Citation Nr: 1328044 Decision Date: 09/03/13 Archive Date: 09/10/13 DOCKET NO. 05-13 079 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to service connection for hypertension, to include as secondary to a service-connected disability. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD L. J. N. Driever INTRODUCTION The Veteran served on active duty from June 1968 to September 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a September 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The Veteran and his spouse testified in support of this claim during a hearing held at the RO before the undersigned Veterans Law Judge (VLJ) in July 2007. In October 2007, August 2011, and August 2012, the Board remanded this claim to the RO for additional development via the Appeals Management Center (AMC) in Washington DC. According to the Veteran's electronic file (Virtual VA), there is additional pertinent evidence of record not in the claims folder, which the RO considered in support of this claim in a Supplemental Statement of the Case issued in January 2013. FINDINGS OF FACT 1. The Veteran's hypertension did not have its onset during active service and is not related to any in-service disease, event, or injury. 2. The Veteran's hypertension was not caused or aggravated by his service-connected diabetes mellitus or arteriosclerotic heart disease. CONCLUSION OF LAW Hypertension was not incurred in active service, may not be presumed to have been so incurred, and is not proximately due to or the result of, or aggravated by, a service-connected disability. 38 U.S.C.A. § 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. The Veterans Claims Assistance Act (VCAA) Upon receipt of a complete or substantially complete application for benefits, VA is tasked with satisfying certain procedural requirements outlined in the VCAA and its implementing regulations. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The U.S. Court of Appeals for Veterans Claims (Court/CAVC) has mandated that VA ensure strict compliance with these provisions of the VCAA. Quartuccio v. Principi, 16 Vet. App. 183 (2002). A. Duty to Notify The VCAA and its implementing regulations provide that VA is to notify a claimant and his representative, if any, of the information and medical or lay evidence not of record that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and his representative, if any, of which portion of the evidence the claimant is to provide and which portion of the evidence VA will attempt to obtain on the claimant's behalf. 38 U.S.C.A. § 5103. These notice requirements apply to all five elements of a service-connection claim: (1) Veteran status; (2) existence of disability; (3) a connection between service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Ideally, the RO should provide the claimant VCAA prior to its initial unfavorable decision on the claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason the RO does not, or provides the notice in a timely manner but it is inadequate or incomplete, the RO can effectively cure this error by providing any necessary VCAA notice and then readjudicating the claim in a statement of the case (SOC) or supplemental SOC (SSOC). In such a case, the intended purpose of the notice is not frustrated, rather preserved, and the claimant is given ample opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Supreme Court has made clear that VCAA notice errors, even when shown to have occurred, are not presumptively prejudicial, instead, must be judged on a case-by-case basis. As the pleading party attacking the agency's decision, the Veteran has the burden of proof of not only establishing error but also, above and beyond that, of showing how it is unduly prejudicial, meaning outcome determinative of his claim, i.e., more than harmless. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The RO provided the Veteran VCAA notice on his claim by way of letters dated in July 2003, April 2005, October 2007, September 2008, December 2008, April 2009, August 2011 and August 2012. The RO most recently readjudicated this claim in a January 2013 SSOC, curing any timing deficit associated with all but the initial notice letter. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). The content of these letters reflects compliance with the pertinent statutory and regulatory provisions and case law. Therein the RO acknowledged the Veteran's claim, notified him of the evidence needed to substantiate it, identified the type of evidence that would best do so, notified him of VA's duty to assist and indicated it was developing his claim pursuant to this duty. The RO also provided him all necessary information on disability ratings and effective dates in the event service connection is granted. The RO identified the evidence it had received in support of the Veteran's claim and the evidence it had requested, but not yet received. The RO identified the evidence that VA is responsible for obtaining and indicated it would make reasonable efforts to assist the Veteran in obtaining all outstanding evidence provided he identified the sources of it. The RO also noted that, ultimately, it was his responsibility to ensure VA's receipt of all pertinent evidence. The Board provided the Veteran further notice during his July 2007 hearing and in subsequently issued remands. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that, pursuant to 38 C.F.R. § 3.103(c)(2), a Veterans Law Judge (VLJ) who chairs a hearing must satisfy two duties: (1) fully explaining the issue; and (2) suggesting the submission of evidence that may have been overlooked. The VLJ in this case satisfied both duties. She discussed the nature of this case, determined that the Veteran was claiming entitlement to the benefit being sought on a secondary basis, as related to his diabetes, not on a direct basis, and questioned whether there was an opinion of record linking the Veteran's hypertension to his diabetes. See transcript at 2, 9-10. Even assuming otherwise, due to the remands that followed, any decision to proceed in adjudicating this claim is harmless, not prejudicial to the Veteran or affecting the essential fairness of the adjudication of this claim. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004); Bernard v. Brown, 4 Vet. App. 384 (1993). In remands dated in October 2007, August 2011 and August 2012, the Board further explained the nature of this claim by noting the deficiencies that existed in the various medical opinions of record. In addition, the Board specifically identified evidence that had been overlooked and emphasized the importance of obtaining that evidence and also an adequate opinion as to the etiology of the Veteran's hypertension. The Veteran has received all essential notice, has had a meaningful opportunity to participate effectively in the development of this claim, and is not prejudiced by any technical notice deficiency along the way. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir., 2004). Neither he nor his representative asserts that VA failed to comply with VCAA's notice provisions or the requirements of Bryant. B. Duty to Assist VA also has a duty to assist a claimant in obtaining evidence necessary to substantiate a claim, including, in certain cases, by affording him a medical examination or obtaining a medical opinion, but such assistance is not required if there is no reasonable possibility that it would aid in substantiating the claim. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b), (c). In this case, in accordance with the Board's remands, the RO obtained all available treatment records, afforded the Veteran VA examinations, and obtained opinions discussing the etiology of the Veteran's hypertension. After the initial opinions were determined to be inadequate to decide this claim, the Board remanded the claim yet again to ensure that a more comprehensive, adequate medical opinion was obtained. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). However, unless the claimant challenges the adequacy of the examination or opinion, the Board may assume that the examination report and opinion are adequate and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011) (holding that, although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-1291 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Id. Indeed, even when there is this challenge, the Board may assume the competency of any VA medical examiner, including even nurse practitioners, as long as, under 38 C.F.R. § 3.159(a)(1), the examiner is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). In a March 2013 Written Brief Presentation, the Veteran claims that the most recent opinion, dated in August 2012, is inadequate to proceed and that another remand is necessary before the Board adjudicates this claim. He argues that the examiner failed to comply with the Board's August 2012 remand order instructing the examiner to determine whether the Veteran's hypertension was aggravated by his diabetes, and to address a March 2003 treatment record (dated after the onset of diabetes) noting that the Veteran's blood pressure was out of control, the average of six blood pressure readings taken between 1998 and 2001 (before the onset of diabetes), and the average of 14 blood pressure readings taken between May 2002 and September 2003 (after the onset of diabetes). Indeed the examiner did not specifically address these findings. And as the representative points out, they do seem to suggest a worsening with the average blood pressure readings increasing from 144/97 to 164/97 after the Veteran was diagnosed with diabetes in 2002 and, at one point in 2003, becoming out of control. The Board does not believe, however, that another remand is necessary to discuss these findings. This is so because the VA examiner substantially complied with the Board's remand instructions. Her August 2012 opinion is premised on the acknowledgement that the Veteran's hypertension may have worsened as alleged, just not due to the diabetes. Given the examiner's concession regarding the worsening, to remand for an addendum opinion addressing findings that show such worsening, would be redundant and would not serve any useful purpose. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Court or the Board confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders); see Dyment v. West, 13 Vet. App. 141 (1999) (holding that remand not required under Stegall where there was substantial compliance with remand directives). The Board also notes that in her August 2012 addendum opinion, the VA examiner concluded that that "it is not likely" that the Veteran's hypertension was aggravated by his diabetes mellitus; thereby employing an incorrect standard. However, in her prior August 2011 opinion she employed the correct standard, i.e., that it was less likely as not (less than 50 percent probability) that the Veteran's hypertension was caused or aggravated by his diabetes mellitus. When viewed in totality, the two medical opinions sufficiently reflect the intent of the examiner's opinion that the Veteran's diabetes mellitus did not aggravate his hypertension. Therefore, a fourth remand for an additional opinion is not required. Given the development that has occurred, it is difficult to discern what additional guidance VA could have provided the Veteran regarding the evidence needed to substantiate his claim. See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."). See also Reyes v. Brown, 7 Vet. App. 113, 116 (1994) and Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances when a remand would not serve any useful or meaningful purpose or result in any significant benefit to the Veteran and, instead, place even greater burden on VA's already limited resources). II. Analysis The Veteran seeks a grant of service connection for hypertension on the basis that it is secondary to, or more specifically, aggravated by his service-connected diabetes and/or heart disease. He claims that Drs. Mounir and Torres have related the hypertension and diabetes. According to the Veteran's and his spouse's July 2007 hearing testimony, the Veteran was controlling his blood pressure with medicine in 1991, but it started to fluctuate in 1994 or 1995 and was still fluctuating in 2001, when Dr. Fitzgerald missed diagnosing the diabetes. Another doctor diagnosed the diabetes in 2002, at the same time the Veteran's heart condition was manifesting. Allegedly, Dr. Fitzgerald later apologized, saying that she did not catch the diabetes because she was so busy treating the blood pressure fluctuations. The representative points out that the Veteran is already service connected for a heart disability, that hypertension and diabetes are medically documented as comorbities with one indubitably complicating the treatment of the other, and that no examiner has discussed how the co-manifestation of the diabetes and hypertension has not affected his hypertension. The representative refers to a March 2003 treatment record (dated after the onset of diabetes) noting that the Veteran's blood pressure was out of control, the average of six blood pressure readings taken between 1998 and 2001 (before the onset of diabetes), and the average of 14 blood pressure readings taken between May 2002 and September 2003 (after the onset of diabetes). Allegedly, these findings establish a worsening with the average blood pressure readings increasing from 144/97 to 164/97 after the Veteran was diagnosed with diabetes in 2002 and, at one point in 2003, becoming out of control. The representative also indicated that the Veteran's heart disorder could exacerbate his hypertension. The representative requests that the benefit-of-the-doubt rule be applied in this case. The Veteran has submitted lay statements dated in 2007 in support of his claim, including from Z. A., his stepson, A. L., his brother, J. M. and D. P., his friends, and C, L., a client. According to these individuals, the Veteran's health and ability to perform his duties as a mechanic have deteriorated over the years, he has lost his ability to enjoy life generally, work, fish, tinker on small motors and ride his motorcycle due to a loss of manual dexterity in his hands and debilitating illness, and often becomes short-winded by the heat. None of these individuals specifically addressed the Veteran's hypertension. The Board acknowledges all lay statements of record, both written and oral, but considering them in conjunction with all of the medical information of record, finds that the preponderance of the evidence is against a grant of service connection for hypertension on any basis. As discussed below, this disability is not related to the Veteran's active service or a service-connected disability, including via aggravation, and did not manifest to a compensable degree within a year of his discharge from active service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval or air service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). To prevail on the issue of service connection, there must be competent evidence of: (1) a current disability; (2) in-service occurrence or aggravation of a disease or injury; and (3) a nexus between the in-service injury or disease and the current disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Once evidence is determined to be competent, its credibility must be evaluated. Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency, a legal concept focusing on whether testimony may be heard and considered, and credibility, a factual determination focusing on the probative value of the evidence); see also Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994) (in rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises or authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). In certain instances, however, a lay statement may be deemed competent and adequate to support a claim for service connection by substantiating the occurrence of lay-observable events or a disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence); Barr v. Nicholson, 21 Vet. App. 303 (2007) (layperson is competent to report disease with unique and readily identifiable features such as varicose veins); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Certain diseases are considered chronic, per se, such as cardiovascular-renal disease, including hypertension. 38 U.S.C.A. § 1101; 38 C.F.R. § 3.309(a). If a chronic disease is shown in service, subsequent manifestations of the same disease, however remote, are to be service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). When a chronic disease is at issue, such as hypertension or any other disease enumerated at 38 C.F.R. § 3.309(a), see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), a claimant may establish entitlement to service connection based on a demonstration of continuity of symptomatology. Evidence of continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Continuity of symptomatology may be demonstrated by submitting evidence showing: (1) that a condition was "noted" during service; (2) post-service continuity of the same symptomatology; and (3) a nexus between the present disability and the post-service symptomatology. Savage v. Brown, 10 Vet. App. 488, 495-97; see also Hickson v. West, 12 Vet. App. 247, 253 (1999) (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection). Service connection may 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) (2012). Service connection may be presumed for chronic disease such as hypertension if it is shown that a veteran served continuously for 90 days or more during a period of war or during peacetime after December 31, 1946, the condition manifested to a degree of 10 percent within one year from the date of discharge, and there is no evidence of record establishing otherwise. 38 U.S.C.A. §§ 1101, 1112(a), 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). Service connection may also be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In this case, post-service medical documents, including VA and private treatment records dated since the Veteran filed his claim, an August 2004 letter from Dr. Mounir, a November 2004 letter from Dr. Torres, reports of VA examinations conducted in May 2005, May 2009, and March 2010, and VA medical opinions dated August 2009 and August 2012, the Veteran currently has essential hypertension. The question thus becomes whether this disability was incurred in the Veteran's active service or was caused or aggravated by his service-connected diabetes mellitus and/or service-connected arteriosclerotic heart disease, status post coronary artery bypass graft, congestive heart failure. The Veteran was not diagnosed with hypertension during active service. Medical professionals checked his blood pressure in January 1968 and September 1969 and his readings were normal, including 112/72 and 118/60. During a VA examination conducted in July 1996, after the Veteran filed a prior claim for service connection for hypertension, the Veteran reported a history of hypertension since approximately 1970. During a VA outpatient treatment visit dated April 2003, after the Veteran filed this claim, the Veteran reported a history of severe hypertension with diastolic readings as high as 130 since the age of 21, which, according to his birth date, means at some point between February 1969 to February 1970. Medical records in the claims file, including those from service, do not substantiate this history. Rather, they indicate that a physician first diagnosed the Veteran with hypertension in 1988. The Veteran began taking medication for this condition in 1988, but in 1990, reported that he had refrained from doing so for the past year. His blood pressure readings were high. Doctors again prescribed medication, but in 1992, the Veteran reported that he had refrained from taking it because it gave him Charlie horses in his legs. He indicated that he had been on the same medication for two years and had not tried any others. Thereafter, through November 1994, physicians prescribed the Veteran different medications for his hypertension, which, according to his spouse, he stopped taking three or four times. In November 1994, he presented indicating that he had stopped taking the most recent medication four months ago due to severe headaches and vomiting. Blood pressure readings reflected uncontrolled hypertension. In May 1995, he was diagnosed with hypertensive cardiovascular disease. During a VA examination conducted in July 1996, an examiner confirmed the Veteran's essential vascular hypertension with hypertensive cardiovascular disease and indicated that he was on therapy for the condition. From 1998 to 2001, the Veteran's hypertension resulted in higher blood pressure readings, including 118/84 (1998), 182/102, which resulted in a recommendation to reevaluate his drugs (1999), and 154/112, which resulted in an increase of medication (2000). In 2001, the Veteran presented complaining of pain and burning while urinating, weakness and shortness of breath on exertion. The Veteran reported that he was taking only half of his medication, rather than the recommended dose. His blood pressure that visit and during other 2001 visits was 168/104, 170/118, 150/118, 125/72 and 148/94. In 2002, the Veteran began complaining of burning and pain in his feet. By May of that year, a physician attributed the burning to untreated diabetes. Blood pressure readings taken between April 2002 and May 2002 include 130/84 and 120/86. A physician officially diagnosed the Veteran with diabetes mellitus on June 12, 2002. That day, the Veteran had blood pressure of 124/74. In July 2002, the Veteran presented with shortness of breath for a couple of months. He had slightly elevated blood pressure of 143/86. In October 2002, he had blood pressure of 142/94. The physician noted that the Veteran had good control of his diabetes, but needed to lose weight, and still had elevated blood pressure. He increased the Veteran's blood pressure medicine. In December 2002, a physician characterized the Veteran's hypertension as severe. He also noted that he was concerned as the Veteran seemed to have developed congestive heart failure since the last visit. In March 2003, the Veteran reported that his blood pressure was always high. A physician confirmed that the Veteran had a progressive problem with hypertension. That month, the Veteran's blood pressure was 217/110, 150/90, 172/111, 117/114, 60/106, 158/114, 180/128, 144/84, 170/100, 172/118 and 178/118. On March 25, 2003, a physician noted that the Veteran's blood pressure was out of control. She wrote that the Veteran had been taking one of his medications, but did not recall that he needed to take another medication as well. She increased the dose of both. The next month, in April 2003, the Veteran had blood pressure of 155/79 and reported that he felt good. Subsequently during a cardiology consultation, a physician noted that the Veteran had a history of severe hypertension with diastolic readings as high as 130 since the age of 21. In May 2003, he had blood pressure of 158/118. The next day he presented to the clinic saying that he had not had his medication for the day. His blood pressure was 184/134, 150/100, 136/84 and 146/96. In May 2003, the Veteran was hospitalized for a right and left heart catheterization and bilateral renal angiogram (for severe hypertension) and left ventricle gram. At the time, his blood pressure was elevated (184/115) even though he had taken his medication. The procedure revealed severe two vessel coronary artery disease, which necessitated surgery. The renal angiogram revealed normal renal arteries without stenoses. Following the procedure, until the third day of recovery, the Veteran had blood pressure of 182/112, 176/99, 151/92, 165/94, 156/91 and 181/112. Thereafter, beginning a week after the procedure, he had blood pressure of 163/96, The Veteran underwent the recommended surgery - a coronary artery bypass - in June 2003. In a letter dated August 2004, Dr. Mounir indicated that, despite medical treatment, the Veteran had significant ventricular dysfunction with a diminished ejection fraction and symptoms of congestive heart failure, and was complaining of visual disturbances and numbness in the arms and legs, which he believed was due to his diabetes. He did not discuss the etiology of the hypertension. Effective May 2002 and May 2003, respectively, the RO granted the Veteran service connection for diabetes mellitus, type II, with cataracts, and arteriosclerotic heart disease, status post coronary artery bypass graft, congestive heart failure. Service connection remains in effect for these conditions. In 2004, the Veteran had his blood pressure read on numerous occasions and intermittently the readings were high. Physicians described the hypertension as uncontrolled and frequently adjusted the Veteran's medication. In a November 2004 letter, Dr. Torres confirmed that, despite treatment, the Veteran has diabetes mellitus manifesting as visual disturbances and numbness in the extremities, uncontrolled hypertension and edema in the lower extremities, a significant left ventricular dysfunction with diminished ejection fraction, symptoms of congestive heart failure and hypercholesterolemia. She noted that the Veteran's severe coronary artery disease necessitated a coronary artery bypass in June 2003. She did not address the relationship between the Veteran hypertension and service-connected diabetes and/or heart disease. Since then, the Veteran has continued to receive treatment for hypertension, sometimes normal, sometimes high, often characterized as controlled, rarely characterized as uncontrolled. He has also continued to receive treatment for diabetes and heart disease. It appears that, since 2004, his hypertension has improved, albeit minimally. In a report of a VA heart examination conducted in May 2005, an examiner confirmed this fact. He noted that the Veteran had hypertension since 1990, which, initially, was poorly controlled with beta blockers and diuretics. The examiner also noted a history of angina syndrome since approximately 1999, diabetes mellitus since approximately 2000, two episodes of acute coronary syndrome in 2000, and heart surgery in 2000 without any further acute coronary syndrome or myocardial infarction. He characterized the Veteran's essential vascular hypertension as well controlled with current management. Multiple medical professionals have addressed whether the hypertension is related to the Veteran's active service or service-connected diabetes and/or heart disease. In an addendum report of a VA examination dated in March 2010, an examiner opined that the Veteran's hypertension was not caused by or aggravated by his diabetes. He based this opinion on a finding that the Veteran had hypertension years before the onset of his diabetes, but no nephropathy. In a written opinion dated August 2011, another examiner opined that it is less likely than not that the Veteran's hypertension had its clinical onset during active service or is related to an in-service disease, event or injury. The examiner based this opinion on the following findings: (a) There is no indication in the service treatment records of elevated blood pressure or hypertension; (b) There is no objective data indicating onset of hypertension prior to the latter 1980s; (c) There is a single statement made in 2003, during a cardio consultation, and no other reference indicating that the Veteran had hypertension since the age of 21; (d) In September 1969, while in service, the Veteran's blood pressure was documented as 118/60; and (e) In other VA examination reports, the Veteran reported a history of hypertension onset in the 1980s. That examiner also opined that it is less likely than not that the Veteran's hypertension was caused or aggravated by his service-connected diabetes. She based this opinion on the following findings: (a) The Veteran had the onset of diabetes in 2002; (b) It is clearly documented that the Veteran had the onset of hypertension since at least 1990; therefore the hypertension preceded the diabetes; (c) A review of the blood pressure readings dated from 1999 to the present reflects no indication of a worsening or aggravation of the hypertension since the onset of the diabetes in 2002; (d) There is also no indication of persistent or recurring proteinuria (June 2011 testing results are normal and negative for protein) so no diagnosis of diabetic nephropathy; and (e) It is through diabetic nephropathy that diabetes is associated with hypertension. That examiner finally opined that it is less likely than not that the Veteran's hypertension was caused or aggravated by his service-connected heart disease. She based this opinion on the following findings: (a) Per literature review and common medical knowledge, hypertension is recognized as a major risk factor for premature cardiovascular disease, left ventricular hypertrophy and heart failure; and (b) These same heart conditions are not risk or aggravating factors for hypertension. In August 2012, on request of the Board, the August 2011 examiner elaborated on the rationale for her previous opinion that the Veteran's service-connected diabetes did not aggravate his hypertension. She again noted that hypertension and diabetes are often comorbid conditions, and acknowledged the Veteran's claim that his hypertension worsened following the 2002 diabetes mellitus, but indicated that, even given any worsening, she would not change her opinion. She explained that medical literature supports a finding that diabetic nephropathy - not simply diabetes - may cause a worsening of hypertension but noted that, in the Veteran's case, there was no evidence of diabetic nephropathy. She cited to the results of urine testing dated from 2010 to 2012, which establish no evidence of proteinuria, including microalbuminuria, findings that would support a diagnosis of diabetic nephropathy. She then concluded that any worsening of the hypertension is not likely caused by his diabetes. Under Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993), the Board must assess the credibility and weight to be attached to medical opinions. An assessment or opinion by a health care provider is never conclusive and is not entitled to absolute deference. Rather, the Board must consider the weight to be placed on an opinion depending upon the reasoning employed to support the conclusion and the extent to which the physician reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). The Veteran does not challenge the adequacy of these opinions as they relate to the question of whether his hypertension is directly related to his active service or was caused by his service-connected diabetes and/or heart disease. He challenges the adequacy of the VA examiner's August 2011/August 2012 opinion as it relates to the question of whether his hypertension is aggravated by his service-connected diabetes. As previously indicated, however, even when there is such a challenge, the Board may assume the competency of the VA examiner, including a nurse practitioner, as long as she is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Cox v. Nicholson, 20 Vet. App. at 563. There is no evidence in the claims file to suggest the VA examiner is not so qualified. In any event, the Board accords her opinion full weight as it is well-reasoned, based on clinical evidence of record, medical literature and common medical knowledge, and supported by rationale. It appears that the Veteran's hypertension may have worsened during the 2001 to 2003 time frame, as alleged. However, there is some suggestion of record that the worsening might have been due to the Veteran's failure to comply with his doctor's recommendations regarding his medications, or temporary, in response to the newly diagnosed diabetes and heart disease. Whatever the reason, according to the most recent VA examiner, the Veteran's diabetes did not play a role in the worsening. The Veteran did not submit a medical opinion refuting those of the VA examiners. His assertions thus represent the only evidence of record suggesting that his hypertension was aggravated by his service-connected diabetes and/or heart disease. The Veteran is competent to report that he felt certain lay-observable symptoms after the diagnoses of his service-connected diabetes and heart disease and that those symptoms worsened, but because he has no special training or expertise in medicine, he is not competent to find that those disabilities aggravated his hypertension. See Jandreau, 492 F.3d at 1372; Buchanan, 451 F.3d at 1336; Barr, 21 Vet. App. at 303; Davidson v. Shinseki, 581 F.3d at 1313. The Board finds that the Veteran's hypertension is not related to his active service. During a cardio consultation in 2003, the Veteran stated that had hypertension since the age of 21 with diastolic readings as high as 130. He has also asserted that his hypertension initially manifested in 1970. However, the Board finds that the Veteran's statement are not credible, as the medical evidence, i.e., the September 1969 separation examination, shows that the Veteran's blood pressure was 118/60, and a June 1990 VA treatment record notes an active problem of hypertension with an approximate date of onset in 1988. The competent and credible medical evidence of record shows that the Veteran's hypertension is not related to service. Of note, the VA examiner concluded in August 2011 that it is less likely than not that the Veteran's hypertension had its clinical onset during active service or is related to an in-service disease, event or injury. She provided a well reasoned rationale for her opinion and cited to specific evidence in the claims folder as support for her opinion. Her opinion is found to be probative. There is no medical opinion to the contrary. There is also no evidence of record showing that the Veteran's hypertension manifested to a compensable degree within a year of his discharge from active service. The Board also finds that the Veteran's hypertension is not related to, or aggravated by, his service-connected diabetes mellitus or arteriosclerotic heart disease. As explained above, the Veteran's own statements in this regard are not competent. The opinion of the August 2011/August 2012 VA examiner that the hypertension was not caused or aggravated by the service-connected diabetes mellitus or arteriosclerotic heart disease is found to be probative, as it was based upon a review of the evidence of record and supported by a well-reasoned rationale. In light of these findings, the Board concludes that hypertension was not incurred in active service, may not be presumed to have been so incurred, and is not proximately due to or the result of, or aggravated by, a service-connected disability. A claimant is responsible for presenting evidence in support of his claim for benefits under laws administered by VA. VA is responsible for considering all such evidence, lay and medical. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA is to give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). With regard to this particular claim, the evidence is not in relative equipoise. The benefit-of-the-doubt rule is thus not applicable. ORDER Service connection for hypertension, to include as secondary to a service-connected disability, is denied. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs