Citation Nr: 1325090 Decision Date: 08/07/13 Archive Date: 08/13/13 DOCKET NO. 02-01 951A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for heart disease (claimed as chest pain), to include as due to herbicide exposure and/or as secondary to service-connected anxiety neurosis. 2. Entitlement to service-connection for hypertension, to include as due to herbicide exposure and/or as secondary to service-connected anxiety neurosis. (The Veteran's claims of clear and unmistakable error in the August 2009 Board decision are addressed in a separate Board decision.) REPRESENTATION Veteran represented by: Arkansas Department of Veterans Affairs ATTORNEY FOR THE BOARD M. McPhaull, Counsel INTRODUCTION The Veteran had active service from January 1969 to April 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in October 2001 and September 2007 by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas, which denied service connection for hypertension and heart disease, respectively. A hearing before a Veterans Law Judge was scheduled for April 2003, but was cancelled by the Veteran. As such, the Veteran's request for a Board hearing is considered withdrawn. 38 C.F.R. § 20.702(e) (2012). The issue of entitlement to service connection for hypertension was denied by the Board in February 2005, but later vacated and remanded by the United States Court of Appeals for Veteran's Claims (Court) in November 2005. The issue was then remanded by the Board again in April 2006 and November 2008. During the course of this appeal, the Veteran also perfected regarding the denial of service connection for heart disease. The two appeals were then merged in this decision under the older docket number. In August 2009, these matters were again remanded for further development, to include adequate notification and obtaining a VA examination and nexus opinion. 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 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). 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. Finally, the Board notes that the Veteran was previously represented by The American Legion. In February 2010, the Veteran signed a VA Form 21-22a (Appointment of Individual as Claimant's Representative) appointing Virginia A. Girard-Brady as his attorney. By way of March 2010 correspondence, Ms. Girard-Brady informed VA that she was no longer representing the Veteran. In March 2012, the Veteran appointed the Arkansas Department of Veterans Affairs as his current representative. The Board notes the change in the Veteran's representation is reflected on the title page. FINDINGS OF FACT 1. The Veteran served in Korea near the Demilitarized Zone (DMZ) during the relevant time frame and exposure to herbicides coincident to such service is presumed. 2. At no time during the pendency of the appeal does the Veteran have a current diagnosis of heart disease. 3. 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 the Veteran's discharge from service; and was not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. Heart disease 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); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2006), (2012). 2. 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); 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 imposes 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 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 the 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 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. Relevant to the Veteran's claim for service connection for heart disease, May 2006 and October 2006 letters, sent prior to the unfavorable rating decision issued in September 2007, as well as September 2009 and April 2010 letters, advised the Veteran of the evidence and information necessary to substantiate his service connection claim on a direct and secondary basis as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letters advised the Veteran of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Pertinent to the Veteran's claim for service connection for hypertension, February 2004, May 2006, June 2008, September 2009, and April 2010 letters, sent after the unfavorable rating decision issued in October 2001, advised the Veteran of the evidence and information necessary to substantiate his service connection claim 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, September 2009, and April 2010 letters advised the Veteran of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. While the February 2004, May 2006, June 2008, September 2009, and April 2010 letters were issued after the initial September 2007 and October 2001 decisions denying the Veteran's claims for service connection for heart disease and hypertension, respectively, the United States Court of Appeals for the Federal Circuit has held that VA could cure such a timing problem by readjudicating the Veteran's claim following a compliant VCAA notification letter. Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006). The Court clarified that the issuance of a statement of the case could constitute a readjudication of the Veteran's claim. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In the instant case, after the February 2004, May 2006, September 2009, and April 2010 letters were issued, the Veteran's claims were readjudicated in July 2004, February 2008, February 2009, and January 2013 supplemental statements of the case. Therefore, any defect with respect to the timing of the VCAA notice has been cured. Relevant to the duty to assist, the Veteran's service treatment records as well as post-service VA, to include those dated June 8, 2001, September 28, 2001, and February 20, 2002, and private treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. In this regard, the Veteran identified VA treatment records dated from 1972, 1973, 1978, and 1983. An August 2007 correspondence from the relevant VA facility documents that there were no records for the Veteran during this time and the Veteran was advised in the February 2008 supplemental statement of the case that such records were unavailable. Furthermore, in a June 2008 letter, the Veteran was requested to provide a copy of an April 11, 1972, VA treatment record that he had previously indicated was in his possession and to provide an authorization and consent form so as to allow VA to obtain private treatment records from Malvern Family Healthcare. To date, no response from the Veteran has been received. Therefore, the Board finds that VA's duty to assist in this regard has been met. In the August 2009 remand, the Board determined that a VA examination was necessary in order to determine the nature and etiology of the Veteran's claimed heart disease and hypertension. However, in March 2010 correspondence, the Veteran advised the AOJ that he refused to attend a VA examination and further indicated that he did not want to be scheduled for a VA examination in his appeals case. In this regard, the duty to assist in the development and adjudication of a claim is not a one-way street. Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996). If a Veteran wishes help, he cannot passively wait for it in circumstances where he may or should have evidence that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193, reconsideration denied, 1 Vet. App. 406 (1991) (per curiam). Therefore, due to the Veteran's refusal to cooperate and attend a VA examination, any evidence expected to be obtained at such examination may not be considered in the adjudication of the Veteran's claims. In light of the Veteran's refusal to attend a VA examination, in January 2013, the AOJ obtained an opinion addressing the nature and etiology of the Veteran's claimed heart disease and hypertension. The Board finds that the opinions of record are adequate to decide such issues as they are predicated on a review of the claims file, which includes the Veteran's statements, his service treatment records, and post-service treatment records. Additionally, the opinions proffered considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. Therefore, the Board finds that the opinion is adequate to decide the Veteran's case as the examiner offered clear conclusions with supporting data as well as a reasoned medical explanation 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"). Therefore, in light of the Veteran's refusal to attend a VA examination, the Board finds that such opinions are adequate to decide the claims herein. With respect to the Veteran's heart disease claim, such issue was remanded in August 2009 in order to provide the Veteran with secondary VCAA notice and afford him a VA examination so as to determine the current nature and etiology of his heart disease. As previously discussed, the Veteran was afforded appropriate VCAA notice, to include on a secondary basis, in September 2009 and April 2010 letters. Additionally, as the Veteran refused to attend a VA examination, an opinion was obtained based on a review of his records in January 2013. Thereafter, the Veteran's claim was readjudicated in the January 2013 supplemental statement of the case. Regarding the Veteran's hypertension claim, such issue was remanded by the Board in November 2003, April 2006, June 2008, and August 2009 in order to provide the Veteran was appropriate VCAA notice as to all aspects of his claim, obtain outstanding VA and private treatment records, and afford him a VA examination so as to determine the current nature and etiology of his hypertension. Likewise, as indicated in the Introduction, the Court remanded such issue in November 2005 in order to obtain outstanding VA treatment records. As previously discussed, February 2004, May 2006, June 2008, September 2009, and April 2010 letters provided the Veteran with appropriate VCAA notice as to all aspects of his claim. Additionally, all identified VA and private treatment records were either requested or obtained. Finally, as the Veteran refused to attend a VA examination, an opinion was obtained based on a review of his records in January 2013. Thereafter, the Veteran's claim was readjudicated in the January 2013 supplemental statement of the case. Therefore, the Board finds that the AOJ has substantially complied with the November 2003, April 2006, June 2008, and August 2009 Board remand directives as well as the November 2005 Court remand directives such that no further action is necessary in this regard. See D'Aries, supra. 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 appellant); 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 appellant 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, he 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 hypertension and cardiovascular-renal disease, to a degree of 10 percent within one year 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, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). The use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A Veteran who, during active military, naval, or air service, served between April 1, 1968, and August 31, 1971, in a unit that, as determined by the Department of Defense, operated in or near the Korean DMZ in an area in which herbicides are known to have been applied during that period, 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)(iv) (in effect since February 14, 2011). Service records document the Veteran was stationed in Korea from July 25, 1969 to August 25, 1970. He was assigned to Unit A Trp. 2d. Sqdn. 10th Cavalry 7th Infantry Division. Herbicides were noted to be used from April 1968 up through August 1971 along the DMZ. Therefore, exposure to herbicides coincident to such service is presumed. If a Veteran was exposed to an herbicide agent during active service, presumptive service connection is warranted for numerous disorders, to include ischemic heart disease. Ischemic heart disease includes acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease and coronary bypass surgery; and stable, unstable, and Prinzmetal's angina. However, hypertension is not included on such list. 38 C.F.R. § 3.309(e), as amended, 75 Fed. Reg. 53,203 (August 31, 2010). In this regard, VA's Secretary has determined that a presumption of service connection based on exposure to herbicides used is not warranted for any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See 68 Fed. Reg. 27,630 (May 20, 2003). 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. Lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). 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). Heart disease The Veteran claims he has heart disease that was incurred during his military service, to include as a result of his exposure to herbicides while serving along the DMZ in Korea, or, in the alternative, as secondary to his service-connected anxiety neurosis. The Veteran's service treatment records reflect that a September 1967 letter from Dr. Berry indicates that the Veteran's father had organic heart disease, but did not mention heart disease with respect to the Veteran. In September 1970, the Veteran complained of a hurting in the chest unrelated to exercise. He was subsequently admitted for treatment for syncopal episodes. Chest X-ray was negative. In December 1971, service treatment records reflect complaints of fainting spells, which were preceded by a bitemporal pain and a left chest pain. Following examination, psychoneurosis, anxiety type; conversion reaction; and hyperventilation syndrome were diagnosed. The service treatment records are negative for any findings or diagnoses referable to heart disease. On service discharge examination, clinical evaluation of the Veteran's heart was normal. In May 1972 the Veteran underwent VA evaluation for his blackout complaints. The blood pressure reading was 132/80. An electrocardiogram (ECG) was considered normal. A chest x-ray was normal. A VA examination was conducted in January 1978. The report of an ECG was considered normal. VA treatment records include a September 2001 and a February 2002 treatment record that documents a diagnosis of coronary artery disease based upon the Veteran's complaints of chest pain. The Veteran notably refused any testing that would definitively show heart disease. Post-service treatment records include 2006 private treatment records from Malvern Family Healthcare, which documents the Veteran's complaints of and treatment for chest pain. No definitive diagnosis of heart disease is noted. In January 2006, August 2006, and March 2007 letters, Dr. Rivas from Malvern Family Healthcare indicated that the Veteran's diagnosis of hypertension with chest pains had been an ongoing complaint and, according to all of the records provided to him, such was a military service-related medical problem. Dr. Rivas further indicated that the Veteran discussed his prior medical history with him and provided extensive medical documentation, which indicated that the Veteran was given a medical discharge from military service due to his hypertension and chest pains. Furthermore, in the March 2007 letter, he further stated that the Veteran had discussed his prior medical history with him and the Veteran indicates a previous cerebrovascular accident and demonstrates residual left hemiparesis, and coronary artery disease with status post myocardial infarction. Based on the notations in the VA treatment records as well as Dr. Rivas's letters, in the August 2009 remand, the Board noted that the Veteran had a diagnosis of coronary artery disease and, in light of his complaints of left chest pain in service (although such had been attributed to anxiety), determined that a VA examination was necessary in order to determine the nature and etiology of the Veteran's heart disease. As discussed previously, due to the Veteran's refusal to cooperate and attend a VA examination, any evidence expected to be obtained at such examination may not be considered in the adjudication of the Veteran's claim for service connection for heart disease. On January 2013 VA medical chart review, the examiner noted that the Veteran's service treatment records did not show treatment for heart disease. He observed that, post-service, the Veteran declined catherization or stress testing to clarify if he indeed has ischemic heart disease. The examiner further noted that the available laboratory testing for heart disease was unremarkable for an acute myocardial infarction. Based upon the complete review of the Veteran's claims file, the examiner found no evidence of ischemic heart disease or atherosclerotic heart disease. Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C.A. § 1110; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). "In the absence of proof of a present disability there can be no valid claim." See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The current disability requirement for a service connection claim is satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007). The Board finds that the Veteran does not have a current diagnosis of heart disease. While VA treatment records and Dr. Rivas have indicated a reported diagnosis of heart disease, to include coronary artery disease (which is recognized as ischemic heart disease), the Board finds that such diagnoses are not supported by objective testing. Instead, such diagnoses were made based on the Veteran's reported history. In this regard, Dr. Rivas's opinion has completely misstated the Veteran's history in that he was not discharged from military service for hypertension with chest pains. Rather, his service treatment records reflect no diagnosis of hypertension and relate his chest pains to a psychiatric diagnosis. The Court has held that a medical opinion based on an inaccurate or incomplete factual premise is not probative. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Therefore, as noted by the January 2013 VA examiner, objective testing is needed in order to determine a diagnosis of heart disease; however, as the Veteran did not report for such examination, the diagnostic testing could not take place. Therefore, the Board finds that the probative evidence of record shows that, at no time during the pendency of the appeal, does the Veteran have a current diagnosis of heart disease. Moreover, while the Veteran, as a layperson, has stated that his chest pain is indicative of heart disease, the Board finds that he is not competent to relate such symptomatology to a specific diagnosis or etiology as he does not possess the requisite specialized knowledge. In this regard, a diagnosis of heart disease requires the administration and interpretation of testing and laboratory results. As noted, the Veteran has refused the necessary testing in order to determine if he does in fact have heart disease. Therefore, as such is a complex medical question, the Veteran is not competent to offer a diagnosis of heart disease. 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). Consequently, the probative evidence is against the finding that the Veteran has a current diagnosis of heart disease during the appeal period. For the foregoing reasons, service connection is not warranted for heart disease on a direct, presumptive, or secondary basis. 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 heart disease. 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. Hypertension The Veteran contends that his hypertension is related to service, to include his presumed exposure to herbicides, or, in the alternative, as secondary to his service-connected anxiety neurosis. He asserts he was diagnosed with hypertension during service and was prescribed medication. Service treatment records do not note a diagnosis of hypertension. However, the Veteran complained of several symptoms of hypertension throughout service and had elevated blood pressure levels. According to the National Institutes of Health and the National Heart, Lung and Blood Institute, normal blood pressure is a systolic reading of less than 120 or a diastolic reading of less than 80. Prehypertension is classified as a systolic reading between 120-139 or a diastolic of 80-89. Stage one hypertension is a systolic of 140-159 or a diastolic of 90-99 and stage two hypertension is a systolic of 160 or a diastolic greater than or equal to 100. "Prevention, Detection, Evaluation, and Treatment of High Blood Pressure," National Institute of Health, National Heart, Lung, and Blood Institute (2003). For VA purposes, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. The term hypertension means that the diastolic blood pressure is predominantly 90mm. or great, and isolated systolic hypertension means that the systolic blood pressure 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. The Veteran's entrance examination noted a blood pressure of 120/80, and did not note any history of hypertension. This blood pressure is considered prehypertension. The Veteran complained of blacking out in September 1970. His blood pressure was 142/68, which falls under the stage one hypertension category. Additionally, the Veteran complained of other symptoms common with hypertension such as headaches and nosebleeds. The Veteran was subsequently hospitalized for his blackouts in September 1970. A blood pressure reading taken there reported a pressure of 130/80, indicative of prehypertension. The Veteran's separation examination in December 1971 reported a blood pressure of 136/84, also a prehypertensive reading. In the report of medical history taken for the separation examination, it was noted that the Veteran stated he was told he had high blood pressure once. The Veteran was afforded a VA examination in May 1972, a year after discharge from service. Blood pressure at that time was 132/80, indicating prehypertension. Additionally, during a VA examination in March 1983, the Veteran's blood pressure was 140/84, which falls into the stage one hypertension category. A VA examination was conducted in January 1978. The report of an ECG was considered normal. The blood pressure reading was 110/78. The diagnosis was anxiety neurosis. Of record are private medical records showing treatment during 2000 and 2001. On May 2000 the Veteran's blood pressure was 146/90. A June 2000 report shows a diagnosis of hypertension. Subsequent VA records dated from March 2001 to September 2009 show treatment for various disorders, to include hypertension. A June 2001 report contains a diagnosis of hypertension. It was remarked that his medication Atenolol was to be increased. In January 2006, August 2006, and March 2007 letters, Dr. Rivas from Malvern Family Healthcare indicated that the Veteran's diagnosis of hypertension with chest pains had been an ongoing complaint and, according to all of the records provided to him, such was a military service-related medical problem. Dr. Rivas further indicated that the Veteran discussed his prior medical history with him and provided extensive medical documentation, which indicated that the Veteran was given a medical discharge from military service due to his hypertension and chest pains. Furthermore, in the March 2007 letter, he further stated that the Veteran had discussed his prior medical history with him and the Veteran indicates a previous cerebrovascular accident and demonstrates residual left hemiparesis, and coronary artery disease with status post myocardial infarction. As discussed previously, due to the Veteran's refusal to cooperate and attend a VA examination, any evidence expected to be obtained at such examination may not be considered in the adjudication of the Veteran's claim for service connection for hypertension. On January 2013 VA medical chart review, the examiner noted that the Veteran's service treatment records did not show treatment for essential hypertension. The examiner noted that the hypertension was diagnosed well after service. Based on a thorough review, the examiner found that there was no evidence of essential hypertension during active duty therefore it was less likely as not that the hypertension was related to service. Also the examiner opined that there was no objective medical evidence that hypertension was medically related to Agent Orange exposure, and therefore it was less likely as not related. Finally, the examiner noted that the hypertension was not caused or aggravated by the service-connected anxiety disorder. He indicated that there was no repeated objective medical study that proves anxiety disorder causes or aggravates hypertension. The Board finds that the preponderance of the evidence is against service connection for hypertension on a presumptive basis. First, there is no evidence of a diagnosis of hypertension within one year after the Veteran's discharge. While he had blood pressure readings that may have fallen into the prehypertensive or stage one hypertension categories during such time, there is no indication that hypertension in accordance with VA regulations was diagnosed. Moreover, the earliest record that documents a diagnosis of hypertension is in 2000, which is 28 years after his service discharge. Furthermore, a continuity of hypertension symptomatology between the time of the Veteran's discharge and the diagnosis of such disease is not demonstrated or alleged. See Walker, supra. Therefore, service connection based on the manifestation of a chronic presumptive disease within one year of service discharge is not warranted. Second, presumptive service connection based on exposure to herbicides is also not warranted. In this regard, while the Veteran served in Korea along the DMZ during the relevant time period and is therefore presumed to have been exposed to herbicides during service, hypertension is not a disease for which a presumption based on herbicide exposure is warranted under section 3.309(e). Significantly, in July 2009, the National Academy of Sciences (NAS) issued "Veterans and Agent Orange: Update 2008" (Update 2008). The Secretary, based upon Update 2008 and prior NAS reports, has specifically concluded that a presumption of service connection based on exposure to herbicides is not warranted for hypertension. See 75 Fed. Reg. 32540 (June 10, 2008). Notwithstanding the foregoing presumption provisions, the Federal Circuit has determined that a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Nevertheless, the claim is also denied on a direct basis. First, there is no evidence of a diagnosis of hypertension in conformity with VA regulations in service. Moreover, hypertension was not diagnosed until 2000, approximately 28 years after service. Furthermore, the January 2013 VA examiner determined that, based on the time period in which the Veteran's hypertension manifested (many years after discharge), it did not exist in service, did not originate in service, and was not etiologically related to service. As the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two, the Board accords great probative weight to his opinion. 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"). In contrast, Dr. Rivas's opinion has completely misstated the Veteran's history in that he was not discharged from military service for hypertension with chest pains. Rather, his service treatment records reflect no diagnosis of hypertension and relate his chest pains to a psychiatric diagnosis. The Court has held that a medical opinion based on an inaccurate or incomplete factual premise is not probative. See Reonal, supra. Moreover, Dr. Rivas's opinion relating hypertension to the Veteran's military service is conclusory in nature and he does not provide a rationale. See Nieves-Rodriguez, supra; Stefl, supra. Therefore, the Board accords his opinion no probative weight. Finally, the Board finds that service connection for hypertension as secondary to anxiety neurosis is not warranted. In this regard, the January 2013 VA examiner specifically opined that the Veteran's hypertension was not caused by his anxiety neurosis. With regard to whether the hypertension is aggravated by the Veteran's service-connected anxiety neurosis, as above, the January 2013 VA examiner could find no evidence that anxiety disorder aggravates hypertension, indicating that there were no medical studies to support such theory. As the VA examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two, the Board accords great probative weight to the opinion. See Nieves-Rodriguez, supra; Stefl, supra. There is no contrary medical opinion of record. While the Veteran contends that his hypertension is related to military service or secondary to anxiety neurosis, the Board accords his statements regarding the etiology of this 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. West, 12 Vet. App. 460, 465 (1999). In this regard, the question of causation and aggravation of hypertension involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. 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. See Jandreau, supra; see also Woehlaert, supra. Therefore, based on the foregoing, the Board finds that service connection for hypertension is not warranted on a presumptive, direct, or secondary basis. 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 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 heart disease is denied. Service-connection for hypertension is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs