Citation Nr: 1311948 Decision Date: 04/10/13 Archive Date: 04/19/13 DOCKET NO. 07-32 114 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to service connection for hypertension, to include as secondary to the Veteran's service-connected type II diabetes mellitus. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Alexander Barone, Counsel INTRODUCTION The Veteran served on active duty from April 1960 to June 1977. This matter came before the Board of Veterans' Appeals (Board) on appeal from a December 2006 rating decision of the San Diego, California, Regional Office (RO) which, in pertinent part, denied service connection for hypertension. In January 2010, the Board denied service connection for hypertension to include as secondary to the Veteran's Type II diabetes mellitus. The Veteran subsequently appealed the issue to the United States Court of Appeals for Veterans Claims (Court). In November 2010, the Court granted the Parties' Joint Motion for Remand, vacated the January 2010 Board decision, and remanded the issue of service connection for chronic hypertension to the Board for additional action. The Board then remanded the issue to the RO for appropriate development in October 2011 and again in September 2012. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT Hypertension was not manifested during service, or within one year of discharge from service, nor is hypertension otherwise caused or aggravated by such service or any service-connected disability. CONCLUSION OF LAW Hypertension was not incurred in or aggravated by the Veteran's active service, nor may in-service incurrence be presumed, nor is hypertension proximately caused by or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim 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 and 3.326(a). Duty to Notify Upon receipt of a complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant pre-adjudication notice by a letter dated in August 2006. The notification complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. While this notice does not provide any information concerning the evaluation or the effective date that could be assigned should service connection be granted, Dingess v. Nicholson, 19 Vet. App. 473 (2006), since this decision affirms the RO's denial of service connection, the Veteran is not prejudiced by the failure to provide him that further information. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist VA has obtained service treatment records; obtained private and VA post-service treatment records; assisted the Veteran in obtaining evidence and afforded the Veteran VA examinations in November 2006 and December 2011, with an important additional October 2012 addendum to the December 2011 VA examination report. The Board finds that the most recent VA examination report (as amended in October 2012) now presents sufficient discussion of the pertinent history, current findings, and expert determinations informed by review of the claims file and direct evaluation of the Veteran such that it presents adequate and probative evidence in this case. All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Board notes that the October 2011 and September 2012 Board remands directed that the RO obtain an adequate VA medical opinion addressing the etiology of the Veteran's hypertension, to include addressing questions of whether hypertension has been caused or aggravated by service-connected disability and to include consideration of the Veteran's hypertension medications reducing his blood pressure. An October 2012 VA examination report addendum (expanding and clarifying the findings of a December 2011 VA examination report) shows that the directed medical opinions have been adequately provided. The complete medical opinion, as amended, now adequately addresses all of the essential questions raised by the Board's remands and the issue on appeal; the discussion expressly contemplates the Veteran's hypertension medication and addresses whether the Veteran's hypertension has been caused or aggravated by his service-connected diabetes mellitus or his service-connected prostate cancer. The Board finds that the VA examiner's opinion's discussion of the significance of diabetes to the etiology of hypertension substantially contemplates the Veteran's service-connected peripheral neuropathy and erectile dysfunction which are part of the referenced service-connected diabetes disability picture. There has been no suggestion in the evidence or contentions of this case that the erectile dysfunction or peripheral neuropathy have caused or aggravated hypertension in any manner independently from the broader diabetes mellitus pathology. The Board's October 2011 remand additionally directed that the RO take action to ensure that all pertinent private and VA medical records were made available in the claims-file. Since that time, the Veteran's VA treatment records have been updated and made available for review in the Virtual VA claims-file. The RO also sent the Veteran a letter in October 2011 requesting that he identify any additional private treatment records he would like VA to assist him in obtaining. The Veteran has not identified any new sources of outstanding medical records and has indicated that he has no additional evidence to submit (including in February 2013 correspondence from his representative). The Board finds that the actions directed by the prior remands have been completed in substantial compliance with the terms and purposes of those remands. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision at this time. Analysis The Veteran claims entitlement to service connection for hypertension. Essentially, the Veteran contends that he currently suffers from hypertension as a result of military service or as secondary to service-connected disability. Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury or disease in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 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). Certain chronic disabilities, such as hypertension, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Additionally, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service- connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). 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). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). 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"). A veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr, 21 Vet. App. 303 ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Also, a veteran as a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the lay person is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F. 3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a lay person is competent to identify the medical condition; he is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). The Board further notes that it has reviewed all of the evidence in the Veteran's claims file and in "Virtual VA" (VA's electronic data storage system), with an emphasis on the evidence relevant to the matter on appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. 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 so doing; the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board may not make its own independent medical determinations; the Board must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans v. West, supra; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. The Veteran has claimed entitlement to service connection for hypertension, to include as secondary to his service-connected diabetes mellitus Type II. Service connection is in effect for diabetes mellitus Type II as well as for associated erectile dysfunction and peripheral neuropathy of bilateral lower extremities. Service connection is also in effect for residuals of prostate cancer. A service Report of Medical Examination dated in October 1959 for induction purposes reflects that the Veteran's blood pressure reading as 120/64. On examination performed for separation purposes in January 1977, the Veteran's blood pressure reading was 110/60 recumbent and 118/68 standing. Service treatment records do not reflect a diagnosis of hypertension nor do they present any other suggestion that the Veteran or trained medical professionals believed the Veteran may have had hypertension during service; the January 1977 service separation examination report shows that trained medical professionals found that the Veteran's vascular system and all other relevant systems were clinically normal with no pertinent abnormalities at that time. VA outpatient treatment records dated in November 2005 reflect that the Veteran was assessed with hypertension. In November 2006, the Veteran underwent a VA examination. He reported that he was diagnosed with hypertension approximately 5 years earlier. He stated that he had been taking lisinopril for the past year for control of his blood pressure. The examiner noted that there were no medical records available for review. Upon physical examination, the Veteran's blood pressure reading was 120/82 sitting, 122/82 standing, and 120/80 lying. The examiner noted that diabetes mellitus can affect the course of hypertension. Following physical examination, the examiner opined that the hypertension is not directly related to diabetes mellitus. The examiner stated that there did not appear to be any aggravation of the hypertension. The examiner reasoned that the Veteran's blood pressure was normal. The Joint Motion granted by the Court found that the November 2006 VA examination report was inadequate for the purposes of appellate review in this case. The conclusory analysis and inadequate basis for the negative etiology opinion has no probative weight in the Board's analysis. The Board's current analysis considers the November 2006 VA examination report only to the extent of a review to determine whether any evidence supportive of the Veteran's claim is presented; the Board finds no support for the Veteran's claim in the November 2006 report. A letter from a private physician dated in October 2007 reflects that the doctor had treated the Veteran since 1999. The private doctor noted that the Veteran had been treated with an ACE inhibitor since June 2001, was treated with Lotensin (benazepril) from June 2001 to January 2005, and had been treated with lisinopril since January 2005. The doctor opined that the Veteran's blood pressure treatment was "strongly linked" to his diabetic care because "optimum care for any diabetic patient includes strict blood pressure control." A December 2011 VA examination report prepared by a competent medical expert concludes, after review of the claims file, that the Veteran's hypertension was "less likely than not (less than 50 percent probability)" incurred in or caused by military service, citing that hypertension was diagnosed in June 2001, approximately 23 years after separation from service. The examiner further noted that the October 1959 service induction examination report shows blood pressure of 120/64, and that multiple readings on the January 1977 service separation examination report show blood pressure of 110/60 and 118/68. The examiner explained that the reviewed service treatment records do not contain any evidence of diagnosis or treatment of hypertension during service, and that "no nexus can be established linking his HTN to any time spent in the service." The December 2011 VA examiner additionally concluded that the Veteran's hypertension is "less likely than not (less than 50 percent probability)" proximately due to or the result of service-connected diabetes mellitus. The examiner cited that both the hypertension and the diabetes are well controlled and that diabetes is not a recognized etiology generally associated with causation of hypertension. The examiner explained that diabetes "may, in very rare cases, indirectly cause HTN in the context of late stage kidney disease." However, the examiner explains that the Veteran has no renal dysfunction in this case. The Board finds that this rationale from the competent medical expert reasonably explains the medical basis for the determination that the Veteran's hypertension is not attributable to his diabetes mellitus (as such a medical link would involve kidney disease, which the Veteran does not have). The December 2011 VA examination report failed to further address etiological questions at issue in this case. In September 2012, the Board remanded the issue while noting that the December 2011 VA examination report did not address the question of whether the Veteran's hypertension was aggravated (i.e. permanently increased in severity) beyond its natural progression by his service-connected diabetes mellitus or other service-connected disabilities. The September 2012 Board remand also noted that the December 2011 opinion failed to discuss the impact the Veteran's hypertension medications may have on his blood pressure readings in considering whether his diabetes mellitus could be aggravating his hypertension, as this had been ordered in the Joint Motion granted by the Court. Following the Board's September 2012 remand, the VA examiner who prepared the December 2011 VA examination report prepared a new expanded report in October 2012. The report indicates that the examiner reviewed the claims-file. The examiner opined that the Veteran's hypertension is less likely than not aggravated by the service-connected diabetes mellitus, explaining that "in the absence of nephropathy, DM 2 does not have any [e]ffect on blood pressure." The Board again finds that the competent medical expert's rationale reasonably explains the medical basis for the determination that the Veteran's hypertension is not caused or aggravated by his diabetes mellitus (as such a medical link would involve kidney disease, which the Veteran does not have). The examiner further indicated that this conclusion was drawn with consideration of the Veteran's blood pressure medications and the fact that they contribute to keeping the Veteran's blood pressure readings within a target range; this effect of the blood pressure medication was specifically acknowledged in the examiner's discussion. The examiner additionally concluded that the Veteran's hypertension is less likely than not aggravated by his service-connected prostate cancer, citing that prostate cancer is not known to permanently aggravate systemic blood pressure issues, and citing that the Veteran's prostate cancer has been in remission since 2005 and is no longer active. As set forth above, the Veteran seeks service connection for hypertension. Although VA medical treatment records reflect a current diagnosis of hypertension, there is no medical evidence to support that the disability is due to his active service or any incident therein. In addition, although hypertension is among the chronic diseases subject to presumptive service connection under the provisions of § 3.307(a), there is no competent evidence of record to show that the Veteran's hypertension had manifested to a compensable degree within the one-year presumptive post-service period. Physical examinations performed during active service which reflect the Veteran's blood pressure readings do not evidence high blood pressure or a diagnosis of hypertension. Private medical records reflect an assessment of hypertension in June 2001. Accordingly, a diagnosis of hypertension was rendered over 23 years after separation from service. This significant gap is one factor that weighs heavily against the Veteran's claim. See Maxson v. West, 12 Vet.App. 453, 459 (1999). The Board notes that the Veteran does not contend that he had any symptoms or diagnosis of hypertension more proximately to service. There is no competent evidence to support an etiological relationship to his period of active service. The Veteran primarily claims that his hypertension developed due to his service-connected diabetes mellitus. The Board has considered the October 2007 letter from a private medical doctor presenting the opinion that the Veteran's blood pressure treatment is "strongly linked" to his diabetic care because "optimum care for any diabetic patient includes strict blood pressure control." This opinion does not clearly indicate that any hypertension pathology may have been caused or aggravated by diabetes; indeed, the opinion appears to suggest that the Veteran's hypertension presents a risk of complicating the treatment for diabetes (which is not a basis for service connection for hypertension). The medical statement appears to be describing the necessity to coordinate his hypertension treatment with his diabetes treatment, not providing a clear statement on the etiology of the hypertension. Furthermore, no rationale is presented to suggest any basis for finding that the Veteran's hypertension has been caused or aggravated by his diabetes. At most, the October 2007 private opinion indicates that the Veteran's blood pressure treatment is "strongly linked" to his diabetic care, the opinion does not address the probability that the Veteran's hypertension itself has been caused or aggravated by his diabetic care or diabetes disease pathology. The Board finds that the October 2007 opinion does not present evidence probatively supporting the Veteran's claim that his hypertension has been caused or aggravated by his service-connected diabetes. The Board has given careful attention to the contents of the November 2010 Joint Motion for Remand in this case. The key concerns discussed in the Joint Motion focused upon the inadequacy of the November 2006 VA examination report in that the report failed to make clear whether consideration had been given to the provisions of VA's Adjudication Procedure Manual Rewrite, M21-1MR, Subpart iv, Chap. 4, Section F, para. 22(c), which state that the complications of diabetes mellitus include hypertension (among others). The Joint Motion found that the "conclusory opinion that diabetes does not cause hypertension" required greater explanation, particularly in light of those provisions. The Joint Motion further found that the November 2006 VA examination report's conclusion was "not supported by a reasoned analysis," was inadequate in failing to address the impact the Veteran's hypertension medications may have had on his blood pressure readings in considering whether aggravation of underlying hypertension has occurred, and was not informed by review of the pertinent medical evidence in the Veteran's claims-file. The concerns of the November 2010 Joint Motion have been remedied in that the new VA examination report from December 2011, as amended in October 2012, is: (1) clear in providing a reasoned explanation that diabetes may cause or aggravate hypertension under the specific circumstances where there is pertinent kidney disease / nephropathy, but that these circumstances were not present in this case; (2) clear in acknowledging that the Veteran's hypertension medications lower his blood pressure, indicating that such fact was contemplated in the medical analysis; and (3) clear in indicating the examiner's review of the contents of the claims-file. Conclusion The Board finds that the preponderance of the evidence is against the claim of entitlement to service connection for hypertension. In reaching this decision, the Board has reviewed the entirety of the evidence of record but finds that there is no other evidence of record which probatively contradicts the findings presented in the most probative evidence discussed above with regard to the issues decided at this time. The Board acknowledges that the claims file contains a quantity of other documents, but none of the information in these records substantially supports the Veteran's claim or otherwise contradicts the evidence deemed to be most probative in the discussion above. Here, the evidence does not support finding that the Veteran's hypertension is related to his military service or any service-connected disability. The Veteran has now been afforded a VA examination with adequate medical report and opinion in connection with this claim; the examiner has provided clear findings and opinions with persuasive discussion of rationale weighing against the claim. The examiner's pertinent findings and opinions are uncontradicted by the rest of the competent evidence of record. No medical professional has provided any opinion clearly indicating that the Veteran's hypertension is related to his military service or any service-connected disability. The Board acknowledges that service connection may indeed be granted when a chronic disease or disability is not present in service, but there is evidence of continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). In this case, the Veteran has not alleged a continuity of symptomatology for hypertension dating back to any time proximate to service. Contemporaneous medical evidence shows that neither the Veteran nor trained medical professionals believed that the Veteran had hypertension during service or at separation, nor does any evidence indicate the presence of hypertension proximately following separation. The Board finds that there is no credible evidence in this case establishing continuity of pertinent symptomatology for hypertension from around the time of active duty military service. The Board acknowledges the Veteran's belief that his hypertension is related to his military service or to a service-connected disability. However, there is no evidence of record showing that the Veteran has the specialized medical education, training, and experience necessary to render a competent medical opinion as to the diagnosis and etiology of a disability. 38 C.F.R. § 3.159(a)(1). Consequently, the Veteran's own assertions as to diagnosis and etiology of a disability have no probative value. Lay statements may be competent 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. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). See also Robinson v. Shinseki, 312 Fed. Appx. 336 (Fed. Cir. 2009) (non-precedential) (confirming that, in some cases, lay evidence will be competent and credible evidence of etiology). However, a determination concerning diagnosis of an internal disease or a determination concerning the possibility of a causal relationship between military service and a chronic disability which the evidence shows did not manifest until many years after service requires specialized training, and may therefore not be established by lay opinions on etiology. Likewise, a determination concerning an etiological link between hypertension and service-connected disabilities featuring complex internal pathologies requires specialized training, and may therefore not be established by lay opinions on etiology. As the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for hypertension, the benefit-of-the-doubt rule does not apply and this claim is denied. See 38 U.S.C.A § 5107. ORDER The appeal is denied. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs