Citation Nr: 1328913 Decision Date: 09/10/13 Archive Date: 09/17/13 DOCKET NO. 08-17 448 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for service connection for hypertension secondary to service-connected diabetes mellitus (DM). 2. Whether new and material evidence has been received to reopen a claim for service connection for bilateral upper extremity neuropathy secondary to service-connected DM. 3. Whether new and material evidence has been received to reopen a claim for service connection for supraventricular tachycardia secondary to service-connected diabetes mellitus (DM). 4. Entitlement to service connection for sleep apnea secondary to service-connected posttraumatic stress disorder (PTSD). 5. Entitlement to service connection for pulmonary disease secondary to service-connected DM. 6. Entitlement to service connection for benign prostatic hypertrophy secondary to service-connected DM. 7. Entitlement to service connection for kidney disease secondary to service-connected DM. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. W. Loeb INTRODUCTION The Veteran served on active duty from February 1971 to August 1978, including service in Vietnam. This case originally came before the Board of Veterans' Appeals (Board) on appeal of multiple rating decisions of the Department of Veterans Affairs (VA) regional office in Little Rock, Arkansas (RO). In August 2010, the Board remanded the issues listed on the title page, as well as the issue of entitlement to service connection for peripheral neuropathy of the lower extremities, back to the RO to obtain Social Security Administration (SSA) records, additional VA treatment records, nexus opinions on whether the disabilities at issue are caused or aggravated by service-connected disability, and to provide the Veteran with adequate notice in accordance with Dingess v. Nicholson, 19 Vet. App. 473 (2006) and Kent v. Nicholson, 20 Vet. App. 1 (2006). SSA records, additional VA treatment reports, and relevant VA nexus opinions were subsequently obtained and added to the claims files. Additionally, adequate notice was provided to the Veteran. Consequently, there has been substantial compliance with the August 2010 remand instructions. 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). A May 2012 rating decision granted entitlement to service connection for peripheral neuropathy of each lower extremity and assigned separate 10 percent ratings effective February 18, 2003. Consequently, the issue of entitlement to service connection for peripheral neuropathy of the lower extremities has been granted in full and is no longer part of the current appeal. The other issues on appeal were denied by a May 2012 Supplemental Statement of the Case (SSOC). The May 2012 SSOC denied the claims for service connection for supraventricular tachycardia, hypertension, and peripheral neuropathy due to DM on a de novo basis. The Board notes, however, that even if the RO determined that new and material evidence was presented to reopen these claims, such is not binding on the Board, which must first decide whether evidence has been received that is both new and material to reopen each claim. Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996); McGinnis v. Brown, 4 Vet. App. 239 (1993) (Board reopening is unlawful when new and material evidence has not been submitted). Consequently, the Board will adjudicate the question of whether new and material evidence has been received, furnishing a complete explanation as to its reasons and bases for such a decision. The Veteran testified at a videoconference hearing before the undersigned Acting Veterans Law Judge (AVLJ) in April 2010, and a copy of the hearing transcript is of record. It was noted in the May 2012 SSOC that the Veteran's claim as to whether an overpayment was properly created and, if so, for a waiver of that overpayment will be handled by the VA Pension Maintenance Center (PMC) because the Center has the Veteran's pension file and performed the action that caused the creation of the debt. Consequently, as this issue is in the process of being adjudicated by the PMC, it is not currently before the Board. FINDINGS OF FACT 1. The claims for entitlement to service connection for hypertension and for peripheral neuropathy of the left and right upper extremities due to DM was denied by an unappealed rating decision in June 2003. 2. Additional evidence received since June 2003 does not raise a reasonable possibility of substantiating the claims for service connection for hypertension and peripheral neuropathy of the upper extremities due to DM. 3. The claim for entitlement to service connection for supraventricular tachycardia due to DM was denied by an unappealed rating decision in May 2005. 4. Additional evidence received since May 2005 does not raise a reasonable possibility of substantiating the claims for service connection for supraventricular tachycardia due to DM. 5. The Veteran does not have sleep apnea that is related to his service-connected DM. 6. The Veteran does not have pulmonary disease that is related to his service-connected DM. 7. The Veteran does not have BPH that is related to his service-connected DM. 8. The Veteran does not have kidney disease that is related to his service-connected DM. CONCLUSIONS OF LAW 1. The June 2003 rating decision that denied reopening of the claims for service connection hypertension and for peripheral neuropathy of the upper extremities due to DM has become final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2002). 2. New and material evidence has not been received to reopen a claim for service connection for hypertension or for peripheral neuropathy of the upper extremities due to DM. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 3. The May 2005 rating decision that denied reopening of the claim for service connection for supraventricular tachycardia due to DM has become final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2004). 4. New and material evidence has not been received to reopen a claim for service connection for supraventricular tachycardia due to DM. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 5. The Veteran does not have sleep apnea that is secondary to service-connected disability. 38 U.S.C.A. §§ 5103A, 5107 (West 2002); 38 C.F.R. § 3.310 (2012). 6. The Veteran does not have pulmonary disease that is secondary to service-connected disability. 38 U.S.C.A. §§ 5103A, 5107 (West 2002); 38 C.F.R. § 3.310 (2012). 7. The Veteran does not have BPH that is secondary to service-connected disability. 38 U.S.C.A. §§ 5103A, 5107 (West 2002); 38 C.F.R. § 3.310 (2012). 8. The Veteran does not have kidney disease that is secondary to service-connected disability. 38 U.S.C.A. §§ 5103A, 5107 (West 2002); 38 C.F.R. § 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist Proper notice from VA must inform the claimant of any information and medical or lay 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements apply to all five elements of a service connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The RO's February 2007, June 2008, and May 2009 letters advised the Veteran of the foregoing elements of the notice requirements for secondary service connection. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). These letters also provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. See Dingess/Hartman, 19 Vet. App. at 486. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records, as well as identified private and VA medical treatment records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran was also provided with relevant VA examinations in 2012 in conjunction with the service connection claims on appeal. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159; see McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA opinions obtained in this case are adequate, as they are predicated on a reading of relevant medical records in the Veteran's claims files and physical examination findings. The opinions considered all of the pertinent evidence of record at the time, to include the Veteran's medical records and statements, and provided a supporting rationale. The Board concludes that all available evidence has been obtained and that there is sufficient medical evidence on file on which to make a decision on the service connection issues decided herein. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion on this issue has been met. 38 C.F.R. § 3.159(c)(4). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. With respect to a claim of whether new and material evidence has been presented to reopen the claim for service connection, in Kent. v. Nicholson, 20 Vet. App. 1 (2006), the United States Court of Appeals for Veterans Claims (Court) held that VA must notify a veteran of the evidence and information that is necessary to reopen the claim and VA must notify a veteran of the evidence and information that is necessary to establish entitlement to the underlying claim for the benefit sought. The Court also held that VA's obligation to provide a veteran with notice of what constitutes new and material evidence to reopen a service connection claim may be affected by the evidence that was of record at the time that the prior claim was finally denied. The question of what constitutes material evidence to reopen a claim for service connection depends on the basis on which the prior claim was denied. In order to satisfy the legislative intent underlying the VCAA notice requirement to provide claimants with a meaningful opportunity to participate in the adjudication of their claims, the VCAA requires, in the context of a claim to reopen, VA to examine the bases for the denial in the prior decision and to respond with a notice letter that describes what evidence would be necessary to substantiate the element or elements required to establish service connection that were found insufficient in the previous denial. The VCAA notification letter provided to the Veteran in November 2011 complies with the holding in Kent. In essence, this letter informed the Veteran that his claims for service connection for supraventricular tachycardia, hypertension, and peripheral neuropathy of the upper extremities were previously denied because the evidence did not show that the disorder was incurred in or aggravated by service or secondary to service-connected disability. Although VA is not required to provide a medical examination in a new and material evidence case unless it is first determined that the claim is reopened, the Board notes that VA evaluations of the Veteran's supraventricular tachycardia, hypertension, and peripheral neuropathy were obtained in January 2012. The Veteran has been given ample opportunity to present evidence and argument in support of his claims, including at his April 2010 videoconference hearing. General due process considerations have been complied with by VA, and the Veteran has had a meaningful opportunity to participate in the development of the claims. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); 38 C.F.R. § 3.103 (2007). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court recently held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. The Veteran's representative and the AVLJ asked the Veteran questions about the service connection issues on appeal. No pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran. The hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate the claims. Therefore, the Board finds that, consistent with Bryant, the AVLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Although the Veteran complained in a January 2012 letter that this case should be remanded to the RO for new VA evaluations because the examiner who examined the Veteran in January 2012 told him that the claims files were not actually reviewed, the Board does not agree. The examiner noted in the evaluations that he did review the claims files, and he periodically referred to evidence in the files, indicating that he had reviewed them. Analysis of the Claims New and Material Evidence Claims The Veteran seeks to establish service connection for hypertension, peripheral neuropathy of the upper extremities, and supraventricular tachycardia due to DM. He has contended, including at his April 2010 videoconference hearing, that he has been told by VA doctors that these disabilities are due to his service-connected DM. A June 2003 rating decision denied service connection for hypertension and for peripheral neuropathy of the upper extremities, and the Veteran was notified of the decision later in June 2003. A notice of disagreement was received later in June 2003, and a Statement of the Case was issued in July 2004. Although a substantive appeal was received later in July 2004, the Veteran withdrew his substantive appeal on the issues of entitlement to service connection for hypertension and for peripheral neuropathy of the upper extremities in a June 2006 statement, which was prior to adjudication by the Board. Consequently, these issues were dismissed by the Board in September 2006. See 38 C.F.R. § 20.204(c) (2012). The Veteran filed a claim to reopen for service connection for hypertension in January 2008 and filed a claim to reopen for service connection for peripheral neuropathy of the upper extremities in April 2009; and the current appeals ensue from a February 2009 rating decision, which denied service connection for hypertension, and from an August 2009 rating decision, which denied service connection for peripheral neuropathy of the upper extremities. The Veteran timely appealed these issues. A May 2005 rating decision denied service connection for supraventricular tachycardia on a secondary basis. The Veteran was notified of the denial later in May 2005, and he did not timely appeal. The Veteran filed a claim to reopen for service connection for supraventricular tachycardia on a secondary basis in January 2007. This claim was denied by rating decision in August 2007, and the Veteran timely appealed. A previously denied claim may be reopened by the submission of new and material evidence. 38 U.S.C.A. § 5108; 38 C.F.R. 3.156. Evidence is new if it has not been previously submitted to agency decision makers. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). Evidence is material if it, either by itself or considered in conjunction with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence cannot be cumulative or redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. For purposes of determining whether VA has received new and material evidence sufficient to reopen a previously-denied claim, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992); see also Madden v. Gober, 125 F.3d 1477, 1481 (1997); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Hypertension The evidence on file at the time of the June 2003 rating decision consisted of the Veteran's service treatment records, private treatment records dated in November 1986 and June and September 2000, and VA treatment reports dated from April 2002 to May 2003. The Veteran's service treatment reports do not show any complaints or clinical findings indicative of hypertension; his blood pressure was 90/60 in December 1970 and 100/60 in May 1978. Blood pressure readings while hospitalized at Memorial Hospital in November 1986 were 130/96, 128/70, and 130/70. Blood pressure readings in VA treatment reports were 140/100 and 142/94 in December 2002 and 150/100 and 178/104 in January 2003, and hypertension was diagnosed. It was noted that there was no previous diagnosis of hypertension. It was reported on VA treatment records for May 2003 that the Veteran was diagnosed with hypertension in approximately January 2003, when he was diagnosed with DM. He was taking medication for his hypertension but did not have good control. The diagnoses included hypertension, diagnosed in January 2003 and currently controlled on oral medication. The examiner concluded that the Veteran did not have diabetic nephropathy and that his hypertension was not likely to be related to diabetes. The evidence received by VA since June 2003 consists of private treatment reports beginning in December 1984, VA examination and treatment records dated from August 2001 to May 2012, the Veteran's April 2010 videoconference hearing transcript, and the Veteran's written statements. Hypertension was diagnosed in Memorial Hospital records dated in May 2004. It was noted in VA treatment records for July 2004 that there was no evidence of clinically significant pulmonary hypertension based on echocardiogram and physical examination. It was noted on VA heart evaluation in January 2009 that hypertension started in 2003. After review of the claims files and examination of the Veteran, the diagnoses included hypertension, and the examiner concluded that the Veteran's hypertension was a primary condition and was not secondary to service-connected DM or PTSD. On VA evaluation in January 2012, after review of the claims files and examination of the Veteran, the examiner concluded that it was less than likely that the Veteran's hypertension was secondary to DM because the hypertension preexisted a diagnosis of DM and because the Veteran does not have renal disease or proteinuria. The examiner noted in a separate January 2012 opinion that it was less than likely that the Veteran's hypertension was caused or aggravated by his DM. The evidence added to the record since June 2003 is new because it had not previously been submitted; however, it is not considered material because the evidence could not reasonably substantiate the claim were it to be reopened. More specifically, the new medical evidence remains devoid of any indication that the Veteran has hypertension due to DM. The only nexus opinions on file, in January 2009 and January 2012, conclude after examination of the Veteran and review of the claims files, that the Veteran's hypertension is not due to DM. For the foregoing reasons, the Board finds that the record does not contain new and material evidence to reopen the claim for entitlement to service connection for hypertension due to DM, and that the claim to reopen must be denied. Peripheral Neuropathy of the Upper Extremities The evidence on file at the time of the June 2003 rating decision consisted of the Veteran's service treatment records, private treatment records dated in November 1986 and June and September 2000, and VA treatment reports dated from April 2002 to May 2003. The Veteran's service treatment reports do not show any complaints or clinical findings indicative of peripheral neuropathy, to include on discharge medical history and medical evaluation reports in May 1978. When evaluated by VA in May 2003, the examiner concluded that the Veteran had mild peripheral neuropathy of the distal hands and feet of unknown etiology but not likely related to DM. The evidence received by VA since June 2003 consists of private treatment reports beginning in December 1984, VA examination and treatment records dated from August 2001 to May 2012, the Veteran's April 2010 videoconference hearing transcript, and his written statements. The pertinent impression on VA evaluation in July 2009, which included review of the claims files, was quadriceps and calf discomfort with normal dopplers. On VA evaluation in January 2012, after review of the claims files and examination of the Veteran, the examiner diagnosed bilateral peripheral neuropathy of the legs but not in the upper extremities. The evidence added to the record since June 2003 is new because it had not previously been submitted; however, it is not considered material because the evidence could not reasonably substantiate the claim for service connection for peripheral neuropathy of the upper extremities were it to be reopened. The new medical evidence does not include any evidence of peripheral neuropathy of the upper extremities. In fact, the VA examination in January 2012 does not find any evidence of peripheral neuropathy in the upper extremities. For the foregoing reasons, the Board finds that the record does not contain new and material evidence to reopen the claim for entitlement to service connection for peripheral neuropathy of the upper extremities due to DM, and that the claim to reopen must be denied. Supraventricular Tachycardia The evidence on file at the time of the May 2005 rating decision consisted of the Veteran's service treatment records, private treatment records dated from December 1984 to May 2004, and VA treatment reports dated from August 2001 to May 2005. The Veteran's service treatment reports do not show any complaints or clinical findings indicative of tachycardia, to include on separation medical history and medical evaluation reports in May 1978. The Veteran was hospitalized at Memorial Hospital in May 2004 with a rapid heartbeat. New onset of supraventricular tachycardia was diagnosed. Myocardial perfusion testing was performed by VA in August 2004. The evidence received by VA since May 2005 consists of a June 2000 private sleep study, VA examination and treatment records dated from January 2005 to May 2012, the Veteran's April 2010 videoconference hearing transcript, and his written statements. The Veteran was provided a VA heart evaluation in January 2009, which included review of the claims files. The pertinent diagnosis was atrial tachycardia, twice, with pharmacologic cardioversion to sinus rhythm. The examiner concluded that the Veteran's tachycardia was a primary condition and was not secondary to DM or psychiatric disability. The diagnoses on VA heart evaluation in May 2010 were supraventricular tachycardia, postoperative ablation; and no evidence of coronary artery disease. Supraventricular arrhythmia was diagnosed on VA heart evaluation in January 2012, and the VA examiner concluded, after review of the claims files and examination of the Veteran, that it was less than likely that the Veteran's heart condition is secondary to his DM because there is no medical relationship between DM and supraventricular tachycardia. The examiner noted in a separate January 2012 opinion that it was less than likely that the Veteran's supraventricular arrhythymia was caused or aggravated by his DM. The evidence added to the record since May 2005 is new because it had not previously been submitted; however, it is not considered material because the evidence could not reasonably substantiate the claim were it to be reopened. The new medical evidence does not indicate that the Veteran's supraventricular tachycardia is secondary to DM. The nexus opinions on file, in January 2009 and January 2012, conclude after examination of the Veteran and review of the claims files that the Veteran's supraventricular tachycardia is not due to DM. For the foregoing reasons, the Board finds that the record does not contain new and material evidence to reopen the claim for entitlement to service connection for supraventricular tachycardia due to DM, and that the claim to reopen must be denied. Service Connection Claims The Veteran seeks service connection for sleep apnea, pulmonary disease, BPH, and kidney disease as secondary to service-connected DM. He has contended, including at his April 2010 videoconference hearing, that these disabilities are causally related to service-connected disability. Service connection for DM was granted by rating decision in June 2003, which assigned a 20 percent rating effective February 18, 2003. Service connection for PTSD with associated major depressive disorder, was granted by rating decision in December 2006 and assigned a 100 percent rating effective February 4, 2004. Service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2011). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439 (1995). In order to prevail on the issue of entitlement to secondary service connection there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (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. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). 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. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). Sleep Apnea The Veteran's service treatment records do not reveal any complaints or clinical findings indicative of sleep apnea, including on separation evaluation in May 1978. The initial post-service evidence of sleep apnea is a private sleep study dated in June 2000, in which the Veteran is reported to have severe obstructive sleep apnea. Mild obstructive airways disease was noted in Penrose Hospital records dated in September 2000. It was reported in VA treatment records for May 2003 that the Veteran might have obstructive sleep apnea and that it was unlikely to be related to diabetes. A VA compensation and pension evaluation in December 2004 includes a diagnosis of sleep apnea. Evidence of significant nocturnal hypoxemia was found on sleep oximetry in June 2005 VA treatment records. The Veteran testified in support of his claim at his April 2010 videoconference hearing that his sleep apnea is secondary to service-connected PTSD. After review of the claims files and examination of the Veteran in January 2012, it was concluded by the VA examiner that it was less likely than not that the Veteran's obstructive sleep apnea is secondary to DM, depression, or PTSD because there was no causation and the sleep apnea was diagnosed earlier than DM or psychiatric disability. The examiner noted in a separate January 2012 opinion that it was less than likely that the Veteran's sleep apnea was caused or aggravated by his DM. The above evidence does not show any complaints or clinical findings of sleep apnea until June 2000, and there is no medical evidence linking the Veteran's sleep apnea to service-connected disability. Moreover, the only nexus opinions on file, in May 2003 and January 2012, are against the claim. Although the Veteran is competent to report his subjective symptoms related to sleep apnea, he is not competent to report that he has sleep apnea due to service-connected disability. The diagnosis of a condition such as sleep apnea, as well as the determination of the etiology of the disability, are medical questions and require medical expertise. A layperson is generally not competent to provide a diagnosis or opine on the etiology of a disability. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Circ. 2007). Because the preponderance of the objective and probative medical evidence of record is against the Veteran's claim for service connection for sleep apnea on a secondary basis, the claim must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Pulmonary Disease Service treatment records do not reveal any complaints or clinical findings indicative of pulmonary disease, including on separation evaluation in May 1978. The initial post-service evidence of pulmonary disease is a November 1986 hospital report from Memorial Hospital in which the Veteran complains of recent respiratory distress. An acute bronchospastic episode with secondary respiratory distress was diagnosed. Asthma was diagnosed in September 2000 treatment records from Penrose Hospital. May 2003 VA treatment reports include a diagnosis of a bronchial condition with asthma; it was concluded that it was not likely that the Veteran's asthma was related to diabetes and that there was no evidence to suggest that the asthma was related to service. The Veteran testified in support of his claim at his April 2010 videoconference hearing that his pulmonary disease is secondary to service-connected DM. Asthma was diagnosed on VA evaluation in May 2012. After review of the claims files and examiner of the Veteran, including pulmonary function studies, the examiner noted that because there was no objective medical data showing that DM caused asthma, it was less likely as not that the Veteran's DM either caused his asthma or aggravated it beyond normal progression. The above evidence does not show any complaints or clinical findings of pulmonary disease until November 1986, when he was hospitalized for an acute respiratory episode. Asthma was diagnosed in September 2000,. There is no medical evidence linking the Veteran's pulmonary disease to service-connected DM. The only nexus opinions on file, in May 2003 and May 2012, are against the claim. Although the Veteran is competent to report his subjective symptoms related to pulmonary disease, such as shortness of breath, he is not competent to report that he has pulmonary disease due to service-connected disability. The diagnosis of pulmonary disease, such as asthma, as well as the determination of the etiology of the disability, are medical questions and require medical expertise. A layperson is generally not competent to provide a diagnosis or opine on the etiology of a disability. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Circ. 2007). Because the preponderance of the objective and probative medical evidence of record is against the Veteran's claim for service connection for pulmonary disease on a secondary basis, the claim must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). BPH The Veteran's service treatment records do not reveal any complaints or clinical findings indicative of BPH, including on separation evaluation in May 1978. The diagnosis on VA genitourinary evaluation in September 2008 was erectile dysfunction with complete impotence. The diagnoses on VA evaluation in July 2009, which included review of the claims files, included BPH, which was noted to be age related. The Veteran testified in support of his claim at his April 2010 videoconference hearing that his BPH is secondary to service-connected DM. Prostatic hypertrophy was diagnosed on VA genitourinary evaluation in January 2012. After review of the claims files and examination of the Veteran, it was concluded by the VA examiner that it was less than likely that the Veteran's BPH with obstructive symptoms is secondary to DM because there is no correlation between the conditions. The examiner noted in a separate January 2012 opinion that it was less than likely that the Veteran's BPH was caused or aggravated by his DM. The above evidence does not show any complaints or clinical findings of BPH until July 2009, and there is no medical evidence linking the Veteran's BPH to service-connected DM. Moreover, the only nexus opinions on file, in July 2009 and January 2012, are against the claim. Although the Veteran is competent to report his subjective symptoms related to BPH, he is not competent to report that he has BPH due to service-connected disability. The diagnosis of a condition such as BPH, as well as the determination of the etiology of the disability, are medical questions and require medical expertise. A layperson is generally not competent to provide a diagnosis or opine on the etiology of a disability. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Circ. 2007). Because the preponderance of the objective and probative medical evidence of record is against the Veteran's claim for service connection for BPH on a secondary basis, the claim must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Kidney Disease The Veteran's service treatment records do not reveal any complaints or clinical findings indicative of kidney disease, to include on separation evaluation in May 1978. The Veteran testified in support of his claim at his April 2010 videoconference hearing that he had kidney disease secondary to service-connected DM. A VA evaluation of the Veteran's kidney complaints was obtained in May 2012. After review of the claims files and examination of the Veteran, the examiner noted that the Veteran had not been previously diagnosed with kidney disease, that he did not have proteinuria, and that no diabetic kidney disease was found. The evidence of record does not show any complaints or clinical findings of kidney disease, including on VA evaluation in May 2012. Although the Veteran is competent to report his subjective symptoms related to what he believes is kidney disease, he is not competent to diagnose kidney disease. As noted above, the diagnosis of a condition such as kidney disease, as well as the determination of the etiology of a kidney disability, are medical questions and requires medical expertise, which cannot be provided by a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Circ. 2007). Because the preponderance of the objective and probative medical evidence of record is against the Veteran's claim for service connection for kidney disease on a secondary basis, the claim must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER New and material evidence has not been received to reopen the claim for service connection for hypertension due to DM. The request to reopen this claim is denied. New and material evidence has not been received to reopen the claim for service connection for bilateral upper extremity neuropathy due to DM. The request to reopen this claim is denied. New and material evidence has not been received to reopen the claim for service connection for supraventricular tachycardia due to DM. The request to reopen this claim is denied. Service connection for sleep apnea is denied. Service connection for pulmonary disease is denied. Service connection for BPH is denied. Service connection for kidney disease is denied. ____________________________________________ WILLIAM YATES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs