Citation Nr: 1316913 Decision Date: 05/23/13 Archive Date: 05/31/13 DOCKET NO. 10-06 745 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for chronic obstructive pulmonary disease. 2. Entitlement to service connection for diabetes mellitus, to include as due to exposure to Agent Orange. 3. Entitlement to service connection for cataracts, to include as secondary to service-connected disability. 4. Entitlement to service connection for depression, to include as secondary to service-connected disability. 5. Entitlement to service connection for hypertension, to include as secondary to service-connected disability. 6. Entitlement to service connection for impotency, to include as secondary to service-connected disability. 7. Entitlement to service connection for vascular disease, to include as due to service-connected disability. 8. Entitlement to service connection for coronary artery disease. 9. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Ronald C. Sykstus, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD James R. Siegel, Counsel INTRODUCTION The Veteran served on active duty from July 1965 to August 1966. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). By rating action dated August 2009, the RO denied the Veteran's claims for service connection for diabetes mellitus, cataracts, depression, coronary artery disease, hypertension, impotency and vascular disease. A July 2011 rating decision concluded that new and material evidence had not been received, and the claim for service connection for chronic obstructive pulmonary disease was not reopened. In addition, the RO denied the Veteran's claim for TDIU. The issue of entitlement to benefits under 38 U.S.C.A. § 1805 (West 2002) for a child born with spina bifida, and the claim for service connection for basal cell carcinoma of the face have been raised by the record, but 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. The issues of service connection for depression and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. An unappealed August 2009, rating decision denied service connection for chronic obstructive pulmonary disease. The Veteran was notified of this decision, but did not file a timely appeal. 2. The evidence added to the claims file since the August 2009 determination is essentially cumulative of the evidence previously of record and does not provide a reasonable possibility of substantiating the claim of service connection for chronic obstructive pulmonary disease. 3. The Veteran did not serve in Vietnam, to include its inland waters, or its offshore waters with duties or visitation in Vietnam, and he was not otherwise exposed to Agent Orange. 4. Diabetes mellitus was not manifested in service or in the first post-service year, and the preponderance of the evidence is against a finding that the Veteran's current diabetes mellitus is related to an event, injury, or disease in service. . 5. Service connection is not in effect for any disability. 6. Cataracts were initially documented many years after service, and the preponderance of the evidence is against a finding that the Veteran's has cataracts related to an event, injury, or disease in service.. 7. Coronary artery disease was not manifested in service or in the first post-service year, and the preponderance of the evidence is against a finding that the Veteran's current coronary artery disease is related to an event, injury, or disease in service. 8. Hypertension was not manifested in service or in the first post-service year, and the preponderance of the evidence is against a finding that the Veteran's current hypertension is related to an event, injury, or disease in service. 9. Impotency has not been documented following service. 10. Vascular disease, if present, was initially demonstrated many years after service and the preponderance of the evidence is against a finding that the Veteran's current vascular disease is related to an event, injury, or disease in service. CONCLUSIONS OF LAW 1. The RO's decision of August 2009, which denied service connection for chronic obstructive pulmonary disease, is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104(a), 20.302, 20.1103 (2012). 2. The evidence received since the August 2009 rating decision is not new and material to reopen the appellant's claim of service connection for chronic obstructive pulmonary disease. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2012). 3. Diabetes mellitus was not incurred in or aggravated by active service, nor may it be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5107 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). 4. Cataracts were not incurred in or aggravated by active service, and are not proximately due to or the result of, or chronically aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.310(a) (2012). 5. Coronary artery disease was not incurred in or aggravated by active service, nor may it be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). 6. Hypertension was not incurred in or aggravated by active service, may it be presumed to have been so incurred or aggravated, and is not proximately due to or the result of, or chronically aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.307, 3.309, 3.310(a) (2012). 7. Impotency was not incurred in or aggravated by active service, and is not proximately due to or the result of, or chronically aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.310(a) (2012). 8. Vascular disease was not incurred in or aggravated by active service, and is not proximately due to or the result of, or chronically aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.310(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also 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); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The duties to notify and assist were met in this case. Notice was provided in September 2008, January 2009 and March 2011 letters. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the appellant. Specifically, the information and evidence that have been associated with the claims file include the service treatment records, service personnel records, private and VA medical records, Social Security Administration records, and the Veteran's testimony at a hearing before the undersigned. The Board acknowledges the Veteran has not been afforded a VA medical examination to obtain an opinion regarding the etiology of his claimed disabilities. Based on the evidence in this case, the Board finds that an examination is not necessary. As is discussed in greater detail below, there has been no demonstration that the claimed disorders occurred in service or, where applicable, manifested during a presumptive period. There is also no indication that the claimed disabilities may be associated with service, so as to warrant a VA examination. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Secretary's obligation under 38 U.S.C. § 5103A(d) to provide the Veteran with a medical examination or to obtain a medical opinion occurs when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App.79, 81 (2006). Analysis The Board has reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by 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 the claims 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). I. New and material evidence Pursuant to 38 U.S.C.A. § 7105(c), a final decision by the RO may not thereafter be reopened and allowed. The exception to this rule is found at 38 U.S.C.A. § 5108, which provides that "[i]f new and material evidence is presented or secured with respect to a claim, which has been disallowed, the [VA] shall reopen the claim and review the former disposition of the claim." Therefore, once an RO decision becomes final under section 7105(c), absent the submission of new and material evidence, the claim cannot be reopened or adjudicated by VA. 38 U.S.C.A. §§ 5108, 7105(c) (West 2002); Jackson v. Principi, 265 F. 3d 1366 (Fed. Cir. 2001). A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The VA is required to review for its newness and materiality only the evidence submitted by a claimant since the last final disallowance of a claim on any basis in order to determine whether a claim should be reopened and re-adjudicated on the merits. See Evans v. Brown, 9 Vet. App. 273 (1996). The prior evidence of record is important in determining newness and materiality for the purposes of deciding whether to reopen a claim. Id. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. In determining whether evidence is new and material, the credibility of the new evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). The evidence of record at the time of the August 2009 determination included the service treatment records and post-service medical records. The service treatment records are negative for complaints or findings pertaining to any lung disorder, to include chronic obstructive pulmonary disease. A clinical evaluation of the lungs and chest on the separation examination in August 1966 was normal. Private medical records show the Veteran was seen in December 2006. The report indicates he had a medical history of chronic obstructive pulmonary disease. VA outpatient treatment records disclose it was stated the Veteran had a history of chronic obstructive pulmonary disease in July 2008. It was also noted he had been a heavy smoker for about 30 years. By rating action dated August 2009, the RO denied the Veteran's claim for service connection for chronic obstructive pulmonary disease on the basis that chronic obstructive pulmonary disease was not present in service or for many years thereafter, and that it was not related to service. The Veteran was notified of this decision, but did not file a timely appeal. Nor did he submit any additional evidence with respect to his COPD claim within a year following this decision. See 38 C.F.R. § 3.156(b). As such, that determination is final. 38 U.S.C.A. § 7105. Hence, the issue before the Board is whether new and material evidence has been received to reopen the previously denied claim for service connection for chronic obstructive pulmonary disease. The additional evidence includes private and VA medical records. The Veteran was admitted to a private hospital in March 1997 for complaints including chest discomfort with radiation to his back and left arm, associated with shortness of breath and diaphoresis. The diagnoses included chronic obstructive pulmonary disease. While the medical records received in conjunction with his attempt to reopen his claim confirm the Veteran has chronic obstructive pulmonary disease, this does not constitute new and material evidence. The evidence merely provides information that was of record at the time of the June 1990 determination, that is, that the Veteran had chronic obstructive pulmonary disease many years after service. The fact remains there is no competent medical evidence linking chronic obstructive pulmonary disease to service. The additional evidence fails to establish the Veteran has chronic obstructive pulmonary disease that is related to service. Thus, the element of the claim lacking substantiation in August 2009 remains lacking. The Board further notes the Veteran's belief that he has chronic obstructive pulmonary disease that is related to service. Although he is competent to state his symptoms, he is not, as a lay person, qualified to render a medical diagnosis or an opinion concerning medical causation with respect to COPD. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, namely, the etiology of COPD, the issue of causation of such condition is a medical determination outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The etiology of COPD involves a complex medical question addressing internal respiratory processes. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Board emphasizes that the initial indication following service of any lung problem was in 1997, when chronic obstructive pulmonary disease was diagnosed. Thus, the additional evidence does not raise a reasonable possibility that the Veteran's chronic obstructive pulmonary disease is related to service, when considered in conjunction with the record as a whole. The Board concludes, therefore, that the evidence is not new and material, and the claim for service connection for chronic obstructive pulmonary disease is not reopened. II. Service connection 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, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may 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). Certain specific conditions are considered chronic diseases under VA law. These include the following: Anemia, primary; Arteriosclerosis; Arthritis; Atrophy, progressive muscular; Brain hemorrhage; Brain thrombosis; Bronchiectasis; Calculi of the kidney, bladder, or gallbladder; Cardiovascular-renal disease, including hypertension (This term applies to combination involvement of the type of arteriosclerosis, nephritis, and organic heart disease, and since hypertension is an early symptom long preceding the development of those diseases in their more obvious forms, a disabling hypertension within the 1-year period will be given the same benefit of service connection as any of the chronic diseases listed); Cirrhosis of the liver; Coccidioidomycosis; Diabetes mellitus; Encephalitis lethargica residuals; Endocarditis (This term covers all forms of valvular heart disease); Endocrinopathies; Epilepsies; Hansen's disease; Hodgkin's disease; Leukemia; Lupus erythematosus, systemic; Myasthenia gravis; Myelitis; Myocarditis; Nephritis; Other organic diseases of the nervous system; Osteitis deformans (Paget's disease); Osteomalacia; Palsy, bulbar; Paralysis agitans; Psychoses; Purpura idiopathic, hemorrhagic; Raynaud's disease; Sarcoidosis; Scleroderma; Sclerosis, amyotrophic lateral; Sclerosis, multiple; Syringomyelia; Thromboangiitis obliterans (Buerger's disease); Tuberculosis, active; Tumors, malignant, or of the brain or spinal cord or peripheral nerves; Ulcers, peptic (gastric or duodenal)(A proper diagnosis of gastric or duodenal ulcer (peptic ulcer) is to be considered established if it represents a medically sound interpretation of sufficient clinical findings warranting such diagnosis and provides an adequate basis for a differential diagnosis from other conditions with like symptomatology; in short, where the preponderance of evidence indicates gastric or duodenal ulcer (peptic ulcer)). Whenever possible, of course, laboratory findings should be used in corroboration of the clinical data. 38 C.F.R. § 3.309(a). Where one of the above chronic diseases is shown to be chronic 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 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, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Where a veteran served 90 days or more during a period of war, and diabetes mellitus, coronary artery disease or hypertension becomes manifest to a degree of 10 percent or more within one year from 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. VA regulations provide that a veteran who had active military, naval, or air service in the Republic of Vietnam during the Vietnam Era (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 C.F.R. § 3.307(a)(6)(iii). The term "herbicide agent" means a chemical in an herbicide, including Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. If a Veteran was exposed to an herbicide agent during active service, the following diseases shall be service-connected 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 C.F.R. § 3.307(d) are also satisfied: Chloracne or other acneform disease consistent with chloracne; Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes); Hodgkin's disease; chronic lymphocytic leukemia; B cell leukemia, Parkinson's disease, multiple myeloma; non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma); and ischemic heart disease, (including, but not limited to, 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). 75 Fed. Reg. 53202 (August 31, 2010), 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which a veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). The Secretary 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 72 Fed. Reg. 32,395 (2007). The United States Court of Appeals for the Federal Circuit has held, however, that a claimant is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In other words, the fact that a veteran may not meet the requirements for service connection on a presumptive basis does not in and of itself preclude the establishment of service connection, as entitlement may alternatively be established on a nonpresumptive direct-incurrence basis. The Veteran asserts service connection is warranted for diabetes mellitus. He claims he was exposed to Agent Orange when he was in Subic Bay or Guam. He argues he was on a work detail at Subic Bay for three to six weeks. He maintains that he served on the USS Worden and that the ship picked up downed pilots. He further alleges he has cataracts, hypertension, impotency and vascular disease secondary to diabetes mellitus. The thrust of the Veteran's argument is that he was exposed to Agent Orange in service. Personnel records show the Veteran served on the USS Worden from November 1965 to May 1966. VA has compiled a list of ships associated with service in Vietnam and exposure to Agent Orange. Under 38 C.F.R. § 3.307(a)(6)(iii), for veterans who served aboard ships operating on the inland waterways of Vietnam, the evidence must establish that the ship was on the inland waterways and that the Veteran was aboard at that time. The Board acknowledges the list is not complete, and that the presumption of herbicide exposure should not be denied solely because the Veteran's ship is not on the list. It is significant to point out, however, that the USS Worden is not on the list of ships that operated on the inland waterways of Vietnam. The Veteran has not provided any other corroborating evidence his ship served in the inland waterways of Vietnam. Of record is a ship's history of the USS Worden which disclosed that it departed for Subic Bay in January 1966 and, after arriving later that month, set course for the Gulf of Tonkin and operations with the 7th fleet. On February 4, 1966, the USS Worden assumed "Tomcat" duties west of Hainan Island. After an eight-day visit to Japan, the ship departed on March 1 and returned to the Gulf of Tonkin to assume plane-guard duties for Ranger (CVA-61). It was indicated that the USS Worden conducted operations in the Gulf of Tonkin until June 17. In May 2009, the National Personnel Records Center reported there were no records showing the Veteran was exposed to herbicides. Following a request for information from the RO, VA C&P Service indicated that Department of Defense documents do not show any use, testing, or storage of tactical herbicides, such as Agent Orange, at any location in the Philippines or on Guam, with the exception of a period of herbicide storage on Guam from 1951 to 1953. In August 2009, the Joint Services Records Research Center (JSRRC) stated it was unable to locate documentation that verified Agent Orange was stored or used in Subic Bay, Republic of the Philippines, or Guam during the period January 1 through December 31, 1966. The JSRRC also noted it reviewed the Department of Defense listing of herbicide test sites outside Vietnam and herbicides were not listed as being sprayed, stored, tested or transported in the Republic of the Philippines or Guam during 1966. Since the record does not establish the Veteran served in Vietnam, to include the waters offshore, there is no presumption of exposure to Agent Orange. Further, the preponderance of the evidence is against a finding that the Veteran was exposed to Agent Orange while serving in Subic Bay or Guam. As noted above, the Veteran may alternately establish service connection for diabetes mellitus by showing the condition is related to service. The service treatment records are negative for complaints or findings pertaining to diabetes mellitus. When the Veteran was seen at a private facility for unrelated complaints in March and June 1997, on both occasions it was noted he did not have diabetes mellitus. A past medical history of diabetes was noted in August 2006. Diabetes mellitus is a chronic disease listed under 38 C.F.R. § 3.309(a); therefore the presumption of service connection under 38 C.F.R. § 3.307 and the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) must be addressed. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that symptoms of diabetes mellitus were not chronic in service; symptoms of diabetes mellitus were not continuous after service; and the current diabetes mellitus is not related to service. It is significant to point out that diabetes mellitus had its onset many years after service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed.Cir.2000) ("evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the veteran's health and medical treatment during and after military service, as evidence of whether a pre-existing condition was aggravated by military service"). After service, the first reference to diabetes mellitus comes in medical records in 2006. At that time, it was noted that the Veteran had a history of diabetes mellitus. As noted above, medical records in 1997 clearly noted that the Veteran did not have diabetes mellitus. While the exact date of onset of diabetes mellitus is not established by the record, the evidence is clear that he did not have diabetes mellitus in 1997, many years after service. Therefore the preponderance of the evidence is against a finding that diabetes mellitus became manifest to a compensable degree within a year of service separation. Moreover, the 1997 clinical evidence is highly probative and persuasive evidence that there was not continuous symptomatology after service. The Board acknowledges the Veteran's assertions that he has diabetes mellitus as the result of his military service. Although he is competent to state his symptoms, he is not, as a lay person, qualified to render a medical diagnosis or an opinion concerning medical causation with respect to diabetes mellitus. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, namely, the etiology of diabetes mellitus, the issue of causation of such condition is a medical determination outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The etiology of diabetes mellitus involves a complex medical question addressing the internal endocrine system. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In the absence of any indication of diabetes for many years after service, or of medical evidence linking it to service, the Board finds that the preponderance of the evidence is against the claim. The Veteran also asserts service connection is warranted for cataracts, hypertension, impotency and vascular disease as secondary to diabetes mellitus. Since service connection has not been established for diabetes, service connection for these disabilities on a secondary basis is precluded. In addition, the Board notes that hypertension, cataracts and vascular disease were initially demonstrated many years after service, and the preponderance of the evidence does not support linking these conditions to service. With regard to service connection for hypertension on a presumptive basis, the evidence fails to show that hypertension became manifest to a compensable degree within the Veteran's first post-service year. Accordingly, service connection on a presumptive basis is denied. Hypertension is included as a chronic disease listed under 38 C.F.R. § 3.309(a); therefore the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) must be addressed. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that symptoms of hypertension were not chronic in service; symptoms of hypertension were not continuous after service; and the current hypertension is not related to service. It is significant to point out that hypertension was first noted in the medical record many years after service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed.Cir.2000) ("evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the veteran's health and medical treatment during and after military service, as evidence of whether a pre-existing condition was aggravated by military service"). Medical records in March and June 1997 clearly noted that the Veteran did not have hypertension. While the exact date of onset of hypertension is not established by the record, given the 1997 medical records, the preponderance of the evidence does not support a finding that hypertension became manifest to a compensable degree within a year of service separation. Moreover, the 1997 medical records also are against a finding that there was continuous symptomatology after service. The Board gives more probative weight to the opinions of the 1997 medical providers than to the lay statements of the Veteran, to the extent the Veteran asserts otherwise. For these reasons, the Board concludes that the preponderance of the evidence is against the claims for service connection for hypertension, cataracts or vascular disease. With respect to the claim for service connection for impotency, the Board notes there is no clinical evidence of impotency. In Brammer v. Derwinski, 3 Vet. App. 223 (1992), the United States Court of Appeals for Veterans Claims noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability. In the absence of proof of a present disability, there can be no valid claim for service connection for impotency. Finally, with respect to the claim for service connection for coronary artery disease, the Board notes that the service treatment records show no complaints or findings of heart disease. The Veteran was admitted to a private hospital in March 1997 with a several hour history of waxing and waning chest discomfort with radiation to his back and left arm, associated with shortness of breath. An electrocardiogram showed no significant abnormalities, cut cardiac enzymes were mildly abnormal, suggesting a myocardial infarction. The diagnosis was acute non-Q wave myocardial infarction. Thus, the first indication of any heart disease is nearly 30 years following the Veteran's discharge from service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed.Cir.2000) ("evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the veteran's health and medical treatment during and after military service, as evidence of whether a pre-existing condition was aggravated by military service"). With regard to service connection for coronary artery disease on a presumptive basis, the evidence fails to show that it became manifest to a compensable degree within the Veteran's first post-service year. Accordingly, service connection on a presumptive basis is denied. Coronary artery disease is included as a chronic disease listed under 38 C.F.R. § 3.309(a); therefore the provisions regarding chronicity and continuity under 38 C.F.R. § 3.303(b) must be addressed. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that symptoms of coronary artery disease were not chronic in service; symptoms of coronary artery disease were not continuous after service; and the current coronary artery disease is not related to service. The Board acknowledges the Veteran's assertions that he has coronary artery disease as a result of his military service or continuous symptoms since service. Although he is competent to state his symptoms, he is not, as a lay person, qualified to render a medical diagnosis or an opinion concerning medical causation with respect to heart disease. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, namely, the etiology of heart disease, the issue of causation of such condition is a medical determination outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The etiology of coronary artery disease involves a complex medical question addressing internal cardiovascular processes. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In the absence of any indication of cardiovascular disease for many years after service, or of medical evidence linking it to service, the Board finds that the preponderance of the evidence is against the claim. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Since new and material evidence has not been received to reopen a claim for service connection for chronic obstructive pulmonary disease, the appeal is denied. Service connection for diabetes mellitus is denied. Service connection for cataracts, hypertension, impotency and vascular disease, all to include on a secondary basis, is denied. Service connection for coronary artery disease is denied. REMAND The Veteran also asserts service connection is warranted for depression. The service treatment records disclose the Veteran was hospitalized in June 1966, with a diagnosis of acute depressive reaction. He was transferred to another hospital where it was noted he was admitted after making a suicidal gesture by slashing his left wrist. The Veteran stated he had no idea what the Navy was going to be like when he enlisted, and discovered very shortly that he does not like it and wanted out. He reported he kept getting more depressed at having to take orders, obey regulations and follow the usual Navy routine. A mental status evaluation disclosed his mood was depressed. The diagnosis was emotionally immature personality. It was recommended that the Veteran be discharged on grounds of unsuitability. VA medical records disclose that a history of mental illness was noted in July 2008. There is no other indication of any psychiatric problems following service. In view of the in-service findings, and the current record, a VA examination is needed to adequately address the claim for service connection for depression. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). In light of the development regarding the claim for service connection for depression, the issue of TDIU is deferred. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he furnish the names, addresses, and dates of treatment of all medical providers, VA and non-VA, from whom he has received treatment for a psychiatric disability since his discharge from service. After securing the necessary authorizations for release of this information, the RO should seek to obtain copies of all treatment records referred to by the Veteran, not already of record. 2. Schedule a VA psychiatric examination to determine whether the Veteran has an acquired psychiatric disability and, if so, its etiology. If an acquired psychiatric disability is present, the examiner should furnish an opinion concerning whether it is at least as likely as not (50 percent probability or higher) that the Veteran's current psychiatric disability had its onset in service. The rationale for any opinion should be set forth. The claims folder should be made available to the examiner in conjunction with the examination. 3. Following completion of the above, the RO should review the evidence and determine whether the Veteran's claims may be granted. If not, he and his representative should be furnished an appropriate supplemental statement of the case and be provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ M. C. GRAHAM Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs