Citation Nr: 1333327 Decision Date: 10/23/13 Archive Date: 10/24/13 DOCKET NO. 09-08 488 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for a heart disability. 2. Entitlement to service connection for headaches. 3. Entitlement to service connection for right ear hearing loss disability. 4. Entitlement to service connection for hypertension. 5. Entitlement to service connection for a cervical spine disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel INTRODUCTION The Veteran served on active duty from July 1956 to October 1976, including service in Vietnam. These matters initially came before the Board of Veterans' Appeals (Board) from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego California. In that decision, the RO continued the denial of service connection for a heart disorder and denied applications to reopen previously denied claims for service connection for headaches, bilateral hearing loss disability, hypertension, and a cervical spine disorder. Each of those claims had been denied in March 2007. The RO received new evidence in August 2007 and readjudicated the claims in the February 2008 decision. The Virtual VA claims file has been reviewed. In November 2010, the Board remanded all of the claims to the RO, via the Appeals Management Center (AMC), for additional development. In August 2011, the RO readjudicated the claim for service connection for a heart disorder pursuant to Nehmer v. United States Veterans Administration, 284 F.3d 1158, 1161 (9th Cir. 2002). In November 2012, the Board found that new and material evidence had been received to reopen the previously denied claims for service connection for headaches, bilateral hearing loss disability, hypertension, and a cervical spine disorder. These claims and the claim for service connection for a heart disorder were remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. Following additional development, the Veteran was granted service connection for left ear hearing loss; as such, the Veteran's claim for right ear hearing loss remains on appeal. The case has been returned to the Board. The RO/AMC complied with the Board's remand instructions; the Veteran was afforded additional VA examinations and the reports have been associated with the Veteran's claims file. Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT 1. The Veteran served in Vietnam and is presumed to have been exposed to Agent Orange. 2. The Veteran does not have a disease that is presumed to be service connected in veterans exposed to Agent Orange. 3. The Veteran's trace mitral valve regurgitation and trace tricuspid valve regurgitation were not manifested during service or within one year of separation. 4. The Veteran's trace mitral valve regurgitation and trace tricuspid valve regurgitation are not attributable to service. 5. The Veteran's headaches are not attributable to service. 6. The Veteran does not have right ear hearing loss disability. 7. Hypertension was not manifest during service or within one year of separation. 8. Hypertension is not attributable to service. 9. Cervical spine joint and disc disease was not manifest during service or within one year of separation. 10. Cervical spine joint and disc disease is not attributable to service. CONCLUSIONS OF LAW 1. A heart disability was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 2. Headaches were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2013). 3. Right ear hearing loss disability was not incurred in or aggravated by service, and an organic disease of the nervous system, may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2013). 4. Hypertension was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 5. Cervical spine joint and disc disease was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this case, the agency of original jurisdiction (AOJ) issued notice letters, dated in October 2007 and December 2010 to the Veteran. These letters explained the evidence necessary to substantiate the Veteran's claim for service connection, as well as the legal criteria for entitlement to such benefits. The letters also informed him of his and VA's respective duties for obtaining evidence. The AOJ decision that is the basis of this appeal was decided after the issuance of an initial, appropriate VCAA notice. As such, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA also has a duty to assist a veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The claims file contains the Veteran's available service treatment records, reports of private and VA post-service treatment, and the Veteran's own statements in support of his claims. The Veteran was afforded VA examinations responsive to the claims for service connection. McClendon v. Nicholson, 20 Vet. App. 79 (2006). The opinions were conducted by medical professionals, following thorough examination of the Veteran, solicitation of history, and review of the claims file. The Board finds that the opinions are adequate. Additionally, the Veteran has not alleged that any examination is inadequate to decide the current claims, so the examinations are presumed to have been adequate. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of the opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran's claims. For these reasons, the Board finds that the VCAA duties to notify and assist have been met. Legal Criteria for Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2013). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006). Service connection may be granted for any disease initially diagnosed after service 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). VA laws and regulations provide that, if a Veteran was exposed to Agent Orange during service, certain listed diseases are presumptively service-connected. 38 U.S.C.A. § 1116(a)(1); 38 C.F.R. § 3.309(e). A Veteran who "served in the Republic of Vietnam" between January 9, 1962 and May 7, 1975 is presumed to have been exposed during such service to Agent Orange. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). The listed diseases are: AL amyloidosis, chloracne or other acneform disease consistent with chloracne, Type II diabetes mellitus (adult-onset diabetes), Hodgkin's disease, ischemic heart disease, chronic B-cell leukemias, multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx or trachea); and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). In addition, the Secretary of VA has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-46 (1994); Notice, 61 Fed. Reg. 41, 442-49 (1996); Notice, 72 Fed. Reg. 32,395-32,407 (Jun. 12, 2007); Notice, 74 Fed. Reg. 21,258-21,260 (May 7, 2009); Notice, 75 Fed. Reg. 32540 (June 8, 2010). As will be discussed below, the evidence does not reflect that the Veteran has been diagnosed as having any of the diseases presumed service connected in veterans exposed to Agent Orange. He is therefore not entitled to service connection on a presumptive basis due to his exposure to Agent Orange. The fact that a Veteran cannot establish entitlement to service connection on a presumptive basis does not preclude him from establishing entitlement on a direct incurrence or other basis. See 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.304(d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994) (Radiation Compensation Act does not preclude a veteran from establishing service connection with proof of actual direct causation). The threshold for normal hearing is from 0 to 20 decibels. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including cardiovascular-renal disease (including hypertension), organic diseases of the nervous system (including sensorineural hearing loss), and degenerative joint disease (including arthritis), are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. 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 degenerative joint disease (i.e., arthritis), organic disease of the nervous system (i.e., sensorineural hearing loss), and cardiovascular-renal disease (i.e., hypertension) are considered to be chronic diseases for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Analysis for Service Connection Factual Background The Board notes initially that, the Veteran served during a period of war. Likewise, the Veteran's DD Form 214 reflects that his military occupational specialty was aircraft electrical repairman. Service personnel records indicate that he had service in Vietnam from June 1968 to November 1969. The evidence does not suggest, and the Veteran does not contend, that he engaged in combat with the enemy; therefore, the combat provisions of 38 U.S.C.A. § 1154 (West 2002) are not applicable. However, he was granted service connection for PTSD on the basis of "fear of hostile military activity" related to exposure to incoming mortar rounds and the death of friends while serving in Vietnam. The Veteran's service treatment records did not show any evidence of headaches, right ear hearing loss, coronary artery disease, or a cervical spine disability. In June 1957, the Veteran had lacerations of the face after a motor vehicle accident. Blood pressure readings in service showed 130/86 at a March 1976 periodic examination, 124/96 and 132/102 at an April 1974 examination, and 126/88 in May 1973. In 1974, he was in a motor vehicle accident wherein he had muscle spasms of the thoracic spine. An August 1968 examination report indicates that the Veteran had chest pain related to valley fever, but that it was resolved and did not recur; chest x-ray and evaluation of the heart were normal. At the Veteran's July 1976 retirement examination, the Veteran reported that he lost consciousness after a car accident in 1957, wherein he was treated for a laceration to his forehead. The Veteran denied all other significant medical or surgical history beyond that which was listed. Upon evaluation, there were no findings of headaches, right ear hearing loss disability, coronary artery disease, or cervical spine arthritis; all systems were normal. Blood pressure was 108/76 and an EKG was normal. A partial May 1973 EKG report is of record; however, no findings are noted. At a February 1977 VA examination, the Veteran reported that he was in an auto accident during service, with an injury to his right foot, being treated for Valley Fever during service, and a history of treatment for hemorrhoids. Examination showed a scar from inguinal hernia repair, normal heart sounds, and chest x-ray showed normal heart and lungs. His blood pressure was 130/70 and no hearing loss was noted. An August 1978 record shows blood pressure was 120/78. April 1979 VA treatment records indicate that the Veteran's blood pressure was 134/94. In April 1979, the Veteran was hit in the head by a chain while working, causing him to fall. The Veteran had a hematoma and was treated for complaints of intermittent neck pain and stiffness related to his industrial injury through August 1979. A May 1979 VA radiology report, noting the Veteran had a history of an industrial accident, indicates that examination of the skull was without abnormality. There was slight rotation of the cervical spine, possibly related to positioning. There were slight degenerative changes, but interspaces and intervertebral foramina were adequately maintained. Soft tissues were unremarkable and no definite acute abnormality was noted. A January 1987 VA report shows that the Veteran denied any complaints of neck pain and stiffness, headaches, cardiovascular symptoms, or difficulty hearing. An April 1989 VA treatment record shows that blood pressure was 130/90; the assessment was borderline blood pressure. In December 1991, his blood pressure was 130/88. Private treatment records from Kaiser Permanente have been associated with the record. An August 2001 record showed that audiometric testing showed normal hearing through 1000 Hertz, with mild sensorineural impairment through 4000 Hertz, falling to a moderate high frequency loss. Reports dated in 2004 and 2005 show treatment for hypertension and hypercholesterolemia. In September 2006, a treadmill stress test and EKG were negative for ischemia. A January 2007 EKG showed a mildly dilated left heart atrium, trace tricuspid regurgitation, and trace mitral regurgitation. A June 2007 letter from A. H., M.D., states a review of letters and the Veteran's "DV214" indicate that the Veteran was exposed to hostile fire and "massive doses of Agent Orange, which many or may not be described in this report." The Veteran related that he had frequent rashes during his service, but that now he has no problems with rashes. Dr. H stated that the Veteran applied for migraine headaches, hearing loss, cardiovascular disease, hypertension, and cervical spine arthritis. According to Dr. H, the Veteran has these disorders, and they are related to his military service. With regard to the Veteran's hearing loss, Dr. H points to the Veteran's history of noise exposure in service. Regarding his cervical spine disorder, Dr. H relies on a May 1979 record showing a diagnosis of probable post-concussive torticollis of the cervical spine; according to Dr. H, the Veteran's current cervical spine disorder is related to the cervical torticollis in 1979. Dr. H also stated that the Veteran's hypertension was "in keeping with the [Veteran's] 20 years [of] service" and "led to early coronary artery disease." Dr. H opined that the Veteran had elevated blood pressure readings in service, and that the initiation of hypertension is related to the stress of the Veteran's Vietnam service. Dr. H also stated that there is interplay between PTSD and hypertension. An October 2007 letter from Dr. H reiterates many of the same assertions as the June 2007 letter. Dr. H stated that a March 1973 EKG that shows wave changes is evidence of coronary artery disease. Dr. H alleges that "the blood pressure had its instigation" during the Veteran's service and that stress was a factor. Dr. H asserts that the Veteran has cervical spine arthritis due to an in-service auto accident in 1957; Dr. H alleges that the Veteran was diagnosed with a cervical spine arthritic change and hypertension in March 1974. VA treatment records indicate that the Veteran has a history of possible Agent Orange exposure, with no related conditions. His unrelated conditions included hypertension and degenerative joint disease. A November 2008 VA Agent Orange examination indicates that he has a family history of diabetes and myocardial infarction. The Veteran reported a 10 pack year history of smoking, a history of exertional chest pain, a history of hypertension and gout, bilateral foot pain, and decreased hearing. Examination showed normal spinal curvatures, regular pulse, no heart murmurs, and normal neurological examination. Upon heart evaluation, he had no murmurs or carotid, renal or abdominal bruits. A June 2011 VA ischemic heart disease examination report notes that ischemic heart disease does not include hypertension; a definition of ischemic heart disease and the included conditions was also noted. The VA examiner concluded that the Veteran did not have any ischemic heart disease or congestive heart failure. The VA examiner also stated that there was no evidence of cardiac hypertrophy or dilation. Blood pressure readings were 148/79, 133/77, and 143/69. Lungs were clear to auscultation, with normal heart rate and rhythm. A chest x-ray was normal. At the December 2012 VA audiological examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 15 20 30 The Maryland CNC speech recognition score was 94 percent for the right ear. After examining the Veteran and reviewing the claims file, the audiology examiner opined that the Veteran had sensorineural hearing loss in the frequency range of 6000 to 8000 Hertz, which was at least as likely as not caused by or the result of military noise exposure. The December 2012 VA headaches examination report indicates that the Veteran has a history of tension headaches. The Veteran reported that his headaches occur once every 2 months, with pulsating or throbbing pain on both sides of the head, which worsens with activity. The Veteran's headaches last less than a day, and are not accompanied by nausea, sensitivity to noise and light, vision changes, and sensory changes. The VA examiner opined that the Veteran's headaches are less likely than not related to the Veteran's service. The VA examiner noted that there is no diagnosis of chronic headaches in service, or within one year of discharge. The VA examiner noted that there is an April 1979 note of intermittent headache after a head injury. At the December 2012 VA heart disorders examination, the Veteran has a history of trace mitral valve regurgitation and trace tricuspid valve regurgitation in 2007. The VA examiner noted that the Veteran reported a history of occasional chest pain with physical activity. The Veteran complained of fatigue and dyspnea upon activities similar to running, moderate bicycling, and climbing stairs quickly. The VA examiner noted that the Veteran does not show any indication of cardiac hypertrophy and his ejection fraction is within normal limits; tests for ischemic heart disease are negative. The Veteran reported that he has not sought treatment for his intermittent chest pain, as it occurs randomly and resolves spontaneously. The Veteran has no history of congestive heart failure, myocardial infarction, cardiac arrhythmia, infectious cardiac diseases, or pericardial adhesions. Upon examination, his heart rhythm is regular and his heart sounds are normal; there was no evidence of jugular venous distension, auscultation of the lungs was clear, and his peripheral pulses were normal. There was no evidence of peripheral edema and his blood pressure was 142/75. There was no evidence of cardiac hypertrophy or dilation. Chest x-ray and echocardiogram were normal. The VA examiner found that the Veteran's trace mitral and tricuspid valve regurgitation are less likely than not caused by or the result of his service, as they were not manifested during service or within one year of discharge. The VA examiner stated that these conditions were most likely caused by the Veteran's advanced age and that the Veteran had no related symptoms during service; the valve regurgitations were not shown until January 2007 and there were no related symptoms during his service. The VA examiner also concluded that the Veteran does not have ischemic heart disease or coronary artery disease. The VA examiner also noted that Dr. H stated that the Veteran's chest pains were related to Valley Fever, but opined that that Valley fever is a transient infectious disease and not a cardiac condition. The VA examiner acknowledged the Veteran's complaints of chest pain, but reiterated that such chest pain was not caused by coronary artery disease. The VA examiner pointed out that a 2006 adenosine stress test, a reliable diagnostic evaluator of ischemic heart disease, was negative; the Veteran's ejection fraction was 78 percent. The VA examiner acknowledged the assertion of Dr. H, that the Veteran had ischemia on EKG in March 1973, but pointed out that there was no evidence of any ischemic heart disease in 2006 and that all other EKGs have been normal; the VA examiner also reiterated that the adenosine stress test provides a more reliable indication of ischemic heart disease and is a more precise diagnostic evaluation tool than a EKG. The VA examiner further noted that Dr. H's assertion that the Veteran's hypertension caused coronary artery disease is incorrect as the Veteran does not have coronary artery disease. The VA examiner also noted that the Veteran's subjective chest pain is not caused by the Veteran's trace mitral and tricuspid valve regurgitation and reiterated that there is no evidence of ischemic heart disease. Regarding the Veteran's hypertension, the December 2012 VA examination report indicates that the Veteran has a history of hypertension, diagnosed in 1979. The Veteran's claims file was reviewed and his blood pressure readings were noted. The Veteran's hypertension is well-controlled with medication. Blood pressure readings were 142/78, 140/70, and 138/69. The VA examiner found that it was less likely than not that the Veteran's hypertension is related to the Veteran's service. The VA examiner noted that the Veteran had some elevated blood pressure readings in service, characterized as mildly elevated, and pointed out that there was no evidence of three readings greater than 140/90 during military service, which would be indicative of hypertension, or a diagnosis of hypertension during or within one year of service. With regard to the Veteran's cervical spine, the December 2012 VA examination report indicates that the Veteran has been diagnosed with degenerative joint and disc disease of the cervical spine. The Veteran reported that his neck pain began in service, but that he did not recall treatment for his neck. He complained of intermittent neck pain, self-treated with stretching and rest. The VA examiner noted that the Veteran was treated in 1979 for concussive torticollis without evidence of degeneration at that time. Following physical examination and x-rays, the VA examiner found that the Veteran has cervical spine arthritis, but that the Veteran's cervical spine degenerative joint and disc disease is less likely than not incurred in service or caused by a service-connected disorder. The VA examiner noted that the Veteran was treated for concussive torticollis in 1979, but that there was no evidence of a chronic neck disorder during service which would cause his current degenerative disease. The VA examiner explained that concussive torticollis is an acute strain of the neck due to a physical trauma to the head; it is an acute injury. The VA examiner also noted that the Veteran was discharged in 1976, and there is no evidence of a chronic neck condition during service or within one year of discharge. The VA examiner further opined that Veteran's cervical spine arthritis is most likely related to his advanced age and wear and tear, and that the Veteran's 1979 concussive torticollis was not a chronic neck condition related to his cervical degenerative joint and disc disease; it was an acute injury. Heart Disorder The Veteran has appealed the denial of service connection for a heart disorder. Service connection may be established for disability incurred in or aggravated by service. In addition, service connection may be established if a cardiovascular disease was manifest within one year of separation. 38 U.S.C.A. § 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. § 3.307, 3.309. Furthermore, since the appellant was in Vietnam and exposed to Agent Orange, service connection may be granted if he has ischemic heart disease. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.309(e). Cardiovascular disease and valvular heart disease are chronic diseases. Here, neither heart nor valvular diseases were noted or identified during service or within one year of separation. Furthermore, the record establishes that he did not have characteristic manifestations of the disease processes during service. Rather, at examination in May 1973 and retirement in July 1976, the heart and vascular system were normal. Although he reported a history of pain or pressure in his chest in March 1974, the complaint was attributed to valley fever rather than heart pathology. Since neither heart nor valvular processes were noted or diagnosed during service, and here were not characteristic manifestations of the disease process during service the provisions of section 3.303(b) are not applicable. The record does establish that the appellant served in Vietnam. However, the presumptions relating to herbicide exposure are limited to ischemic heart disease and do not extend to valvular disease. Here, there is a conflict in the record. Dr. H and the Veteran each report that the Veteran has coronary artery disease. Dr. H is competent to enter a diagnosis and the Veteran is competent to relate that which he has been told. However, although Dr. H relates his diagnosis to service, to include the in-service report of chest pain, Dr. H's opinion is inconsistent with the contemporaneous service records and the absence of related complaints for many years after service. The Board notes that the medical evidence of record contradicts Dr. H, as the weight of the evidence demonstrates that no coronary artery disease or ischemic heart disease is shown in the Veteran. Simply put, medical testing during and in the years since service fails to demonstrate any objective evidence of these disorders. To the extent that Dr. H claims that a March 1973 EKG showed sinus waves indicative of coronary artery disease, the Board points out that the 1973 EKG was discredited by the December 2012 VA examiner as anomaly amongst normal EKG reports from service to the present. The December 2012 VA examiner found that any such assertions were inherently unreliable, as subsequent diagnostic testing did not show clinical indications of any ischemic heart disease. The VA examiner further pointed out that all other EKGs prior to and since the 1973 EKG consistently demonstrated that there was no evidence of coronary artery disease or ischemic heart disease. As the Veteran does not have coronary artery disease or ischemic heart disease, his claim for service connection must fail. See Degmetich v. Brown, 104 F.3d 1328 (1997) (holding that section 1110 of the statute requires the existence of a present disability for VA compensation purposes); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). In this case, the most probative evidence establishes that he does not have coronary artery disease. As the weight of the evidence is against the existence of coronary artery disease or ischemic heart disease, there is also no basis for service connection as secondary to Agent Orange exposure. As the Veteran does not have coronary artery disease or ischemic heart disease related to Agent Orange exposure, it follows that service connection on a presumptive basis is not warranted. The weight of the evidence establishes that he did not have complaints, treatment, or diagnoses of any cardiovascular disorder during or within one year of service. The Board acknowledges the diagnosis of mildly dilated left heart atrium, trace tricuspid regurgitation, and trace mitral regurgitation since service, but reiterates the December 2012 VA examiner found that the Veteran does not have ischemic heart disease or coronary artery disease. The Board also reiterates that the VA examiner found that the Veteran's trace mitral valve regurgitation and trace tricuspid valve regurgitation were unrelated to service, or to his complaints of chest pain during or after service. Here, there is a remarkable conflict in the evidence. We have some medical and lay evidence to the effect that there is heart pathology consistent with coronary artery disease or ischemic heart disease. Of note, the Board acknowledges that Dr. H concluded that the Veteran had early coronary artery disease related to service. Although Dr. H attributed coronary artery disease to the Veteran's hypertension, as will be discussed below, the Veteran's hypertension is not service-connected. Moreover, Dr. H's assertion that the Veteran has coronary artery disease, based on some sinus waves in 1973 is inconsistent with the record, which shows that all subsequent EKGs were normal. Moreover, cardiac stress testing is negative for coronary artery disease and ischemic heart disease. Furthermore, Dr. H did not provide any indication as to more recent clinical findings confirming such a diagnosis or provide a rationale for his opinion that 20 years of military service could cause coronary artery disease, particularly in light of the absence of related symptoms, treatment, complaints, or diagnoses during service, at separation from service, and in the years since service. In sum, the VA opinion is far more reasoned and substantiated by the totality of the evidence. The Board also points out that the Veteran's assertions of chest pain are not in any way related to his complaints of chest pain in service; there is not In short, Dr. H's letters, as positive evidence, are remarkably lacking in clinical findings adequate to support a diagnosis of coronary artery disease and a rationale relating the Veteran's alleged coronary artery disease to his service; both of the VA examiners found that the Veteran did not meet the diagnostic criteria for coronary artery disease or ischemic heart disease. Although the evidence remains competent, the lack of supporting evidence to justify the diagnosis renders such lay and medical evidence to be of little probative value. We conclude that the recent VA examination and opinion to be detailed and reasoned. The examiner established that there was a lack of evidence to justify any coronary artery disease or ischemic heart disease. There was also no evidence of congestive heart failure. Although there was evidence of trace mitral regurgitation and tricuspid mitral valve regurgitation, the examiner concluded that these were related to the Veteran's age, and that there was no evidence of a coronary disorder. We find that the in-service normal finding, and current findings that there is no coronary artery disease or ischemic heart disease upon VA examination in June 2011 and December 2012 are far more probative than the opinions of Dr. H and the Veteran. The most probative and credible evidence establishes that the appellant does not have coronary artery disease or ischemic heart disease. It necessarily follows that he did not have acquired pathology during service or within one year of separation from service. In the absence of disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The preponderance of the evidence is against the claim and there is no doubt to be resolved. Headaches In this case, the Veteran must show that he has currently has headache disorder due to disease or injury in service or caused or aggravated by service-connected disability. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). See also Sanchez-Benitez, 259 F.3d at 1362 (without factual finding of nexus between current neck pain and in-service neck trauma, Federal Circuit could not reach the question of whether veteran's current pain was statutorily compensable). The Veteran reported that he had headaches when he filed his claim for service connection. However, the weight of the evidence is against the existence of a headache disorder due to a disease or injury in service or caused or aggravated by service connected disability. The evidence shows that service treatment records do not show any complaints, treatment, or diagnoses of headaches during service. Post-service treatment records also do not show any evidence of a headache disorder after service. Moreover, the Veteran has not alleged any in-service treatment for headaches and his head and neurological system were normal upon separation. The Veteran alleges that his headaches are related to his motor vehicle accidents during service, but acknowledged that he did not seek treatment for headaches during his service. However, the Veteran's later allegation of headaches related to the 1957 and 1974 motor vehicle accidents during service, first given only when seeking service connection for this disability, is not credible when seen in light of the other evidence of record. We find that the absence of complaints of headaches when seeking treatment for his motor vehicle accidents, in-service normal findings, and the normal separation examination are far more probative than a remote assertion advanced in support of a claim for monetary benefits. See Pond v. West, 12 Vet. App. 341, 345 (1999); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest may affect the credibility of testimony). To the extent that there is an assertion of in-service onset and continuing symptoms, the Veteran's remote lay assertion is inconsistent with the clinical evidence of record. That record establishes a remote post-service onset. This determination is consistent with the fact that he was normal at separation and he denied pertinent pathology at that time. Furthermore, the record establishes that the post service diagnosis is unrelated to service. The Veteran had no complaints at the 1977 VA examination or the November 2008 VA Agent Orange evaluation. The Board observes that the Veteran made no assertions of headaches and did not relate his headaches to his service. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). The Board acknoweldges that Dr. H diagnosed the Veteran with migraine headaches and asserted that it is related to the Veteran's service. However, this opinion is of little probative value. Dr. H's finding and opinion is lacking in detail; in essence, his statement is entitled to little probative value, compared to the December 2012 VA examination, as the medical assessment by Dr. H is remarkably lacking in clinical findings and reasoning upon which to support the diagnosis and opinion. In this case, the lay and medical positive evidence is less credible and probative than the detailed, reasoned negative medical evidence provided by the December 2012 VA examiner. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). The December 2012 VA examination report explained the reasons for the VA examiner's conclusion that the Veteran's current headaches are unrelated to service is based on an accurate characterization of the evidence of record; the VA examiner noted that the only post-service complaints of headaches was related to a 1979 head injury, and that there is no indication of headaches between that acute headache and the Veteran's current tension headaches. Thus, this opinion is entitled to substantial probative weight. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (stating that factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion). Simply put, the probative value of the Veteran's general lay assertions relating his headaches to service are outweighed by the specific, reasoned opinion of the December May 2012 VA examination report. In sum, the probative evidence establishes that there was a remote post-service onset of a headache disorder and such disorder is unrelated to service. For the foregoing reasons, the preponderance of the evidence is against the claim for entitlement to service connection for a headache disorder. The benefit-of-the-doubt doctrine is therefore not for application with regard to the service connection claim decided herein. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). Right Ear Hearing Loss Despite the Veteran's complaints of right hearing loss, the post-service medical evidence does not reflect disabling right ear hearing loss for VA disability benefits purposes at any time. He had a Maryland CNC speech recognition score of 94 percent for his right ear at the December VA examination. Similarly, his military and VA audiological evaluations show that the Veteran does not have sufficient right ear hearing loss to meet the threshold minimum requirements of 38 C.F.R. § 3.385 to be considered an actual hearing disability by VA. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1998) ("Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. 38 U.S.C. § 1110 (formerly § 310)). The Board has also considered the Veteran's noise exposure and his assertions that he did not have sufficient hearing protection during his service. Nonetheless, the Board notes that, despite the Veteran's complaints, the Veteran did not have auditory thresholds of 26 decibels or greater in at least three frequencies for the left ear, or auditory threshold in excess of 40 decibels in the right ear at any time; likewise, his Maryland CNC speech recognition score was 94 percent in the right ear at the December 2012 VA examination. Moreover, although the VA audiological examiner characterized the Veteran as having bilateral hearing loss, the VA examiner found that the Veteran's right ear hearing was within normal limits below 6000 Hertz, such that there is no pathology. Hypertension and Cervical Spine Disorder The Board observes that the Veteran has claimed that his hypertension and cervical spine joint and disc disease are due to service. Specifically, the Veteran asserts that his hypertension began during service and that a blood pressure reading of 108/76 at separation demonstrates in-service incurrence. Additionally, the Veteran asserts that his cervical spine degenerative joint and disc disease is related to an injury in service. The Veteran's claim is limited neither by the theory that he advances nor the precise disability he identifies. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009) (in direct appeals, all filings must be read in a liberal manner); EF v. Derwinski, 1 Vet. App. 324, 326 (1991) (Board must review all issues reasonably raised from a liberal reading of all documents in the record). In this case, the Veteran's claims must be denied because his hypertension and cervical spine degenerative joint and disc disease are neither caused nor aggravated by a disease or injury in service. As the Veteran has been diagnosed with hypertension and cervical spine joint and disc disease, the provisions of 38 C.F.R. § 3.303(b) are potentially applicable. Here, no cervical spine or cardiovascular pathology, including hypertension and arthritis, were "noted" during service and there were no characteristic symptoms or manifestations of hypertension or cervical spine joint and disc disease were identified during or within one year of service. Therefore, section 3.303(b) does not assist the Veteran. The Board reiterates that hypertension and cervical spine arthritis were not shown in service or within one year of separation; the Veteran was first diagnosed with borderline blood pressure in 1989 and the first confirmed diagnosis of hypertension in the record was in 2004. Rather, the Veteran's blood pressure and cervical spine were normal upon examination at separation and at the February 1977 VA examination. We also note that the Veteran denied a history of pertinent pathology at separation and at the 1977 VA examination; cardiovascular and musculoskeletal evaluations were also normal. The argument by the Veteran and Dr. H that both disorders had their onset during service is inconsistent with the separation examination. To the extent that the Veteran has reported that he had chronic hypertension and cervical spine arthritis that started in service and continued, such pleading is not credible. Furthermore, there is every indication that there were no symptoms leading to a diagnosis of hypertension until 1989, at the earliest. The Board acknowledges that Dr. H opined that the Veteran's in-service blood pressure readings were indicative of hypertension and that this hypertension was thus related to the Veteran's service and the stress. However, this opinion is afforded little probative value. The December 2012 VA examiner clearly indicated that the Veteran's in-service blood pressure readings were no more than mildly elevated and that these readings, as well as those for many years after service, did not constitute hypertension as they were not in excess of 140/90. The VA examiner pointed out that there were not 3 readings in excess of 140/90 during service, or within one year of separation; to the contrary, there were no such readings during that time frame. Additionally, the Board points out that Dr. H's assertion that 20 years of military service and the "stress" of such service is causally or etiologically related to the Veteran's hypertension is based on an inaccurate factual premise, as the Veteran's service is too remote to the onset of hypertension (somewhere between 1989 and 2004) for the hypertension to be the result of in-service stress. There is nothing in the evidence of record demonstrating that the Veteran had characteristic manifestations of hypertension prior to 1989, approximately 13 years after his separation from service. Furthermore, the December 2012 VA examiner clearly indicated that the Veteran's hypertension is unrelated to the Veteran's service in light of the absence of related complaints, symptoms, and diagnoses in service. Similarly, the Board acknowledges that the Veteran had early degenerative changes of the cervical spine upon x-ray in 1979, but points out that this was more than one year after service and that there was no indication that this was in any way related to the Veteran's service. Likewise, the Veteran's post-concussive torticollis of the cervical spine in 1979, which Dr. H states as the etiology of the Veteran's current cervical spine arthritis was caused by an acute industrial injury in 1979; this, again, was over a year after the Veteran's separation from service. The industrial injury, not the Veteran's service, was the cause of the cervical torticollis, which was acute and unrelated to the Veteran's current cervical spine disorder. Additionally, the December 2012 VA examiner found that the Veteran had no symptoms or complaints indicative of a chronic neck disorder or otherwise characteristic of degenerative joint and disc disease, and that the Veteran's concussive torticollis is not the cause of degenerative changes. The Board also points out that there is no indication that the Veteran had any complaints or treatment for his neck between 1976 and 1979, or between 1979 and his claim in 2007; the Veteran's 2008 Agent Orange examination and VA treatment records are negative. The Veteran is competent to report his experiences in service and to state that he experiences symptoms related to his hypertension and cervical spine degenerative joint and disc disease, but these statements must be weighed against the other evidence of record. Since Dr. H has attributed the Veteran's hypertension and cervical spine disorder to in-service events, the Veteran's opinion is competent. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Nevertheless, the Board finds that the specific findings of the December 2012 VA examiners, indicating that the Veteran's hypertension and cervical spine arthritis are not related to his service, are of greater probative weight than the more general lay assertions of the Veteran and Dr. H, even assuming those assertions as etiology were competent. See Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011) (noting impropriety of the Board categorically discounting lay testimony and requiring the Board to determine, on a case by case basis, whether a veteran's particular disability is the type of disability for which lay evidence is competent). The Board acknowledges the opinion of Dr. H, wherein he attributes the Veteran's hypertension and cervical spine arthritis to the Veteran's service, but points out that Dr. H provides no rationale for his opinions, and relied on an inaccurate medical history by the Veteran. Of note, the Board reiterates that the Veteran's cervical torticollis occurred approximately 3 years after the Veteran's separation from service, as did the Veteran's initial diagnosis and treatment for hypertension. The report of hypertension since service is inconsistent with the normal cardiovascular findings at separation and for approximately thirteen years after service; Dr. H provided no explanation as to how the "stress" of the Veteran's service caused his hypertension three years after his discharge, and the events are too remote to be causally related. Additionally, the report of cervical spine arthritis since service is inconsistent with the lack of complaints related to his cervical spine during service and at separation; other than the Veteran's acute injury in 1979, there are no cervical complaints until 2006. Dr. H opined that the Veteran's 1979 post-concussive cervical torticollis caused his cervical spine arthritis, but did not explain the absence of cervical spine complaints and symptoms between his discharge in 1976 and the post-service, 1979 injury, nor did he explain the lack of related manifestations between 1979 and 2006, when degenerative joint and disc disease of the cervical spine was diagnosed. To the extent that the Veteran and Dr. H provided opinions linking the remote onset of hypertension to the stress of service and the remote onset of cervical spine degenerative joint and disc disease to an undocumented event or injury in service, we have found that the appellant is not a credible historian and that a medical opinion based upon an inaccurate factual predicate and without any rationale, is equally inaccurate. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (the Board is not bound to accept a physician's opinion when it is based exclusively on the recitations of a claimant that have been previously rejected). As such, we find the positive medical evidence to be of little probative value. The opinions of Dr. H and the Veteran are less credible and probative than the negative medical evidence. The December 2012 VA examiner found that, as the Veteran's hypertension did not develop until many years after service, it was not likely related to the Veteran's service; the VA examiner also found that the Veteran's elevated blood pressure readings in service did not meet the requirement for a diagnosis of hypertension. Likewise, the December 2012 VA examiner found that the Veteran's cervical spine arthritis is not likely related to the Veteran's service, as the Veteran did not have any complaints related to his cervical spine until 1979, approximately 3 years after his discharge from service, and then not again until 2006. The VA examiner also found that the Veteran's cervical degenerative disease is related to age and "wear and tear." These opinions are well reasoned and consistent with the actual factual record. We find the December 2012 VA opinions to be highly probative. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Although there are letters dated in 2007 from Dr. H, stating that the Veteran's hypertension was due to the stress of serving and that his cervical spine arthritis was due torticollis in service, the Board is not bound to accept medical opinions that are based on a history based upon an inaccurate factual background. Black v. Brown, 5 Vet. App. 177 (1993). Furthermore, the December 2012 VA examiners reviewed the claims file, examined the Veteran, and reviewed the pertinent medical literature prior to providing a clear medical opinion that the Veteran's hypertension began many years after service and is unrelated to any mildly elevated blood pressure readings in service. The VA examiner noted that the Veteran was not treated for high blood pressure for thirteen years after service, and that there is no relationship between the Veteran's service and his current hypertension. Regarding both the claim for hypertension and the claim for cervical spine arthritis, as the December 2012 VA examiners explained the reasons for the opinions based on an accurate characterization of the evidence of record, the opinions are entitled to substantial probative weight. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (stating that factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion). To the extent that the Veteran contends that his hypertension and cervical spine arthritis are related to his service, the probative value of his general lay assertions is outweighed by the specific, reasoned opinion of the December 2012 VA examiners. The weight of the evidence therefore reflects that his hypertension and cervical spine arthritis are unrelated to service. In sum, pathology of hypertension and cervical spine arthritis were not manifest during service or within one year of separation. Rather, there was a remote post-service onset. There is no reliable evidence linking the remote hypertension and cervical spine arthritis to service or to a service-connected disease or injury. The weight of the evidence therefore reflects that the Veteran's hypertension and cervical spine arthritis are unrelated to service. For the foregoing reasons, the preponderance of the evidence is against the claims for service connection for hypertension and cervical spine arthritis. The benefit-of-the-doubt doctrine is therefore not for application, and the claims must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ORDER Entitlement to service connection for a heart disability is denied. Entitlement to service connection for headaches is denied. Entitlement to service connection for right ear hearing loss is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for a cervical spine disability is denied. ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs