Citation Nr: 1333449 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 10-02 277 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as due to in-service herbicide exposure and service-connected Type II Diabetes Mellitus (DMII). 2. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as due to in-service herbicide exposure and service-connected DMII. 3. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as due to in-service herbicide exposure and service-connected DMII. 4. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as due to in-service herbicide exposure and service-connected DMII. 5. Entitlement to service connection for hypertension, to include as due to in-service herbicide exposure and service-connected DMII. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1967 to September 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Albuquerque, New Mexico, which in pertinent part, denied the claims currently on appeal. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam during the Vietnam era and was exposed to herbicides. 2. The Veteran does not have peripheral neuropathy of the upper extremities. 3. Currently diagnosed peripheral neuropathy of the lower extremities is related to service. 4. No vascular injury, disease, or chronic symptoms of hypertension were manifested during service. 5. The Veteran did not continuously manifest symptoms of hypertension in the years after service. 6. Hypertension was not manifested to a degree of ten percent within one year of service separation. 7. The Veteran's hypertension is not caused by any in-service event, including herbicide exposure, during service. 8. The currently diagnosed hypertension is not due to or permanently worsened in severity by the service-connected DMII. CONCLUSIONS OF LAW 1. The criteria for service connection for peripheral neuropathy of the right upper extremity, to include as due to in-service herbicide exposure and service-connected DMII, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 2. The criteria for service connection for peripheral neuropathy of the left upper extremity, to include as due to in-service herbicide exposure and service-connected DMII, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 3. Peripheral neuropathy of the right lower extremity was incurred in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2013). 4. Peripheral neuropathy of the left lower extremity was incurred in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2013). 5. The criteria for service connection for hypertension, to include as due to in-service herbicide exposure and service-connected DMII. 38 U.S.C.A. §§ 1110, 1112, 1131, 1133, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating a claim for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2013). A VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. VCAA notice requirements apply to all five elements of a service connection claim (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). The Board finds that in this case VA has satisfied its duties to notify under the VCAA. The RO provided a VCAA notice letter to the Veteran in October 2007, which notified the Veteran of what information and evidence must be submitted to substantiate a claim for service connection and secondary service connection. The October 2007 letter also provided information regarding the general criteria for the assignment of an effective date and initial rating. Further, the Board finds that all relevant evidence has been obtained with regard to the Veteran's claims on appeal, and the duty to assist requirements have been satisfied. All available service treatment records were obtained. VA treatment records and private medical records and private medical opinions are associated with the claims folder. The Veteran was also afforded VA examinations in May 2008, June 2010, and April 2012 to obtain medical evidence as to the nature and likely etiology of the Veteran's peripheral neuropathy, hypertension, and service-connected DMII disability. These examinations were adequate because each was performed by a medical professional based on either a review of claims file or solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran, offered opinions, and provided a rationale for the opinions provided. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). 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). Significantly, neither the Veteran nor his representative have identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection - Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). In this case, hypertension and organic disease of the nervous system are each a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as hypertension or an organic disease of the nervous system, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. A veteran, who had active service in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975 (the Vietnam era) will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. See 38 U.S.C.A. § 1116(f) (West 2002); 38 C.F.R. § 3.307(a)(6)(iii). The presumption of herbicide exposure is warranted for service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii); see also Haas v. Nicholson, 20 Vet. App. 257 (2006), rev'd sub nom, Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008), cert. denied, 77 U.S.L.W. 3267 (Jan. 21, 2009) (No. 08-525). In order to establish qualifying "service in Vietnam," a veteran must demonstrate actual duty or visitation in the Republic of Vietnam to have qualifying service. 38 C.F.R. § 3.307(a)(6)(iii); VAOPGCPREC 27-97. Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne or other acneform disease consistent with chloracne, non-Hodgkin's lymphoma, soft tissue sarcoma, Hodgkin's disease, porphyria cutanea tarda (PCT), multiple myeloma, early onset peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, type II (adult-onset) DMII, chronic lymphocytic leukemia, AL amyloidosis, Parkinson's disease, ischemic heart disease, and B-cell leukemias, such as hairy cell leukemia. See 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). VA's Secretary has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See 68 Fed. Reg. 27,630 (May 20, 2003). In this regard, the Board observes that VA has issued several notices in which it was determined that a presumption of service connection based upon exposure to herbicides used in Vietnam should not be extended to certain specific disorders, based upon extensive scientific research. See, e.g., Notices, 68 Fed. Reg. 27,630-41 (2003); 64 Fed. Reg. 59,232-243 (1999); 61 Fed. Reg. 57,586-589 (1996). However, the United States Court of Appeals for the Federal Circuit has determined that an appellant is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom, Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). Service connection may also 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). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disease caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disease or ionjury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) evidence establishing a connection between the current disability and the service-connected disability. 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. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for Peripheral Neuropathy of the Upper Extremities The Veteran contends that he has peripheral neuropathy of the upper extremities manifested by occasional pain, tingling, and a burning sensation on the palms of his hands. See May 2008 VA examination report. Upon review of the evidence of record, both lay and medical, the Board finds that the Veteran does not have a current diagnosis of peripheral neuropathy of the upper extremities. In this regard, service treatment records are negative for any complaints, diagnosis, or treatment for peripheral neuropathy of the upper extremities. Post-service VA and private treatment records do not reveal a diagnosis of upper extremity peripheral neuropathy. The Board has considered the Veteran's assertions that he experiences tingling and pain in the palms of his hands. As a lay person, the Veteran is competent to relate some symptoms that may be associated with his conditions, such as tingling and burning sensation, but he does not have the requisite medical knowledge, training, or experience to be able to diagnose the medically complex disorder of peripheral neuropathy. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that requires a medical opinion to diagnose and to relate to service or differentiate from in-service symptoms and diagnosis). Peripheral neuropathy is a medically complex disease process because of its multiple etiologies, it requires specialized testing to diagnose, and manifests even observable symptomatology that overlaps with other disorders. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis). As such, the Veteran is not competent to render a diagnosis of upper extremity peripheral neuropathy. See Jandreau. For these reasons, the Board finds that service connection for peripheral neuropathy of the upper extremities, both on a direct and secondary basis, is not warranted because in the absence of proof of a present disability there can be no valid claim. See Brammer v, 3 Vet. App. 223, 225; see also Rabideau, 2 Vet. App. at 143-44. Further, although the Veteran served in the Republic of Vietnam (See service personnel records showing duty in Vietnam), without a diagnosis of neuropathy, service connection may not be established on a presumptive basis. As noted above, in order to establish presumptive service connection for in-service exposure to herbicides, early onset peripheral neuropathy must have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active service. 38 C.F.R. § 3.307(a)(6)(ii). In addition to no diagnosis for peripheral neuropathy, the Veteran has not alleged that the numbness and burning in his hands began within a year after the last date of exposure to herbicides (i.e., July 23, 1969). Instead, the Veteran has asserted that the upper extremity numbness and burning sensation began in approximately 2000. See March 2008 VA examination report. In his September 2007 claim for VA compensation, the Veteran reported that his peripheral neuropathy began in 1971, more than one year after his exposure to herbicide agents and more than one year after separation. For these reasons, the Board finds that service connection on a presumptive basis is not warranted. In making its determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b) regarding benefit of the doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. 38 U.S.C.A. § 5107(b) ; 38 C.F.R. § 3.102. Service Connection for Peripheral Neuropathy of the Lower Extremities The Veteran contends that he experiences tingling, pain, and a burning sensation in both feet as a result of exposure to herbicides in service, or, alternatively as a result of service-connected DMII. The Board finds that the Veteran has currently diagnosed peripheral neuropathy of the lower extremities. See treatment records from Dr. J.P.S., VA treatment records, and May 2008 VA examination report. The Board finds that the evidence is in equipoise as to whether the Veteran's currently diagnosed peripheral neuropathy of the lower extremities is related to service, to include exposure to herbicides. Weighing in favor of the Veteran's claim is a September 2007 private medical opinion from the Veteran's treating neurologist, Dr. J.P.S. In this medical opinion, Dr. J.P.S. noted that the Veteran had been seen at the neurology clinic for complaints of painful burning of the feet superimposed on a substrate of reduced sensations. The Veteran's clinical diagnosis was noted as peripheral neuropathy, confirmed by nerve conduction studies. It was further noted that the Veteran had undergone extensive serologic testing in search for other extrinsic and intrinsic potentials for the etiology for the neuropathy. According to Dr. J.P.S., the extensive search yielded no other potential causes. Dr. J.P.S. opined that "to date, as other etiologies have been ruled out, my opinion is that the most proximate etiology for his neuropathy remains Agent Orange exposure." The Board finds the September 2007 medical opinion from Dr. J.P.S. highly probative. Dr. J.P.S. was the Veteran's treating neurologist and was aware of the Veteran's exposure to Agent Orange and post-service back injuries, which the Veteran has reported in VA and private treatment records. See November 2004 private treatment record from Dr. J.P.S. Further, his medical opinion is based on electromyography (EMG) results, nerve conduction studies, and serologic testing. For these reasons, the Board finds that the September 2007 private medical opinion weighs in favor of a nexus between peripheral neuropathy of the lower extremities and service. Further weighing in favor of the Veteran's the claim is a May 2007 treatment note from Dr. J.P.S. where the Veteran underwent EMG testing. According to Dr. J.P.S., EMG study results revealed no evidence to support a diagnosis of lumbar radiculopathy and, instead, suggested a sensory mononeuroptahy multiplex. Despite the Veteran's reports of a low back injury in the 1970s, which could have potentially served as an alternative basis for the etiology of the Veteran's neuropathy, the results from the May 2007 EMG study demonstrate that the current neuropathy did not appear to be related his lumbar spine as there was no evidence of lumbar radiculopathy. Although the Veteran was afforded VA examinations in May 2008, June 2010, and April 2012, none of these evaluations provide an opinion as to the etiology of the Veteran's peripheral neuropathy. In the May 2008 VA examination report, the Veteran noted tingling and a burning sensation in his feet. The VA examiner also reviewed the claims file and noted Dr. J.P.S.'s treatment and medical opinion. During the evaluation, the Veteran stated that he did not believe that his peripheral neuropathy was part of his lumbar spine condition. Although the May 2008 VA examiner diagnosed the Veteran with peripheral neuropathy of the lower extremities, citing Dr. J.P.S.'s findings, the May 2008 VA examiner did not provide an opinion as to whether currently diagnosed peripheral neuropathy was related to service, to include Agent Orange exposure. For these reason, the Board finds the March 2008 is of no probative value on the question of a relationship between the Veteran's peripheral neuropathy and service. Likewise, the Board finds that the June 2010 VA examination is also of no probative value. Specifically, the June 2010 VA medical examiner only provided an opinion as to a whether the Veteran had currently diagnosed DMII, and did not render an opinion as to whether peripheral neuropathy of the lower extremities is related to service. In the April 2012 VA examination report, the examiner reviewed the claims file, interviewed the Veteran, and confirmed the diagnosis of DMII and peripheral neuropathy of the lower extremities. The April 2012 VA examiner noted that the Veteran underwent an EMG in January 2010 during a VA treatment session, which revealed prolonged latency of a single nerve. According to the April 2012 VA examiner, a mononeuropathy, as noted on the January 2010 EMG, was more consistent with the Veteran's history of back pain as opposed to the polyneuropathy that is classically seen with DMII. The Board finds the April 2012 VA medical opinion to be of little probative value as to whether the Veteran's peripheral neuropathy of the lower extremities is related to service, to include Agent Orange exposure. In part, the April 2012 medical opinion weighs against such a finding as it is suggestive of a low back injury etiology. On the other hand, the April 2012 VA examiner's rationale does not address the issue of herbicide exposure and the opposing opinion and EMG results from Dr. J.P.S., which found that the evidence did not support a diagnosis of lumbar radiculopathy and suggested a sensory mononeuroptahy multiplex. Upon review of all the evidence, both lay and medical, the Board finds that the competent, credible, and probative evidence of record is at least in relative equipoise on the question of whether the Veteran's currently diagnosed peripheral neuropathy of the lower extremities is related to service. Resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for peripheral neuropathy of the lower extremities have been met. 38 U.S.C.A. § 5107(b) ; 38 C.F.R. § 3.102. Service Connection for Hypertension The Veteran is seeking service connection for hypertension, which he contends is caused by service-connected DMII. Alternatively, he asserts that his current hypertension is due to exposure to Agent Orange in the Republic of Vietnam while in service. At the outset, the claim of service connection for hypertension on a presumptive basis as due to Agent Orange exposure must fail because the herbicide presumption set forth in 38 U.S.C.A. § 1116 and 38 C.F.R. § 3.307 does not apply. Hypertension is not one of the enumerated disabilities that are presumed due to herbicide exposure that are listed under 38 C.F.R. § 3.309(e). The amended version of 38 C.F.R. § 3.309(e), Note 3, specifically states that the term ischemic heart disease does not include hypertension. That notwithstanding, a veteran may still establish service connection for hypertension with proof of direct causation, or on any other recognized basis. See Combee at 1042. After a review of all the evidence, the Board finds that, although the Veteran served in the Republic of Vietnam during the Vietnam era, he did not sustain a vascular injury or disease during service, or experience chronic symptoms of hypertension during service. The evidence shows no diagnosis of hypertension in service or for many years thereafter. During the May 2008 VA examination report, the Veteran stated that he was diagnosed and prescribed hypertension medications when he was 32 or 33 years old (i.e., 1980 to 1981), and approximately 10 years after service separation. The service examination reports dated in June 1967 and April 1969 indicate that examination of the heart and vascular system was normal. The June 1967 enlistment examination notes a blood pressure reading of 112/68. The April 1969 examination revealed a blood pressure reading of 132/84. The blood pressure readings recorded in the service records are not 160/90 or higher. See 38 C.F.R. § 4.104, Diagnostic Code 7101 which defines hypertension in Note 1 as dialostic blood pressure predominantly 90mm or greater, or isolated systolic blood pressure 160mm or greater. Thus, the Board finds that the service treatment records do not document a diagnosis, "note" or reflect characteristic manifestations during service. See Wagner. Furthermore, the Veteran asserted that he did not seek medical treatment for approximately 10 years after service separation. The Veteran has not presented any competent evidence of hypertension symptoms since separation from service until the time of the diagnosis of hypertension in 1980. The Board next finds that hypertension did not manifest to a compensable (10 percent) degree within a year of service separation. The Veteran asserts that he was first treated for hypertension in approximately 1980 to 1981, approximately 10 years after service separation. See May 2008 VA examination report. The remaining evidence of record, to include post-service VA and private treatment records do not demonstrate a diagnosis or treatment for hypertension within one year of service separation. As such, the Board finds that the weight of the evidence establishes that the Veteran's hypertension did not manifest to a compensable degree within a year of service separation. Finally, the Veteran's representative has asserted that the Veteran's hypertension is related or caused by the service-connected DMII disability. See June 2013 Appellate Brief in Virtual VA electronic claims file. In this regard, the Board notes that the Veteran was granted service connection for DMII associated with herbicide exposure in an April 2012 rating decision. Also, as noted above, service connection may be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). In addition, a claimant is entitled to service connection on a secondary basis when it is shown that a service-connected disability has chronically aggravated a nonservice-connected disability. Allen, 7 Vet. App. at 448. The Veteran was afforded a VA examination in April 2012. The VA examiner reviewed the claims folder, considered the Veteran's reported medical history, examined the Veteran, and determined that it was less likely than not that the Veteran's hypertension was due to DMII as there was no diabetic renal involvement. The April 2012 VA examiner stated that given that the Veteran's DMII was of questionable diagnosis until January 2011, it was not likely that the DMII was the source of permanent aggravation of any specific condition, to include hypertension. In the absence of renal affectation, the VA examiner opined that aggravation of hypertension (by DMII) was much less likely than not. The May 2008 and June 2010 VA examination reports do not provide medical opinions on the question of whether the Veteran's hypertension is caused or aggravated by service-connected DMII. Moreover, VA and private treatment records do not demonstrate any changes in the amounts of medication or level of blood pressure readings to support the theory of aggravation of hypertension by service-connected DMII. The Board finds the April 2012 VA medical opinion to have great evidentiary weight as the opinion reflects a comprehensive and reasoned review of the entire evidentiary record. The VA examiner reviewed the claims folder and the Veteran's medical history, and examined the Veteran before rendering the medical opinion. Factors for assessing the probative value of a medical opinion are the examiner's access to the claims file and the thoroughness and detail of the opinion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The medical opinion was based on sufficient facts and data. In Nieves-Rodriguez, 22 Vet. App. 295, the Court held that guiding factors in evaluating the probity of a medical opinion are whether the opinion was based on sufficient facts or data, whether the opinion was the product of reliable principles and methods, and whether the medical professional applied the principles and methods reliably to the facts of the case. There is probative evidence of record which supports the VA medical opinion. The service treatment records show that a diagnosis of hypertension was not made in service. The medical evidence of record also shows that hypertension was diagnosed more than one year after service separation and hypertension was diagnosed well before DMII. The Board has also considered the Veteran's statements purporting to relate his hypertension to his active service and to the service-connected DMII. The Veteran, as a lay person, is competent to describe observable symptoms such as pain. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, an opinion as to the etiology and onset of hypertension falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 (lay persons not competent to diagnose cancer). Lay testimony on the question of the etiology of hypertension to service or to DMII is not competent in the present case because the Veteran is not competent to state that hypertension was incurred in service or whether hypertension was caused or aggravated by service-connected DMII. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana, 24 Vet. App. at 433 (lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent). Such a diagnosis requires clinical blood pressure readings which are neither found within the record during or immediately following his service period. Additionally, an opinion of etiology would require knowledge of the complexities of the cardiovascular system, the various causes of unobservable hypertension, and would involve objective clinical testing that the Veteran is not competent to perform. For these reasons, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for hypertension, including as a presumptive disease, as due to herbicide exposure, and as due to or aggravated by service-connected DMII, and this claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for peripheral neuropathy of the right upper extremity, to include as due to in-service herbicide exposure and service-connected DMII, is denied. Service connection for peripheral neuropathy of the left upper extremity, to include as due to in-service herbicide exposure and service-connected DMII, is denied. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as due to in-service herbicide exposure and service-connected DMII, is granted. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as due to in-service herbicide exposure and service-connected DMII, is granted. Service connection for hypertension, to include as due to in-service herbicide exposure and service-connected DMII, is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs