Citation Nr: 1319926 Decision Date: 06/20/13 Archive Date: 07/02/13 DOCKET NO. 06-29 480 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for hypertension, to include secondary to service-connected diabetes mellitus. 2. Entitlement to service connection for a cerebrovascular accident, to include as secondary to the service-connected diabetes mellitus. REPRESENTATION Appellant represented by: Arizona Department of Veterans Services WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD H. Seesel, Counsel INTRODUCTION The Veteran had active service from August 1968 to April 1970. He also had subsequent service with the Arizona Air National Guard from February 1974 to November 1975. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from an August 2005 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The Board previously considered this appeal in June 2010 and remanded the claim for further development. In October 2012, the Board requested a Veterans Health Administration (VHA) opinion in this case. The VHA opinion was obtained in November 2012 and the file was subsequently returned to the Board. Upon review of the November 2012 VHA opinion, the Board determined that further development was necessary and requested a second VHA opinion in January 2013. The second VHA opinion was obtained in February 2013, and the file was returned to the Board for appellate consideration. FINDINGS OF FACT 1. Hypertension did not manifest during service or within one year thereafter and is not causally or etiologically related to service. 2. Hypertension was not caused or aggravated by the Veteran's service-connected diabetes mellitus. 3. A cerebrovascular accident did not manifest during service or within one year thereafter and is not causally or etiologically related to service. 4. A cerebrovascular accident was not caused or aggravated by the Veteran's service-connected diabetes mellitus. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. The criteria for entitlement to service connection for a cerebrovascular accident have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and 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. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims (Court) held that notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) includes notice that a disability rating and an effective date for the award of benefits will be assigned if the claim is granted. In the present case, the RO sent letters to the Veteran in March 2005, March 2006, July 2010 and December 2011 that fully addressed all notice elements. The claims were subsequently readjudicated in a July 2012 supplemental statement of the case. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating claim and notifying claimant of such readjudication in the statement of the case). VA also has a duty to assist the Veteran in the development of the claim which includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the record includes the Veteran's service treatment records, VA outpatient treatment records, private medical records, lay statements, the report of VA examinations, and VHA opinions. Additionally, the Veteran provided testimony at a December 2009 Board hearing. The presiding Veterans Law Judge clearly set forth the issue to be discussed, sought to identify pertinent evidence not currently associated with the claims folder, and elicited further information as to the dates and locations of treatment when appropriate. The hearing focused on the elements necessary to substantiate the claims and the Veteran, through his testimony and questioning by his representative, demonstrated his actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that VA complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The Board also finds that the November 2012 and February 2013 VHA opinions are adequate. The VHA experts considered the Veteran's subjective history and complaints and reviewed the claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed); 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."). Although the VHA experts did not provide an opinion as to the relationship between the claimed hypertension and cerebrovascular accident and service, neither the Veteran nor the record raises a claim of direct entitlement. In fact, in the January 2005 claim for benefits, October 2005 Notice of Disagreement and the August 2006 Substantive Appeal, the Veteran explicitly stated the claim was for service connection for hypertension and a cerebrovascular accident secondary to service-connected diabetes mellitus. The Veteran further testified in December 2009 that he was not arguing that hypertension manifested or was related to service. Furthermore, the service treatment records fail to reflect any complaints or treatment related to the hypertension or a cerebrovascular accident, and the Veteran has not described any event or incident in service related to these disabilities. 38 C.F.R. § 3.159; See McLendon v. Nicholson, 20 Vet. App. 79 (2006). As such, there is no duty on the part of VA to provide a medical examination on the theory of direct entitlement. Id. Accordingly, the Board finds the VHA opinions provided in November 2012 and February 2013 are adequate. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. The Veteran recently attested that he did not have any additional evidence concerning his claims in an April 2013 statement. As such, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of his claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Factual Background The Veteran seeks service connection for hypertension and a cerebrovascular accident and specifically alleges that both disabilities are related to his service-connected diabetes mellitus. The Veteran has testified and consistently alleged that he was diagnosed with diabetes mellitus and hypertension when he was initially treated for a cerebrovascular accident (CVA) in 1996. Multiple VA treatment records and VA examination reports include a medical history of diagnoses of DMII, hypertension, and CVA in 1996. As will be outlined below, however, other medical records provide conflicting reports of the nature, date of onset, and etiology of the disabilities. A May 1996 private hospital record reflected that the Veteran suffered a transient ischemic attack (TIA) and was treated with heparin. At that time, a strong family history of coronary artery disease and cerebrovascular disease was noted. The May 1996 discharge summary explained that the Veteran was seen two days prior to the admission with left-sided facial weakness and slurred speech, which improved rapidly. On the date of admission, he presented with the same symptoms, and an examination showed mild left hemiparesis with slurred speech. The Veteran was treated with heparin. His speech returned to normal, and his weakness of the left side improved. By the day of discharge, he had normal strength and no speech impediment or facial weakness. Magnetic resonance imaging test (MRI) showed a small right lacunar infarct, and the diagnosis was a right cerebral infarction. A July 1999 private hospital record from S.H.M.C. (initials used to protect privacy) indicated that the Veteran was seen for left arm numbness and weakness, and he was diagnosed with a TIA. The note indicated that the Veteran had a history of another attack in February 1998 and also noted a history of silent myocardial infarction. An April 2002 VA outpatient treatment record indicated the Veteran reported a history of headaches since his CVA in 1996. An August 2002 letter from Dr. V.J.M. further states that the Veteran's type II diabetes mellitus was diagnosed in 1999 during routine blood work. The Veteran was afforded a VA examination in November 2002 to assess the etiology of his diabetes mellitus. The examiner noted a history of diabetes found in 1996. His blood pressure on the day of examination was 148/86. The examiner concluded that the Veteran had diabetes with minimal early symptoms of neuropathy of the feet and some development of renal insufficiency. The examiner stated that it was not known at that point if the reported hypertension was secondary to diabetes and explained that the Veteran was not aware of being hypertensive until recently. The examiner indicated that, if there was significant nephropathy, it may well be secondary and that the likelihood would be determined when studies were reviewed. An addendum to this examination indicated that the renal studies were normal, and there was no proteinuria or renal disease. As such, the hypertension was not secondary to or aggravated by the Veteran's diabetes mellitus. A September 2003 VA examination concerning diabetes mellitus also indicated that the disorder was diagnosed in 1996. The Veteran's blood pressure was 140/80. There was nothing suggesting a clinically significant diabetic retinopathy, erectile dysfunction, or clinically significant coronary artery disease. A laboratory analysis demonstrated elevated creatinine of 1.4 with a normal microalbumin level, ruling out a diabetic nephropathy. Instead, the mild renal insufficiency was as likely as not secondary to a hypertensive nephropathy. The examiner noted a history of a CVA that occurred in 1996, which was as likely as not multifactorial in that the diabetes, hyperlipidemia, and hypertension all played a significant and equal role in the cause of this complication, which at the present time, had no residual. A February 2005 evaluation performed by the Arizona Department of Economic Security concluded the Veteran had a history of stroke with no evidence of focal neuromuscular deficit. A March 2005 VA outpatient treatment record noted that the Veteran had a CVA in 1996 with residual left-sided weakness and memory loss. A March 2005 neuropsychology consultation further determined that the impaired memory function was due to the CVA and pain. In addition, a May 2005 VA outpatient treatment record concluded the dizziness and headaches probably had a cerebral vascular cause. The Veteran was afforded another VA examination in March 2005. He explained that his diabetes mellitus was diagnosed in 1996 at the time of admission for left-sided weakness and dysarthria, which was diagnosed as a CVA. He also reported that he had a history of hypertension diagnosed in 1996 for which he took medication. In general, the Veteran indicated that his blood pressure was under good control, and he did not report symptoms from hypertension, but he felt the medication could be the cause of his dizziness. Concerning the stroke, the examiner indicated that it occurred in 1996 when the Veteran was initially diagnosed with diabetes. The Veteran underwent physical therapy, and the left arm and leg numbness and weakness improved, but he still had some mild residual weakness in the left leg. He was treated with medication for a year, but since then, he only took baby aspirin. The Veteran denied any recurrence of the stroke, but recalled multiple incidents of numbness affecting the left side, which were believed to be TIAs, with the most recent one being in 2002. He indicated that, since the stroke, he had memory loss, particularly for events that occurred prior to1996. A clinical examination, including blood pressure readings and neurological, motor and sensory testing, was performed. After considering the subjective history, treatment records, and results of the examination, the assessment was diabetes mellitus, poorly controlled. The examiner noted that the Veteran suffered from a CVA in 1996 at which time the diabetes was diagnosed and that, since then, he had recurrent TIAs. The examiner stated that it is more likely than not that the Veteran's diabetes contributed to these events. The examiner indicated the hypertension was diagnosed in1996 and was not a complication of the diabetes, but was rather a co-morbid condition that can impact the progression of many diabetic complications. In a January 2006 statement, a private physician indicated the Veteran had type II diabetes mellitus and took oral medication and insulin. The private physician noted the Veteran had been diagnosed with hypertension and indicated it could possibly be related to the diabetes mellitus or could be independent of diabetes. Private hospital records from J.C.L. Health Network reflect that a TIA was diagnosed in January 2009, and the record shows that hyperglycemia and hypertension were discussed as contributing comorbid conditions. The Veteran was afforded a VA examination in March 2009 to assess the severity of his diabetes mellitus. The examiner stated that the onset of diabetes was at age 46 and was diagnosed at the time of a CVA. It was noted that the Veteran had episodes of hypoglycemia with blood sugars dropping to the 60 to 65 range about every 3 months and that he was easily responsive to carbohydrate intake. Significantly, the examiner indicated the Veteran was hypertensive since 2002 and explained that it was found on a routine physical examination without arteriosclerotic or venous peripheral disease. Neurologic symptoms manifested as tingling and burning of the lower extremities, as well as recent TIAs with the last one occurring about 4 months earlier. He had a TIA at least every 2 years. The examiner indicated the Veteran sustained a CVA with left hemiplegia without residual, except for recurrent TIAs with transient weakness of the left arm and leg occurring approximately twice a year. The frequency was twice a year in the absence of pain, but the attacks were associated with weakness and fatigue of the left side of the body and functional loss. The diagnoses included diabetes mellitus, peripheral sensory neuropathy, essential vascular hypertension, impotence or erectile dysfunction, and cerebrovascular accident with transient left hemiplegia. The examiner again noted that the hypertension was discovered in 2002 when the Veteran underwent investigation for his diabetes. In June 2010, the Board remanded the claim to obtain a clarifying opinion from the March 2005 VA examiner. It was specifically requested that he identify any current residuals of the CVA and comment on the likelihood that those residuals and the hypertension were either caused by or aggravated by the Veteran's service-connected diabetes mellitus or were otherwise related to service. In response to the remand, the RO obtained another VA examination in July 2010. The examiner concluded that the onset of hypertension was in 1996 and explained that, when the Veteran developed a CVA, further evaluation revealed diabetes mellitus and hypertension. The stroke was reported in 1996 with residuals of left-sided weakness and memory loss. The Veteran also had a history of headaches related to hypertension. He had a positive history of myocardial infarction in 1996, angina, and dizziness, but no history of other heart disease. The diagnosis was essential hypertension with no evidence of hypertensive heart disease. Complications affecting the hypertension included CVA, TIA, and coronary artery disease. The examiner opined that the hypertension was not caused by or a result of diabetes mellitus. He explained that diabetes does not cause hypertension, but noted that they frequently co-exist. The examiner, however, checked the box that the "condition, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness." The examiner's rationale was that the Veteran's diabetes had been uncontrolled at times and likely exacerbated his hypertension. VA outpatient treatment records reflect the Veteran was seen in April 2011 for a probable CVA. The note indicated that a TIA was suspected, as there was no definitive infarction on MRI. An October 2011 VA outpatient treatment record noted that the Veteran had diabetes mellitus with complications of neuropathy, hypertension, and hyperlipidemia. The Veteran was afforded an examination of the central nervous system in January 2012 to provide an opinion concerning the relationship between the CVA and his diabetes mellitus. The examiner concluded the Veteran had thrombosis, TIA, or cerebral infarction in May 1996. The Veteran also reported that his first stroke was on May 4, 1996, for which he was admitted to a private hospital. Following that incident, he sustained three additional TIAs involving the left side for which he was not admitted, but was seen in emergency room. He had another stroke in 2008 for which he was admitted to a private hospital for two days, and it was a TIA according to the Veteran. In 2009, he was also seen at a private hospital for another TIA. He had yet another admission in April 2011 for right-sided numbness, but magnetic resonance angiography (MRA) did not exhibit a stroke, although there was evidence of small vessel ischemia. The Veteran's current complaints included some numbness of the left foot, left hand, and left leg. After reviewing the record, including imaging studies, and performing a physical examination, the examiner checked the box indicating the "claimed condition is at least as likely as not (50 percent or greater probability) proximately due to or the result of the Veteran's service connected condition." The examiner explained the Veteran had a stroke and recurrent TIAs in the past and that he had residuals of mild weakness in the distal part of the left-sided extremities as well as documented depression. The examiner opined that it was as likely as not that the memory problem was due to the chronic pain syndrome. The examiner noted that the Veteran has memory problems that were diagnosed to be present since the stroke by the Veteran's report, but another VA neuropsychological evaluation attributed it to chronic pain from the back, shoulder, knees, and headache disabilities. The examiner further explained the mild weakness was likely due to a combination of the stroke and neuropathy. The examiner concluded that the CVA residuals were as likely as not caused by hypertension. The examiner specifically did not provide an opinion as to whether the hypertension was caused or aggravated by the Veteran's diabetes and deferred this opinion to a specialist. A June 2012 addendum to the July 2010 VA hypertension examination opined that the hypertension was not aggravated by the Veteran's service-connected diabetes mellitus. No rationale for this addendum opinion was provided. After reviewing the prior VA examination reports, the Board concluded that an expert medical opinion was necessary in October 2012. The Board outlined the relevant treatment records for the VHA expert and requested opinions as to whether it was at least as likely as not that hypertension and any residual of CVA was caused or aggravated by the Veteran's service-connected diabetes mellitus. In November 2012, a VHA neurologist provided an opinion as to the relationship between the CVA and the diabetes mellitus. The examiner reviewed the file and summarized the history surrounding the stroke. The examiner noted there was very little data from the original event that informed his review and observed most data was six or more years removed from the event and did not reference the source of information. It appeared that, by the time the Veteran received care at VA, his diabetes, hypertension, obesity, and hyperlipidemia were all active issues. By all reports, he had stopped smoking around 1996, and the examiner cited a March 2005 VA note that included a history of quit smoking in 1996 after the CVA. The expert concluded he was not able to find anything in the record that documented the Veteran as having diabetes at the time of the stroke. The discharge summary from 1996 indicated there was no documented metabolic disorder contributing to the event. Instead, the first reference to diabetes was in the letter from the private physician suggesting the diagnosis was in 1999. The examiner concluded that, given the presence of hypercholesterolemia and obesity as listed in the discharge summary in 1996, and the self-reported smoking history, it was more likely that the stroke in 1996 could be attributed to those risk factors rather than diabetes mellitus. The expert explained, however, that the evidence was scant and that, if he was indeed diabetic at the time of the 1996 stroke, the calculation was more complicated. Nevertheless, the expert noted that there were references to treatment for a myocardial infarction in 1996 prior to the stroke in May, and the expert thought it was unlikely that he would be treated for a myocardial infarction and not be recognized as diabetic given the overlap in risk factors between a stroke and myocardial infarction. This was significant because the relative risk of stroke with diabetes increased with the duration of being diabetic. The expert explained the relative risk for stroke attributable to individual vascular risk factors varied across studies, but based on references he reviewed, there was a 1.7 risk for stroke with diabetes for less than 5 years, a 1.8 risk with smoking, a 2.0 risk for dyslipidemia, and a 1.75-2.37 risk for obesity. Given the cumulative increase in relative risk related to other risk factors, it appeared that these outweighed the contribution of the diabetes if the diabetes was present at the time of the stroke. Concerning the question of aggravation, the VHA expert again noted it was difficult to answer. He explained that the discharge summary noted normal strength in all four limbs and made no mention of cognitive problems during that hospitalization or the subsequent TIA in 1999. Neurology testing in March 2005 noted that chronic pain was a significant contributing factor to the memory complaint. Given the scant documentation, if the memory problems began with the 1996 stroke and the Veteran was diabetic, the role of diabetes affecting the outcome from the event in 1996 was relevant, as both stroke mortality and outcome were worse in patients with diabetes mellitus. However, it was controversial, and it may be that the presence of hyperglycemia around the time of the acute stroke, rather than being diabetic, had the greatest impact on outcome. There was nothing in the record to suggest the Veteran was hyperglycemic during the 1996 admission, and the discharge summary noted no metabolic disorder contributing to the event. The expert explained that checking glucose on stroke patients was the standard of care in 1996, so there was no reason to think this was omitted even though it was not specifically listed. Accordingly, he felt that it was at least likely as not that the residuals of a CVA were neither caused nor aggravated by the Veteran's service-connected diabetes mellitus. Concerning the question of hypertension, the expert noted that it was outside his expertise and should instead be addressed by an endocrinologist or nephrologist. The claims file was subsequently sent to a VHA endocrinologist in February 2013. The VHA endocrinologist explained that hypertension was not caused by diabetes mellitus. He explained that there were several risk factors for hypertension, including obesity, inflammatory changes, and atherosclerosis, and noted that some of these are also risk factors for diabetes. Thus, there was a "common soil" hypothesis for the development of hypertension and diabetes. However, hypertension was a co-morbid condition and not specifically caused by the diabetes mellitus. The physician further explained that the Veteran's hypertension was not permanently aggravated by his diabetes. He indicated that untreated and uncontrolled hypertension itself leads to several co-morbidities and JNC 7 guidelines give a detailed account for management. Some of the causal factors leading to hypertension are the same as that for diabetes. The expert concluded that the hypertension was a co-morbid condition that is not caused or aggravated by diabetes. The Veteran also provided testimony at a December 2009 Board hearing. He explained that the claim was denied because he had hypertension in 2000 and diabetes in 1996, but he argued that this was incorrect. He testified that they found the hypertension when they determined he had diabetes and that happened when he had the CVA. He also stated that, when he went to the hospital and was treated for a stroke, the doctors asked him how long he had hypertension and diabetes, and he explained he never knew he had them. He further testified that the doctors told him that his blood sugar was very high and could have caused his situation. The Veteran's representative explained that it was common for individuals to not be tested for diabetes and was therefore likely that the Veteran had diabetes for a long time. The Veteran's representative also argued that the fact that the diabetes, hypertension, and CVA were all diagnosed at the same time should not exclude the possibility that the undiagnosed diabetes and the hypertension culminated in causing the stroke. Law and Analysis Service connection will be granted if it is shown that a Veteran has a disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a preexisting injury or disease contracted in the line of duty in the active military, naval or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury was incurred in service alone is not enough. Instead, there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Generally, to prove service connection, the record must contain evidence concerning: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and a disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In certain cases, competent lay evidence may demonstrate the presence of any of these elements. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). Several alternative paths to service connection exist for certain chronic diseases identified in 38 C.F.R. §3.309(a), such as hypertension and brain thrombosis or hemorrhage. Service connection may be awarded if a chronic disease manifests itself and is identified as such in service, or within the presumptive period under 38 C.F.R. § 3.307, and the Veteran presently has the same condition, unless the condition is clearly attributable to intercurrent causes. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309; see Walker v. Shinseki, 708 F.3d 1331, 1336 (Fed. Cir. 2013) (finding that "§3.303(b) is constrained by §3.309(a), regardless of the point in time when a Veteran's chronic disease is either shown or noted, in that the regulation is only available to establish service connection for the specific chronic diseases listed n §3.309(a)."). If, however, a chronic disease is noted during service but is either not chronic or the diagnosis could be legitimately questioned, then a showing of continuity of related symptomatology after discharge is required in order to grant service connection. 38 C.F.R. §§ 3.303(b); Walker, 708 F.3d at 1336. Service connection may be granted, on a secondary basis, for a disability, which is proximately due to, or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Similarly, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice- connected disease, will be service connected. Allen v. Brown, 7 Vet. App. 439 (1995). In the latter instance, the nonservice-connected disease or injury is said to have been aggravated by the service-connected disease or injury. 38 C.F.R. § 3.310. In cases of aggravation of a Veteran's nonservice-connected disability by a service-connected disability, such Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.322. Effective October 10, 2006, VA amended 38 C.F.R. § 3.310 to implement the Veterans Claims Court's decision in Allen v. Principi, 7 Vet. App. 439 (1995), which addressed the subject of the granting of service connection for the aggravation of a nonservice-connected condition by a service-connected condition. See 71 Fed. Rg. 52,744-47 (Sept. 7, 2006). The existing provision at 38 C.F.R. § 3.310(b) was moved to sub-section (c). Under the revised section 3.310(b), the regulation provides that: Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 71 Fed. Reg. 52,744 (2006) (codified at 38 C.F.R. § 3.310(b)). The new regulation appears to place additional evidentiary burdens on claimants seeking service connection based on aggravation, specifically, in terms of establishing a baseline level of disability for the non-service-connected condition prior to the aggravation. Because the new law appears more restrictive than the old, and because the Veteran's appeal was already pending when the new provisions were promulgated, the Board will consider this appeal under the law in effect prior to October 10, 2006. See, e.g., Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (new regulations cannot be applied to pending claims if they have impermissibly retroactive effects). The Veteran has a current disability of hypertension, as reflected in VA outpatient treatment records and VA examinations. Concerning the CVA, the Board notes that the claimed CVA occurred in May 1996, prior to the Veteran's January 2005 claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (finding that the requirement for a current disability is satisfied if the claimant has a disability at the time a claim was filed or at any time during the pendency of the appeal, even if the disability resolves prior to the Secretary's adjudication of the claim). The medical evidence above provides conflicting evidence regarding the nature and extent of any residuals of the CVA. For example, some records, such as the September 2003 VA examination and February 2005 evaluation performed by the State of Arizona for disability purposes, suggested that there were no residuals. Other records suggest residuals, such as memory loss, headaches, left sided weakness, depression, and recurrent TIAs. Giving the Veteran the benefit of the doubt, the Board accepts these residuals as a current disability. Having found current disabilities of hypertension and residuals of a CVA, the remaining questions are whether those disorders are related to service or the Veteran's service-connected diabetes mellitus. The Veteran's service treatment records do not reflect any complaints, treatment, or diagnoses of hypertension or anything that could be related to a CVA. His June 1968 entrance examination noted no defects or diagnoses other than marks and scars, decreased visual acuity, and asymptomatic pes planus. The April 1970 examination performed in connection with the Veteran's release from active duty also indicated his heart and vascular and neurologic systems were normal and reflected a blood pressure reading of 128/76. Furthermore, the Veteran does not contend and the record does not suggest that the current hypertension or CVA is related to any event or incident during service or manifested within one year of his separation from service. Although the January 2012 VA examination indicated the Veteran had hypertension prior to service that was aggravated during service, this appears to be a matter of the examiner either having the incorrect facts or checking the incorrect box. As noted above, the record fails to reflect any evidence suggesting the hypertension preexisted service, and none of the service treatment records reflect blood pressure readings that would suggest the condition worsened during service or otherwise document treatment for hypertension during service. Accordingly, to the extent this opinion suggests a preexisting condition was aggravated by service, because it conflicts with the medical record, it is afforded no probative value. Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996)(holding that credibility can be impeached generally by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character). As there is no competent and credible evidence linking the disabilities to service or indicating they manifested within one year of the Veteran's separation from service, service connection on a direct basis is not warranted. The Veteran specifically contends that his hypertension and CVA are related to his service-connected diabetes mellitus. As noted above, 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). In this regard, the Veteran has current disabilities of hypertension and residuals of a CVA and has a service-connected disability of diabetes mellitus. Thus, the remaining question is whether there is evidence of a link between the disabilities. "Competent medical evidence" is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a). "Competent lay evidence" is any evidence not requiring that the proponent have specialized education, training or experience, but is provided by a person who has the knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). It is the Board's fundamental responsibility to evaluate the probative value of all medical and lay evidence. See Owens v. Brown, 7 Vet. App. 429 (1995); Gabrielson v. Brown, 7 Vet. App. 36 (1994); see also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (observing that the evaluation of medical evidence involves inquiry into, inter alia, 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). In the evaluation of evidence, VA adjudicators may properly consider internal inconsistency, facial plausibility and consistency with other evidence submitted on behalf of the Veteran. See Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996)(holding that credibility can be impeached generally by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character). It has also been observed that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence." Madden v. Brown, 125 F. 3d 1447, 1481 (Fed. Cir. 1997). In this case, the Board finds the November 2012 and February 2013 VHA opinions are the most probative pieces of evidence. Specifically, the VHA experts reviewed the entire record, including the favorable opinions of record, considered the subjective history, summarized the pertinent evidence, and provided a thorough rationale for the opinion that the Veteran's claimed hypertension and CVA were not caused or aggravated by his service-connected diabetes mellitus. Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). Black v. Brown, 5 Vet. App. 177, 180 (1993); see also, Kightly v. Brown, 6 Vet. App. 200 (1994); Miller v. West, 11 Vet. App. 345, 348 (1998). The November 2012 VHA neurologist persuasively described the risk factors for stroke, explained why it was unlikely that the Veteran had diabetes prior to 1996, and further explained that, even if the Veteran had diabetes, that the Veteran's other risk factors outweighed the risk of diabetes. Most significantly, the November 2012 VHA neurologist pointed out that the 1996 records created coincident with the stroke noted no metabolic disorder and further explained that the standard of care for stroke patients included checking glucose. Accordingly, the Board finds the opinion that the Veteran did not have diabetes prior to the stroke and accordingly that the diabetes did not cause or aggravate the 1996 CVA and its residuals to be highly probative. Similarly, the February 2013 VHA endocrinologist reviewed all of the records and explained that the risk factors for hypertension were also factors for diabetes. As such, the hypertension was a co-morbid condition and was not specifically caused or aggravated by the diabetes. This opinion is further supported by the November 2002 VA examination, which indicated that renal studies were normal and that hypertension was not secondary or aggravated by diabetes mellitus, as well as the March 2005 VA examination indicating that hypertension was a co-morbid condition. The Board very carefully considered the favorable opinions of record. However, these opinions are less probative because they include conflicting opinions or fail to provide a rationale. For example, the January 2006 private treatment record of J.G.A. noted that the hypertension is "possibly" related to the diabetes mellitus. In the same opinion, however, Dr. A. noted that the hypertension "could be independent of his diabetes." The March 2005 VA examination noted that the diabetes mellitus may have contributed to the subsequent TIA. It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. See e.g. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Obert v. Brown, 5 Vet. App. 30, 33 (1993); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Applicable regulations also provide that a finding of service connection may not be based on a resort to speculation or even remote possibility. See 38 C.F.R. § 3.102 (2012). Furthermore, these records failed to provide any form of rationale explaining why the condition was felt to be related to the Veteran's diabetes mellitus. See Black v. Brown, 5 Vet. App. 177, 180 (1993); see also Miller v. West, 11 Vet. App. 345, 348 (1998) (medical opinions must be supported by clinical findings in the record, and conclusions of medical professionals which are not accompanied by a factual predicate in the record are not probative medical opinions). Other records suggested that diabetes was one of several possible causes of the claimed disabilities. For example, the September 2003 VA examination noted that the CVA was multifactorial with the diabetes, hyperlipidemia, and hypertension all playing a role. However, this record did not definitely indicate the diabetes caused or aggravated the CVA, and furthermore, no rationale for the opinion was offered. See Black v. Brown, 5 Vet. App. 177, 180 (1993); see also Miller v. West, 11 Vet. App. 345, 348 (1998). The Board also reviewed the July 2010 VA examination that suggested that the uncontrolled diabetes likely exacerbated the hypertension. Strangely, however, the examiner had checked the box next to the statement "medical opinion for aggravation of a condition that existed prior to service, the claimed condition, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness." As discussed above, the Veteran never claimed that his hypertension was related to service, let alone preexisted service. Furthermore, the evidence does not support a finding that hypertension preexisted service. In fact, the June 1968 entrance examination recorded blood pressure of 132/68, and the Veteran specifically denied having a history of high or low blood pressure on the June 1968 report of medical history. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (noting that a medical opinion based upon an inaccurate factual premise has no probative value); see also Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury but relied on the service medical records to provide a negative opinion). Furthermore, when the file was returned to the same examiner to clarify this opinion, the examiner indicated that the hypertension was not aggravated by the service-connected diabetes mellitus, but provided no rationale. As such, the July 2010 examiner appears to have applied the wrong legal standard or considered an incorrect factual history and further provided contradictory opinions without providing any form of rationale to support either opinion or the subsequent change in position. Thus, neither the July 2010 nor the subsequent addendum are afforded much probative value. See Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996)(holding that credibility can be impeached generally by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character); Madden v. Brown, 125 F. 3d 1447, 1481 (Fed. Cir. 1997). Similarly, the Board considered the January 2012 VA examination where the examiner checked the box that the claimed condition, the CVA, is "at least as likely as not (50 percent or greater probability) proximately due to or the result of the Veteran's service connected condition." The Board finds this opinion to be of no probative value because the underlying rationale contradicts the opinion. Although the checked box suggests the CVA was related to the service-connected condition (diabetes mellitus), the examiner specifically explained that the CVA residuals were as likely as not caused by the hypertension. Hypertension, however, is not service-connected. To the extent that the January 2012 VA examiner suggests a relationship to the diabetes mellitus, he failed to provide the necessary opinion and rationale to support such an opinion. Furthermore, to the extent the examiner linked the condition to the Veteran's hypertension, the examiner specifically declined to provide an opinion as to the relationship between the hypertension and diabetes mellitus. Significantly, even finding that the CVA was caused by the hypertension, the evidence does not reflect that the Veteran's hypertension was caused or aggravated by service or his service-connected diabetes. As such, the link to hypertension, without more, is insufficient to warrant service connection for the CVA. The Board has also considered the Veteran's testimony that, at the time he was treated for his stroke, a doctor informed him that the diabetes could have caused his situation. Although a Veteran may be competent to report contemporaneous findings of a medical professional, in the present case, the evidence of record affirmatively contradicts the Veteran's assertions, including his assertion as to what he was told by another medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (noting that lay evidence is competent and sufficient in certain instances to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional); see e.g. Robinette v. Brown, 8 Vet. App. 69 (1995) ("the connection between the layman's account, filtered as it was through a layman's sensibilities, of what a doctor purportedly said is simply too attenuated and inherently unreliable to constitute 'medical' evidence"). Specifically, the May 1996 records created coincident with the treatment for the CVA indicated that there was no underlying metabolic cause of the CVA. The Board finds that these records to carry far more weight of credibility and probative value than the recent lay statements. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the Veteran). As these records were generated with a view toward ascertaining the Veteran's then-state of physical fitness, they are akin to statements of diagnosis and treatment and are of increased probative value. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (Observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision); LILLY'S: AN INTRODUCTION TO THE LAW OF EVIDENCE, 2nd Ed. (1987), pp. 245-46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rational that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). The Board has further considered the benefit of the doubt rule in this case, but as the preponderance of the evidence is against the claim, the evidence is not in equipoise, and there is no basis to apply it. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, service connection for hypertension and residuals of a cerebrovascular accident is denied. ORDER Service connection for hypertension is denied. Service connection for residuals of a cerebrovascular accident is denied. ____________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs