Citation Nr: 1337412 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 09-19 668 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUE Entitlement to service connection for a kidney disorder, claimed as renal cysts, to include as due to herbicide exposure. ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from February 1968 to July 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines, which, in pertinent part, denied service connection for renal cysts. In an October 2007 rating decision, the RO, in pertinent part, denied service connection for a psychiatric disorder. Subsequently, the Veteran appealed this issue to the Board. Prior to certification of this issue to the Board, in a June 2011 rating decision, the RO granted service connection for major depression and posttraumatic stress disorder. As the June 2011 rating decision acted as a full grant of the Veteran's claim on appeal, the issue of service connection for a psychiatric disorder is not in appellate status, and is not before the Board. In a May 2008 rating decision, the RO, in pertinent part, denied service connection for disorders manifested by pain/numbness/tingling in the left elbow, right wrist, and right arm; increased ratings for a low back disability, radiculopathy of the left lower extremity, and bilateral hearing loss; and denied reopening of service connection for hypertensive arteriosclerotic heart disease. Subsequently, the Veteran appealed these issues to the Board. Prior to certification of these issues to the Board, in a June 2011 rating decision, the RO reopened and granted service connection for hypertensive arteriosclerotic heart disease. As the June 2011 rating decision acted as a full grant of the Veteran's claim on appeal, the issue of service connection for hypertensive arteriosclerotic heart disease is not in appellate status, and is not before the Board. Subsequently, in a July 2011 written statement, the Veteran withdrew all his appeals except for service connection for a kidney disorder. As the Veteran withdrew his appeals for service connection for disorders manifested by pain/numbness/tingling in the left elbow, right wrist, and right arm, and increased ratings for a low back disability, radiculopathy of the left lower extremity, and bilateral hearing loss, these issues are not in appellate status, and are not before the Board. The Veteran requested a hearing before a Veterans Law Judge, to be held at the RO (i.e. Travel Board hearing), but subsequently withdrew this request in writing. The issue on appeal was previously remanded by the Board in April 2012 for translation of documents and to obtain a VA medical examination to assist in determining the nature and etiology of the kidney disorders. This was accomplished, and the claim was readjudicated in an August 2013 supplemental statement of the case. For this reason, the Board concludes that the Board's remand orders have been substantially complied with, and it may proceed with a decision at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). The RO is asked to consider whether Diagnostic Code 7005 under 38 C.F.R. § 4.104 is the more appropriate rating for the grant of service connection for "hypertensive arteriosclerotic heart disease." See June 2011 rating decision. The Veteran was assigned a 30 percent disability rating under Diagnostic Code 7007 for hypertensive arteriosclerotic heart disease; however, the March 2011 VA examination report, which was the basis of the grant of service connection, did not find that hypertension was incurred in or related to service. The March 2011 VA examiner opined that "arteriosclerotic heart disease," and not hypertension, was related to service. This distinction is relevant because a grant of service connection for "hypertensive arteriosclerotic heart disease" would suggest that both hypertension and arteriosclerotic heart disease were found to be related to or incurred in service, which would require them to be rated separately. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 3 (evaluate hypertension separately from hypertensive heart disease). FINDINGS OF FACT 1. The Veteran has currently diagnosed chronic kidney disease, renal cysts, diabetic nephropathy, nephrolithiasis (calculi in the kidneys), and nephrosclerosis. 2. The Veteran was not exposed to herbicides (Agent Orange) during service. 3. Symptoms relating to a kidney disorder were not chronic in service and have not been continuous since service separation. 4. A kidney disorder did not manifest in service or to a compensable degree within one year of service separation. 5. A currently diagnosed kidney disorder did not have its onset in service and is not otherwise etiologically related to service, to include in-service exposure to Agent Orange or other "toxins." CONCLUSION OF LAW The criteria for service connection for kidney disorder, claimed as renal cysts, to include as due to herbicide exposure have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1154(b), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA 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. The Board finds that the VCAA notice requirements have been satisfied by a July 2006 letter. In this letter, VA informed the Veteran that, in order to substantiate a claim for service connection, the evidence needed to show he had a current disability, a disease or injury in service, and evidence of a nexus between the post-service disability and the disease or injury in service, which was usually shown by medical records and medical opinions. As to informing the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf, VA informed the Veteran it had to obtain any records held by any federal agency. This letter also informed the Veteran that on his behalf VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the letter told the Veteran that he could obtain private records himself and submit them to VA. The VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the July 2006 letter included the type of evidence necessary to establish a disability rating and effective date. The Board notes there are missing service treatment records in this case from 1968 to 1983. The Board has applied a heightened obligation to assist in the development of the case, a heightened obligation to explain findings and conclusions, and a heightened duty to consider carefully the benefit of the doubt rule. See Washington v. Nicholson, 19 Vet. App. 362, 369-70 (2005); see also Cromer v. Nicholson, 19 Vet. App. 215, 217 (2005) citing O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). Regarding the duty to assist, VA must make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the service connection claim currently on appeal, the evidence of record includes service treatment records, service personnel records, VA and private treatment records, and the July 2013 VA examination obtained pursuant to the April 2012 Board remand directives. The July 2013 VA examiner reviewed the Veteran's claims file and medical history, recorded pertinent examination findings, and provided conclusions with supporting rationale. The VA examination report is probative with regard to the service connection claim on appeal. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim on appeal that is addressed on the merits in this decision. The evidence of record provides sufficient information to adequately evaluate the claim, all obtainable evidence identified by the Veteran relative to the claim has been obtained and associated with the claims file, and the Board is not aware of the existence of any additional relevant evidence which was not obtained; therefore, no further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). 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, 1131; 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). The Veteran's kidney disorders involve, in part, conditions which are considered "chronic disease" under 38 C.F.R. § 3.309(a), to include nephrolithiasis (calculi in the kidneys) and nephrosclerosis (kidney disease usually associated with hypertension); therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) for "chronic" in-service symptoms and "continuous" post-service symptoms apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Generally, 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); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In the case of a veteran who engaged in combat with the enemy in a period of war, lay evidence of in-service incurrence or aggravation of a disease or injury shall be accepted if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the lack of official record of such incurrence or aggravation. See 38 U.S.C.A. § 1154(b); Libertine v. Brown, 9 Vet. App. 521, 524 (1996); Collette v. Brown, 82 F.3d 389, 392-94 (Fed. Cir. 1996). The standard used to determine whether a veteran engaged in combat with the enemy is reasonable doubt, which is to be resolved in a veteran's favor. See VAOPGCPREC 12-99. The provisions of 38 U.S.C.A. § 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See Libertine, 9 Vet. App. at 522-23. The provisions of 38 U.S.C.A. § 1154(b) do not establish service connection for a combat veteran; it aids a veteran by relaxing the adjudicative evidentiary requirements for determining what happened in service. Clyburn v. West, 12 Vet. App. 296, 303 (1999). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975." Service in the Republic of Vietnam" includes 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). The following diseases are deemed associated with herbicide exposure, under VA law: AL amyloidosis, Chloracne or other acneform disease consistent with chloracne, Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), 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). 38 C.F.R. § 3.309(e). In Combee v. Brown, the United States Court of Appeals for the Federal Circuit held that when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994), reversing in part Combee v. Principi, 4 Vet. App. 78 (1993). As such, the Board must not only determine whether the Veteran has a disability which is recognized by VA as being etiologically related to prior exposure to herbicide agents that were used in Vietnam, but must also determine whether his current disability is the result of active service under 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303(d). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 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. See 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 disability 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 disability. 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) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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); Gilbert, 1 Vet. App. at 57. 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). Service Connection for a Kidney Disorder The Veteran contends that a current kidney disorder is related to in-service exposure to either a single chemical or many different chemicals. Initially, the Veteran maintained that his kidney disorder was related to in-service herbicide exposure, to include Agent Orange, related to service in the Vietnam War. Subsequently, in an April 2009 report of contact, a VA employee indicated that the Veteran claimed that his kidney disorder was not related to herbicide exposure, but was, instead, related to in-service exposure to dioxins. When asked which particular dioxin he believed had caused his kidney disorder, the Veteran could not specify a particular type. In a September 2010 statement, the Veteran listed the chemicals to which he claimed exposure during service, which he labeled as "toxics." The chemicals listed by the Veteran were: liquid solvent, dry cleaning solvent, aliphatic naptha, aromatic naptha, methyl ethyl ketone, aircraft corrosion preventive compound 1-2-3-4, aircraft paint remover, zinc chromate primer, aircraft epoxypolymide primer, aircraft thinners, aircraft paints, alodine, liquid freon, water emulsion cleaner, chemicals in a fiberglass repair kit (including hardener), beryllium, and asbestos. In a January 2011 statement, the Veteran again claimed that the kidney disorder was related to in-service exposure to herbicides. The Veteran contended that he was exposed to Agent Orange while working on ships in the waters off Vietnam. The Veteran stated that he was at the Da Nang U.S. Naval Air Base in 1973 for three days while awaiting a flight back to his ship after flying from Subic, the Philippines. The evidence of record includes a September 2010 VA formal finding of the unavailability of evidence required to corroborate the claim for exposure to Agent Orange. Review of service medical and personnel records do not demonstrate that the Veteran served in-county, to include inland "brown water" rivers and delta areas of the Republic of Vietnam. For these reasons, the Board finds that the Veteran is not presumed to have been exposed to herbicide agents during service. Even if the evidence did demonstrate that the Veteran served in the Republic of Vietnam and was exposed to herbicide agent, the Veteran's kidney disorders (chronic kidney disease, renal cysts, diabetic nephropathy, nephrolithiasis, and nephrosclerosis) are not among the diseases listed under 38 C.F.R. § 3.309(e), for which presumptive service connection based on herbicide exposure is available; therefore, there is no basis for a presumptive grant of service connection for a kidney disorder. Notwithstanding the inapplicability of the Agent Orange presumptive service connection regulations, the Board is obligated to fully consider the Veteran's service connection claim on a direct basis. See Combee, 34 F.3d at 1043-1044. In this regard, the Board finds that the Veteran has currently diagnosed chronic kidney disease, renal cysts, diabetic nephropathy, nephrolithiasis, and nephrosclerosis. See July 2013 VA examination report. Next, symptoms relating to a kidney disorder were not chronic in service. Available service treatment records are absent for complaints, diagnosis, or treatment for a kidney disorder. A Report of Medical History dated June 1987 revealed no kidney stones or blood in urine. A Report of Medical Examination dated February 1984 revealed a "normal" genitourinary system. Dental health questionnaires dated March 1980 and March 1984 show that the Veteran checked "no" as to liver or kidney trouble. The June 1988 service separation examination report demonstrated no kidney stones or blood in urine and the urinalysis was within normal limits. For these reasons, the Board finds that symptoms of a kidney disorder were not chronic in service and a kidney disorder did not have its onset in service. The Board further finds that the weight of the probative evidence demonstrates that a kidney disorder did not manifest to a compensable degree within one year of service separation. The evidence demonstrates no symptoms relating to a kidney disorder during the one year period after service, and no diagnosis or findings of a kidney disorder during the one year post-service presumptive period. See 38 C.F.R. §§ 3.307, 3.309. As will be discussed in detail below, the evidence shows the first assessment of renal cysts was in 2003, chronic kidney disease was first noted in 2005, diabetic nephropathy was first diagnosed in 2009, and nephrolithiasis diagnosed in 2004. Because a kidney disorder did not manifest to a compensable degree within one year of service separation; therefore, the presumptive provisions for a kidney disorder are not applicable in this case. 38 C.F.R. §§ 3.307, 3.309. The Board next finds that the weight of the evidence demonstrates that symptoms associated with a kidney disorder have not been continuous since service separation to warrant presumptive service connection on the basis of continuous post-service symptoms under 38 C.F.R. § 3.303(b). Post-service VA and private treatment records reveal that the Veteran manifested kidney disorder symptoms after service and was first diagnosed with a kidney disorder in 2003, approximately 15 years after service separation. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006) (stating the Board may weigh the absence of contemporaneous medical evidence in service as a factor in determining credibility of lay evidence, but the Board cannot determine that lay evidence of onset of psychiatric symptoms in service lacks credibility merely because it is unaccompanied by contemporaneous service treatment/medical record evidence). Aside from statements made pursuant to his current claim for VA compensation, the Veteran has not reported to medical professionals that his kidney disorders were due to service or that he experienced continuous symptoms associated with a kidney disorder since service. See Cartright, 2 Vet. App. at 25; Pond v. West, 12 Vet. App. 341 (1991) (interest may affect the credibility of testimony). Instead, the Veteran has maintained that kidney disorder symptoms are related to exposure to herbicides and other "toxins" during service. For these reasons, the Board finds that service connection on the basis of continuous post-service symptoms under 38 C.F.R. § 3.303(b) is not warranted. Further, the Board finds that the weight of the competent and probative evidence demonstrates that the currently diagnosed kidney disorders are not related to or caused by service. Although post-service treatment records reveal ongoing treatment for kidney disorders, beginning years after service separation, they do not provide an opinion relating a kidney disorder to service. On the question of relationship of current kidney disorders to service, and pursuant to the April 2012 Board remand directives, the Veteran was afforded a VA examination in July 2013 to assist in determining whether the Veteran's kidney disorders were related to service. The July 2013 VA examiner reviewed the claims file, interviewed the Veteran, conducted laboratory testing, and diagnosed the Veteran with chronic kidney disease, renal cysts, diabetic nephropathy, nephrolithiasis, and nephrosclerosis. The VA examiner opined that all of the kidney disorders were less likely than not incurred in or caused by service. Specifically regarding renal cysts, the July 2013 VA examiner reasoned that a cyst was first seen on an ultrasound study in August 2003. The VA examiner noted that a review of service treatment records, including review of the medical history, reports of medical examination, and dental questionnaires showed no evidence of renal cysts or consultation due to renal cyst or a kidney disorder in service. Further, the service separation urinalysis dated June 1988 showed normal results. The VA examiner further observed that the medical literature revealed that there was a 35 percent predisposition of forming simple renal cysts among people 50 years and above. When the cyst was first documented by ultrasound in 2003, the Veteran was already over 50 years of age. As for exposure to Agent Orange and other toxins alleged to have caused renal cysts, the July 2013 VA examiner noted that common effect of dioxin toxicity is in the skin, in the form of chloracne, or reproductive problems as well a depressed immune system. The examiner indicated that there was no literature stating that exposure to these substances could result in renal cysts, and the examiner further stated that renal cysts were not recognized presumptive disability secondary to Agent Orange exposure. According to the July 2013 VA examiner, a review of service treatment records did not show that the Veteran consulted or was confined due to any poisoning or ingestion of a toxic substance in service. The VA examiner further explained that most of the chemicals mentioned by the Veteran were liquids and solvents and the most probable route, if indeed there was intoxication, was inhalation or skin contact over ingestion. According to the VA examiner, the route of contact to the toxic chemicals was very important in the causation of a kidney disease because most likely toxic nephropathy would present with an acute rather than an chronic kidney disease resulting from exposure to toxins administered either via ingestion or via iatrogenic injection and less likely inhaled or through the skin. The toxic chemicals upon entry to the body should be brought by the blood to the kidneys in order for it to cause renal damage, which was usually seen in the tubules causing toxic nephropathy commonly in the form of acute tubular necrosis. In the Veteran's case, the VA examiner reasoned that there was no evidence of the toxic effect of these chemicals in lungs which would be the first organ affected by inhalation of these chemicals over the kidneys. In regard to the diagnosis for diabetic nephropathy, the July 2013 VA examiner stated that the diagnosis was confirmed by microalbuminuria in June 2013. The VA examiner opined that the etiology of diabetic nephropathy was diabetes mellitus which, after review of the record, was first noted around 2009. The Board notes that the Veteran is not service connected for diabetes mellitus; therefore, secondary service connection for diabetic nephropathy is not for application. See 38 C.F.R. § 3.310 (2013). Further, the July 2013 VA examiner stated that the nephrolithiasis (calculi in the kidneys) was first noted on ultrasound in 2004. The VA examiner opined that the etiology of the stones was at least as likely as not a complication of the renal cyst or secondary to hyperuricemia. By virtue of the onset in 2004, absence of any complaint of kidney stone in service, normal urinalysis taken prior to service discharge, no relationship of toxic chemical exposure in the pathogenesis of a urinary stone, the VA examiner opined that this condition was less likely as not related to service. As to chronic kidney disease, the July 2013 VA examiner opined that it was secondary to hypertensive nephrosclerosis. According to the VA examiner, chronic kidney disease was first noted in 2005 when the Veteran had elevated creatinine levels. The VA examiner opined that the most likely etiology of chronic kidney disease was the Veteran's (non-service-connected) chronic hypertension, which was more likely to result in nephrosclerosis causing the chronic kidney disease in time. The Board notes that although the VA examiner opined that chronic kidney disease was secondary to "chronic hypertension," and the Veteran is service-connected for "hypertensive arteriosclerotic heart disease," service connection has not been established for hypertension. See June 2011 RO rating decision; see also Mach 2011 VA examination report finding that hypertension was not incurred in or etiologically related to service. As such, secondary service connection under 38 C.F.R. § 3.310 is not for application for chronic kidney disease. The Board has also considered the Veteran's statements purporting to relate the kidney disorders to service; however, as a lay person, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex kidney disorders. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). Chronic kidney disease, renal cysts, diabetic nephropathy, nephrolithiasis, and nephrosclerosis are medically complex disease processes because of their multiple etiologies, require specialized testing to diagnose, and manifest symptomatology that overlap with other disorders. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis). The etiology of the Veteran's current kidney disorders, to include how, if at all, herbicides and other toxins impact the disorders, is a complex medical question involving internal and unseen system processes unobservable by the Veteran. For these reasons, the Board finds that a preponderance of the evidence is against the claim for service connection for a kidney disorder, claimed as renal cysts, to include as due to herbicide exposure, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for a kidney disorder, claimed as renal cysts, to include as due to herbicide exposure, is denied. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs