does not equate a chronic physiological disease state (e.g., hypertension) or chronic aggravation beyond normal primary disease state. In other words, the VA examiner opined that the episodes of increased blood pressure precipitated by anxiety experienced by the Appellant during his National Guard service did not constitute aggravation, or permanent worsening beyond natural progression, of hypertension. The Board finds the August 2012 VA examiner's opinion to be more probative than that of the 1991 and 1992 private clinicians. The 2012 VA opinion is of significant probative value because it is factually accurate, as it appears the VA examiner was informed of the relevant evidence in this case, relied on accurate facts, conducted a thorough examination, and gave a fully articulated opinion that is supported by sound reasoning. By contrast, the private clinicians in 1991 and 1992 did not discuss whether the Appellant's hypertension was permanently aggravated by National Guard service, or whether such manifestations of high blood pressure constituted temporary episodes rather than a permanent worsening of a chronic condition. The Appellant also contends that his hypertension was caused or aggravated by his service-connected PTSD or CAD. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 16-17. The Appellant has service connection for PTSD and CAD. Service connection for CAD and PTSD was granted in January and May 2011 rating decisions, respectively. The Board finds that the weight of the evidence is against a finding that the Appellant's hypertension was caused or aggravated by service-connected PTSD or CAD. A VA opinion was obtained in August 2012 to address the question of whether the Veteran's hypertension was caused or aggravated by his PTSD or CAD. The VA examiner indicated that she personally conducted the examination of the Veteran and provides a medical opinion stating that hypertension was less likely than not caused or aggravated by his service-connected PTSD or CAD. With regard to CAD, the VA examiner reasoned that the Veteran was diagnosed with hypertension in 1988, but was not diagnosed with CAD until 2003; thus, the hypertension significantly pre-dated the CAD. Moreover, the examiner stated that CAD was not a risk factor for hypertension. With regard to PTSD, the VA examiner stated that evidence based medicine did not primarily correlate PTSD with anxiety and depressive disorders as primary causation/risk stratification for development of hypertension. Rather, this Veteran's predominant risk factors for hypertension included race/ethnicity as non-Hispanic black, hyperlipidemia, and primary family history (as noted in the Veteran's service treatment records). Further, there was no evidence of aggravation of hypertension beyond the normal primary disease progression. As discussed above, the VA examiner explained that pure acute and transitory sympathetic nervous system response to anxiety or other psychologic issue with elevated blood pressure and pulse rate (such as those experienced by the Appellant in 1991 and 1992, as described above) does not equate a chronic physiological disease state (e.g., hypertension) or chronic aggravation beyond normal primary disease state. The examiner cited to medical literature in support of her opinions. There are no medical opinions of record which relate the Veteran's hypertension to his service-connected PTSD or CAD. Regarding the Veteran's statements as to the cause of the current hypertension, the Board recognizes that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson, 581 F.3d at 1316 (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau, 492 F.3d 1372). However, in this case, the cause of the Veteran's hypertension involves a complex medical etiological question because it deals with the origin and progression of the Veteran's cardiovascular system and disorder of such internal and complex disease process (cardiovascular disorder) is diagnosed primarily on clinical findings and physiological testing. The Veteran is competent to relate symptoms of hypertension that he experienced at any time, but is not competent to opine on whether there is a link between the current hypertension and a service-connected disability, including PTSD and CAD, because such diagnosis requires specific medical knowledge and training. See Rucker, 10 Vet. App. at 74 (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). For these reasons, the Board finds that weight of the lay and medical evidence that is of record outweighs the Veteran's more recent contentions regarding the relationship between his hypertension and either his National Guard service or his service-connected PTSD and CAD. Based on the foregoing, the Board finds that the weight of the evidence is against a finding that the Veteran's hypertension was caused or aggravated by any service-connected disability. In this case, the record of evidence indicates that the Veteran did not incur hypertension during a period of active service, has not experienced continuous hypertension symptomatology since active duty, including not to a 10 percent degree within one year of service, and that there is no relationship, of either causation or aggravation, between his hypertension and any service-connected disability. For these reasons, service connection for hypertension must be denied. As the preponderance of the evidence weighs against the Veteran's claim for service connection for hypertension, the benefit of the doubt doctrine is not applicable, and the claim for service connection must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353 -356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The notice included provisions for disability ratings and for the effective date of the claim. In a timely August 2004 letter, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection, what information and evidence must be submitted by the Veteran, and what information or evidence VA will attempt to obtain. The May 2006 Statement of the Case (SOC) described how VA determines disability ratings and effective dates. The Board finds that any untimeliness in providing Dingess notice was nonprejudicial, as the Veteran had ample opportunities to submit additional evidence throughout the course of the claim following issuance of the May 2006 SOC. Then, following the Court remand of this case, additional notice was sent to the Veteran in August 2012 which addressed the secondary aspects of this claim. The Veteran submitted a statement in response, but did not identify any additional evidence that he wanted VA to obtain on his behalf. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, and the Veteran's statements. A VA opinion was obtained in August 2012 with regard to the question of whether the Veteran's hypertension was caused or aggravated by a service-connected disability. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the August 2012 VA opinion obtained in this case is adequate as to the question of whether the Veteran's hypertension is related to a service-connected disability. The opinion was predicated on a full reading of the private and VA medical records in the Veteran's claims file, and a contemporaneous physical examination and interview of the Veteran. The VA nexus opinion considered all of the pertinent evidence of record, to include VA treatment records, comprehensive physical examinations, and the statements of the Veteran, and provides a complete rationale for the opinion stated, relying on and citing to the records reviewed. The Board acknowledges that a VA opinion has not been obtained regarding the question of whether the Veteran's hypertension was incurred in or caused by active service; however, the Board finds that a VA examination is not necessary in order to decide this issue. Two pivotal Court cases exist that address the need for a VA examination. Those are Duenas v. Principi, 18 Vet. App. 512 (2004) and McLendon v. Nicholson, 20 Vet. App. 79 (2006). In McLendon, the Court held that in disability compensation claims, the Secretary must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurring 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 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 Secretary to make a decision on a claim. In Duenas, the Court held that a VA examination is necessary when the record: (1) contains competent evidence that the veteran has persistent or recurrent symptoms of the claimed disability, and (2) indicate that those symptoms may be associated with his active military service. In this case, the Veteran does not contend that his hypertension began during or is related to his period of active duty from 1970 to 1972. Moreover, the Veteran's service treatment records for his single period of active duty are negative for any complaints of or treatment for hypertension. Thus, the weight of the evidence demonstrates that the Veteran did not sustain an injury, disease, or event relating to hypertension in service, and there is no duty to provide a VA medical examination. See Bardwell v. Shinseki, 24 Vet. App. 36, 40 (2010) (holding that that where the evidence has failed to establish an in-service injury, disease, or event, VA is not obligated to provide a medical examination). As explained in this decision, the Board also finds that the weight of the evidence demonstrates no chronic symptoms of hypertension in service and no continuity of symptoms of hypertension since service separation. Because there is no in-service injury or disease to which a competent medical opinion could relate the current disability, there is no reasonable possibility that a VA examination or opinion could aid in substantiating the current claim for service connection for hypertension. See 38 U.S.C.A. § 5103A(a)(2) (VA "is not required to provide assistance to a claimant . . . if no reasonable possibility exists that such assistance would aid in substantiating the claim"); 38 C.F.R. § 3.159(d) (VA to discontinue assistance where there is "no reasonable possibility that further assistance would substantiate the claim"). Further, as discussed in this decision, the weight of the evidence does not demonstrate that hypertension manifested during a period of ADT. Thus, since that is the sole basis for service connection as it relates to periods of ADT in this case and there is ample medical evidence upon which to make that determination, a VA opinion is not necessary to fulfill the duty to assist. The Board has considered the decision in Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); however, in the absence of evidence of an in-service disease or injury, referral of this case to obtain an examination and/or an opinion as to the etiology of the Veteran's hypertension would in essence place the examining physician in the role of a fact finder, would suggest reliance on an inaccurate history of occurrence of an in-service injury or disease, and could only result in a speculative opinion or purported opinion of no probative value. In other words, any medical opinion which purported to provide a nexus between the Veteran's hypertension and military service would necessarily be based on an inaccurate history regarding what occurred in service, so would be of no probative value. The Court has held on a number of occasions that a medical opinion premised upon an unsubstantiated account of a claimant is of no probative value. See, e.g., Swann v. Brown, 5 Vet. App. 229, 233 (1993) (generally observing that a medical opinion premised upon an unsubstantiated account is of no probative value, and does not serve to verify the occurrences described); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (the Board is not bound to accept a physician's opinion when it is based exclusively on the recitations of a claimant that have been previously rejected). The holding in Charles was clearly predicated on the existence of evidence of an in-service injury, disease, or event and a current diagnosis. Referral of this case for an examination or to obtain a medical opinion would be a useless act. The duty to assist by providing a VA examination or opinion is not invoked in this case because there is no reasonable possibility that such assistance would aid in substantiating the claim. See 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d). Notably, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist 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 v. Principi, 16 Vet. App. 183 (2002). ORDER Service connection for hypertension is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs