Citation Nr: 1319799 Decision Date: 06/19/13 Archive Date: 06/27/13 DOCKET NO. 08-01 328 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for hypertension claimed as secondary to service-connected diabetes mellitus, type 2. 3. Entitlement to service connection for bilateral upper extremity peripheral neuropathy claimed as secondary to service-connected diabetes mellitus, type 2. 4. Entitlement to service connection for gastroesophageal reflux disease (GERD) claimed as secondary to service-connected diabetes mellitus, type 2. 5. Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Whitehead, Counsel INTRODUCTION The Veteran served on active duty from September 1966 to September 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision issued by the Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. During the course of this appeal, the RO issued a September 2012 rating decision which granted entitlement to service connection for depression, as secondary to service-connected diabetes mellitus type II with peripheral neuropathy of the bilateral lower extremities. Accordingly, the issue of service connection for an acquired psychiatric disorder other than PTSD is no longer on appeal. See Grantham v. Brown, 114 F.3d 1136 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection). The issue of entitlement to service connection for PTSD was previously included as part of the claim for service connection for an acquired psychiatric disorder. However, the medical evidence suggests that the claimed PTSD disorder is of a separate origin and symptomatology than the service-connected depression disability. But see Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran has not indicated that the grant of service connection for depression has fully satisfied his request for benefits or otherwise indicated that he no longer wishes to pursue a claim for PTSD. Thus, the Board has recharacterized the issue on appeal as entitlement to service connection for PTSD. The issues of service connection for peripheral neuropathy of the bilateral upper extremities and PTSD are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the evidence does not show that the Veteran's current low back disorder is related to his military service or any incident therein. 2. The preponderance of the evidence does not show that the Veteran's hypertension is related to his military service or that the disorder is caused or aggravated by a service-connected disability. 3. The preponderance of the evidence does not show that the Veteran's gastroesophageal reflux disease (GERD) is related to his military service or that the disorder is caused or aggravated by a service-connected disability, to include treatment of his service-connected disabilities. CONCLUSIONS OF LAW 1. A low back disorder was not incurred in service. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. Hypertension was not incurred in or aggravated by service, and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 3. GERD was not incurred in or aggravated by service, and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Proper notice from VA must inform the claimant of any information and 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements apply to all five elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The RO's notice letters dated in January 2006 and March 2006 advised the Veteran of the foregoing elements of the notice requirements. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The March 2006 letter also provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. See Dingess/Hartman, 19 Vet. App. at 486. Accordingly, with these letters, the RO effectively satisfied the remaining notice requirements with respect to the issue on appeal. Nothing more is required. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records, as well as identified VA and private medical treatment records, have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Additionally, the Veteran submitted written statements as to his contentions. Neither the Veteran nor his representative has identified any other outstanding evidence and none is found by the Board. Evidence of record reflects that the Veteran currently receives Social Security benefits. However, the Veteran has not alleged, nor does the record reflect, that the award of these benefits resulted from the claimed low back, hypertension, or GERD disorders. As there is no indication that the Social Security Administration has evidence relevant to the issues on appeal, there is no additional duty to undertake further development in an attempt to obtain these records and associate them with the Veteran's claims file. Golz v. Shinseki, 590 F.3d 1317, 1321-23 (2010). Additionally, VA provided the Veteran with VA examinations and medical opinions were obtained to determine the etiology of the claimed low back, hypertension, and GERD disorders. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159; see McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). In compliance with the Board's September 2011 remand, medical examinations and opinions were provided in October 2011 as to the claims on appeal. The Board finds that the October 2011 VA examinations are adequate, as they were based upon a complete review of the Veteran's claims file, and the VA examiner provided written rationale for the conclusions reached. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board finds that there has been substantial compliance with September 2011 remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. Legal Criteria for Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. Generally for service connection, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004) citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); Caluza v. Brown, 7 Vet. App. 498, 505 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table). Service connection may be established under the provisions of 38 C.F.R. § 3.303(b) when the evidence, regardless of its date, shows that a Veteran had a chronic condition in service or during the applicable presumptive period. In addition, certain chronic diseases, including arthritis, may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. A Veteran is presumed to have been sound upon entry into the military, except as to conditions noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. By "clear and unmistakable evidence" is meant that which cannot be misunderstood or misinterpreted; it is that which is undebatable. Vanerson v. West, 12 Vet. App. 254 (1999). In determining whether there is clear and unmistakable evidence to rebut the presumption of soundness, all evidence of record must be considered, including post service medical opinions. Harris v. West, 203 F.3d 1347 (Fed. Cir. 2000); Adams v. West, 13 Vet. App. 453 (2000). VA General Counsel has issued a precedent opinion holding that to rebut the presumption of sound condition under 38 U.S.C.A. § 1111 VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-03 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. Id. In its decisions, the Board is bound to follow the precedent opinions of the General Counsel. 38 U.S.C.A. § 7104(c). Under section 3.310(a) of VA regulations, service connection may be established 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(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Finally, in a claim for service connection, the ultimate credibility or weight to be accorded evidence must be determined as a question of fact. The Board determines whether (1) the weight of the evidence supports the claim, or (2) the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim; the appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. Ap. 49 (1990). Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Low Back Disorder The Veteran asserts that his currently diagnosed low back disorder is related to his military service. Specifically, he claims that he injured his low back during his service in Vietnam when he fell down a pit approximately twelve feet deep. He reportedly spent two days recovering from the incident, but has continued to experience low back symptomatology since that time. Service treatment records have been reviewed and are negative for reports or diagnoses related to a low back disorder. On an August 1968 separation report of medical history, the Veteran reported having or having had back trouble, but he did not provide any specific details regarding this report. The associated August 1968 separation report of medical examination shows that the clinical examination of the spine was normal. Private treatment records dated following the Veteran's separation show intermittent reports of back symptomatology. A July 1980 treatment record documents his report of severe left flank and back pain, which was associated with a diagnosis of left ureteral calculus with renal colic and pain. A November 1999 consultation report includes the Veteran's reported history of chronic disc herniation in his back, a condition which the Veteran stated only bothered him occasionally. A March 2001 magnetic resonance imaging study (MRI) of the lumbar spine revealed central disc herniation at L5-S1, broad-based disc bulge at L3-4, and mid disc dehydration at other levels, without central or foraminal stenosis. A December 2003 physical examination revealed diffuse arthralgias in the back. An August 2003 private treatment record shows a diagnosis of lumbar disc displacement. A July 2005 MRI revealed degenerative disc disease of the lumbar spine. During a June 2006 VA examination, the Veteran reported that he sustained a back injury during service when he fell eighteen feet down into a pit. He identified this incident as the onset of his back condition. The physical examination of the Veteran's spine revealed some flattening of the lordotic curve. Following the assessment, the examiner highlighted that there was no documentation of a back condition in the claims file or on the Veteran's discharge physical. The examiner indicated that an x-ray of the Veteran's lumbosacral spine was pending. Given the physical examination findings and claims file review, the examiner was unable to state that the Veteran's back condition was due to or caused by his military service. The Veteran underwent an additional VA examination in October 2011 to assess the etiology of his claimed low back condition. The examiner noted the Veteran's report of injuring his low back due to a fall into a fourteen foot pit during his service in Vietnam. The Veteran denied seeking treatment for his condition, but he stated that he stayed in his tent for a couple of days, after which his low back pain somewhat improved. The examiner noted that there was no documentation in the service treatment records of evaluation or treatment for a lumbar spine condition, nor was there documentation within a year following service of ongoing lower back symptoms. The clinical examination revealed a diagnosis of lumbar degenerative disc disease. Based on the examination results and following a review of the claims file, the examiner opined that the Veteran's current condition was not the result or an aggravation of events that occurred during his military service. The examiner highlighted that the service treatment records did not show degenerative disease while in the military. According to the examiner, the Veteran more likely as not sustained a lumbar strain/contusion due to his in-service injury. The examiner noted that this type of condition is typically self-limiting and does not result in a chronic ongoing condition such as disc disease. The examiner concluded that the Veteran's current condition was more likely as not a result of his occupational duties as a carpenter/construction worker and age-related changes. In support of his claim, the Veteran submitted a February 2012 letter from his former chiropractor, J.L.T., D.C. This clinician reportedly treated the Veteran from 1996 to 2005. (According to the letter, Dr. J.L.T. retired in 2005, and the records of the Veteran's treatment by this clinician were destroyed in 2011.) Dr. J.L.T. provided over fifty treatments for the Veteran's neck, upper back, low back, and hip pains. The chiropractor recalled that x-ray images of the Veteran's thoracic spine revealed old compression fractures, which the clinician explained appeared to be from vertical compression of the spine. The Veteran relayed to Dr. J.L.T. that he fell down a pit during his service in Vietnam. Dr. J.L.T. reportedly informed the Veteran that the amount of calcification and spurring indicated that his back injury could have occurred during that time period. Dr. J.L.T. ultimately opined that the Veteran sustained a significant musculoskeletal injury when he fell into the pit during his service in Vietnam. The claims file also includes a statement received in February 2012 from J.K., who reportedly served with the Veteran during his service in Vietnam. J.K. stated that one night during this service, he and the Veteran were walking to find the available showers when the Veteran fell into a hole approximately twelve feet deep. J.K. further recalled that the Veteran stayed in his tent for two days after the incident and then returned to work despite having some difficulty. In light of the foregoing evidence, the Board finds that service connection for a low back disorder is not warranted. The Board recognizes that the medical evidence shows a current diagnosis of degenerative disc disease of the lumbar spine. Degmetich v. Brown, 104 F.3d 1328, 1333 (Fed. Cir. 1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). However, the preponderance of the evidence does not show that this disorder is related to the Veteran's military service. The Veteran essentially maintains that his current low back disorder is related to an in-service injury during which he fell into a deep pit. Although his service treatment records do not reflect this incident, they do reflect his August 1968 report of having back trouble. J.K.'s competent lay statement also supports the Veteran's claim of an in-service fall. The Board has considered the Veteran's statements regarding his in-service back injury and his report of continued low back pain since service. The Veteran's contentions regarding his in-service back injury and continuing low back pain, capable of lay observation, are competent evidence of what he actually observed and was within the realm of his personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The Board also finds the Veteran's statements as to his low back pain credible in this regard. However, the preponderance of the evidence does not show that the Veteran has a chronic low back disability that is attributable to his military service, to include his in-service back injury and symptomatology. Here, the Board highlights that although the Veteran reported having back problems at service separation, no spine abnormalities were found during the clinical examination performed in August 1968 just prior to his discharge. The Board also finds highly probative the October 2011 VA examiner's opinion. Based on clinical and diagnostic testing of the Veteran and a review of the claims file, to include consideration of the Veteran's report of a continuity of low back symptomatology, the examiner essentially opined that the Veteran's current low back disorder is not a result of his military service, to include the events therein. Instead, the October 2011 examiner attributed the Veteran's low back disorder to his post-service occupational duties and age. The October 2011 VA examiner's opinion is considered highly probative, as it is definitive, based upon a complete review of the Veteran's claims file and clinical examination of the Veteran, and is supported by a detailed rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 299-301 (2008) ("The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches.") quoting Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also, Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Accordingly, the opinion is found to carry significant probative weight. See Prejean v. West, 13 Vet. Ap. 444, 448-49 (2000). In reaching the above decision, the Board has also considered Dr. J.L.T.'s February 2012 opinion that the calcification and spurring shown in the Veteran's spine could have occurred during service. Dr. J.L.T. also opined that the Veteran sustained significant musculoskeletal injury due to his in-service fall. While the conclusions of a physician are medical conclusions that the Board cannot ignore or disregard, see Willis v. Derwinski, 1 Vet. App. 66 (1991), the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. See Wilson v. Derwinski, 2 Vet. App 614 (1992). Here, the Board highlights that Dr. J.L.T. did not expressly provide a detailed rationale to support his opinion relating the Veteran's musculoskeletal disorder to his claimed in-service fall. See Nieves-Rodriguez v. Peake, 22 Vet. Ap. 295, 304 (2008) (explaining that "most of the value of a medical opinion comes from its reasoning" and that "[n]either a VA medical examination report nor a private medical opinion is entitled to any weight in a service-connection or rating context if it contains only data and conclusions"). Moreover, Dr. J.L.T.'s first comment is couched in terms of "could have" and is therefore speculative. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (holding that medical opinions are speculative and of little or no probative value when a physician makes equivocal findings such as "the veteran's death may or may not have been averted"). Moreover, it is also unsupported by any rationale. See Nieves-Rodriguez, 22 Vet. App. at 304. As such, Dr. J.L.T.'s opinion is of little probative value. Under these circumstances, the Board concludes that the October 2011 VA examiner's opinion constitutes the most probative (persuasive) evidence on the question of whether the Veteran's current low back disorder is related to his military service, to include the claimed in-service injury. It is the responsibility of the Board to review all the evidence of record and reach a conclusion by applying the standard of review set forth above. The Federal Circuit has recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). "[I]t is not error for the BVA to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reason or bases. It is the responsibility of the BVA, . . . to assess the credibility and weight to be given to evidence." Owens v. Brown, 7 Vet. App. 429, 433 (1994). Also weighing against the claim, the medical evidence does not show a diagnosis of a low back disorder for many years following the Veteran's separation from active duty. The medical evidence does not show a definitive low back diagnosis until decades following the Veteran's separation; coeternal disc herniation and a bulging disc of the lumbar spine was diagnosed in 2001 and degenerative disc disease was first diagnosed in 2005. The Board notes that evidence of a prolonged period without medical complaint and the amount of time that elapsed since active duty service can be considered as evidence against a claim. Maxson v. Gober, 230 F.3d 1330, 1333 (2000). Thus, while the Veteran has reported having low back symptomatology since his military service, and the lay statements include reports of ongoing low back problems, his statements are outweighed by the other evidence of record. Essentially, the preponderance of the evidence does not show a continuity of symptomatology to suggest that his current lumbar spine degenerative disc disease is related to his period of active service. Thus, service connection is not warranted based on the theory of a continuity of symptomatology or under a theory of presumptive service connection for a chronic disability. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309; Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013) (holding that service connection based on a theory of continuity of symptomatology is limited to only the specific chronic diseases listed under 38 C.F.R. § 3.309(a)). In reaching the above determination, the Board again notes that consideration has been given to the Veteran's statements that his current low back disorder is related to his military service. Lay statements may be competent to support a claim for service connection where the events or the presence of disability or symptoms of a disability are subject to lay observation. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a), 3.159(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1313 (Fed. Cir. 2006). However, degenerative disc disease is not a disability subject to lay opinions as to diagnosis and etiology. While some symptoms of the disorder, such as pain, may be reported by a layperson, the diagnosis and etiology of the disorder require medical training. The Veteran does not have the medical expertise to diagnose himself with the claimed disorder, nor does he have the medical expertise to provide an opinion regarding its etiology. Thus, the Veteran's lay assertions as to the etiology of current low back diagnosis are not competent or sufficient in this instance. Jandreau, 492 F.3d 1372. Essentially, as the weight of the competent and probative evidence is against a finding that the Veteran's claimed low back is related to service, the preponderance of the evidence is against the service connection claim. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The benefit sought on appeal is therefore denied. Hypertension The Veteran claims that service connection is warranted for his currently diagnosed hypertension disorder. He asserts that his hypertension is caused or aggravated by his service-connected diabetes mellitus disability. The Veteran has not specifically claimed that his hypertension began during his military service. Service treatment records have been reviewed and are negative for a diagnosis of hypertension. The Veteran was not diagnosed with hypertension at the time of his May 1966 enlistment report of medical examination; his blood pressure reading at that time was 132/90. On the associated August 1968 separation report of medical history, the Veteran reported a history of high or low blood pressure. However, the August 1968 separation examination report is negative for a hypertension diagnosis and shows a blood pressure reading of 148/85. Post-separation private and VA medical records show the first evidence of a hypertension diagnosis in 1988. An October 2001 private treatment record indicates that the Veteran was diagnosed with hypertension as a teenager; however, this diagnosis is not reflected in the available evidence of record. The Veteran underwent a VA examination in June 2006, which continued his diagnosis of hypertension. The examiner reviewed the claims file and noted that the Veteran's hypertension appeared to have been diagnosed approximately around the same time he was diagnosed with coronary artery disease, peripheral vascular disease, hypercholesterolemia, and diabetes. According to the examiner, hypertension and hypercholesterolemia appeared to have been diagnosed first. Following a clinical examination, the June 2006 examiner stated that a medical opinion relating hypertension to diabetes mellitus, type 2, would require mere speculation. In support of his claim, the Veteran submitted a February 2007 letter from his private physician, C.F., M.D., in which the physician opined that the Veteran's hypertension was caused by his type II diabetes. In October 2011, the Veteran underwent an additional VA examination with respect to his hypertension claim. The Veteran reported that a diagnosis of hypertension since the 1970s. The examiner reviewed the claims file and noted the medical records showed a diagnosis of hypertension in 1988. The clinical examination revealed a continued diagnosis of hypertension. Based on the examination results and claims file review, the examiner opined that the Veteran's hypertension was not a result of and was not aggravated by his service-connected diabetes mellitus or coronary artery disease. The examiner stated that hypertension may be related to or aggravated by diabetes in the presence of an estimated glomerular filtration rate (EGFR) less than 25 or severe diabetic nephropathy, neither of which is present in this case. The examiner further stated that coronary artery disease is not a risk factor for hypertension, but rather, hypertension is a known risk factor for contributing to coronary artery disease. The examiner also noted that the Veteran's hypertension was diagnosed many years prior to the diagnosis of diabetes or coronary artery disease. Having reviewed the evidence of record, the Board finds that the preponderance of the evidence is against the claim for service connection for hypertension, and the appeal must be denied. As an initial matter, the Board must first address whether the Veteran's hypertension existed prior to his enlistment into the military. To the extent that the Veteran's claims or the medical evidence suggests that the Veteran's hypertension existed prior to his military service, the Board finds that a hypertension diagnosis was not "noted" at the time of the Veteran's May 1966 enlistment examination or during any time during his military service. Indeed, the Veteran himself reported during the October 2011 VA examination that he was diagnosed with hypertension in the 1970s. As clear and unmistakable evidence has not been demonstrated as is necessary to rebut the presumption of soundness, the Veteran is presumed to have entered service in sound condition and free from hypertension at the time of his enlistment into active duty service. The evidence of record does not show, nor does the Veteran assert, that service connection for hypertension is warranted on a direct basis. Although the Veteran reported a history of high or low blood pressure on his August 1968 separation report of medical history, the evidence does not show that he experienced the onset of hypertension during his military service. Pursuant to VA regulations, "the term hypertension means that the diastolic blood pressure is predominately 90 mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominately 160 mm. or greater with a diastolic blood pressure of less than 90 mm." 38 C.F.R. § 4.101, Diagnostic Code 7101 Note (1). The available service treatment records do not reflect any complaints of, or treatment sought for, any problem related to high blood pressure during active duty or indicate that his blood pressure levels reached the thresholds for hypertension as defined by VA regulations. Thus, the preponderance of the evidence does not support a finding that the Veteran's hypertension began during his military service. The preponderance of the evidence also fails to show that the Veteran's hypertension is caused or aggravated by a service-connected disability, to include his diabetes mellitus and coronary artery disease. In reaching this conclusion, the Board notes that the October 2011 VA examination report provides the most probative evidence against the claim for service connection on a secondary basis. The October 2011 VA examiner thoroughly reviewed the claims file, after which the examiner essentially opined that the Veteran's hypertension was not caused or aggravated by his diabetes mellitus or coronary artery disease. As the VA examiner's opinion was based on a review of the pertinent medical history and is supported by sound medical rationale, it provides compelling evidence against the Veteran's claim that his hypertension is secondary to a service-connected disability. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (indicating "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion"); Wray v. Brown, 7 Vet. App. 488, 493 (1995) (holding that the adoption of an expert medical opinion may satisfy the Board's statutory requirement of an adequate statement of reasons and bases if the expert fairly considered the material evidence seemingly supporting the Veteran's position). In contrast, the Board finds Dr. C.F.'s February 2007 opinion to be of little probative value. While Dr. C.F. opined that the Veteran's hypertension was caused by his diabetes, this private physician failed to provide the medical basis to support his conclusion. The value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). See also Nieves-Rodriguez, 22 Vet. App; Stefl v. Nicholson, 21 Vet. App. 120,124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In light of this, the Board finds the October 2011 VA opinion to be the most probative medical evidence of record. In reaching the above determination, the Board has also considered the Veteran's own lay statements that his hypertension is somehow related to a service-connected disability, to include diabetes mellitus and coronary artery disease. The Veteran, though, is not competent to comment on issues of medical etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that lay evidence may be sufficient to establish a diagnosis of a condition, but not stating that lay evidence may be used to establish a medical etiology of a condition). See also Woehlaert v. Nicholson, 21 Vet. Ap. 456 (2007) (certain disabilities are not conditions capable of lay diagnosis). While the Board will accept the Veteran's contentions as to his symptoms, because the Veteran is not competent to testify as to the etiology of his claimed disability, the Board will not consider his testimony for the purpose of establishing the causation of his hypertension. Since the Board finds him not competent to comment on this matter, there is no need to consider his credibility. Layno v. Brown, 6 Vet. Ap. 465, 469 (1994). Accordingly, the Board finds that the preponderance of the evidence is against this claim for service connection for hypertension. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against his claim. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. GERD The Veteran claims that service connection on a secondary basis is warranted for his currently diagnosed GERD. He does not claim, nor does the evidence suggest, that GERD is related to his military service. Instead, the Veteran claims that his GERD condition is caused by his service-connected disabilities, to include as a side effect of his current medications. Private treatment records include the Veteran's October 2002 report of experiencing epigastric pain all summer. He reported taking Tums which helped his symptoms. The physical examination revealed a diagnosis of history of epigastric pain, rule out gastric hyperacidity. The Veteran was prescribed medication for his symptoms, with a note that a gastric endoscopy examination was necessary if his symptoms persisted. A February 2006 private upper gastrointestinal endoscopy report shows that the examination of the esophagus and duodenum was normal. A private upper gastrointestinal series performed in March 2006 was negative for the esophagus, stomach, and duodenum. The Veteran was afforded a VA examination with respect to his claim in June 2006. Following a clinical examination and review of the claims file, the examiner stated that there was no evidence or scientific literature to support that GERD "is in any way" related to diabetes. The examiner's opinion, however, did not address whether the Veteran's GERD may be related to the medications used for his service-connected disabilities. In August 2007, the RO obtained a VA medical opinion with respect to the Veteran's GERD claim. The examiner noted that the claims file and medical records were reviewed. The Veteran's service-connected disabilities were noted to include coronary artery bypass surgery, diabetes mellitus, type II with peripheral neuropathy of the lower extremities, peripheral vascular disease, and tinnitus. The examiner also noted the Veteran's nonservice-connected conditions. After listing the Veteran's medical regimen, the examiner commented that there was no mention in the records of any problems with medication side effects. The examiner stated that this would leave the weight of the evidence indicating that GERD was a primary condition in and of itself. Thus, the examiner concluded that GERD was less likely than not due to the medication used for the Veteran's service-connected conditions. However, the examiner's opinion did not take into account the Veteran's competent lay statements that GERD is a side effect of his medications. In October 2011, the Veteran underwent a VA examination, and he reported that he had experienced symptoms such as heartburn since the early 1970s. He reported that his symptoms were initially triggered by eating anything with tomato sauce and stress. The examiner indicated that the claims file was reviewed and noted the Veteran's reports of epigastric symptomatology documented as early as 2002. The Veteran denied that any medication that he was currently taking caused any type of gastrointestinal distress. Following the clinical examination, the examiner continued the GERD diagnosis. The examiner opined that the Veteran's current condition was not a result of side effects from treatment of his service-connected conditions. According to the examiner, GERD is due to an increase in acid production of the stomach, and this increase in stomach acid production was not caused by the Veteran's current medications. The examiner noted that the Veteran continued to take aspirin for a cardiac condition, but this did not cause any gastrointestinal problems in view of the normal findings on the Veteran's last two esophagogastroduodenoscopy examinations. The examiner also highlighted that the Veteran denied that any of his current medications were causing any reflux symptoms. Based on the foregoing, the preponderance of the evidence is against the claim for service for GERD. Again, the Board reiterates that the available evidence of record does not indicate, nor does the Veteran claim, that his GERD began during his military service or is related to his military service. Additionally, the medical evidence of record and the Veteran's competent lay statements do not indicate that this disorder was diagnosed until years after his discharge from the military. See Maxson v. Gober, 30 F.3d 1330, 1333 (Fed. Cir. 2000). Thus, service connection on a direct basis is denied and need not be discussed further. The Veteran's primary theory in support of this claim is that his GERD is caused or aggravated by his service-connected disabilities, to include the medications used to treat his conditions. Unfortunately, the Veteran's claim also fails under a secondary theory of entitlement. In reaching this conclusion, the Board notes that the October 2011 VA examiner's opinion provides the most probative evidence against this theory of entitlement. The October 2011 VA examiner thoroughly reviewed the claims file, after which he essentially opined that the Veteran's GERD was not caused or aggravated by his service-connected disabilities or any of his current medications. Indeed, the October 2011 VA examiner highlighted that the Veteran's current medications did not cause any gastrointestinal problems as reflected by diagnostic test results. The examiner also highlighted that the Veteran himself denied having any gastrointestinal problems due to his medications. Since the October 2011 examiner's opinion is based on a review of the pertinent medical history and is supported by sound medical rationale, it provides compelling evidence against the Veteran's claim that his GERD is secondary to any of his service-connected disabilities or the treatment thereof. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (indicating "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion"). The Veteran has not provided any competent medical evidence to rebut the opinion against his claim or otherwise diminish its probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). In addition to the medical evidence, the Board has also considered the Veteran's statements that his GERD is related to the medications prescribed to treat his service-connected disabilities. A veteran's lay statements may be competent to support a claim for service connection where the events or the presence of disability or symptoms of a disability are subject to lay observation. 38 U.S.C.A. § 1154(a); 38 C.F.R. §§ 3.303(a), 3.159(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). However, the Veteran's claim is for a disability that is not subject to lay opinions concerning etiology. While some symptoms of the disorder, such as heartburn, may be reported by a layperson, the diagnosis and etiology of the claimed disorder requires medical training. The Veteran simply does not have the medical expertise to provide an opinion regarding the etiology of this disorder. Thus, the Veteran's lay assertions as to the etiology of the claimed disorder are not competent, credible, or sufficient in this instance. Jandreau, 492 F.3d 1372. In summary, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for GERD. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claims. See Gilbert, 1 Vet. App. at 53. ORDER Service connection for a low back disorder is denied. Service connection for hypertension is denied. Service connection for GERD is denied. REMAND Unfortunately, additional development is needed with respect to the Veteran's remaining claims. As for the peripheral neuropathy claim, the Veteran most recently underwent a VA examination in October 2011, which revealed mildly decreased sensory testing to monofilament for the upper extremities. The October 2011 examiner stated, however that this testing was inconsistent; the examiner concluded that there was no objective evidence of peripheral neuropathy of the upper extremities and that the Veteran had not been diagnosed with this condition. However, given that the test results were inconsistent, it is unclear whether the October 2011 examination reflects an accurate assessment of the Veteran's current condition. Moreover, the October 2011 examiner's opinion does not take into account a previous diagnosis of bilateral peripheral neuropathy of the hands provided in February 2006. As the nature and etiology of the claimed peripheral neuropathy disorder remains unclear from the medical evidence, the Veteran must be afforded an additional examination with respect to his claim. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that if VA provides a Veteran with an examination in a service connection claim, the examination must be adequate). Additional development is also warranted for the PTSD claim. Although service connection has been granted for depression, the medical evidence of record reflects a diagnosis of PTSD that is separate and distinct from the service-connected depression disability. The Veteran underwent a VA mental disorders examination in October 2011, which primarily addressed his depression disability. According to a review of the treatment notes, the October 2011 examiner stated that the Veteran had a listed diagnosis of PTSD and ongoing symptomatology of the disorder, which likely serves to worsen his depressive symptoms rather than the other way around. The examiner concluded that the Veteran's PTSD symptoms did not appear to cause his depression, per se. However, the examiner indicated that the PTSD diagnosis was not formally addressed during the examination. The Board observes in this regard that, if a Veteran has separate and distinct manifestations relating to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). The evaluation, however, of the same manifestation under different diagnostic codes is to be avoided. 38 C.F.R. § 4.14. While service connection is already in effect for a depression related to his service-connected diabetes and lower extremities peripheral neuropathy disabilities, it is unclear whether service connection may also be warranted for PTSD based on stressful events the Veteran claims to have occurred during his service in Vietnam. (The Board notes that the Veteran's service in Vietnam has been conceded.) Thus, on remand, the agency of original jurisdiction must provide the Veteran with an examination to determine whether service connection is warranted for PTSD. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Colvin v. Derwinski, 1 Vet. App. 171 (1991) (When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering a medical examination.). In the event that service connection for PTSD is granted, the disability should be evaluated based on its unique symptomatology which can be separated from the service-connected depression. Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding VA records and private medical records identified by the Veteran as relevant to the claims being remanded. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure the same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claims; and (d) that the Veteran is ultimately responsible for providing the evidence. The Veteran and his representative must be given an opportunity to respond. 2. Thereafter, the Veteran must be afforded a VA examination conducted by an appropriate examiner to determine whether he currently has a neurological disorder affecting his bilateral upper extremities. The examiner must review the claims file and all records on Virtual VA, as well as this remand, and must specify in the report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records, if any, that are reviewed. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies, including nerve conduction studies, must be accomplished and reported in detail. The examiner is asked to identify all neurological disorders of the bilateral upper extremities found to be present. Following the examination of the Veteran, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must provide an opinion as to whether any previously diagnosed peripheral neuropathy or any currently diagnosed peripheral neuropathy is due to or aggravated by a service-connected disorder. The examiner must also opine whether any previously diagnosed peripheral neuropathy or any currently diagnosed peripheral neuropathy is due to the Veteran's military service. All opinions expressed must include a complete rationale. If the examiner cannot provide the requested opinions without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would be speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report must be typed. 3. After obtaining all outstanding records, schedule the Veteran for an appropriate examination to determine the current nature and etiology of his claimed PTSD. The claims file and a copy of this remand must be made available to the examiner in conjunction with the examination. All appropriate tests and studies should be accomplished. Based on a review of the Veteran's claims file and the results of his clinical examination, the examiner must determine whether PTSD, if diagnosed, is manifested by any unique psychiatric symptomatology that can be separated from the service-connected depression disability (if possible). If a diagnosis of PTSD is deemed appropriate, the examiner must explain how the diagnostic criteria of the Diagnostic and Statistical Manual for Mental Disorders are met, to include identification of the specific stressor(s) underlying the diagnosis, and comment upon the link between the current symptomatology and one or more of the stressors. If PTSD is found to be related to an in-service stressor, the examiner must specifically state whether that stressor was related to the Veteran's fear of hostile military or terrorist activity. If a diagnosis of PTSD is not deemed appropriate, the examiner must specifically explain how the diagnostic criteria for PTSD of the Diagnostic and Statistical Manual for Mental Disorders have not been met. In rendering the diagnosis, the VA examiner must take into account and attempt to reconcile other medical psychiatric diagnoses of record, to include the PTSD diagnosis reflected in the VA treatment records. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would be speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report must be typed. 4. The RO must notify the Veteran that it is his responsibility to report for any examination scheduled, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained and associated with the Veteran's claims file that shows that notice scheduling the examination was sent to the last known address. Documentation must be also be obtained and associated with the Veteran's claims file demonstrating any notice that was sent was returned as undeliverable. 5. The examination reports must be reviewed to ensure that they are in complete compliance with the directives of this remand. If any report is deficient in any manner, implement corrective procedures at once. 6. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, readjudicate the claims. If any benefit sought on appeal remains denied, the Veteran and his representative must be furnished a supplemental statement of the case and be given the opportunity to respond thereto. The appeal must then be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence and argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ JENNIFER HWA Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs