Citation Nr: 1315503 Decision Date: 05/10/13 Archive Date: 05/15/13 DOCKET NO. 05-09 538 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected coronary artery disease or diabetes or as due to exposure to herbicides. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Sorisio, Counsel INTRODUCTION The Veteran served on active duty from January 1968 to January 1971. This matter is before the Board of Veterans' Appeals (Board) on appeal from a June 2004 rating decision of the Columbia, South Carolina Department of Veterans Affairs (VA) Regional Office (RO). A Board hearing was held before the undersigned in March 2008. A transcript of the hearing is of record. In March 2010 and April 2011, the Board remanded the claim for further development. In June 2012, the Veteran submitted additional evidence. In June 2012 written argument, the Veteran's representative waived RO initial consideration of such evidence. In September 2012, the Board referred the case to the Veterans Health Administration (VHA) for an advisory medical opinion. As noted on the first page of this decision, the Veteran is represented by the Disabled American Veterans (DAV). However, in February 2011, in conjunction with claims that are unrelated to the appeal before the Board, the Veteran submitted to the RO a VA Form 21-22 for the South Carolina Department of Veterans Affairs (DVA). The Board concludes that this VA Form 21-22 does not change the Veteran's representation for the appeal before the Board. Although the VA Form 21-22 provides for unlimited representation by the South Carolina DVA, it was submitted to the RO more than 90 days after the appeal was certified to the Board. If a request to change representation is received more than 90 days after an appeal is certified to the Board the appellant must submit a motion for good cause for the delay in conjunction with the request. 38 C.F.R. § 20.1304(b) (2012). Here, there was no indication that the appellant wanted the South Carolina DVA to represent him in his appeal before the Board, as he did not specifically request to change his representation before the Board and did not provide good cause for delaying in any request to change his representation. Notably, the Veteran submitted his request in conjunction with different claims and to the RO rather than to the Board. Therefore, the Board concludes that DAV remains his representative for purposes of this appeal. The issues of whether new and material evidence has been received to reopen claims of service connection for bilateral hearing loss and tinnitus and entitlement to an increased rating for coronary artery disease were raised by the Veteran in a letter received in June 2012. These claims have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran's hypertension did not manifest during his military service and is not otherwise related to an event or injury in service, to include exposure to herbicides during service; hypertension did not manifest to a compensable level within one year of his discharge from service. 2. The Veteran's hypertension is not caused or aggravated by service-connected coronary artery disease or diabetes. CONCLUSION OF LAW Service connection for hypertension is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION A. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA applies to the instant claim. VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA 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/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran was advised of VA's duties to notify and assist in the development of his service connection claim. Although he did not receive complete notice prior to the initial rating decision, an April 2010 letter provided certain essential notice prior to the readjudication of his claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). This letter explained the evidence necessary to substantiate his claim based on the multiple theories alleged, the evidence VA was responsible for providing, and the evidence he was responsible for providing. March 2006 and April 2010 letters informed him of disability rating and effective date criteria. August 2010 and May 2012 Supplemental Statements of the Case (SSOCs) readjudicated the matter after the Veteran and his representative responded and further development was completed. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that a VCAA timing defect may be cured by the issuance of fully compliant notification followed by readjudication of the claim). All relevant evidence necessary for an equitable resolution of the issue on appeal has also been identified and obtained, to the extent possible. The Veteran and his representative have not identified any outstanding relevant evidence. The Veteran was provided an opportunity to set forth his contentions on his claim for service connection during the March 2008 hearing before the undersigned. The United States Court of Appeals for Veterans Claims (Court) has held that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board and that a Veterans Law Judge has a duty to explain fully the issues and to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The record reflects that at the March 2008 hearing the undersigned identified the issue of entitlement to service connection for hypertension, focused on the elements necessary to substantiate the claim, and sought to identify any further development that was required to help substantiate the claim. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. Regardless, the Board notes that any error that may have been committed at the hearing pursuant to Bryant was subsequently cured by the March 2010 and April 2011 Board remands and the September 2012 VHA opinion request, which completed further development in the Veteran's appeal. There is also substantial compliance with the Board's March 2010 and April 2011 remand directives pertinent to this claim in that VCAA notice was sent via an April 2010 letter, VA treatment records were secured and associated with the claims file, a VA examination was completed in April 2010 with an addendum opinion completed in May 2011, and the appeal was readjudicated by August 2010 and May 2012 SSOCs. Stegall v. West, 11 Vet. App. 268, 271 (1998). Regarding the adequacy of the April 2010 examination and May 2011 addendum opinion, the April 2010 VA examination included all necessary testing, physical examination of the Veteran, and review of his claims file. The April 2010 examination report and May 2011 addendum together provided the findings requested by the remands. Therefore, the Board finds that the VA examination and addendum opinion are adequate for rating purposes. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (finding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Further, the October 2012 opinion from a VHA specialist is adequate for rating purposes as the specialist reviewed the Veteran's claims file and pertinent medical literature and provided a thorough response with rationale to the question asked by the Board. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (requiring substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion). Accordingly, appellate review may proceed without prejudice to the Veteran with respect to his claim. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). B. Legal Criteria, Factual Background, and Analysis The Veteran seeks service connection for hypertension based on multiple theories of entitlement. Specifically, he has alleged that his hypertension is secondary to his service-connected diabetes or coronary artery disease or that it is related to his exposure to herbicides in service. The Board will address these theories of entitlement in turn. Service Connection on a Direct or Presumptive Basis Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. A disorder may be service connected if the evidence of record shows that the Veteran currently has a disorder that was chronic in service or, for certain chronic diseases detailed in 38 C.F.R. § 3.309(a), that was seen in service with continuity of symptomatology demonstrated thereafter. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the continuity of symptomatology provisions of 38 C.F.R. § 3.303(b) only apply to a chronic disease listed in § 3.309(a)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Where a Veteran served 90 days or more during a period of war or during peacetime service after December 31, 1946, and cardiovascular renal disease, including hypertension, as a chronic disease, becomes manifest to a degree of 10 percent or more within one year from the date of termination of such service, such disease shall be presumed to have been incurred in or aggravated by service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). In order to establish service connection for a claimed disorder, the following must be shown: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Pertinent law and regulations provide that a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period starting on January 9, 1962, and ending on May 7, 1975, is presumed to have been exposed during such service to an herbicide agent. 38 C.F.R. § 3.307(a)(6)(iii). Certain diseases shall be service connected if the Veteran was exposed to an herbicide agent during service, if the requirements of 38 C.F.R. § 3.307(a)(6) are met, 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 and 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). During the course of this appeal, VA added ischemic heart disease to the disabilities listed in 38 C.F.R. § 3.309(e) as being presumptively related to herbicide exposure. 75 Fed. Reg. 53,202, 53,216 (Aug. 31, 2010). The final rule is applicable to claims pending before VA on August 31, 2010 and therefore applies to the Veteran's claim. Id. at 53,202. Ischemic heart disease is defined as "acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina." 38 C.F.R. § 3.309(e). Note 3 of § 3.309(e) specifically states that hypertension is not included within the generally accepted medical definition of ischemic heart disease. Therefore, hypertension is not entitled to presumptive service connection based on exposure to herbicides. However, when a claimed disorder is not included as a presumptive disorder, direct service connection may nevertheless be established by evidence demonstrating that the disease was in fact "incurred" during service, to include as based on exposure to herbicides. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Since the Veteran has mainly contended that his hypertension is related to his exposure to herbicides during service, the Board first addresses this theory of entitlement. In the instant case, there is substantial medical evidence demonstrating that the Veteran has a current disability of hypertension. VA treatment records throughout the appeal period reflect diagnoses of and treatment for hypertension, to include January 2008 and March 2010 records and the report of an April 2010 VA examination. Therefore, the first element of service connection is met. The Veteran's DD Form 214 reflects that he served in Vietnam from November 1968 to November 1969. As this evidence shows the Veteran was in Vietnam during the pertinent time period, he is presumed to have been exposed to an herbicide agent, which establishes an in-service event. 38 U.S.C.A. §§ 1113, 1116; 38 C.F.R. §§ 3.307, 3.309. Since hypertension is not one of the enumerated diseases entitled to presumptive service connection based on exposure to herbicides, the Board must consider whether the evidence demonstrates that hypertension was actually incurred in service, to include as based on exposure to herbicides. See Combee, 34 F.3d at 1042. Textual evidence submitted by the Veteran's representative and an October 2012 opinion provided by a VHA specialist address this theory of entitlement. When evaluating the evidence of record, the Board must analyze its credibility and probative value, account for evidence which it finds to be persuasive or unpersuasive, and provide reasons for rejecting any evidence favorable to the Veteran. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Although the Board may appropriately favor the opinion of one competent medical authority over another, see Wensch v. Principi, 15 Vet. App. 362, 367 (2001), it must consider and weigh all medical evidence, keeping in mind the command of Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), that the benefit of the doubt in resolving such issues shall be given to the Veteran. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. In argument submitted in June 2012, the Veteran's representative cited to a 2003 study that he alleges found that exposure to herbicides was associated with various health impacts in Korean Vietnam era veterans, including hypertension. "Impact of Agent Orange Exposure among Korean Vietnam Veterans," Industrial Health, vol. 41, at 149-157 (2003). The Veteran's representative also stated that there is medical literature that tends to link the development of hypertension with herbicide exposure through the same mechanism that results in diabetes, which is a presumptive condition based on herbicide exposure. Specifically, he alleged that herbicide exposure causes diabetes by inducing insulin resistance and that insulin resistance is also linked to the development of hypertension. Sowers, J.R., Frohlick, E.D., "Insulin and Insulin Resistance: Impact on Blood Pressure and Cardiovascular Disease," Medical Clinics of North America, vol. 88, at 63-82 (2004). Although this textual evidence raises questions about a possible relationship between herbicide exposure and hypertension, it is too general and inconclusive on its own to establish causality between the Veteran's hypertension and his exposure to herbicides. See Sacks v. West, 11 Vet. App. 314, 316 (1998) (finding that medical treatise evidence on its own is generally too abstract to prove the nexus element of a service connection claim); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (holding that medical evidence that is speculative, general, or inconclusive cannot be used to support a claim). However, since this evidence raised questions about whether there is a relationship between herbicide exposure and hypertension, in September 2012, the Board sought an advisory medical opinion from a VHA specialist. In October 2012, a VHA general internist, Dr. D.G., provided an opinion on the matter. Dr. D.G. noted that he sees patients in a special clinic for environmental examinations, specifically including Vietnam veterans who are being seen for issues or questions regarding their exposure to herbicides in service. He reported that he reviewed in detail all records provided to him regarding the Veteran and that he completed a literature search regarding studies pertinent to whether hypertension is related to exposure to herbicides. Dr. D.G. found an abundance of medical literature on the long term effects of herbicides and noted that a study currently being conducted by VA is attempting to provide a definitive answer as to whether or not there is a causal relationship between herbicide exposure and the development of hypertension. He noted that one study entitled the "Health Status of Army Chemical Corps Vietnam Veterans Who Sprayed Defoliant in Vietnam" showed an elevated odds ratio for hypertension of 1.32 compared to an odds ratio of 1.5 for diabetes and an odds ratio of 1.52 for heart disease. He noted that this data only applied to veterans actually involved in the spraying of herbicides and that the data was not statistically significant for Vietnam veterans not directly involved in the spraying of herbicides. Dr. D.G. stated that while a wealth of data is highly suggestive that herbicide exposure is an independent risk factor for the development of hypertension and that there are plausible biologic arguments to support the conclusion, he found this literature to be inconsistent and too general and inconclusive to establish causality between herbicide exposure and hypertension. Therefore, Dr. D.G. concluded that the Veteran's hypertension was not at least as likely as not related to his presumed exposure to herbicides during Vietnam service. He indicated that if the Veteran had been involved in the actual spraying of herbicides he may have reached the opposite conclusion and that the results of the VA study that is currently underway may also alter his conclusion. The Board places substantial weight of probative value on Dr. D.G.'s opinion. This opinion reflects a full review of the evidence of record and reveals a familiarity with the Veteran's history and with the medical literature available on the medical question at issue. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (finding that an examination report is adequate where it describes the disability in sufficient detail so the Board can make a fully informed evaluation of the disability). The opinion is supported by detailed findings and rationale explaining the inconsistent and inconclusive nature of the medical literature on the topic and considering that if an alternative situation existed, i.e., the Veteran actually sprayed herbicides, the specialist may have reached a different conclusion regarding the relationship between herbicide exposure and hypertension. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that it is the reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion). Regarding the specialist's indication that his opinion may have been different if the Veteran had sprayed herbicides, the evidence of record does not reflect that the Veteran engaged in such activity during his service. The Veteran's DD Form 214 and DA Form 2-1 show that his military occupational specialties were Lineman and Combat Signaler. There is no indication the duties of these positions would have involved herbicide spraying and the Veteran has never contended that he sprayed herbicides. The specialist also noted that the results of a VA study may alter his conclusion. However, there is no indication regarding when this study will be completed or that the conclusions of the study will be favorable to the Veteran's claim. Therefore, the Board will not delay the adjudication of this case in order to await the results of this study. The Board recognizes that the medical treatise evidence submitted by the Veteran's representative is contradictory to the October 2012 opinion and that the VHA specialist did not specifically discuss this evidence. However, the Board has no reason to believe the specialist did not consider this medical literature since he indicated that he had reviewed the Veteran's records and he discussed other medical literature that had similar findings to what was submitted by the Veteran's representative. See Roberson v. Shinseki, 22 Vet. App. 358, 365 (2009) ("A medical examiner need not discuss all evidence favorable to an appellant's claim when rendering an opinion."). Hence, the Board places more weight of probative value on the October 2012 VHA opinion than on the medical treatise evidence submitted by the Veteran's representative. See Sacks, 11 Vet. App. at 316. The Board concludes that a preponderance of the evidence is against the theory of entitlement that hypertension is related to the Veteran's exposure to herbicides. The Board turns next to whether hypertension is directly related to the Veteran's service or presumptively related to his service as a chronic disease. Although the Veteran has not specifically alleged these theories of entitlement, the Board is addressing them to ensure the completeness of its analysis of the claim for service connection. Although the evidence, as described above, shows the Veteran has a current diagnosis of hypertension, there is no evidence that hypertension was incurred in service. There is no notation of hypertension or elevated blood pressure readings in the Veteran's service records and on September 1970 separation examination the Veteran's blood pressure was 116/76. See 38 C.F.R. § 4.104, Diagnostic Code 7101 (stating that the term hypertension means that diastolic blood pressure is predominantly 90 mm. or greater). Additionally, the evidence of record fails to establish that the Veteran had hypertension to a compensable level within one year of his separation from service or that he experienced continuity of symptomatology of hypertension symptoms after service. 38 C.F.R. §§ 3.303(b), 3.309(a). Specifically, on March 2004 VA examination, the examiner noted the Veteran was found to have high blood pressure in 1998. A subsequent June 2005 VA examination report indicates the Veteran was diagnosed with hypertension in 1991. Additionally, a June 2007 VA examination report notes the Veteran was diagnosed with hypertension in 1992. Therefore, although the exact date of diagnosis of hypertension is unclear, it appears the Veteran initially received a diagnosis of hypertension at some time during the years from 1991 to 1998. The Veteran has not alleged that he experienced symptoms of hypertension prior to the early 1990s. Since the Veteran was diagnosed with hypertension about twenty years after his January 1971 discharge from service, a preponderance of the evidence is against a finding that the Veteran incurred hypertension to a compensable level within a year of service discharge or that he experienced continuity of symptomatology of hypertension since service. There is no other evidence in the record indicating a relationship between the Veteran's service and hypertension. Hence, a preponderance of the evidence is against these theories of entitlement. Service Connection on a Secondary Basis The Veteran also contends that his hypertension is secondary to his service-connected coronary artery disease or diabetes mellitus. Service connection may be granted on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Under 38 C.F.R. § 3.310, secondary service connection is permitted based on aggravation; compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between a service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The regulation governing secondary service connection claims, 38 C.F.R. § 3.310, was amended, effective October 10, 2006, during the pendency of this appeal. See Claims Based on Aggravation of a Nonservice-Connected Disability, 71 Fed. Reg. 52,744 (Sept. 7, 2006). Under the revised regulation, the rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. Part 4) 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. 38 C.F.R. § 3.310(b). Generally, when the law or regulations governing a claim are changed while the claim is pending, the version most favorable to the claimant applies. See Kuzma v. Principi, 341 F.3d 1327, 1329 (Fed. Cir. 2003), see also VAOPGCPREC 7-2003 (Nov. 19, 2003). The Veteran's claim for secondary service connection was received in October 2003, prior to the regulation change. Since the version of 38 C.F.R. § 3.310 in effect at the time the Veteran filed his claim is more favorable, as it did not require the rating activity to determine the baseline level of severity of the disability, the Board will apply the version of the regulation in effect prior to the October 2006 amendments. As explained above, the evidence clearly shows the Veteran has a diagnosis of hypertension. Additionally, a June 2004 rating decision granted service connection for diabetes, while an August 2004 rating decision granted service connection for coronary artery disease. Hence, the first two elements of the claim for secondary service connection have been established. The key inquiry in this case is whether these service-connected disabilities caused or aggravated the Veteran's hypertension. Coronary Artery Disease The record contains evidence that either directly or indirectly addresses whether hypertension is caused or aggravated by service-connected coronary artery disease. The relevance and probative value of this evidence will be discussed in turn. In October 2004, the Veteran submitted an opinion from private physician W.S.A. that noted the Veteran had been diagnosed with hyperlipidemia, hypertension, and diabetes mellitus. Dr. W.S.A. opined that hyperlipidemia was either caused or aggravated by the Veteran's diabetes mellitus. This opinion does not address any relationship between coronary artery disease and hypertension; however, in an accompanying statement, the Veteran contended that based on this opinion coronary artery disease was also secondary to hyperlipidemia and that as a result, hypertension would be secondary to coronary artery disease. Therefore, he relied on this opinion to contend that hypertension should be service-connected as secondary to coronary artery disease. However, a February 2005 rating decision denied the Veteran's claim of service connection for hyperlipidemia. The Veteran did not appeal this decision and it became final. Thus, the specific contentions raised by the Veteran in October 2004 are moot as they were premised upon service connection for hyperlipidemia being granted. Other evidence of record reaches conclusions that are contrary to the theory that service-connected coronary artery disease caused or aggravated hypertension. On July 2004 VA examination, after reviewing the Veteran's claims file, the examiner opined that although the cause of the Veteran's coronary artery disease was multifactorial, it was at least as likely as not that high blood pressure and diabetes contributed to its onset. As a result of this opinion, the RO issued an August 2004 rating decision that granted service connection for coronary artery disease as secondary to service-connected diabetes mellitus. Further, on June 2007 VA examination, after reviewing the Veteran's claims file and discussing the Veteran's disabilities in detail, the examiner opined that it was at least as likely as not that coronary artery disease was caused by or related to both the Veteran's diabetes and hypertension. Rather than supporting a theory that service-connected coronary artery disease caused or aggravated hypertension, these opinions indicate the opposite conclusion-that nonservice-connected hypertension, in part, caused or aggravated service-connected coronary artery disease. Secondary service connection is not warranted for a nonservice-connected disability where that nonservice-connected disability aggravates an already service-connected disability. See Allen, 7 Vet. App. at 448-49. It is also notable that the Veteran testified at the March 2008 Board hearing that his physicians had never indicated to him that his hypertension was secondary to his service-connected coronary artery disease. Board Hearing Tr. at 5. Since there is no probative evidence indicating that hypertension was caused or aggravated by service-connected coronary artery disease, a preponderance of the evidence is against this theory of entitlement. Diabetes Mellitus Multiple medical opinions address whether service-connected diabetes mellitus caused or aggravated the Veteran's hypertension. On March 2004 VA examination, the examiner noted a history that the Veteran was diagnosed with diabetes in 1991, and that in 1998, it was discovered that the Veteran's blood pressure was high at which time he was placed on medications. The examiner provided a diagnosis of hypertension and opined that the Veteran's hypertension was not considered secondary to his diabetes. The Veteran was re-examined by the same examiner in July 2004, and the report of VA examination indicates that the examiner reviewed the claims file. The examiner again reported the history that the Veteran was diagnosed with diabetes in 1991 and was discovered to have high blood pressure in 1998. The examiner opined that the Veteran's high blood pressure "was not related" to his diabetes. The Veteran was re-examined yet again by the same examiner in June 2005, but this time the examiner noted a history that the Veteran was diagnosed with diabetes and hypertension in 1991. The examiner maintained that the Veteran had hypertension of "simultaneous onset," and therefore, it was not considered secondary to his diabetes. These opinions are inadequate for three reasons. First, in regard to the March and July 2004 opinions, the examiner provided no rationale for concluding that the Veteran's hypertension was not causally related to diabetes. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the conclusions to the supporting data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (providing that a medical opinion must support its conclusion with an analysis that the Board can consider and weigh against any contrary opinions). Second, in regard to the June 2005 opinion, at all times the Veteran has contended that the onset of his hypertension occurred after he was diagnosed with diabetes (albeit variously described as beginning in 1992 (see October 2003 VA Form 21-526) or sometime thereafter (see June 2004 notice of disagreement). The VA examiner similarly noted a history of onset of hypertension after the diabetes in his 2004 opinions. Thus, it is unclear why the VA examiner then concluded in his June 2005 opinion that the Veteran's hypertension and diabetes were of "simultaneous onset" as there is no basis in the facts provided by the Veteran or in the medical evidence of record for this position. Consequently, the Board's reliance on the June 2005 opinion in a manner unfavorable to the Veteran would be improper. See generally Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005). Third, these opinions are incomplete as they do not provide an opinion on whether the Veteran's hypertension was aggravated by his diabetes. See Allen, 7 Vet. App. at 448-49. The combination of these insufficiencies results in the Board placing little weight of probative value on these opinions. An April 2010 VA examination report addresses whether hypertension was caused by service-connected diabetes. The examination report reflects that B.S. completed the examination and Dr. R.T. reviewed and approved of the examination. The examiner examined the Veteran, completed all necessary testing, and reviewed the Veteran's claims file. The examiner stated that the Veteran was diagnosed with hypertension in the late 1990s and was diagnosed with diabetes in 1990. The examiner opined that the Veteran had essential hypertension that was not caused by or a result of his diabetes. She explained that diabetes only causes hypertension in the presence of end-stage renal disease and that the Veteran did not exhibit nor had exhibited in the past any renal failure. She further noted that review of the Veteran's medical records revealed that prior lab work had been normal for any renal failure. In May 2011, Dr. R.T. reviewed the Veteran's claims file and provided an addendum opinion to the April 2010 VA opinion. The reviewing physician noted that he reviewed the Veteran's claims file, including his previous VA examination reports and VA records. He found no indication in the evidence that diabetes had caused him any renal insufficiency. He noted that his BUN and creatinine lab test results have been and are presently normal. There was no evidence of proteinuria and no evidence of significant microalbuminuria. The reviewing physician stated that generally the primary mechanism by which diabetes can affect or worsen hypertension is through renal insufficiency. Since the physician did not find any evidence that the Veteran has had any renal insufficiency at all, he concluded that there was no indication that diabetes mellitus had aggravated the Veteran's hypertension. Thus, he concluded that service-connected diabetes mellitus has not aggravated the Veteran's hypertension. The Board places substantial weight on these probative opinions. When considered together, they address the pertinent questions at hand, that is, whether service-connected diabetes caused or aggravated hypertension. Both opinions describe the disability in sufficient detail and thoroughly explain the reasoning for the conclusions reached, thus, allowing the Board to make a fully informed evaluation of the underlying medical issues. See Stefl, 21 Vet. App. at 123. Further, the reports reflect that pertinent evidence, including medical test results and the Veteran's history, was considered in reaching the medical conclusions. See Nieves-Rodriguez, 22 Vet. App. at 304 (holding that it is the reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion). At the March 2008 hearing, the Veteran testified that several of his VA doctors had told him that it was as likely as not that his hypertension was caused by diabetes because they believed it to be from his kidney area, but the physicians were all scared of VA and would not sign statements to that effect. Board Hearing Tr. at 3. The Veteran is competent to report what his physicians have told him. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the rationale provided by his statements, that hypertension is related to diabetes because it is from the kidney area, is specifically contradicted by the medical evidence of record. Specifically, the April 2010 and May 2011 opinions clearly state findings that lab results of record do not reveal any renal insufficiency or renal failure. Thus, the Board places little probative weight on the Veteran's statements that his physicians have told him that his hypertension is related to his service-connected diabetes and finds that the April 2010 and May 2011 opinions outweigh this testimony. The Board concludes that a preponderance of the evidence is against a finding that hypertension was caused or aggravated by service-connected diabetes. In summary, the claim of service connection for hypertension is denied based on consideration of direct, presumptive, and secondary service connection theories of entitlement. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran's claim for service connection for hypertension, the benefit-of-the-doubt rule is not for application. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for hypertension is denied. ____________________________________________ Laura H. Eskenazi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs