Citation Nr: 1314541 Decision Date: 05/02/13 Archive Date: 05/15/13 DOCKET NO. 04-23 695 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUE Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD R. Dodd, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1964 to July 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Togus, Maine. Jurisdiction over the claims folder was subsequently transferred to the RO in New York, New York. In August 2006, the claims were remanded to the RO for further development. After completing the requested development, the RO continued to deny the claims and returned the matters on appeal to the Board for further consideration. In May 2010, the Board denied the Veteran's claims on appeal. The Veteran appealed the Board decision to the United States Court of Appeals for Veterans Claims (Court). In May 2010, the Court granted the joint motion for remand filed by representatives for both parties, vacating the Board's decision, and remanding the claim to the Board for further proceedings consistent with the joint motion. In July 2011, the Board remanded the claims for additional development, to include a VA examination. In April 2012, the Board again denied the claims on appeal. The Veteran appealed the Board decision to the Court. In February 2013, the Court granted the joint motion for remand filed by representatives for both parties, vacating the Board's decision, and remanding the claim to the Board for further proceedings consistent with the joint motion. Although a claim for service connection for a heart condition was also originally before the Board, the joint motion found that portion of the April 2012 decision should not be disturbed. As such, only the claim for service connection for hypertension is once again before the Board. FINDINGS OF FACT 1. Service connection is in effect for diabetes mellitus, evaluated as 20 percent disabling. 2. Hypertension was not present in service, did not manifest for many years thereafter, and the preponderance of the medical evidence is against a finding that it is caused by or aggravated by service-connected diabetes mellitus. CONCLUSION OF LAW Hypertension was not incurred in, or aggravated during active service, nor is it proximately due to, or the result of, a service connected disability. 38 U.S.C.A. §§ 1101 , 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102 , 3.159, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VCAA The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2011), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The Court further held that VA failed to demonstrate that "lack of such a pre-AOJ-decision notice was not prejudicial to the appellant, see 38 U.S.C. § 7261(b)(2) (as amended by the Veterans Benefits Act of 2002, Pub. L. No. 107-330, § 401, 116 Stat. 2820, 2832) (providing that '[i]n making the determinations under [section 7261(a)], the Court shall...take due account of the rule of prejudicial error')." The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Although the Veteran was not provided complete notice until after the initial adjudication of the claim, the Board finds that there is no prejudice to him in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the Veteran's claim. The claims were most recently readjudicated in September 2011. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters on appeal. Pertinent medical evidence associated with the claims file consists of service, VA and private treatment records, and the reports of August 2002, June 2008, and July 2011 VA examinations. Also of record and considered in connection with the appeal are various written statements provided by the Veteran and by his representative on his behalf, and private treatment records. The Board also finds that no additional RO action to further develop the record is warranted. Legal Criteria Service connection may be established where the evidence demonstrates that an injury or disease resulting in disability was contracted in the line of duty coincident with military service, or if preexisting such service, was aggravated therein. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. If hypertension becomes manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of heart disease or hypertension during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Court has held the requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007). The Board notes that, in the case at hand, the Veteran filed his claims prior to his separation from service. He also underwent a VA examination in January 2010 prior to his separation from service. The Board notes that any disabilities that were diagnosed during this examination satisfy all three elements of service connection. Service connection may also be granted for chronic disabilities, such as hypertension, if such are shown to have been manifested to a compensable degree within one year after the Veteran was separated from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As an alternative to the nexus requirement, service connection for these chronic disabilities may be established through a showing of continuity of symptomatology since service. 38 C.F.R. § 3.303(b)(2012). The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities, such as hypertension, listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F .3d 1331, 1337 (Fed.Cir.2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept 14, 2009). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Service connection may be granted on a secondary basis for a disability which is proximately due to or the result of a service-connected disability. When service connection is established for a secondary condition, the secondary condition shall be considered part of the original condition. 38 C.F.R. § 3.310(a). According to Allen v. Brown, 7 Vet. App. 439 (1995), secondary service connection may be found where a service-connected disability aggravates another condition (i.e., there is an additional increment of disability of the other condition which is proximately due to or the result of a service-connected disorder). The provisions of 38 C.F.R. § 3.310 were amended in 2006. See 71 Fed. Reg. 52744-47 (Sept. 7, 2006). The amended regulation provides that any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disease, will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the non-service-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the non-service-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. See 38 C.F.R. § 3.310(a), (b), as amended effective October 10, 2006. The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. Although VA has indicated that the purpose of the regulation was merely to apply the Court ruling in Allen, it was made clear in the comments to the regulation that the changes were intended to place a burden on the claimant to establish a pre-aggravation baseline level of disability for the non-service-connected disability before an award of service connection may be made. Allen, 7 Vet. App. 439. This had not been VA's practice, which suggests that the recent changes amount to a substantial change. Allen, 7 Vet. App. at 447-449. Significantly, the Board observes that the Veteran's service connection claim was filed in July 2002, prior to the effective date of the revised regulation. Thus, to whatever extent that revised regulation may be more restrictive than the previous one, the Board will afford the Veteran review under both the old and new versions. See VAOPGCPREC 7-2003 (Nov. 19, 2003). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) . Factual Background The Veteran contends he has hypertension secondary to his diabetes mellitus. Service treatment records do not show, and the Veteran does not contend that he developed hypertension during his active service. His blood pressure at entrance was 120/80, and was 120/75 at discharge. Private treatment records from November 1987 noted a blood pressure reading of 140/100. In December 1987, his blood pressure was 140/95 and he was assessed with high blood pressure. He was additionally noted to have high blood sugar with, what appears to say, a history of ischemia. A stress test was ordered. In 1988 (the month is illegible) his blood pressure was 150/108. Laboratory tests from November 1988 noted high glucose, high cholesterol, and high triglycerides. He was started on a low cholesterol diet. Private treatment records do not document the Veteran's weight at any point. Laboratory tests from December 1993 revealed high glucose, low sodium, high triglycerides, and high cholesterol. He also had a high cholesterol percentile. In April 1994, the Veteran requested an "eating suppressant." A December 1993 private treatment record from South Nassau Communities Hospital noted complaints of intermittent chest pain and resting blood pressure of 130/95. A diagnosis of normal EKG response to maximal exercise was provided. An October 1996 private treatment record showed the Veteran was on high blood pressure medication, although it does not indicate when he was first prescribed the medication. Blood testing results from September 1997 noted high glucose, high cholesterol and high triglycerides. A notation on the laboratory results stated that the normal range indicated for cholesterol was consistent with the National Institute of Health recommendation that cholesterol levels should not exceed 200 mg/dl when evaluating for coronary heart disease. The Veteran's cholesterol was 262 mg/dl. An April 1998 record assessed diabetes mellitus and prescribed Glucotrol. He was also assessed with hyperlipidemia. During an August 2001 VA diabetes examination the Veteran noted he was diagnosed with diabetes mellitus, type II, in 1993. His weight at the time of the examination was 242 lbs. He described medication for diabetes, cholesterol and bronchitis, but did not indicate he was on medication for high blood pressure. He was noted to have normal creatinine and liver function tests. During a general medical VA examination, also in August 2001, the Veteran again did not indicate he was on medication for hypertension, nor did he complain of high blood pressure. His blood pressure at the time of the examination was 136/70. He was not assessed with hypertension during the evaluation. VA treatment records dated August 2001 to August 2002 reflected complaints of chest pain and shortness of breath. An August 2001 record assessed diabetes mellitus and primary hypertension. He denied chest pain or pressure with exertion. His blood pressure was 140/80. His diabetes was noted to be "fairly controlled." In a July 2002 letter, private physician N.J.B. stated that he was treating the Veteran for hypertension and hyperlipidemia. In August 2002, the Veteran was afforded VA examinations for diabetes mellitus and hypertension. At his examination regarding hypertension, the Veteran reported that he was diagnosed with hypertension in 1993, but denied any current symptoms. Blood pressure on examination was 140/70. The examination for diabetes mellitus noted that the Veteran did not have any cardiovascular symptoms and his hypertension was controlled with Atacand. An October 2002 letter from Dr. N.J.B., indicated that he treated the Veteran for type II diabetes, hyperlipidemia, and COPD since August 2001. The physician noted that upon initial examination, the Veteran had a blood pressure of 160/100. The physician provided diagnoses of COPD/asthma, diabetes mellitus, hypertension, hyperlipidemia, morbid obesity, and abnormal EKG changes with low ejection fraction. The physician opined that it was "more than likely that the heart condition was directly related to the hypertension and that the hypertension was secondary" to the Veteran's type II diabetes. No rationale was provided for this opinion. In a December 2002 addendum to the August 2002 VA examination, the examiner stated that both coronary artery disease and hypertension were less likely secondary to the Veteran's diabetes mellitus. No rationale was provided for these opinions. A December 2003 letter from Dr. S.S., noted that the Veteran had hypertension and diabetes mellitus. Further, he stated that the incidence of diabetes is increased in patients with hypertension and that the two co-morbid conditions make it difficult to control each condition. A letter from B.R., M.D., indicated that she had treated the Veteran since February 2006 for diabetes mellitus, hypertension, hypercholesterolemia, gastroesophageal reflux and COPD. From that time to the present, the Veteran had been stable with medications. The physician also indicated that the Veteran had an abnormal EKG in the past that had been attributed to his hypertension. The Veteran provided several medical articles from the internet. A position paper from the Australian Diabetes Society, entitled "Diabetes and Hypertension," noted that hypertension was twice as prevalent in diabetic as in non-diabetic individuals, and that hypertension in a diabetic patient was associated with accelerated progression of microvascular (retinopathy and nephropathy) and macrovascular (atherosclerotic) complications. The article also noted that the presence of hypertension in non-insulin-dependent diabetics was associated with a 4 to 5-fold increase in mortality, predominantly from coronary artery disease. "Non-insulin dependent diabetes and hypertension commonly co-exist and may be part of the insulin resistance or metabolic syndrome...features include obesity, mixed dys-lipidaemia (high triglycerides and low HDL cholesterol levels)." "The underlying association between hypertension and diabetes in this syndrome remains unknown." (Emphasis added). The article also stresses the importance of anti-hypertensive drugs, and the control of hypertension in diabetic patients so as to slow the progression and development of diabetes complications. An additional article, entitled "Hypertension in diabetes" noted that hypertension is twice as prevalent in diabetics compared with non-diabetic individuals, and that hypertension develops as part of the insulin resistance or metabolic syndrome that includes hyperinsulinaemia, obesity, dyslipidaemia and atherosclerotic vascular disease. The last article submitted dealt with the characteristics of patients with coronary artery disease and hypertension. As the record does not show the Veteran has coronary artery disease, the Board will not address this article. The Veteran was afforded a VA examination in June 2008. The examiner noted that hypertension and diabetes were diagnosed in 1993 and have been treated since then. Diabetes and hypertension were controlled without complications. Blood pressures were 160/80, 148/72, and 144/68. The examiner provided diagnoses of stable essential hypertension. The examiner opined that the Veteran's hypertension was not related to his diabetes mellitus. The examiner provided the rationale that hypertension was essential because the serum creatinine was normal in 2008. In July 2011, the Veteran was afforded a hypertension VA examination. The Veteran was noted to have been diagnosed with hypertension in 1993. His blood pressure readings were 138/74, 129/69, and 122/65. He was diagnosed with essential hypertension, and was noted to have a normal serum creatinine of 1.07 mg. He had no hypertensive cardoimyopathy or nephropathy. The examiner opined that his hypertension was not due to his diabetes mellitus because there was no evidence of diabetic nephropathy, and the serum creatinine was normal. The examiner reviewed the article by the Australian Diabetes Society but felt the article did not apply because the Veteran did not have evidence of diabetic nephropathy, his hypertension was controlled, and there was no evidence of cardiac problems as a result of his hypertension. The examiner noted the cardiology article had to do with patients with coexisting hypertension and coronary artery disease, and the Veteran had normal coronary arteries, so the articles findings were inapplicable to the Veteran. In November 2011, the Board requested that an independent medical expert review the Veteran's claims file and provide opinions regarding the potential relationship between the Veteran's hypertension, diabetes, and any diagnosed heart disorder. A December 2011 independent medical examiner reviewed the claims file and noted the Veteran was diagnosed with diabetes and hypertension in 1993. He noted that "according to the American Diabetes Association, 20 -60% of diabetics have hypertension-so the two diagnoses are 'associated'. Obesity, however, has been shown to CAUSE insulin resistance which is paramount to the diagnosis of diabetes." He noted that diabetes could cause diabetic nephropathy, which could cause hypertension, but that the Veteran did not have diabetic nephropathy. He noted that the Australian Diabetes Society position paper noted that diabetes and hypertension are associated, but that association does not equate to causation. He opined that there was a less than 50% probability that the Veteran's diabetes caused his hypertension and that the Veteran's obesity (with a body-mass index of 35.7 in 2001) was far more likely the cause of his diabetes and hypertension. In March 2012, the independent medical examiner provided an addendum to his opinion. He reiterated that the Veteran's hypertension was not caused by his diabetes, and provided an opinion that there was less than a 50% chance that the Veteran's hypertension had been aggravated, beyond the natural course and scope of the disease, by his service-connected diabetes. Analysis As noted above, the Veteran is claiming service connection for hypertension as secondary to his diabetes mellitus, to include that his diabetes mellitus has aggravated his hypertension. The Board finds that the weight of the medical evidence of file is against a finding that the Veteran's hypertension was caused or incurred in service, or caused or aggravated by his service-connected diabetes mellitus. Service treatment records do not show treatment for or diagnosis of hypertension in service. Additionally, there is no medical evidence of the development of hypertension to a compensable degree within one year of discharge from service. As such, presumptive service connection is not warranted for hypertension. The Board notes that there are conflicting medical opinions contained in the claims file. In assessing the claims for service connection, the Board finds that the opinions of the 2008, and 2011 VA examiners and the 2011 independent medical examiner are more probative than the statements of the Veteran's private physicians (Dr. N.J.B. and Dr. B.R.). Factors for assessing the probative value of a medical opinion are the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444, 448-49 (2000). In contrasting these opinions, the Board is cognizant that the United States Court of Appeals for Veterans Claims (Court) has recently stressed that "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). At the outset, Dr. N.J.B. did not provide a rationale for his opinion that the Veteran's hypertension was secondary to his diabetes mellitus. He did note that the Veteran's obesity, hypertension, hyperlipidemia and diabetes mellitus were cardiac risk factors. The Board notes that according to the available medical records, the Veteran developed both high blood pressure and high blood sugar in 1987, although he was not diagnosed with diabetes or hypertension until 1993. He also appears to have been started on high blood pressure medication prior to being placed on diabetic medication, but was instructed to go on a low cholesterol diet in 1988. The records show that he developed high cholesterol, high triglycerides, high glucose levels and high blood pressure all around the same time. Dr. B.R., who began treating the Veteran in 2006, indicated that the Veteran's diabetes preceded his hypertension, which appears to be factually inaccurate based upon the record. She indicated that there are several mechanisms, through which the Veteran's diabetes "likely contributed, along with other risk factors, to his development of hypertension." Aside from the inaccurate notation that the Veteran's diabetes pre-dated his hypertension, she repeats Dr. N.J.B.'s sentiment that the Veteran had multiple comorbidities lending to an overall deterioration of his health. The 2002 VA examiner opined that the Veteran's hypertension was less likely secondary to the Veteran's diabetes mellitus. The examiner did not provide a rationale for this opinion, and thus this examination was inadequate. The 2008 examiner opined that the Veteran's hypertension was essential and not due to diabetes because his creatinine level was normal in 2008. The Veteran complained that this examination was inadequate because it did not address the articles he had submitted or the positive nexus opinions of his private physicians. The 2011 VA examiner found that the Veteran's hypertension was not due to his diabetes as his creatinine serum level was normal, and he did not suffer from diabetic nephropathy. He also reviewed the articles the Veteran had submitted but noted again that the Veteran did not have diabetic nephropathy or cardiac problems as a result of hypertension, and thus the articles were not applicable. Lastly, the independent medical examiner noted that the Veteran likely developed hypertension and diabetes as a result of his morbid obesity. This explanation coincides with the Veteran's test results showing high triglycerides and high cholesterol, as well as the records showing that physicians had prescribed diets beginning in 1988. The medical examiner noted there was a difference between an 'association' between diabetes and hypertension, which the articles addressed, and causation. He also noted that the while diabetes can cause diabetic nephropathy, which in turn can cause hypertension, that the Veteran did not have diabetic nephropathy. The Board also notes that the Veteran's hypertension and diabetes began at the same time. The examiner found that the Veteran's hypertension had not been aggravated beyond its natural course and scope by diabetes. The Board notes that the records in the claims file show that the Veteran's hypertension is controlled. In fact, based on laboratory results between 1987 and 1993, the Veteran's high blood pressure was under control while he was still attempting to control his diabetes. 38 C.F.R. § 3.310(b) notes that unless the baseline level of severity of the nonservice-connected disease needs to be established prior to the Board conceding that a nonservice-connected disease was aggravated by a service-connected disease. The schedule for rating disabilities may be used to determine the baseline and current levels of severity of the nonservice-connected diseases. The Board notes that the Veteran's blood pressure readings in 1987 and 1988 would have met the schedular criteria for a rating of 10 percent. He was then placed on medication. It is unclear from the record whether he continued on medication for high blood pressure throughout the period on appeal. His blood pressure readings from VA examinations in 2002, 2008 and 2011 do not meet the schedular requirements for a compensable rating. Assuming he remained on blood pressure medication continuously, then he would have remained at the 10 percent level. As the Veteran's diabetes was diagnosed at the same time as his hypertension, and his hypertension has not increased in severity, aggravation is not established in accordance to the amended ersion of 38 C.F.R. § 3.310(b). Under the prior version of 38 C.F.R. § 3.310, the Veteran did not have to provide a baseline for the purposes of aggravation. As the Veteran filed his claim prior to the amended rule and the change was determined to be a substantial one, the Veteran is entitled consideration under both the old and new versions. See VAOPGCPREC 7-2003. Although, the old version of 38 C.F.R. § 3.310 gives greater latitude, the result with regard to service connection based upon aggravation by service-connected diabetes mellitus is unchanged. This is because the probative evidence of record, namely the opinions of the 2008, and 2011 VA examiners and the 2011 independent medical examiner for reasons discussed above, show that the Veteran's hypertension had not been aggravated, beyond the natural course and scope of the disease, by his service-connected diabetes mellitus. The Board finds the Veteran to be credible in describing his symptoms, as well as his ability to report about prior medical treatment for his condition. Given the complexity of the etiology of his disability, however, the Veteran is not competent to provide statements regarding the etiology or aggravation of his hypertension. Consequently, the assertions presented by the Veteran have minimal probative value. Accordingly, the evidence of record does not show that the Veteran's hypertension was caused by or aggravated by his service-connected diabetes mellitus, under the prior or current version of 38 C.F.R. § 3.310. As there is not an approximate balance of positive and negative evidence regarding the merits of the appellant's claim that would give rise to a reasonable doubt in favor of the appellant, the benefit of the doubt rule as to these issues is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus, is denied. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs