Citation Nr: 1314733 Decision Date: 05/03/13 Archive Date: 05/15/13 DOCKET NO. 06-23 128 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for Type II diabetes mellitus (diabetes mellitus), to include as a result of exposure to herbicides. 2. Entitlement to service connection for coronary artery disease (CAD), to include as a result of exposure to herbicides and/or secondary to diabetes mellitus. 3. Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus. 4. Entitlement to service connection for diabetic retinopathy, to include as secondary to diabetes mellitus. 5. Entitlement to service connection for trigger finger repair of the right thumb, to include as secondary to diabetes mellitus. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. L. Wallin, Counsel INTRODUCTION The Veteran served on active duty from February 1968 to December 1971. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from an April 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran presented testimony before the Board in June 2007; a transcript has been associated with the claims folder. The matter was previously before the Board in February 2009 and August 2011 and remanded on both occasions for further development and adjudication. The claims have been returned to the Board and are now ready for appellate disposition. In August 2011, the Board referred claims of service connection for trigger finger in the right hand (excluding the thumb) and the left hand (all fingers). To date, it does not appear that the Agency of Original Jurisdiction (AOJ) has developed the claims and/or given them consideration. The Board does not have jurisdiction over these matters and they are again referred to the AOJ. FINDINGS OF FACT 1. The Veteran had no in-country service or documented visitation in the Republic of Vietnam, or exposure to herbicides, including Agent Orange. 2. The competent and probative medical evidence of record preponderates against a finding that the Veteran's diabetes mellitus, is due to events in active service, to include herbicide exposure; as a chronic disease, it is not shown to have been manifested to a compensable degree within one year after the Veteran's separation from service in December 1971. 3. The competent and probative medical evidence of record preponderates against a finding that the Veteran's hypertension, is due to events in active service; it is not proximately due to, the result of, or aggravated by a service-connected disability; and as a chronic disease it is not shown to have been manifested to a compensable degree within one year after the Veteran's separation from service in December 1971. 4. The competent and probative medical evidence of record preponderates against a finding that the Veteran's CAD, is due to events in active service, to include herbicide exposure; it is not proximately due to, the result of, or aggravated by a service-connected disability; and as a chronic disease it is not shown to have been manifested to a compensable degree within one year after the Veteran's separation from service in December 1971. 5. The competent and probative medical evidence of record preponderates against a finding that the Veteran's trigger finger repair of the right thumb, is due to events in active service; it is not proximately due to, the result of, or aggravated by a service-connected disability. 6. The competent and probative medical evidence of record preponderates against a finding that the Veteran's diabetic retinopathy, is due to events in active service; it is not proximately due to, the result of, or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus have not been met. 8 U.S.C.A. §§ 1101, 1110, 1116, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 2. The criteria for service connection for hypertension have not been met. 8 U.S.C.A. §§ 1101, 1110, 1116, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 3. The criteria for service connection for CAD have not been met. 8 U.S.C.A. §§ 1101, 1110, 1116, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 4. The criteria for service connection for diabetic retinopathy have not been met. 8 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). 5. The criteria for service connection for trigger finger repair of the right thumb have not been met. 8 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the Veteran's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided the Veteran pre-adjudication notice by letters dated in February 2004 and April 2004. Additional VCAA and duty to assist letters were sent in May 2004, June 2004, July 2004, October 2004, March 2006, April 2009, July 2009, August 2011, September 2011, December 2011, April 2012, November 2012, and January 2012. Notice pursuant to the Dingess decision was provided in May 2006 and the claims were subsequently readjudicated, most recently in a February 2013 supplemental statement of the case. Mayfield, 444 F.3d at 1333. VA has obtained service treatment and personnel records, assisted the Veteran in obtaining evidence (post-service VA and private outpatient treatment records and lay statements), provided the Veteran VA examinations, afforded the Veteran the opportunity to give testimony before the Board, and attempted to verify his service in the Republic of Vietnam (RVN) with the National Personnel Records Center (NPRC), National Archives and Records Administration (NARA), the Naval History and Heritage Command, and the U.S. Army and Joint Services Records Research Center (JSRRC). All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claims at this time. II. Analysis The Board has reviewed all the evidence in the Veteran's paper claims file and Virtual VA record, which does not contain any additional pertinent information or evidence. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant 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 each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some 'chronic diseases,' such as diabetes mellitus, hypertension, and CAD, presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. With 'chronic disease' shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a '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. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term 'chronic disease', whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. §§ 5107(b), 7104(a); 38 C.F.R. § 3.303(a). 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"). 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). Herbicide Exposure The Veteran contends that he is entitled to service connection for diabetes mellitus, CAD, hypertension, trigger finger of the right thumb, and diabetic retinopathy. Notably, with regard to the claims for diabetes mellitus and CAD, the Veteran alleges that he was exposed to herbicides while stationed aboard the USS Kitty Hawk. He asserts that he was assigned to a fighter squadron (VF-213) aboard the USS Kitty Hawk during the Vietnam Conflict as a plane captain. He reports that during his second Vietnam tour he was told to jump on a mail plane with his crew and travel to Da Nang for the purpose of repairing an aircraft. He testified that he set foot in RVN on two such occasions and stayed a few days both times. He further contends that he cleaned many planes that had been misted with herbicides A Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 U.S.C.A. § 1116(f). Service in Vietnam includes service in the waters offshore, or service in other locations if the conditions of service involved duty or visitation in Vietnam. 38 C.F.R. § 3.313. For purposes of applying the presumption of exposure to herbicides under 38 C.F.R. § 3.307(a)(6)(iii), the service person must have actually been present at some point on the landmass or the inland waters of Vietnam during the Vietnam conflict. See also Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008) (providing that, even where a veteran did not serve upon the landmass of Vietnam, he is always "free to pursue his claim that he was actually exposed to herbicides while" in service.). If a Veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases, including diabetes mellitus and CAD, shall be service-connected, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. §§ 1113, 1116 and 38 C.F.R. §§ 3.307(d), 3.309(e). The Secretary of the Department of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994). See also 61 Fed. Reg. 41442-41449, and 61 Fed. Reg. 57586-57589 (1996). When a disease is first diagnosed after service but not within an applicable presumptive period, service connection may nevertheless be established by evidence demonstrating that disease was in fact incurred during service. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). If there is no presumptive service connection available, direct service connection can be established if the record contains competent medical evidence of a current disease process with a relationship to exposure to an herbicide agent while in military service. See 38 U.S.C.A. § 1110 ; 38 C.F.R. § 3.303 ; Combee at 1043-44. The governing law provides that a "veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 shall be presumed to have been exposed during such service to an herbicide agent . . . unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service." 38 U.S.C.A. § 1116(f) . Initially, the Board notes that the Veteran's service personnel records confirm he had service aboard the USS Kitty Hawk while on active duty. In July 1970, he was designated a plane captain. Declassified documents from the Naval History and Heritage Common's website show the USS Kitty Hawk conducted air operations over Vietnam during the following periods: (1) January 13, 1971, to February 3, 1971; (2) February 21, 1971, to March 31, 1971,; (3) April 10, 1971, to April 25, 1971; (4) May 4, 1971, to May 16, 1971; and (5) May 30, 1971, to June 23, 1971. The Board further notes, however, that "Service in the Republic of Vietnam," includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii) (Emphasis added). The VA General Counsel has determined that the regulatory definition (which permits certain personnel not actually stationed within the borders of the Republic of Vietnam to be considered to have served in that Republic) requires that an individual actually have been present within the boundaries of the Republic. See VAOPGCPREC 27-97. Specifically, the General Counsel has concluded that in order to establish qualifying "service in Vietnam" a veteran must demonstrate actual duty or visitation in the Republic of Vietnam. Service on a deep water naval vessel in waters off the shore of the Republic of Vietnam, without proof of actual duty or visitation in the Republic of Vietnam, does not constitute service in the Republic of Vietnam for purposes of 38 U.S.C.A. § 101(29)(A) (establishing that the term "Vietnam era" means the period beginning on February 28, 1961 and ending on May 7, 1975 in the case of a veteran who served in the Republic of Vietnam during that period). See VAOPGCPREC 27-97. Similarly, in another precedent opinion, the VA General Counsel concluded that the term "service in Vietnam" does not include service of a Vietnam era veteran whose only contact with Vietnam was flying high-altitude missions in Vietnamese airspace. See VAOPGCPREC 7-93. Again, a showing of actual duty or visitation in the Republic of Vietnam is required to establish qualifying service in Vietnam. In Haas v. Peake, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that in order for the presumption of service connection based upon herbicide exposure to apply, a Veteran must have set foot on the landmass of the country of Vietnam or served in the inland waters of Vietnam. Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008). The U.S. Supreme Court has denied further review of that decision, in Haas v. Peake, 129 S. Ct. 1002 (2009). In December 2008, VA Compensation and Pension (C&P) Service released Policy on Vietnam Naval Operations. C&P Service initiated a program to collect data on Vietnam naval operations for the purpose of providing ROs with information to assist with development in Haas related disability claims based on herbicide exposure from Navy Veterans. This particular policy statement provided further definition as to what constitutes Vietnam "Blue Water" versus "Brown Water" for the purpose of determining Agent Orange exposure. It was determined that Da Nang Harbor and all other harbors along the Vietnam coastline were considered by C&P Service to be part of the offshore "blue water" of Vietnam and not part of the inland waterway system or "brown water" of Vietnam. Ultimately, VA considers open deep-water coastal harbors, such as those at Da Nang, Cam Rahn Bay, and Vung Tau to be part of the offshore blue water of Vietnam and not part of its inland waterway. See December 2008 C&P Service Bulletin. In May 2009, the JSRRC issued a Memorandum for Record titled "Research Findings Regarding Navy and Coast Guard Ships During the Vietnam Era;" which noted that "to date, the JSRRC has found no evidence that indicates Navy or Coast Guard ships transported tactical herbicides from the United States to the Republic of Vietnam or that ships operating off the coast of Vietnam used, stored, tested, or transported tactical herbicides." The memorandum further noted that the JSRRC could not document or verify that a shipboard veteran was exposed to tactical herbicides based on contact with aircraft that flew over Vietnam or equipment that was used in Vietnam. See M21-1MR, Part IV, Subpart ii, Chapter 2, Section C, Part 10.l. In January 2010 C&P Bulletin, the C&P provided a list of ships that had confirmed exposure to herbicides. However, the USS Kitty Hawk is not listed among these ships. A subsequent May 2011 C&P Bulletin included information which provided "information to assist with development in Haas-related disability claims based on herbicide exposure from Navy Veterans." The Bulletin noted that VA had received information that several offshore ("blue water") vessels had operations on inland ("brown water") waterways. The Bulletin provided a list of ships that operated primarily or exclusively on Vietnam's inland waterways, ships that operated temporarily on Vietnam's inland waterways or docked to the shore, and ships that operated on Vietnam's close coastal waters for extended periods with evidence that crew members went ashore or that smaller vessels from the ship went ashore regularly with supplies or personnel. For ships identified as operating primarily or exclusively on Vietnam's inland waterways, a claimant need not leave the ship in order for VA to concede herbicide exposure. On the other hand, a claimant who served aboard a ship that docked or operated on the close coastal offshore waters must provide evidence of "visitation in Vietnam" with a lay statement attesting to the fact that he or she personally went ashore, in order for VA to concede herbicide exposure. The updated reference list still did not include the USS Kitty Hawk. The list was most recently updated by C&P on November 8, 2012. The USS Kitty Hawk is still not among the ships that operated within the inland waters of RVN. Though the Veteran contends that he went ashore to RVN while stationed aboard USS Kitty Hawk, there is no official evidence to support his contentions. In February 2004, NPRC indicated there was no record of exposure to herbicides. In April 2004, NPRC indicated they were unable to confirm that the Veteran had in-county service in RVN on various dates between January 1969 and December 1969 and between February 1971 and June 1971. In March 2006, the Naval Historical Center indicated that 1969 and 1971 Command History Reports for VF-213, do not indicate whether the squadron sent repair technicians into RVN. In August 2011, an email was sent to the Naval History Heritage and Command requesting carrier flight/recovery logs for the USS Kitty Hawk, and asked for any documentation regarding standard operating procedures (SOP) for a naval aircraft that experienced in-flight mechanical problems. In September 2011, the Naval History and Heritage Command stated that flight and passenger manifests were not identified for permanent retention. A Memo for Record regarding Naval Aviation Flight Records, as well as the 1971 Command History Report for Fighter Squadron VF-213, accompanied the response. The RO was informed that Command History Reports typically did not document carrier flight and recovery logs. The Command History Report revealed that during the 1971 calendar year the only battle damage received was in April when an F4J was slightly damaged over North Vietnam but recovered safely aboard the USS Kitty Hawk with minor damage. In September 2011, a request was also sent to NARA requesting deck logs to verify the Veteran's claim that he was exposed to herbicides while serving aboard the USS Kitty Hawk between January 1971 and June 1971. In October 2011, NARA responded and indicated that after reviewing deck logs, the USS Kitty Hawk was not in or near Vietnam during those time frames. In April 2012, a request was sent to JSRRC asking them to request/review deck logs from the USS Kitty Hawk from January 1971 to June 1971 and to verify if there were records of the Veteran being sent from the ship to Da Nang in order to repair broken down planes. In July 2012, JSSRC indicated that the 1971 Command History for USS Kitty Hawk showed that it was moored to Leyte Pier at Naval Air Station Cubi Point of the Philippines. The USS Kitty Hawk conducted special operations on Yankee Station in the Gulf of Tonkin at various times in December 1970 and between January 1971 and June 1971. While deployed, the USS Kitty Hawk made port calls in Subic Bay, Republic of the Philippines, Hong Kong, British Crown Colony, Sasebo, Japan, and Pearl Harbor, Hawaii. The USS Kitty Hawk returned to San Diego, California, in July 1971. The History did not document that the personnel assigned to the USS Kitty Hawk stepped foot in RVN. In November 2012, another request was sent to NARA requesting deck logs. In December 2012, NARA indicated that deck logs for USS Kitty Hawk did not provide information regarding individuals aboard ship or indicate names of individuals who departed ship and might have set foot in Vietnam. In January 2013, another request was sent to JSRRC with a narrower 60-day time frame (a median range of March 1, 1971, to April 30, 1971, was used). In February 2013, JSRRC responded and indicated that the history did not document that an aircraft operated from or landed in RVN. The only reference in the deck logs to aircraft landing in RVN was in April 1971 when two persons, none of which were the Veteran, departed USS Kitty Hawk for Da Nag via the ship's Carrier Onboard Delivery Aircraft. The Naval History and Heritage Command, NARA, and JSRRC have all been unable to verify that the Veteran set foot in RVN as he claims. The service personnel records also fail to confirm that he went ashore RVN or flew into RVN. The Veteran's DD Form 214 indicates that among the Republic of Vietnam Campaign Medal and Republic of Vietnam Armed Forces Meritorious Unit Citation, he received the Vietnam Service Medal; however, the Veteran's receipt of the Vietnam Service Medal does not constitute conclusive evidence of service in Vietnam for presumptive herbicide exposure purposes. See Exec. Order No. 11231 (July 8, 1965) (establishing award of the Vietnam Service Medal "to members of the armed forces who serve[d] in Vietnam or contiguous waters or air space").] A June 2007 buddy statement from JDR indicated he knew the Veteran for over 45 years and that the Veteran told him the story about how the mail plane had to make an emergency landing in Da Nang airstrip due to a generator problem. He further indicated that the Veteran told him that he and his crew had to fly into Da Nang with a new generator on the mail run vessel. JDR did not indicate that he had personal knowledge or actually witnessed the Veteran setting foot in RVN. In August 2011, the Veteran indicated that his service buddy passed away two years prior and he was unable to obtain a statement from him. A January 2012 buddy statement from CH indicated he served with the Veteran aboard USS Kitty Hawk and that the ship embarked for rest and recuperation at ports in Hong Kong, Hawaii, Philippines, and Japan. No mention was made of any visitation to RVN. Based on the above determinations, the Board finds that the preponderance of the evidence is against a finding that the Veteran was exposed to Agent Orange or other such herbicide agents at anytime during his active duty service. As exposure to Agent Orange or other herbicide agent(s) during active service has not been established, the presumptions as to service connection for diabetes mellitus and CAD cannot be invoked. See 38 C.F.R. § 3.307(a)(6)(ii) . The Board notes that hypertension, diabetic retinopathy, and trigger finger of the right thumb are not diseases subject to such presumptive service connection. Id. Notwithstanding the aforementioned provisions relating to presumptive service connection, a claimant is not precluded from establishing service connection with proof of direct causation. Combee, 34 F.3d at 1042 . The Board will now consider the issue of direct service connection, including on a one-year presumptive basis for diabetes mellitus, hypertension, and CAD under 38 C.F.R. § 3.309(a) . The Board will also consider the issue of secondary service connection for hypertension, CAD, diabetic retinopathy, and trigger finger of the right thumb. 38 C.F.R. § 3.310. Diabetes Mellitus The Veteran has alleged diabetes mellitus as a result of his active duty service. Diabetes mellitus is a "chronic disease" under 38 C.F.R. § 3.309(a). Thus, consideration under 38 C.F.R. § 3.303(b) is warranted. Where a combination of manifestations sufficient to identify a 'chronic disease' in service, and establish chronicity at the time are present, any later manifestation of the same 'chronic disease' is subject to service connection unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. The Veteran's service treatment records are negative for complaints, treatment, or diagnoses of diabetes mellitus, to include reports of medical examination dated in August 1967, November 1971 (separation examination), and August 1977. Notably, the urine tests for sugar were negative upon each of the examinations listed above, including the separation physical. Post-service, it appears the Veteran was diagnosed with diabetes mellitus in approximately 1985. Notably, the February 2005 VA examiner indicated that diabetes mellitus was diagnosed 20 years prior to examination. In June 2007, the Veteran indicates he was diagnosed with diabetes mellitus in 1996. Affording the Veteran all reasonable doubt, and assuming diabetes mellitus was diagnosed in 1985, this is still 14 years after his discharge from active military service and clearly outside the one-year presumptive period. 38 C.F.R. §§ 3.307, 3.309. The evidence of record reveals that there was a prolonged period without medical complaint or treatment, and the amount of time which has elapsed since military service, can be considered as evidence against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). As diabetes mellitus was not shown during service or for years thereafter, service connection can only be granted if there is some competent evidence linking the current disability to service. Here, there is no such competent evidence, even after the Veteran was examined by VA in 2005. The Veteran is competent to report such symptoms commonly associated with diabetes mellitus like increased thirst, frequent urination, blurred vision, fatigue, increased hunger, and weight loss. The Veteran is not, however, competent to report whether such symptoms are a manifestation of a 'chronic disease.' See Jandreau, supra. As outlined above, the preponderance of the evidence against a finding that the Veteran was exposed to herbicides during his active duty service. The competent medical evidence of record does not support a finding that diabetes mellitus was related to the Veteran's active duty service. The 'chronic disease' was not present to a degree capable of identifying the disease entity during service. No symptoms actually related to diabetes mellitus have been identified for continuity of symptomatology after the Veteran's discharge from service. Moreover, the Veteran has not asserted that he has had observable symptoms of diabetes mellitus which have continued since active duty. The Board concludes that service connection is not warranted under 38 C.F.R. § 3.303(b). The only evidence of record to support the Veteran's contentions is his statements and testimony. The Veteran's statements do not establish a nexus between any acquired pathology and his military service. Although lay evidence is acceptable to prove the occurrence of an injury during active duty or symptomatology over a period of time when such symptomatology is within the purview of or may be readily recognized by lay persons, lay testimony is not competent to prove a matter requiring medical expertise. With regard to diabetes mellitus, it requires specialized training for a determination as to diagnosis and causation and is not susceptible of lay opinions on etiology. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). Therefore, the Board cannot give decisive probative weight to the opinions of the Veteran about the origins of his diabetes mellitus because he is not qualified to offer such opinions. Likewise, his representative is not competent to provide a probative opinion on the question of etiology, either. Therefore, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for diabetes mellitus, and thus, the benefit-of-the-doubt doctrine does not apply. As such, the evidence is insufficient to support a grant of service connection. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Hypertension The Veteran has alleged hypertension is the result of his diabetes mellitus. As service connection has not been awarded for diabetes mellitus in the instant case, entitlement is not warranted on a secondary causation basis. 38 C.F.R. § 3.310. Thus, the Board shall considered hypertension on a direct and presumptive basis. The Board finds that hypertension is a "chronic disease" under 38 C.F.R. § 3.309(a). Thus, consideration under 38 C.F.R. § 3.303(b) is warranted. The Veteran's service treatment records are negative for complaints, treatment, or diagnoses of hypertension, to include reports of medical examination dated in August 1967, November 1971 (separation examination), and August 1977. Notably, blood pressure readings were recorded as follows 130/80 in August 1967, 134/76 at separation examination in November 1971, and 122/80 in August 1977. Post-service, it appears the Veteran was diagnosed with hypertension in approximately 1998. Notably, the Veteran testified before the Board in June 2007. He stated that hypertension was diagnosed in 1998. Private treatment records (catheterization report) shows hypertension in December 1996. The February 2005 VA examiner noted a 20 year history of hypertension; this is still 14 years after his discharge from active military service and clearly outside the one-year presumptive period. 38 C.F.R. §§ 3.307, 3.309. The evidence of record reveals that there was a prolonged period without medical complaint or treatment, and the amount of time which has elapsed since military service, can be considered as evidence against the claim. Maxson, 230 F.3d at 1333. As hypertension was not shown during service or for years thereafter, service connection can only be granted if there is some competent evidence linking the current disability to service. Here, there is no such competent evidence, even after the Veteran was examined by VA in 2005. The Veteran is competent to report such symptoms commonly associated with hypertension like headaches, fatigue, chest pain, vision problems, and difficulty breathing. The Veteran is not, however, competent to report whether such symptoms are a manifestation of a 'chronic disease.' See Jandreau, supra. As outlined above, the preponderance of the evidence against a finding that the Veteran has diabetes mellitus as result of his active duty service and thus, precludes secondary service connection for hypertension. The competent medical evidence of record does not support a finding that hypertension was related to the Veteran's active duty service. The 'chronic disease' was not present to a degree capable of identifying the disease entity during service. No symptoms actually related to hypertension have been identified for continuity of symptomatology after the Veteran's discharge from service. Moreover, the Veteran has not asserted that he has had observable symptoms of hypertension which have continued since active duty. The Board concludes that service connection is not warranted under 38 C.F.R. § 3.303(b). The only evidence of record to support the Veteran's contentions is his statements and testimony. The Veteran's statements do not establish a nexus between any acquired pathology and his military service. Although lay evidence is acceptable to prove the occurrence of an injury during active duty or symptomatology over a period of time when such symptomatology is within the purview of or may be readily recognized by lay persons, lay testimony is not competent to prove a matter requiring medical expertise. With regard to hypertension, it requires specialized training for a determination as to diagnosis and causation and is not susceptible of lay opinions on etiology. See Woehlaert, supra; Jandreau, 492 F.3d at 1377, n. 4. Therefore, the Board cannot give decisive probative weight to the opinions of the Veteran about the origins of his hypertension because he is not qualified to offer such opinions. Likewise, his representative is not competent to provide a probative opinion on the question of etiology, either. Therefore, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for hypertension, and thus, the benefit-of-the-doubt doctrine does not apply. As such, the evidence is insufficient to support a grant of service connection. Fagan, 573 F.3d at 1287; Ortiz, 274 F.3d at 1365. CAD The Veteran alleges his CAD is the result of his diabetes mellitus. As service connection has not been awarded for diabetes mellitus in the instant case, entitlement is not warranted on a secondary causation basis. 38 C.F.R. § 3.310. Thus, the Board shall considered CAD on a direct and presumptive basis. The Board finds that CAD is a "chronic disease" under 38 C.F.R. § 3.309(a). Thus, consideration under 38 C.F.R. § 3.303(b) is warranted. The Veteran's service treatment records are negative for complaints, treatment, or diagnoses of CAD, to include reports of medical examination dated in August 1967, November 1971 (separation examination), and August 1977. Post-service, it appears the Veteran was diagnosed with CAD in approximately 1996. Notably, it was diagnosed after catheterization in 1996; this is 25 years after his discharge from active military service and clearly outside the one-year presumptive period. 38 C.F.R. §§ 3.307, 3.309. The evidence of record reveals that there was a prolonged period without medical complaint or treatment, and the amount of time which has elapsed since military service, can be considered as evidence against the claim. Maxson, 230 F.3d at 1333. As CAD was not shown during service or for years thereafter, service connection can only be granted if there is some competent evidence linking the current disability to service. Here, there is no such competent evidence, even after the Veteran was examined by VA in 2005. The Veteran is competent to report such symptoms commonly associated with CAD like chest pain and shortness of breath on exertion. The Veteran is not, however, competent to report whether such symptoms are a manifestation of a 'chronic disease.' See Jandreau, supra. As outlined above, the preponderance of the evidence against a finding that the Veteran has diabetes mellitus as result of his active duty service and thus, precludes secondary service connection for CAD. The competent medical evidence of record does not support a finding that CAD was related to the Veteran's active duty service. The 'chronic disease' was not present to a degree capable of identifying the disease entity during service. No symptoms actually related to CAD have been identified for continuity of symptomatology after the Veteran's discharge from service. Moreover, the Veteran has not asserted that he has had observable symptoms of CAD which have continued since active duty. The Board concludes that service connection is not warranted under 38 C.F.R. § 3.303(b). The only evidence of record to support the Veteran's contentions is his statements and testimony. The Veteran's statements do not establish a nexus between any acquired pathology and his military service. Although lay evidence is acceptable to prove the occurrence of an injury during active duty or symptomatology over a period of time when such symptomatology is within the purview of or may be readily recognized by lay persons, lay testimony is not competent to prove a matter requiring medical expertise. With regard to CAD, it requires specialized training for a determination as to diagnosis and causation and is not susceptible of lay opinions on etiology. See Woehlaert, supra; Jandreau, 492 F.3d at 1377, n. 4. Therefore, the Board cannot give decisive probative weight to the opinions of the Veteran about the origins of his CAD because he is not qualified to offer such opinions. Likewise, his representative is not competent to provide a probative opinion on the question of etiology, either. Therefore, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for CAD, and thus, the benefit-of-the-doubt doctrine does not apply. As such, the evidence is insufficient to support a grant of service connection. Fagan, 573 F.3d at 1287; Ortiz, 274 F.3d at 1365. Trigger Finger Repair Right Thumb The Veteran alleges his trigger finger repair of the right thumb is the result of his diabetes mellitus. As service connection has not been awarded for diabetes mellitus in the instant case, entitlement is not warranted on a secondary causation basis. 38 C.F.R. § 3.310. Thus, the Board shall consider the claim on a direct causation basis. The Veteran's service treatment records are negative for complaints, treatment, or diagnoses of trigger finger of the right thumb, to include reports of medical examination dated in August 1967, November 1971 (separation examination), and August 1977. They do show that he complained of right finger and back side of the hand numbness in November 1969. There was some swelling. In March 1970, he struck the last three knuckles of his right hand. X-rays were negative. There were no further complaints in service and as noted above, the separation examination was negative for a right thumb disability. Post-service, the Veteran was first treated for right thumb trigger finger in 1981. He underwent a pulley release of the right thumb in April 2001. The Board is cognizant that the Veteran's service treatment records do show treatment for right finger numbness and injury to the knuckles of the right hand; however, the Veteran has not alleged continuous symptoms of the right thumb since service. As noted above, he claims the condition is secondary to his diabetes mellitus. Trigger finger of the right thumb is not a "chronic disease" under 38 C.F.R. § 3.309(a). Thus, consideration under 38 C.F.R. § 3.303(b) is not warranted. Walker, supra. Service connection may also be granted when the evidence establishes a nexus between active duty service and current complaints. However, the competent evidence does not establish that he has a current right thumb trigger finger disability related to service. Trigger finger of the right thumb was first shown in 1981, 10 years after the Veteran's discharge from service. This is a prolonged period without medical complaint or treatment, and the amount of time which has elapsed since military service, can be considered as evidence against the claim. Maxson, 230 F.3d at 1333. The Veteran is competent to report such symptoms commonly associated with his trigger finger like pain and locking of the thumb. The Veteran is not, however, competent to establish a nexus between any acquired pathology and his military service. See Woehlaert, supra; Jandreau, 492 F.3d at 1377, n. 4. The competent medical evidence of record does not support a finding that trigger finger repair of the right thumb was related to the Veteran's active duty service, to include the 2005 VA examination findings. Moreover, the Veteran has not asserted continuous symptoms of trigger finger of the right thumb since active duty. Therefore, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for trigger finger repair of the right thumb, and thus, the benefit-of-the-doubt doctrine does not apply. As such, the evidence is insufficient to support a grant of service connection. Fagan, 573 F.3d at 1287; Ortiz, 274 F.3d at 1365. Diabetic Retinopathy The Veteran alleges his diabetic retinopathy is the result of his diabetes mellitus. As service connection has not been awarded for diabetes mellitus in the instant case, entitlement is not warranted on a secondary causation basis. 38 C.F.R. § 3.310. Thus, the Board shall consider the claim on a direct causation basis. The Veteran's service treatment records are negative for complaints, treatment, or diagnoses of diabetic retinopathy, to include reports of medical examination dated in August 1967, November 1971 (separation examination), and August 1977. Notably, the Veteran's visual acuity was 20/20 bilaterally in 1967 and 1977. The November 1971 separation examination showed visual acuity of 20/15 in the right eye and 20/20 in the left. Post-service, the first objective evidence of record of diabetic retinopathy is dated in 1998. The Veteran has not alleged continuous symptoms of retinopathy since service. As noted above, he claims the condition is secondary to his diabetes mellitus. Diabetic retinopathy is not a "chronic disease" under 38 C.F.R. § 3.309(a). Thus, consideration under 38 C.F.R. § 3.303(b) is not warranted. Walker, supra. Service connection may also be granted when the evidence establishes a nexus between active duty service and current complaints. However, the competent evidence does not establish that he has a current diabetic retinopathy disability related to service. Diabetic retinopathy was first shown in 1998, some 27 years after the Veteran's discharge from service. This is a prolonged period without medical complaint or treatment, and the amount of time which has elapsed since military service, can be considered as evidence against the claim. Maxson, 230 F.3d at 1333. The Veteran is competent to report such symptoms commonly associated with his retinopathy like floaters, blurred vision, or vision loss. The Veteran is not, however, competent to establish a nexus between any acquired pathology and his military service. See Woehlaert, supra; Jandreau, 492 F.3d at 1377, n. 4. The competent medical evidence of record does not support a finding that diabetic retinopathy was related to the Veteran's active duty service, to include the 2005 VA examination findings. Moreover, the Veteran has not asserted continuous symptoms of diabetic retinopathy since active duty. Therefore, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for diabetic retinopathy, and thus, the benefit-of-the-doubt doctrine does not apply. As such, the evidence is insufficient to support a grant of service connection. Fagan, 573 F.3d at 1287; Ortiz, 274 F.3d at 1365. ORDER Entitlement to service connection for diabetes mellitus, to include as a result of exposure to herbicides, is denied. Entitlement to service connection for CAD, to include as a result of exposure to herbicides and/or secondary to diabetes mellitus, is denied. Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus, is denied. Entitlement to service connection for diabetic retinopathy, to include as secondary to diabetes mellitus, is denied. Entitlement to service connection for trigger finger repair of the right thumb, to include as secondary to diabetes mellitus, is denied. ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs