Citation Nr: 1323586 Decision Date: 07/24/13 Archive Date: 08/01/13 DOCKET NO. 04-38 588A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a recurrent skin rash with residuals of scars and mild keloids on the front of the chest, to include as due to herbicide exposure. 2. Entitlement to service connection for a kidney disorder, to include as due to herbicide exposure and/or as secondary to service-connected diabetes mellitus. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD) and/or diabetes mellitus. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from April 1966 to April 1969, including service in the Republic of Vietnam from September 1967 to August 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2003 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which, in pertinent part, denied the Veteran's requests to reopen his claims for service connection for a kidney condition, hypertension and a recurrent skin rash. In November 2001 and January 2004, the Veteran testified before a Decision Review Officer (DRO) at the RO. The Veteran also testified at a video-conference hearing before the undersigned Veterans Law Judge in July 2009. Hearing transcripts have been associated with the claims file. The Board remanded the instant matters in March 2010 and July 2011. As will be discussed herein, the Board finds that the agency of original jurisdiction (AOJ) substantially complied with the remand orders with regard to the claims for service connection and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Additionally, in November 2012 and February 2013, the Board sought opinions as to the instant claims from the Veterans Health Administration (VHA). Such opinions were obtained in January 2013 and April 2013. The Veteran was provided a copy of these opinions in April 2013 and afforded an additional 60-day period to provide additional evidence and/or argument. In May 2013, the Veteran indicated that he had no additional evidence to submit and requested that the Board proceed with the adjudication of his appeals. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam during the Vietnam era and, therefore, exposure to an herbicide agent is presumed. 2. A skin disorder, to include a recurrent skin rash, is not shown to be causally or etiologically related to any disease, injury, or incident during service, to include herbicide exposure. 3. A kidney disorder, to include nephrolithiasis, is not shown to be causally or etiologically related to any disease, injury, or incident during service, to include herbicide exposure, did not manifest within one year of service discharge, and was not caused or aggravated by service-connected diabetes mellitus. 4. Hypertension is not shown to be causally or etiologically related to any disease, injury, or incident during service, to include herbicide exposure, did not manifest within one year of service discharge, and was not caused or aggravated by service-connected PTSD and/or diabetes mellitus. CONCLUSIONS OF LAW 1. A skin disorder, to include a recurrent skin rash, was not incurred in or aggravated by the Veteran's active duty service and may not be presumed to have been incurred in or aggravated by such service,. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 2. A kidney disorder, to include nephrolithiasis, was not incurred in or aggravated by the Veteran's active duty military service, may not be presumed to have been incurred in or aggravated by such service, and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, (2006), (2012). 3. Hypertension was not incurred in or aggravated by the Veteran's active duty military service, may not be presumed to have been incurred in or aggravated by such service, and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2006), (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between a Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, letters dated in May 2003, May 2006, April 2010, and July 2011 advised the Veteran of the evidence and information necessary to substantiate his service connection claims on a direct and secondary basis as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, the May 2006 and July 2011 letters advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. While several of the notice letters were sent to the Veteran after the initial unfavorable decision in August 2003, his claims were later readjudicated in the August 2012 supplemental statement of the case. Therefore, any defect with respect to the timing of the notice is cured. See Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006); Prickett v. Nicholson, 20 Vet. App. 370 (2006). Relevant to the duty to assist, the Veteran's service treatment records, service personnel records, VA treatment records, VA examination reports and VHA opinions have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. In this regard, an August 2003 response from the Alabama National Guard indicated that they were unable to locate any records suggesting that the Veteran had been a member of that unit. In addition, during a January 2004 DRO hearing, the Veteran testified that he had not received any treatment from a private physician. Additionally, the Veteran was afforded VA examinations and VHA opinions were obtained in order to adjudicate his service connection claims. In this regard, the Board notes that the VHA examiner offered etiological opinions as to the claimed disorders and based his conclusions on a review of the record, to include interviews with the Veteran and full examinations. Moreover, such opinions offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); 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"). As such, the Board finds that the opinions proffered by the VHA examiner are sufficient to assist VA in deciding the instant claims. Moreover, based on the foregoing, the Board determines that the AOJ has substantially complied with the March 2010 and July 2011 remand directives in obtaining the Veteran's updated VA treatment records, providing VCAA notice, and affording the Veteran VA examinations, as applicable to the instant claims, and as such that no further action is necessary in this regard. See D'Aries, supra. Additionally, in July 2009, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, the Court held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing to 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. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the July 2009 hearing, the undersigned Veterans Law Judge enumerated the issues on appeal. Also, information was solicited regarding the etiology of the Veteran's claimed skin disorder, hypertension, and a kidney disorder, to include the Veteran's allegations that they are related to his military service. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. Id. at 497. Furthermore, additional development was undertaken subsequent to the hearing in order to ensure that all necessary evidence was of record. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. In regard to the DRO hearings, conducted in November 2001 and January 2004, the Board also finds that appropriate colloquies were conducted during such proceedings in accordance with 3.103(c)(2), Stuckey v. West, 13 Vet. App. 163 (1999), and Constantino v. West, 12 Vet. App. 517 (1999). Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease 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). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including cardiovascular-renal disease, to a degree of 10 percent within one year and three years, respectively, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Inasmuch as the Veteran's skin disorders are not recognized as chronic under 38 C.F.R. § 3.309(a), the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology are inapplicable to such claim. VA regulations provide that a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period from January 9, 1962, to May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 U.S.C.A. § 1116 ; 38 C.F.R. § 3.307(a)(6)(iii). For purposes of applying the presumption of exposure to herbicides under 38 C.F.R. § 3.307(a)(6)(iii), the serviceman must have actually been present on the landmass or the inland waters of Vietnam during the Vietnam era. See Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008). In the instant case, the record reflects that the Veteran served in the Republic of Vietnam from September 1967 to August 1968. Therefore, he is presumed to have been exposed to herbicides coincident to such service. The diseases presumptively associated with herbicide exposure include chloracne or other acneform disease consistent with chloracne, Type II diabetes, Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemias, multiple myeloma, Non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, Parkinson's disease, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), AL amyloidosis, and soft-tissue sarcoma. 38 C.F.R. § 3.309(e). In September 2011, the National Academy of Sciences (NAS) issued Veterans and Agent Orange: Update 2010 (Update 2010). The Secretary of VA has determined, based upon Update 2010 and prior NAS reports, that a presumption of service connection based on exposure to herbicides in the Republic of Vietnam is not warranted for various health outcomes, to include hypertension. See 75 Fed. Reg. 32,540 (June 8, 2010) Service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board notes that the provisions of 38 C.F.R. § 3.310 were amended during the pendency of the Veteran's appeal, effective October 10, 2006; however, the new provisions state that service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). Although the stated intent of the change was merely to implement the requirements of Allen, supra, the Board finds that the new provisions amount to a substantive change to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the Veteran as it does not require the establishment of a baseline level of disability before an award of service connection may granted. See generally, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. Recurrent Skin Rash The Veteran contends that his current skin rash on his chest began during service and has been recurrent since that time. A January 1966 service entrance examination was negative for any relevant abnormalities and the Veteran denied having, or that he has ever had, any skin diseases in an accompanying Report of Medical History (RMH). In December 1967, the Veteran complained of a skin rash on his crotch. An impression of contact dermatitis was noted in April 1968 following complaints of a rash under the left arm from using "glass wool." An April 1969 service discharge examination was negative for any relevant abnormalities and the Veteran denied having, or that he has ever had, any skin diseases in an accompanying RMH. An October 2001 VA examination reflected the Veteran's reports of an itchy skin disease on the front of the chest wall that began in 1968; a diagnosis of a recurrent skin rash with residuals of scars and mild keloids in front of the chest wall was made. Post-service treatment records reflect various dermatological findings, including five linear keloids on the upper chest in January 2003 and four to five linear scars on the anterior chest in November 2003. During DRO hearings held in November 2001 and January 2004, the Veteran testified that his skin rash began as an itchy little bump on his chest. He recalled seeking treatment for this rash during service but that no one recorded had this treatment. During the July 2009 Board hearing, the Veteran testified that his rash began as an itchy keloid in Vietnam and later spread. He was given an ointment to treat his rash during service and it started spreading more as he got older. After service, he just used antibiotic creams to treat the condition and first saw a physician in 1972 or 1973 to treat this condition. An August 2010 VA examiner, following a physical examination and a review of the Veteran's claims file, opined that the Veteran's keloids on the anterior chest wall were not caused by or related to service as his service treatment records were silent for such a condition. A September 2011 addendum to this opinion indicated that the earlier phrase "not related to service" included exposure to herbicides during service and that there was no rash noted on examination. A January 2013 VHA opinion indicated that the Veteran's skin disorder, namely a recurrent skin rash with residuals of scars/keloids on the anterior chest, was not caused by or related to his service, including his exposure to herbicides. The provider reasoned that no skin rash was noted at the time of the Veteran's separation physical, that he reported being in good health at service separation and that he denied having, or ever having, skin diseases at service separation. Although the Veteran reported chronic symptomology of skin rash since Vietnam, the skin condition that he described was not chloracne or a similar acneform type of rash nor was it porphyria cutanea tarda (a blistering skin condition on sun exposed areas). In an April 2013 addendum to the VHA opinion, the provider opined that the Veteran's skin disorder was not related to his in-service treatment for tinea pedis, a skin rash of the crotch and/or a rash under the left arm/contact dermatitis, as the skin condition that he was making a claim on is not located in the same anatomic area. The Board has first considered whether service connection is warranted as presumptively due to herbicide exposure. However, the Veteran's diagnosed skin disorders are not diseases for which service connection may be granted due to herbicide exposure. As such, presumptive service connection due to herbicide exposure is not warranted for a recurrent skin rash. 38 U.S.C.A. §§ 1101, 1112, 1116; 38 C.F.R. §§ 3.307, 3.309. Likewise, as indicated previously, inasmuch as the Veteran's diagnosed skin disorders are not recognized as chronic diseases under 38 C.F.R. § 3.309(a), presumptive service connection, to include on the basis of continuity of symptomatology, is not warranted. Id. In this regard, the Board notes the Veteran's representative's arguments in the June 2013 Informal Hearing Presentation (IHP) that service connection for a skin rash was warranted based upon chronic symptomology. However, it has been recently held that service connection relating to continuity of symptomatology can only be applied in cases involving conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). See Walker, supra. As the Veteran's recurrent skin rash is not recognized as chronic under the provisions of 38 C.F.R. § 3.309(a), presumptive service connection based solely upon chronic symptomology cannot be granted. Additionally, while the medical evidence of record shows that the Veteran has a diagnosis of a recurrent skin rash with residuals of scars/keloids on the chest, the probative evidence of record demonstrates that the Veteran's recurrent skin rash is not related to his service, to include in-service treatment for skin complaints and/or his herbicide exposure. In this regard, the Board places great probative weight on the VHA examiner's opinion that the Veteran's recurrent skin rash was less likely than not related to service as a skin rash on the chest was not demonstrated during service or at service separation and that the in-service rashes were located on the crotch and under the left arm rather than on the chest. This opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Accordingly, as the probative evidence of records demonstrates that the current recurrent skin rash is not related to service, service connection is not warranted. In addition, the Board notes that the August 2010 VA examiner opined that the Veteran's keloids on the anterior chest wall were not caused by or related to service. This opinion, however, contained no rationale. A medical examination report must contain not only clear conclusions, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. This opinion is therefore afforded no probative weight. The Board notes that the Veteran has contended on his own behalf that his recurrent skin rash is related to his service, to include his in-service treatment for skin complaints and/or herbicide exposure. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's recurrent skin rash and any instance of his service to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Additionally, in a single-judge Memorandum Decision issued by the Court, it was noted that "in the absence of any medical evidence, the record must provide some evidence beyond an appellant's own conclusory statements regarding causation to establish that the appellant suffered from an event, injury or disease in service." Richardson v. Shinseki, No. 08-0357, slip. op. at 4 (Vet. App. May 10, 2010). While the Board recognizes that such single judge decisions carry no precedential weight, they may be relied upon for any persuasiveness or reasoning they contain. See Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992). Here, while the Veteran is competent to describe his purported treatment of a skin disorder during service as well as the current manifestations of a skin disorder, the Board accords his statements regarding the etiology of such disorder little probative value as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, the diagnosis and determination of etiology of a recurrent skin rash requires the interpretation of results found on physical examination and knowledge of the dermatological system. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. Moreover, the Veteran has offered only conclusory statements regarding the relationship between his in-service skin complaints and herbicide exposure and his current recurrent skin rash. In contrast, the VHA examiner took into consideration all the relevant facts in providing an opinion, to include the Veteran's contended in-service treatment of a skin rash and his presumed exposure to herbicdes as well as the current nature of his recurrent skin rash. Therefore, the Board accords greater probative weight to the VHA examiner's opinion. In addition, in adjudicating this claim, the Board must assess not only competency of the Veteran's statements, but also their credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board notes that the Veteran testified during his July 2009 hearing that he had received treatment for skin rash on his chest during service and that he had been given medication to treat the condition. He further alleged that his skin rash has been recurrent since such time. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). In the instant case, the Board finds such statements to lack credibility as they are inconsistent with the other evidence of record and were made under circumstances indicating bias or interest and, therefore, accords no probative weight to such contentions. In this regard, the Veteran denied taking medications and that he had suffered from, or that he had ever suffered from, a skin disease at his April 1969 service discharge. He also denied that he had been treated by a health care practitioner within the past five years for other than minor illnesses or that he had ever had any illness or injury other than those already noted. During his November 2001 hearing, the Veteran testified that he had used his prescribed jock itch cream to treat his chest rash. The Board notes that the Veteran was prescribed medication for a rash on his crotch in December 1967. The Board notes that the Veteran's April 1969 statements were made many years prior to the filing of the instant claim for service connection, and are highly probative as they are contemporaneous with the time in question. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment); see also Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). In addition, the Veteran did not identify any civilian physicians or hospitals where he was treated for any disease for which he was claiming service connection in his July 2000 Application for Compensation or Pension (VA Form 21-526). Therefore, in light of these inconsistent statements, the Board finds the Veteran's statements regarding his in-service onset and his treatment within one year of service discharge to not be credible. Therefore, the Board finds that a skin disorder, to include a recurrent skin rash, is not shown to be causally or etiologically related to any disease, injury, or incident during service, to include the Veteran's in-service skin complaints and/or herbicide exposure. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a skin disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. B. Kidney Disorder The Veteran contends that his kidney disorder was caused by his in-service herbicide exposure and/or aggravated by his service-connected diabetes mellitus. A January 1966 service entrance examination was negative for any relevant abnormalities and the Veteran denied having, or that he has ever had, kidney stones in an accompanying RMH. An April 1969 service discharge examination was also negative for any relevant abnormalities and the Veteran again denied having, or that he has ever had, kidney stones in an accompanying RMH. The remaining service treatment records were negative for complaints, treatments or diagnoses related to any kidney disorder. Post-service treatment records document an ureterolithiasis, which passed spontaneously, in July 1994. In May 2000, a large left ureteral calculus with high grade obstruction was found on cystoureteroscopy. A March 2004 VA renal ultrasound revealed hyperechoic foci within the renal pelvis which were suspicious for small stones and simple benign appearing cysts within the right kidney. Two "normal in size" right kidney stones were noted in August 2004 and renal insufficiency was assessed in July 2007. An October 2001 VA examination reflected the Veteran's reports of a history of intermittent kidney stones for the past 15 years, with the last one removed in July 2000. During the July 2009 Board hearing, the Veteran testified that his kidney condition had been recurrent over the years and did not start until after he was in Vietnam. He was not treated for any kind of kidney problem while on active duty. An August 2010 VA examiner, following a physical examination and a review of the Veteran's claims file, opined that the Veteran's nephrolithiasis (kidney stones) was not caused by or related to service as his service treatment records were silent for such a condition. In addition, he reported the onset of nephrolithiasis in 1972, three years after service, and VA urology notes reported that he had passed a kidney stone in 2000. A September 2011 addendum to the August 2010 VA opinion indicated that the phrase "not related to service" included exposure to herbicides while in service, that there was no nexus of connection between kidney stones and herbicide exposure and that the only kidney disorder found was recurring nephrolithiasis, which was noted to have an onset decades post-military service. A January 2013 VHA opinion indicated that the Veteran's kidney disorder, namely nephrolithiasis, was not caused by or related to his service, to include exposure to herbicides. The examiner noted that kidney stones were not recognized by VA as a presumptive disease associated with herbicide exposure and the Veteran was not treated for any kidney conditions during service. The Veteran also reported the onset of nephrolithiasis in 1972, several years after service separation. In addition, his kidney stones were not caused by or permanently aggravated by his service-connected diabetes mellitus as the onset of kidney stones preceded his diabetes, which was diagnosed in 2005. The Board has first considered whether service connection is warranted on a presumptive basis. However, nephrolithiasis is not a disease for which service connection may be granted due to herbicide exposure. In addition, to the extent that nephrolithiasis is considered a cardiovascular-renal disease, the clinical evidence of record fails to show that the Veteran manifested such kidney disease to a degree of 10 percent within the one year following his active duty service discharge in April 1969. In this regard, the Veteran' service treatment records are negative for such disease and, as he has reported conflicting dates of onset, his statements regarding such are not credible. As such, presumptive service connection based upon herbicide exposure and/or as a chronic disease, to include based on continuity of symptomatology, is not warranted. 38 U.S.C.A. §§ 1101, 1112, 1116; 38 C.F.R. §§ 3.307, 3.309. Additionally, while the medical evidence of record shows that the Veteran has a diagnosis of nephrolithiasis, the probative evidence of record demonstrates that such kidney disorder is not related to his service, to include herbicide exposure, or his service-connected diabetes mellitus. In this regard, the Board places great probative weight on the VHA examiner's opinion that the Veteran's nephrolithiasis was less likely than not related to service as kidney stones were not a disease for which presumptive service connection may be granted based on herbicide exposure and that the onset of the disorder was several years after service. Additionally, the VHA examiner found that his kidney stones were not caused by or permanently aggravated by his service-connected diabetes mellitus as the onset of kidney stones preceded his diabetes, which was diagnosed in 2005. This opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Accordingly, as the probative evidence of records demonstrates that the nephrolithiasis is not related to service or a service-connected disability, service connection is not warranted. In addition, the Board notes that the August 2010 VA examiner opined that the Veteran's kidney disorder was not caused by or related to service. This opinion, however, contained no rationale. A medical examination report must contain not only clear conclusions, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. This opinion is therefore afforded no probative weight. The Board notes that the Veteran has contended on his own behalf that his kidney disorder is related to his service, to include herbicide exposure, or, in the alternative, his service-connected diabetes mellitus. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno, supra. Lay evidence may also be competent to establish medical etiology or nexus. Davidson, supra. However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters, supra. In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's kidney disorder and any instance of his service, or his diabetes mellitus, to be complex in nature. See Woehlaert, supra. Additionally, in a single-judge Memorandum Decision issued by the Court, it was noted that "in the absence of any medical evidence, the record must provide some evidence beyond an appellant's own conclusory statements regarding causation to establish that the appellant suffered from an event, injury or disease in service." Richardson, supra. While the Board recognizes that such single judge decisions carry no precedential weight, they may be relied upon for any persuasiveness or reasoning they contain. See Bethea, supra. Here, while the Veteran is competent to describe his current manifestations of a kidney disorder, the Board accords his statements regarding the etiology of such disorder little probative value as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones, supra. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, the diagnosis and determination of etiology of a kidney disorder the interpretation of results found on physical examination and knowledge of the renal system. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. Moreover, the Veteran has offered only conclusory statements regarding the relationship between his service, to include herbicide exposure, or diabetes mellitus and his current nephrolithiasis. In contrast, the VHA examiner took into consideration all the relevant facts in providing an opinion, to include the Veteran's presumed exposure to herbicides, the nature of his service-connected diabetes mellitus, and the current nature of his nephrolithiasis. Therefore, the Board accords greater probative weight to the VHA examiner's opinion. In addition, in adjudicating this claim, the Board must assess not only competency of the Veteran's statements, but also their credibility. See Buchanan, supra. The Board notes that the Veteran testified during the January 2004 hearing that he has had kidney problems since service. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza, supra. In the instant case, the Board finds such statements to lack credibility as they are inconsistent with the other evidence of record and were made under circumstances indicating bias or interest and, therefore, accords no probative weight to such contentions. In this regard, the Veteran denied taking medications and that he had suffered from, or had ever suffered from, kidney stones at his April 1969 service discharge. He also denied that he had been treated by a health care practitioner within the past five years for other than minor illnesses or that he had ever had any illness or injury other than those already noted. However, during his July 2009 hearing, he testified that he had received treatment for kidney stones within three or four years of service discharge and that his kidney disorder had been present since such time. He further reported the onset of his kidney disorder as 1986 in October 2001 and that its onset was 1972 in August 2010. The Board notes that the Veteran's April 1969 and October 2001 statements were made prior to the filing of the instant claim for service connection, and are highly probative as they are contemporaneous with the time in question. See Rucker, supra; see also Williams, supra. In addition, the Veteran did not identify any civilian physicians or hospitals where he was treated for any disease for which he was claiming service connection in a July 2000 Application for Compensation or Pension (VA Form 21-526). Therefore, in light of these inconsistent statements, the Board finds the Veteran's statements regarding his in-service onset to not be credible. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a kidney disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. C. Hypertension The Veteran contends that his hypertension was caused by his in-service herbicide exposure and/or aggravated by his service-connected diabetes mellitus and/or PTSD. A January 1966 service entrance examination was negative for any relevant abnormalities and the Veteran's blood pressure was measured to be 124/74. The Veteran denied high or low blood pressure in an accompanying entrance RMH. An April 1969 service discharge examination was also negative for any relevant abnormalities and the Veteran's blood pressure was measured to be 120/78. The Veteran denied high or low blood pressure in an accompanying RMH. The remaining service treatment records were negative for any treatment, complaints or diagnoses related to hypertension and there were no other recorded blood pressure readings during service. During a January 2004 hearing, the Veteran testified that he was first diagnosed with hypertension by a civilian doctor "years ago" but that he was not placed on medication until years later. An October 2008 VA examiner indicated that the Veteran's hypertension was diagnosed in 2002, prior to his diagnosis of diabetes mellitus. His blood pressure was measured to be 169/99, 141/95 and 167/93. Following a physical examination and a review of the Veteran' claims file, a diagnosis of hypertension was made. The examiner opined that the Veteran's hypertension was not caused by or related to his service-connected diabetes mellitus. During a July 2009 hearing, the Veteran testified that he did not go to the doctor "too much" after service and that he was diagnosed when he began receiving treatment at VA. His treating doctors have told him that his PTSD was part of his high blood pressure. An August 2010 VA examiner, following a physical examination and a review of the Veteran's claims file, opined that the Veteran's hypertension was not caused by or related to service as his service treatment records were silent for such a condition. A September 2011 addendum to the August 2010 VA opinion indicated that the phrase "not related to service" included exposure to herbicides while in service and that there was no nexus of connection between PTSD and hypertension. The examiner further opined that the Veteran's hypertension preceded his diabetes as he was diagnosed with diabetes in 2006 and diagnosed with hypertension in 2002. It was therefore less likely than not that the Veteran's hypertension was caused by, related to, or worsened beyond the natural progression by diabetes mellitus. A January 2013 VHA opinion indicated that the Veteran's hypertension was not caused by or related to his service, to include exposure to herbicides, as his blood pressure was measured to be 120/78 and the Veteran was not diagnosed with hypertension until 2002, many years after service. The examiner noted that records dated in 2000 indicated that the Veteran had no major illnesses, that he was in good general health and that he took no medications. In addition, his hypertension was not caused by his service-connected diabetes mellitus as it preceded the diabetes by several years and was less likely than not permanently aggravated or worsened beyond the natural progression by the diabetes. Moreover, the hypertension was less likely than not caused by or permanently aggravated by the Veteran's PTSD as the Veteran reported having symptoms of PTSD dating back to when he was in Vietnam and he did not develop hypertension until around 2002, over 30 years later. In an April 2013 addendum to the VHA opinion, the provider opined that the Veteran's hypertension was less likely than not permanently aggravated by or worsened beyond the natural progression by his diabetes. The examiner reasoned that despite a progressive worsening of diabetes control, the Veteran's blood pressure readings have remained within the general range. In addition, the Veteran's hypertension was less likely than not permanently aggravated by his service-connected PTSD as there was insufficient medical literature to support a nexus between PTSD and hypertension. The Board has first considered whether service connection is warranted on a presumptive basis. However, the Board notes that the Veteran's hypertension is not a disease for which service connection may be granted due to herbicide exposure. In addition, the clinical evidence of record fails to show that the Veteran manifested hypertension to a degree of 10 percent within the one year following his active duty service discharge in April 1969. In this regard, the Veteran' service treatment records are negative for such disease and he has not alleged, and the evidence does not support, a continuity of symptomology. As such, presumptive service connection based upon herbicide exposure and/or as a chronic disease, to include based on continuity of symptomatology, is not warranted. 38 U.S.C.A. §§ 1101, 1112, 1116; 38 C.F.R. §§ 3.307, 3.309. Additionally, while the medical evidence of record shows that the Veteran has a diagnosis of hypertension, probative evidence of record fails to demonstrate that such hypertension is related to his service or service-connected PTSD and/or diabetes mellitus. In this regard, the Board places great probative weight on the VHA examiner's opinion that the Veteran's hypertension was less likely than not related to his service or his service-connected disabilities as the Veteran's blood pressure was normal at service separation, that there was insufficient medical literature supporting a nexus between PTSD and hypertension and that his blood pressure readings have remained within the same general range despite worsening diabetes control. This opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Accordingly, as the probative evidence of records demonstrates that the current hypertension is not related to service and/or any service-connected disability, service connection is not warranted. In addition, the Board notes that the August 2010 VA examiner opined that the Veteran's hypertension was not caused by or related to service. This opinion, however, contained no rationale. A medical examination report must contain not only clear conclusions, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. This opinion is therefore afforded no probative weight. The Board notes that the Veteran has contended on his own behalf that his current hypertension is related to his service and/or service-connected disabilities. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno, supra. Lay evidence may also be competent to establish medical etiology or nexus. Davidson, supra. However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters, supra. In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's hypertension and any instance of his service, to include his service-connected PTSD and/or diabetes mellitus, to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, the diagnosis and determination of etiology of hypertension requires the interpretation of results found on physical examination and knowledge of the cardiovascular and genitourinary systems. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. Moreover, the Veteran has offered only conclusory statements regarding the relationship between his service or his service-connected PTSD and/or diabetes mellitus and his current hypertension. In contrast, the VHA examiner took into consideration all the relevant facts in providing an opinion, to include the current nature of the Veteran's hypertension. Therefore, the Board accords greater probative weight to the VA examiner's opinion. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for hypertension. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for a recurrent skin rash with residuals of scars with mild keloids in front of the chest is denied. Service connection for a kidney disorder is denied. Service connection for hypertension is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs