Citation Nr: 1322297 Decision Date: 07/11/13 Archive Date: 07/18/13 DOCKET NO. 04-25 366 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1970 to December 1971 and from September 1973 to September 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In April 2008, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing held at the RO. A transcript of that hearing is associated with the claims file. In July 2009 and May 2012, the Board remanded the Veteran's claim on appeal to the RO via the Appeals Management Center (AMC) for additional development. The claim has been returned to the Board for further appellate consideration. In May 2012, the Board also remanded the issue of entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD). In an April 2013 rating decision, the AMC granted entitlement to service connection for PTSD. As the April 2013 rating decision represented a total grant of the benefits sought on appeal with respect to the issue of entitlement to service connection for a psychiatric disability, to include PTSD, this issue is no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). FINDINGS OF FACT 1. The Veteran has a current diagnosis of hypertension. 2. The evidence of record does not establish that the Veteran experienced symptoms of chronic hypertension during service or continuous symptoms of hypertension since separation from service. 3. The Veteran's hypertension did not manifest within one year of separation from service. 4. The probative, competent evidence of record does not demonstrate that the Veteran's hypertension is causally or etiologically related to service. 5. The probative, competent evidence of record does not demonstrate that the Veteran's hypertension is causally or etiologically related to his service-connected diabetes mellitus, nor was it aggravated by the service-connected diabetes mellitus. CONCLUSION OF LAW The criteria for service connection for hypertension, to include as secondary to service-connected diabetes mellitus, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The record shows that a December 2004 letter informed the Veteran of the information and evidence necessary to substantiate the claim for service connection. The Veteran was also advised of the types of evidence VA would assist in obtaining, as well as the Veteran's own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The United States Court of Appeals for Veterans Claims (Court) decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that VCAA notice as required by 38 U.S.C. § 5103(a) must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits. Further, the notice requirements apply to all five elements of a service connection claim: 1) veteran status, 2) existence of a disability, 3) a connection between the veteran's service and the disability, 4) degree of disability, and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Here, notice of the requirements under Dingess was provided in a March 2006 letter to the Veteran after the initial unfavorable decision in February 2005. However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In any event, where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by re-adjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Following the issuance of the March 2006 letter, the Veteran's claim was re-adjudicated in Supplemental Statements of the Case dated in June 2006 and September 2011. For these reasons, the Board finds that the duty to notify the Veteran has been satisfied in this case. See Pelegrini, 18 Vet. App. at 120 (2004). The Board also finds that the duty to assist the Veteran has been satisfied in this case. The record includes service treatment records, VA examination reports, VA treatment records, private treatment records, and lay evidence. The Veteran underwent VA examination in May 2006 and June 2006 in connection with his claim. In July 2009, the Board remanded the Veteran's claim to schedule the Veteran for an additional examination and obtain an opinion as to whether the Veteran's hypertension was related to his diabetes mellitus. The evidence demonstrates that the Veteran underwent additional VA examination in February 2011 and May 2013, and VA physicians provided addendum opinions in March 2011 and May 2011. Upon review, the Board finds the examinations and opinions, when taken together, to be sufficient and adequate for purposes of determining service connection. The record shows the VA examiners reviewed the Veteran's claims file, to include his service treatment records, VA treatment records, and private treatment records, completed physical examinations, and provided complete opinions with respect to the theories of entitlement based on direct and secondary service connection. 38 C.F.R. § 3.159(c)(4); Barr v Nicholson, 21 Vet. App. 303 (2007). In addition, the Board remanded the Veteran's claim in May 2012 to obtain and associate with the claims file any outstanding VA treatment records from the VA Medical Center in Dallas, Texas, dated from May 2010 to the present. A review of the record demonstrates the requested treatment records have been associated with the Veteran's Virtual VA file. As such, the Board finds the AMC substantially complied with the July 2009 and May 2012 remand directives with respect to the issue on appeal. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ asked the Veteran specific questions regarding his symptoms of and treatment for his hypertension. The hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. In addition, the Veteran was assisted at the hearing by an accredited representative from the Texas Veterans Commission. No pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran or his representative. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) . There is no indication in the record that any additional evidence relevant to the issue decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. All of the evidence in the Veteran's claims file has been thoroughly reviewed. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matter decided. The Veteran should not assume that pieces of evidence, not explicitly discussed, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). The Veteran asserts that his current hypertension is related to active duty. Alternatively, the Veteran asserts that his hypertension is causally related to his service-connected diabetes mellitus or is aggravated by his service-connected diabetes mellitus. Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. 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). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as hypertension, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309. Additionally, service connection may be established on a secondary basis for a disability that is shown to be 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) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). Under the pertinent regulations, hypertension means that the diastolic blood pressure is predominantly 90 millimeters (mm.) or greater, and isolated systolic hypertension means that the systolic blood is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1) (2012). The Board is to consider all lay and medical evidence as it pertains to the issues. 38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). A January 1970 entrance examination reflects a blood pressure reading of 118/80, and the Veteran denied a history of high or low blood pressure on the January 1970 report of medical history. A November 1971 separation examination shows a blood pressure reading of 105/70, and the Veteran reported that he was in good health. The Veteran's September 1973 entrance examination reflects a blood pressure reading of 128/80, and he denied a history of high or low blood pressure on a September 1973 report of medical history. A September 1976 separation examination shows a blood pressure reading of 110/80 and the Veteran denied a history of high or low blood pressure on a September 1976 report of medical history. An August 1998 private treatment record indicated the Veteran had had diabetes mellitus since 1993. The Veteran's blood pressure readings were 132/80 and 126/74. A July 2001 private treatment record shows the Veteran's blood pressure was marginal, but the private physician determined that the Veteran obviously needed medication. A January 2002 private treatment record indicates the private physician would schedule the Veteran for a follow-up with respect to hypertension. In February 2002, a private physician noted that the Veteran admitted to having hypertension, which was maintained with daily medication. An October 2002 private treatment record reflects an assessment of hypertension. An April 2003 VA treatment record shows a diagnosis of hypertension. In March 2004, the Veteran reported having elevated blood pressure for eight years, which was controlled with medication. A March 2005 VA treatment record demonstrates that the Veteran agreed to keep a daily log of his blood pressure. The Veteran underwent VA examination in May 2006 in conjunction with his claim. The VA examiner noted that the Veteran was diagnosed as having hypertension and diabetes mellitus in 1988, at which time he was 38 years old. The Veteran reported his high blood pressure began at the same time that his diabetic diagnosis was made; however, the VA examiner found that the Veteran's history was not reliable as his memory was quite compromised. On examination, the Veteran's blood pressure was 170/76 in his dominant right arm, and the VA examiner diagnosed hypertensive vascular disease. The VA examiner stated that an opinion could not be rendered with respect to whether hypertension was caused by diabetes mellitus without reviewing the claims file. After reviewing the Veteran's claims file, the VA examiner provided an addendum opinion in June 2006. The VA examiner noted that in March 2004 the Veteran reported having had high blood pressure for eight years. Information relayed to another examiner indicated the Veteran had had diabetes mellitus since 1993. In addition, a February 1996 sterilization procedure noted that the Veteran had diabetes mellitus but did not have high blood pressure. In July 2001, the records also indicated that the Veteran began taking a renal protective ingredient because of his diabetes mellitus, not hypertension. He had subsequently developed essential hypertension. As a result, the VA examiner found it was less likely than not that the Veteran's hypertension was secondary to his diabetes mellitus. The VA examiner found it significant that the first objective evidence of a diagnosis of diabetes mellitus was either in 1988 or 1993 but that blood pressure medication was not initiated until 2001. At the April 2008 Travel Board hearing, the Veteran testified that hypertension was first diagnosed in 1988. He reported that he did not know he had high blood pressure until that time. In February 2011, the Veteran underwent additional VA examination in connection with his claim. The Veteran reported that hypertension was first diagnosed in 1978, at which time he was started on medication. On examination, his blood pressure readings were 128/68, 128/70, and 130/70, and the VA examiner diagnosed essential hypertension. Although the Veteran's claims file was not available for review, the VA examiner reviewed the VA treatment records from the VA Medical Center in Dallas, Texas. Because the Veteran was diagnosed with hypertension in 1978, according to his assertions, the VA examiner opined that it was as likely as not that his hypertension was related to his military service. In March 2011, a different VA examiner reviewed the Veteran's claims file and opined that the Veteran's hypertension was uncomplicated. Further, the VA examiner stated that diabetes mellitus does not cause hypertension. The VA examiner who performed the February 2011 examination also provided an addendum opinion in May 2011. The VA examiner reviewed the Veteran's claims file and noted that the record showed the Veteran was diagnosed with diabetes in 1993 and that physicians diagnosed hypertension sometime thereafter. The VA examiner also noted that the Veteran was never diagnosed or treated for hypertension while he was in the military. Therefore, the VA examiner changed the opinion because it was now apparent that the Veteran was incorrect in indicating that hypertension developed during or shortly after his military service. As a result, the VA examiner found it was unlikely that the Veteran's hypertension was related to his military service. The Veteran's primary physician at the VA North Texas Healthcare System submitted a letter in September 2011. The physician found that the medical records showed the Veteran was suffering from hypertension a long time prior to beginning medical treatment at the Dallas VA Medical Center. As such, the physician stated hypertension should be added to his service-connected condition. The Veteran's ex-wife also submitted a statement in support of his claim in September 2011. She stated that a private physician had diagnosed the Veteran with diabetes mellitus in 1987 and that around a few months later the same physician diagnosed him with high blood pressure. In May 2013, the Veteran underwent additional VA examination. The VA examiner performed an in-person examination and noted that hypertension was diagnosed in 1978. The VA examiner also noted that the Veteran's treatment plan included taking continuous medication for hypertension. The VA examiner opined that the Veteran's current hypertension was unrelated to service or diabetes mellitus. The VA examiner based the opinion on the lack of elevated blood pressure readings in the service treatment records. In addition, the clinical findings of normal renal function and no proteinuria ruled out diabetes mellitus as a cause of hypertension. Further, the VA examiner found there was no evidence of aggravation of hypertension by any condition. Here, the Veteran's service treatment records do not demonstrate any complaints of, treatment for, or diagnosis of hypertension, and therefore also do not demonstrate that the Veteran experienced chronic symptoms of hypertension during service. The January 1970 entrance examination reflects a blood pressure reading of 118/80; the November 1971 separation examination shows a blood pressure reading of 105/70; the September 1973 entrance examination reflects a blood pressure reading of 128/80; and the September 1976 separation examination shows a blood pressure reading of 110/80. The service treatment records also show that the Veteran denied a history of high or low blood pressure throughout service. In some circumstances, 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). In this respect, the Board acknowledges that the Veteran is competent to testify to matters within the realm of his personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that a lay witness is competent to testify to that which the witness has actually observed and is within the realm of his personal knowledge). The record demonstrates that on one occasion, the Veteran asserted that hypertension was initially diagnosed in 1978. However, the Veteran testified at the April 2008 Travel Board hearing that he did not know that he had hypertension until 1988. In addition, the medical evidence of record does not reflect findings of high blood pressure at the time of separation from service or following the Veteran's separation from service until 2001, approximately 25 years after service. Thus, the Board finds the Veteran has not established a continuity of symptomatology for the purpose of service connection. Moreover, regardless of whether hypertension was diagnosed in 1978, 1988, or 2001, the evidence does not indicate that hypertension manifested to a compensable degree within the year following active duty. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As such, the Veteran is not entitled to service connection for hypertension on a presumptive basis. With respect to service connection on a direct basis, the record reflects a current diagnosis of hypertension, and therefore, the Board finds the Veteran has established a current disability. Concerning the second element of a claim for direct service connection, the Veteran's service treatment records are negative for any complaints of, treatment for, or diagnosis of hypertension. As stated above, the evidence also does not demonstrate that the Veteran experienced chronic symptoms during service or continuous symptoms since separation from service. With respect to a nexus between the Veteran's current disability and his active duty service for the purpose of direct service connection, there are conflicting medical opinions of record. The Board has the authority to "discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence." See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In evaluating the probative value of competent medical evidence, the Court has stated that 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. Further, the credibility and weight to be attached to these opinions [are] within the province of the adjudicator. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). As such, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Here, the Board affords the opinions provided in May 2011 and May 2013 significant probative value with respect to the issue of direct service connection. In May 2011, the VA examiner reviewed the Veteran's claims file and cited specific records in support of the opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The VA examiner found it significant that the service treatment records did not show a diagnosis of or treatment for hypertension during service. In addition, the record indicated hypertension was not diagnosed until 1993. It was apparent that the Veteran's hypertension did not develop during or shortly after the military service, and as a result, the VA examiner found it was unlikely that hypertension was related to military service. Similarly, the May 2013 VA examiner found the Veteran's hypertension was unrelated to service. The VA examiner also cited the lack of elevated blood pressure readings in the Veteran's service treatment records. Here, the Board also finds the May 2013 VA examiner's negative opinion particularly significant as the VA examiner rendered the negative opinion despite the finding that hypertension was first diagnosed in 1978, thereby affording the Veteran the benefit of the doubt with respect to the onset of hypertension. The Board recognizes that the February 2011 VA examiner initially opined that it was as likely as not that his hypertension was related to his military service. However, the VA examiner later changed the opinion after a review of the Veteran's claims file, and therefore, the opinion does not carry probative weight for purposes of service connection. In addition, the Board finds the September 2011 opinion provided by the Veteran's primary physician carries little probative value. Here, the record does not support the physician's finding that the Veteran was suffering from hypertension a long time prior to the beginning of medical treatment at the Dallas VA Medical Center. Specifically, the earliest diagnosis of hypertension in the VA treatment records of record is in March 2004, while the private treatment records indicate treatment for hypertension began in 2001, only three years prior to the onset of VA treatment. Furthermore, the Board finds the Veteran has not specifically alleged that his hypertension is directly related to military service. Here, the Veteran has not asserted that hypertension had its onset during active duty or that he has experienced continuous symptoms of hypertension since separation from service. Rather, the Veteran appears to only contend that his hypertension is related to his diabetes mellitus because it was diagnosed in connection with diabetes mellitus. Even if the Veteran were to assert that his hypertension was directly related to active duty, the Board finds that a layperson without medical training is not qualified to render a medical diagnosis or medical opinion concerning the etiology of hypertension. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions). In certain unique instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Here, however, the evidence does not show that the Veteran or his wife possesses the requisite training or credentials needed to render a competent opinion as to the medical causation of hypertension. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In addition, the record demonstrates that the Veteran's statements regarding the onset of hypertension have been inconsistent during the pendency of the appeal. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). At the May 2006 VA examination, the Veteran reported that his hypertension began with the onset of his diabetes mellitus in 1988. However, the VA examiner found that the Veteran's history was not reliable as his memory was quite compromised. At the April 2008 Travel Board hearing, the Veteran testified that he was unaware that he had high blood pressure until hypertension was diagnosed in 1988. On VA examination in February 2011, however, the Veteran reported that hypertension was first diagnosed in approximately 1978. As such, the Board finds the lay statements provided by the Veteran and his wife do not constitute competent medical evidence and lack probative value with respect to direct service connection. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007). Concerning service connection on a secondary basis, the evidence must show that the current disability was either caused or aggravated by a service-connected disability. Harder v. Brown, 5 Vet. App. 183, 187-89 (1993). Here, the Veteran asserts that his hypertension is caused or aggravated by his service-connected diabetes mellitus. However, the competent clinical evidence of record is against a finding that the Veteran's hypertension is caused or aggravated by his diabetes mellitus. First, the June 2006 VA examiner reviewed the Veteran's claims file, to include the VA treatment records and private treatment records, and opined that it was less likely than not that the Veteran's hypertension was secondary to his diabetes mellitus. The VA examiner found it significant that the first objective evidence of a diagnosis of diabetes mellitus was either in 1988 or 1993 but that blood pressure medication was not initiated until 2001. In addition, the VA examiner highlighted the Veteran's inconsistent reports concerning the initial diagnosis of hypertension. Further, the VA examiner noted that a February 1996 sterilization procedure showed the Veteran had diabetes mellitus but not high blood pressure, and the record indicated the Veteran began taking Altace in 2001 because of his diabetes mellitus and not his hypertension. Additionally, the March 2011 VA examiner reviewed the Veteran's claims file and opined that diabetes mellitus did not cause hypertension and found the Veteran's hypertension was uncomplicated. The May 2013 VA examiner opined that the Veteran's current hypertension was unrelated to diabetes mellitus as the clinical findings of normal renal function and no proteinuria ruled out diabetes mellitus as a cause of hypertension. Further, there was no evidence of aggravation of hypertension by any condition. Again, the Board acknowledges that the Veteran is competent to describe his symptoms. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, a veteran's own conclusion stated in support of his claim that his present disability is secondary to his service-connected disability is not competent evidence as to the issue of medical causation of hypertension. See 38 C.F.R. § 3.159; see also Grivois v. Brown, 6 Vet. App. 136 (1994). Thus, a medical opinion is needed to connect one medical condition to another medical condition. In this case, the probative medical evidence of record provides negative opinions concerning a nexus between the Veteran's hypertension and his service-connected diabetes mellitus. Based on the foregoing, the Board finds that the preponderance of the evidence is against a grant of service connection for hypertension, to include as secondary to service-connected diabetes mellitus. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55-56. ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs