Citation Nr: 1320481 Decision Date: 06/25/13 Archive Date: 07/05/13 DOCKET NO. 05-25 456A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, type II. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD Elizabeth Jalley, Counsel INTRODUCTION The Veteran served on active duty from January 1969 to November 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In May 2008, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge. A transcript of this hearing was prepared and associated with the claims file. In December 2008, August 2010, and March 2013, the Board remanded this case for additional development, and the case has been returned for further appellate review. The Board also notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the Veteran's claim. This evidence has been considered in the following decision. FINDING OF FACT The Veteran did not exhibit hypertension in service or within one year of separation from service, and any such disability is not etiologically related to any injury or disease during the Veteran's active service or to a service-connected disability. CONCLUSION OF LAW Hypertension was not incurred in or aggravated by active service or within a year of separation from service, and such disability is not proximately due to or the result of a service-connected disability or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA), Public Law No. 106-475, 114 Stat. 2096 (2000), substantially amended the provisions of chapter 51 of title 38 of the United States Code, concerning the notice and assistance to be afforded to claimants in substantiating their claims. VCAA § 3(a), 114 Stat. 2096, 2096-97 (2000) (now codified as amended at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012)). In addition, VA published regulations, which were created for the purpose of implementing many of the provisions of VCAA. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (now codified, in pertinent part, at 38 C.F.R. § 3.159 (2012)). The notice requirements of the VCAA require VA to notify the veteran of any evidence that is necessary to substantiate a claim, as well as the evidence VA will attempt to obtain and which evidence the veteran is responsible for providing. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Such notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). The VCAA notice requirements, however, may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Dingess, supra; Pelegrini, supra. The Board finds that the notification requirements of VCAA have been satisfied in this case. In this regard, the Board notes September 2004 and February 2008 evidentiary development letters in which the RO advised the appellant of the evidence needed to substantiate his service connection claim. These letters advised the Veteran of his and VA's responsibilities under VCAA, to include what evidence should be provided by him and what evidence should be provided by VA. The February 2008 letter further advised the Veteran as to the type of evidence needed to substantiate both the disability rating and effective date elements of his claim, pursuant to the Court's holding in Dingess, supra. The Board notes that the February 2008 letter was not issued prior to the initial adjudication of the Veteran's claim in January 2005. The Veteran's claim, however, was readjudicated following the issuance of this notice, most recently in an April 2013 supplemental statement of the case. Thus, any deficiencies in the timeliness of this notice letter would not be prejudicial. The Board further finds that the duty to assist requirements of VCAA have also been satisfied in this case. 38 U.S.C.A. §§ 5103 and 5103A. Specifically, the Board finds that all obtainable evidence identified by the Veteran relative to the issue on appeal has been obtained and associated with the claims folder. In particular, the Board notes that the RO obtained the Veteran's service treatment records, VA medical records, available private medical records, and Social Security Administration records. The Veteran also underwent VA examination in connection with his claim in August 2011, January 2012, and April 2013. The Board finds that the resulting VA medical opinions, in aggregate, are adequate for the purpose of determining the claim decided herein. The examination reports reflect review of the claims file. During the examinations, the examiners elicited from the Veteran his history of complaints and symptoms and provided clinical findings detailing the examination results. The examiners also provided diagnosis and etiology opinions and explained the reasons and bases for these opinions. For these reasons, the Board concludes that the August 2011, January 2012, and April 2013 VA examination reports in this case provide an adequate basis for a decision on the Veteran's claim. The evidence of record provides sufficient information to adequately evaluate the claim. Therefore, no further assistance to the Veteran with the development of evidence is required, nor is there notice delay or deficiency resulting in any prejudice to the Veteran. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was also provided an opportunity to set forth his contentions during the 2008 Board hearing. In Bryant v. Shinseki, the U.S. Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.103(c)(2) requires that the "hearing officer" who chairs a hearing fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. 23 Vet. App. 488 (2010). In regard to the first duty, during the hearing, the Veterans Law Judge enumerated the issue on appeal. In regard to the second duty, the Veterans Law Judge held the record open so that the Veteran could provide medical nexus opinion evidence to support his claim. He was subsequent schedule for VA examination to include medical nexus opinions. The obligations under 38 C.F.R. 3.103(c)(2) were met and even if not met there is no prejudice to the Veteran as VA has made attempts to assist the Veteran in getting the type of evidence necessary to support his claim. II. Service Connection The Veteran has claimed entitlement to service connection for hypertension, which he essentially contends was incurred secondary to his service-connected diabetes mellitus, type II. In general, applicable laws and regulations state that service connection may be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That a condition or injury occurred in service alone is not enough; there must be disability resulting from that condition or injury. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a veteran 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" - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for chronic disabilities, such as hypertension, if such are shown to have been manifested to a compensable degree within one year after the Veteran was separated from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As an alternative to the nexus requirement, service connection for hypertension may be established through a showing of continuity of symptomatology since service. 38 C.F.R. § 3.303(b)(2012). The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (rejecting the argument that continuity of symptomatology in § 3.303(b) has any role other than to afford an alternative route to service connection for specific chronic diseases). A disability which is proximately due to, or results from, another disease or injury for which service connection has been granted shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (2012). The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability and not due to the natural progress of the nonservice-connected disease. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran's service treatment records reflect that his blood pressure was 118/80 at the time of his January 1969 enlistment examination. A June 1969 service treatment record reflects that the Veteran's blood pressure was 112/58, and he claimed a history of low blood pressure. Service treatment records from February 1970 note blood pressure readings of 102/45, 102/78, 140/80, and 125/78. In March 1971, the Veteran's blood pressure was measured at 102/80. The Veteran denied having ever been treated for high blood pressure on an April 1971 dental medical history questionnaire. The October 1971 separation examination report notes a blood pressure of 120/60. The Veteran reported that he did not know whether he had a history of, or current, high or low blood pressure on his October 1971 separation medical history report. A January 1972 VA examination report notes that the Veteran's blood pressure was 110/62. A January 1996 statement by Dr. M. shows that the Veteran had no history of hypertension or diabetes. Private clinical records from Dr. B. of treatment of the Veteran in the 1990s up to 2002 make no reference to the Veteran's having hypertension. An October 2004 VA examination report notes that the Veteran was claiming hypertension as secondary to the service-connected diabetes mellitus, type II. It notes that the Veteran had been found to have an elevated nonfasting serum glucose level in March 2004. After a subsequent fasting glucose in June 2004, he was started on Metformin for control of diabetes and he was given instructions on a diabetic diet. He denied a history of ketoacidosis or hypoglycemia, and had not been hospitalized for diabetes. He reported that he tried to adhere to a diabetic diet. He had never been prescribed insulin. An eye examination in August 2004 found no evidence of diabetic retinopathy. Also in June 2004, he had been placed on Fosinopril which was an ACE inhibitor often used for a renal protective effect in diabetic patients. A review of his claim file reflected that he did not carry a diagnosis of hypotension. Further, on review of blood pressure values prior to the initiation of Fosinopril, there was no documented hypertension, and blood pressure values were less than 140/90 in both March and June 2004. The examiner noted that, given the new onset of diabetes mellitus, type II, it appeared Fosinopril was added to the Veteran's medication regimen for renal protective effects in June 2004. The examiner noted that the Veteran related a history of hypertension, but that his medical records did not confirm this diagnosis. Rather, his primary care physician had prescribed Fosinopril in the context of "new onset diabetes mellitus," as it was common practice for primary care physicians to use ACE inhibitors as a renal protective medication in diabetic patients. The examiner stated that, on review of blood pressure values documented prior to the initiation of Fosinopril, the Veteran had no objective evidence of hypertension. Also, he had no evidence of microalbuminuria, so there was no evidence of diabetes contributing to hypertension and/or nephropathy. After a physical examination, the assessment was that there was no evidence of diabetic retinopathy, diabetic nephropathy, coronary artery disease, or other arteriosclerotic disease to date. The examiner stated that there was no documentation of hypertension in the medical record and the Veteran was placed on Fosinopril in June 2004, in combination with Metformin, for new onset diabetes mellitus. Blood pressure values available on review of the claim file did not reflect values consistent with hypertension prior to the initiation of Fosinopril. On the current examination, the Veteran did not have hypertension. It was noted that, while Fosinopril did have blood pressure lowering effects, in addition to renal protective effects in those with diabetes, blood pressure readings on the current examination were difficult to interpret in the setting of an anti-hypertensive agent use. Blood pressure values documented prior to initiation of Fosinopril were not consistent with a diagnosis of hypertension. The examiner essentially found that the evidence of record and the findings on examination did not support a diagnosis of hypertension. At the May 2008 Travel Board hearing, the Veteran testified that he had been given a diagnosis of hypertension during his active service and that he had been given medication for hypertension during his active duty. He then testified that in some situations during service he had had high blood pressure problems but had not been diagnosed with hypertension. He was now being treated and took medication for hypertension. He reported that he was taking such medication for hypertension, not for renal protection. He had been informed by his primary care physician and by a private physician whose records were on file that he had hypertension secondary to his diabetes. An August 2011 VA examination report notes that the Veteran was taking continuous medication for control of hypertension. It noted that the Veteran had diabetes which required a restricted diet, oral hypoglycemic agents, and insulin. It was reported that he did not have diabetic nephropathy, and he did not have hypertension in the presence of diabetic renal disease. It was not at least as likely as not that his diabetes had permanently aggravated hypertension or renal disease. The Veteran reported that he had been diagnosed with both diabetes and hypertension in 2004. It was concluded that the date of onset of the Veteran's hypertension was not known but there was no evidence of diabetic renal disease. The January 2012 VA examination report states that the Veteran's diagnosis of hypertension was speculative. It was noted that the Veteran dated the onset of hypertension to 2003 or 2004. A review of blood pressure readings in private clinical records from 1995 to 2002 revealed normal readings. A June 2004 VA medical record notes that the Veteran had new onset of diabetes mellitus and was prescribed Fosinopril. His blood pressure at that time was 134/77 and no official diagnosis of hypertension was made. In February 2005, a diagnosis of hypertension was made and it was entered onto a progress note problem list. From that point forward, progress notes and problem lists noted the diagnosis of hypertension. But there was no three to five day blood pressure check and there was no record of high blood pressure readings by home blood pressure check. His blood pressure was 115/74. It was not until February 2006 that hypertension was placed on the official problem list in his VA computerized medical records and it was unknown why hypertension was entered onto the official problem list at that time. His blood pressure at that time was 127/73. In November 2006, there was an assessment that the Veteran had hypertension and his current therapy was to be continued. However, his medication was changed from Lisinopril 5 mgs. daily to "HCTA 12.5/Lisinopril 10 mgs. Tab daily" for unknown reasons. His blood pressure at that time was 138/86. It was commented on careful review of vital signs package that the vast majority of the Veteran's blood pressure readings over 140/90 from 2004 were on dates of procedures, emergency room visits, or when he had acute pain. On occasion, his blood pressure was high on initial readings at medical visits but lower and normal when re-checked. The examiner observed that there was no treatment of the Veteran for hypertension during service, no high blood pressure readings were found in his service treatment records, and that a firm diagnosis of hypertension was speculative. The Veteran currently carried a diagnosis of hypertension on his VA primary care problem list but there were no progress notes discussing on what objective basis the diagnosis was based or how the diagnosis was made. Complicating the picture was that there was some controversy among experts as to what blood pressure readings constituted hypertension in someone with diabetes. In quoting pertinent medical information, it was reported that in those with diabetes the goal was to have blood pressure less than 140/90 and there was a weaker recommendation to lower the systolic pressure below 130 to 135 if it could be done without producing significant side effects. It was noted that the level of blood pressure elevation at which physicians decided to start treating patients with medication varied widely, depending upon preference and comfort level of the treating physician, and even the region of the country. Some physicians began all new diabetics on an ACE inhibitor at the diagnosis of diabetes to attempt to prevent diabetic nephropathy, regardless of blood pressure readings (unless the blood pressure was very low). Some waited until the blood pressure was greater than 140/90, and some physicians started medication for hypertension when the blood pressure was greater than 130/80. In June 2004, the Veteran had been diagnosed with diabetes and started on Fosinopril, an ACE inhibitor and anti-hypertensive agent. His blood pressure then was 134/77. It was unknown from the record if the treating physician felt that 134/77 was hypertensive for this diabetic Veteran, or if the physician started the medication as a preventative measure. In February 2005, hypertension was first found in a progress note, when the blood pressure was 115/74, but the reason for this was unknown from a review of the record. In February 2006, hypertension was entered onto the official problem list, at which time the Veteran's blood pressure was 127/73. While the Veteran might have been on an ACE inhibitor, previous records were not reviewed at that time and the assumption was made that the medication was for hypertension. Noting that hypertension was not on the problem list, it was entered on the problem list at that time. In November 2006, the medication dose was increased but, again, the reason was not known and at that time blood pressure was 138/86. The examiner noted that the Veteran was hypertensive today, with the readings today being higher than any recorded readings in his medical record. It was unknown if this reflected a diagnosis of hypertension, possibly unmasked by no medications having been taken this morning (although the Veteran reported having taken his medication on the morning of the examination) or possibly the stress of a compensation examination. The examiner was hesitant to make a diagnosis of hypertension on the basis of the readings of the current examination because individuals frequently had higher blood pressure readings at the time of such examinations. The Veteran stated that his hypertension and diabetes were diagnosed at the same time, which led the examiner to speculate that the primary care physician had felt that 134/77 was hypertensive in June 2004 and communicated this to the Veteran but did not record it in the progress note. The examiner further stated that, regardless, she did not find clear objective evidence that the Veteran had the onset of diabetes followed by the onset of hypertension due to diabetes. Diabetic medications that could be associated with fluid retention and hypertension were not started until after hypertension was placed on the problem list. Blood pressure readings remained normal, except for visits for acute pain or procedures, indicating that there was no objective evidence of aggravation of blood pressure readings by diabetes. The Veteran also underwent a VA examination in April 2013. The examination report reflects that the Veteran's claims file was reviewed, and that he was interviewed and physically examined by the examiner. Blood pressure readings taken during the examination were 150/90, 148/90, and 142/88. Based on the above, the examiner opined that it is at least as likely as not that the Veteran has hypertension. She noted that the Veteran had reported that his physician had diagnosed diabetes mellitus, type II, and hypertension in 2003 or 2004. She opined that it is most likely that the Veteran's Fosinopril was prescribed for both blood pressure control and renal protection. She further opined that, when the Veteran's consistent recollection of his pertinent history is combined with the objective data, in the setting of newer recommended goals for blood pressure in those with diabetes mellitus, it is most likely that the Veteran's diagnoses of hypertension and diabetes mellitus, type II, had their onset at the same time. The examiner opined that the Veteran's hypertension is not caused by or a result of service and that it did not onset during or within a year after his separation from service in November 1971. In explaining this opinion, she noted that the Veteran's hypertension had its onset in 2004 and cited review of medical literature, the medical record, and her own clinical experience. She also opined that the Veteran's service-connected diabetes mellitus, type II, did not cause or aggravate his hypertension, again citing review of medical literature, the medical record, and her own clinical experience to justify this opinion. She noted that the Veteran's hypertension and its treatment had their onset at the same time as his diabetes mellitus, type II, and that the diabetes mellitus did not cause the hypertension. The examiner noted that there is no objective evidence of diabetic nephropathy at that time, or since that time. Urines have been negative for proteinuria. Laboratory data from February 2013 showed no proteinuria and continued normal renal function. There was no objective evidence of aggravation, as detailed review of the vital sign report package from 2004 through the present, with visit notes, labs, and pharmacy report correlations, shows blood pressure has remained well controlled. The occasional transient elevations have correlated with visits for acute pain/procedures or other events known to cause a transient elevation. The highest vital sign report, of 172/104, was taken in an emergency room in November 2007 after having shot up cocaine and not having taken his regular medications in a few days. The Veteran also tested positive for cocaine in September 2009, at which time his blood pressure was recorded as 126/91 and 131/96. The examiner noted that cocaine is known to cause significant blood pressure elevations and can result in both acute and chronic cardiovascular morbidity. She quoted an explanation that appears in the UpToDate reference database: "'Cocaine may also enhance the release of catecholamines from central and peripheral stores. The ensuing sympathomimetic actions (increased myocardial inotropy, heart rate, systemic blood pressure, and coronary artery constriction) are mediated by stimulation of the alpha- and beta adrenergic receptors and result in increased myocardial oxygen demand.'" The examiner thus concluded that the Veteran's service connection diabetes mellitus, type II, has not aggravated his hypertension or increased the disability beyond the natural progress of the condition. The examiner also opined that the Veteran does not have chronic kidney disease, as reflected in February 2013 laboratory data. The examiner stated that it was not known why chronic kidney disease, stage III (moderate) was entered into the Veteran's master problem list in June 2008. The examiner stated that the corresponding visit note is silent for the condition, and laboratory data near that date does not support the diagnosis. The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, his or her knowledge and skill in analyzing the data, and his or her medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448- 9 (2000). The Board finds the April 2013 VA examination report, in particular, highly probative to resolving the issue of entitlement to service connection for hypertension. The examiner is a physician who is qualified through education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159(a)(1). Her examination report discusses the Veteran's pertinent medical history and describes relevant findings from diagnostic testing. The VA physician expressly discusses theories of direct, presumptive, and secondary service connection, addresses the question of aggravation, and provides complete rationales to justify each opinion. She explains her opinions through citation to the facts of the Veteran's case, including the Veteran's history of hypertension in relation to his history of diabetes mellitus, type II, and his history of emergency medical treatment, and through reference to pertinent medical principles, including a discussion of the effect of cocaine on an individual's blood pressure. The Board thus finds that the April 2013 VA physician has provided a competent medical opinion with adequate rationale to render her opinion highly probative to the question at hand. In terms of medical evidence that supports his claim, the Veteran testified at his May 2008 Board hearing that he has been told by his private and VA physicians that his hypertension was secondary to his diabetes mellitus. The Board has considered whether this evidence may be considered competent medical evidence of an etiological link between the Veteran's hypertension and a service-connected disability. The Board observes, however, that a layperson's account of a physician's medical opinion "is simply too attenuated and inherently unreliable to constitute [competent] 'medical' evidence." Robinette v. Brown, 8 Vet. App. 69, 77 (1995). Furthermore, this testimony is inconsistent with the VA and private medical records that have been associated with the claims file. Therefore, this aspect of the Veteran's hearing testimony cannot be accepted as competent or credible medical nexus evidence. Otherwise, the only other nexus evidence comes directly from the Veteran himself. The Board recognizes that there are instances in which lay testimony can provide probative evidence in medical matters. A layperson may be competent to offer testimony on certain medical matters, such as describing symptoms observable to the naked eye, or even diagnosing simple conditions such as a dislocated shoulder. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). However, as a layperson, the Veteran cannot competently opine on the question of whether his hypertension was caused or aggravated by his diabetes mellitus, type II. For this reason, the Board ultimately places more probative weight on the opinions of the April 2013 VA examiner, who is a competent medical professional who considered the Veteran's lay reports and medical records and provided her own well-supported medical opinion. Finally, the Board has considered the Veteran's reports, particularly at his May 2008 personal hearing, suggesting that he was diagnosed with, was treated for, or, at the very least, has experienced symptoms of, high blood pressure since service, in the context of establishing presumptive service connection for a chronic disability pursuant to Walker. The Board finds that the Veteran is not competent to assert that any symptoms in service or within a year after service was a manifestation of hypertension. The Veteran is not found to have the medical training necessary to make such conclusions. Post service medical evidence does not demonstrate that the Veteran was diagnosed with hypertension for approximately 33 years following his separation from service, and there is no suggestion that the Veteran was living with undiagnosed hypertension for more than three decades following his separation from service. Moreover, the Board notes that in a May 2013 Appellant's Post-Remand Brief, his representative argued that there was medical literature which linked hypertension with herbicide exposure. The Board observes that the Veteran is presumed to have been exposed to Agent Orange due to his Vietnam service. What is missing in this case is any competent medical evidence which links the Veteran's hypertension to Agent Orange. No evidence has been submitted by the Veteran or his representative which makes such a connection. As noted by the Veteran's representative, hypertension is not a presumptive service-connected disease based on Agent Orange exposure. 38 C.F.R. §§ 3.307, 3.309. In light of the foregoing, a claim of service connection for hypertension based on exposure to Agent Orange must fail. Lastly, the Board also notes that the evidence does not show that the Veteran currently has a chronic kidney disease or that he has had such during the appeal period. The April 2013 VA examination report provided a probative and complete rationale for finding that the Veteran did not have a chronic kidney disease. This rationale included referencing postservice laboratory results which did not support such a finding. As such, any contention that the Veteran's service-connected diabetes mellitus caused kidney disease which caused hypertension must fail. In summary, the Board finds that a preponderance of the evidence is against finding that the Veteran's hypertension is etiologically related to his military service, either on a direct, presumptive, or secondary basis. The Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against this claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, is not warranted. ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, type II, is denied. ____________________________________________ K. OSBORNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs