Citation Nr: 1338097 Decision Date: 11/20/13 Archive Date: 12/06/13 DOCKET NO. 08-26 298 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for the claimed bilateral knee disorder. 2. Entitlement to service connection for the claimed residuals of a head injury. 3. Entitlement to service connection for claimed diabetes mellitus. 4. Entitlement to service connection for claimed bilateral upper extremity neuropathy, to include as secondary to diabetes mellitus. 5. Entitlement to service connection for claimed bilateral lower extremity neuropathy, to include as secondary to diabetes mellitus. 6. Entitlement to service connection for claimed erectile dysfunction, to include as secondary to diabetes mellitus. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD G. E. Wilkerson, Counsel INTRODUCTION The Veteran served on active duty from May 1976 to May 1980. These matters initially came to the Board of Veterans' Appeals (Board) on appeal from September 2007 and February 2008 rating decisions of the RO. In March 2010, the Board remanded the case to the RO, via the Appeals Management Center (AMC) for additional development of the record. In December 2011, the Board denied the claims of service connection for a bilateral knee disorder and the residuals of a head injury. The Veteran appealed the December 2011 Board decision to the United States Court of Appeals for Veterans Claims (Court). In August 2012, the Court granted a Joint Motion for Remand, filed by representatives for both parties, partially vacating the decision to the extent that it denied service connection for a bilateral knee disorder and the residuals of a head injury and remanding those claims to the Board for further proceedings consistent with the Joint Motion. In December 2011, the Board had also remanded the claims of service connection for diabetes mellitus, bilateral upper and lower extremity neuropathy, and erectile dysfunction to the RO, via the AMC, for additional development. These matters have since been returned the Board for further appellate action. As will be discussed, the RO is deemed to have complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). In May 2013, the Board sought an advisory medical opinion from the Veterans Health Administration (VHA) with respect to the claim for service connection for diabetes mellitus and related complications. The opinion, dated in July 2013, has been received at the Board, and the Veteran and his representative have been provided a copy of this opinion. A review of the Veteran's Virtual VA and VBMS electronic claims file reveals additional VA outpatient treatment records dated through August 2012. As the RO has reviewed these records in connection with the claims herein decided-as noted in the September 2012 Supplemental Statement of the Case-remand for initial RO consideration of this evidence is not required. The issues of service connection for a bilateral knee disorder and the residuals of a head injury are being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran is not shown to have manifested complaints or findings referable to diabetes mellitus in service or for many years thereafter. 2. The Veteran is not shown to have manifested complaints or findings referable to neuropathy of the upper or lower extremities or erectile dysfunction in service or for many years thereafter. 3. Neither diabetes mellitus, related neuropathy of the upper and lower extremities nor erectile dysfunction is shown to be due to an event or incident of the Veteran's period of active service. 4. As service connection for diabetes mellitus has not been established, there is no legal basis for an award of service connection for neuropathy of the upper and lower extremities or erectile dysfunction as secondary to diabetes mellitus. CONCLUSIONS OF LAW 1. The Veteran's disability manifested by diabetes mellitus is not due to disease or injury that was incurred in or aggravated by active service; nor may it be presumed to have been incurred therein. 38 U.S.C.A. § 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 2. The Veteran's disability manifested by bilateral upper and lower extremity neuropathy is not due to disease or injury that was incurred in or aggravated by active service, nor is it proximately due to or a result of a service-connected disability. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). 3. The Veteran's disability manifested by erectile dysfunction is not due to disease or injury that was incurred in or aggravated by active service, nor is it proximately due to or a result of a service-connected disability. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The RO provided a pre-rating VCAA notice letters to the Veteran in July 2007 and October 2007. The letters notified the Veteran of what information and evidence must be submitted to substantiate a claim for service connection. These letters also informed the Veteran of what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. The Veteran was also told to inform VA of any additional information or evidence that VA should have, and was told to submit evidence in support of his claim to the RO. The content of the letters complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The requirements of VCAA also include notice of a disability rating and an effective date for award of benefits if service connection is granted. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was provided with notice of the type of evidence necessary to establish a disability rating and effective dates in the July 2007 and October 2007 letters. The Board finds that all relevant evidence has been obtained with regard to the Veteran's claims, and the duty to assist requirements has been satisfied. All available service treatment records were obtained. VA outpatient treatment records as well as various private treatment records and medical opinions are associated with the claims file. The Veteran underwent VA examination to determine the nature an etiology of his diabetes mellitus and related complications in August 2010. In addition, the Veteran was afforded a second VA examination in January 2012 to determine the etiology of the claimed diabetes mellitus and related complications, as instructed in the Board's December 2011 remand. The examiner provided the requested opinions thus complied with the Board's remand instructions. Stegall, 11 Vet. App. at 271. In July 2013, an advisory medical opinion from the VHA as to the etiology of the Veteran's claimed diabetes mellitus and related complications was also obtained. Under the circumstances, the Board finds that there is no reasonable possibility that further assistance would aid the Veteran in substantiating the claims herein decided. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claims herein decided. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third elements is through a demonstration of continuity of symptomatology. However, 38 C.F.R. § 3.303(b), applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With respect to the current appeal, this list includes diabetes mellitus. See 38 C.F.R. § 3.309(a). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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 diabetes mellitus, 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; 38 C.F.R. §§ 3.307(a), 3.309(a). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). The provisions of 38 C.F.R. § 3.310 were amended effective from October 10, 2006. The new provisions require that service connection not be awarded on an aggravation basis without establishing a pre-aggravation baseline level of disability and comparing it to current level of disability. 71 Fed. Reg. 52744 -47 (Sept. 7, 2006). Although the stated intent of the change was merely to implement the requirements of Allen, the new provisions amount to substantive changes to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. In certain circumstances, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.102, 4.3. Analysis The Veteran seeks service connection for diabetes mellitus, because he believes that this disease originated during his period of active service. He asserts that, because he had symptoms of diabetes mellitus and was referred for glucose testing in service, it is reasonable to conclude that his diabetes mellitus had its onset in service. As regards the claims for bilateral upper and lower extremity neuropathy and erectile dysfunction, he believes that these conditions are secondary to his diabetes mellitus. The Veteran's service treatment records showed that, in April 1977, the Veteran sought medical attention for complaints of urethral discharge. A urinalysis reflected no findings with respect to glucose. An April 1978 urinalysis also noted no pertinent findings with respect to glucose. In August 1979, the Veteran complained of having a numbing sensation in both arms with an onset approximately two months earlier. The treatment provider noted that the Veteran was a heavy drinker. A physical examination was essentially negative. An assessment of alcoholic neuropathy was recorded. It was recommended that the Veteran discontinue the use of alcohol. He was also referred for a glucose tolerance test (GTT) because of a family history of diabetes mellitus. He was to return in one week for re-evaluation, but no record of re-evaluation is contained in these records. A May 1980 discharge examination was noted to be normal with endocrine, neurological and genitourinary systems. The Veteran denied having or having had symptoms or complaints related to these claimed disabilities on May 1980 report of medical history at discharge. Following service, a VA outpatient treatment report dated in May 2000 reflects a history of diabetes mellitus. A March 2001 treatment report noted a history of diabetes mellitus for 3 to 5 years, while a VA active problems list noted that diabetes mellitus had been identified in May 1999. A March 2001 VA outpatient treatment report noted an assessment of erectile dysfunction. In December 2003, the Veteran reported having numbness in his finger tips for the last two months and an on-going problem with the feeling in his legs and feet. A March 2004 podiatry record noted that the Veteran had a "pins-and-needles" sensation on the bottom of the arches of his feet. In April 2006, the Veteran underwent diabetic foot examination. A sensory examination was abnormal. Paresthesias in both feet in the toes was indicated. A statement from the Veteran's wife indicated that she had witnessed the Veteran's struggles with his diabetes mellitus and related complications such as erectile dysfunction and diabetic diarrhea. A statement from the Veteran's brother noted that, after his discharge from service, the Veteran would get up several times a night to urinate; had symptoms such as irritability, dizziness and lethargy; and was always hungry. He stated that he knew that a doctor once told the Veteran that he was diabetic while in the service. A December 2007 report from a private physician noted that the Veteran probably developed type II diabetes in the late 1970s. A January 2008 report indicated that he had erectile dysfunction and some numbness in the toes and fingers. The physician noted no evidence of diabetic neuropathy; however, a January 2008 treatment report reflected that a neurological examination was positive for peripheral neuropathy. A February 2008 private treatment report noted an assessment of diabetic diarrhea. A December 2008 report from a private physician noted that he had reviewed the Veteran's claims file, to include service treatment records and post-service treatment records and lay statements, reviewed pertinent medical literature, and performed a medical examination. The Veteran was noted to have peripheral neuropathy with numbness on his examination of his hands and feet. The physician opined that the diabetes mellitus and related problems of neuropathy and impotence were due to his time in service. In so finding, the physician noted that the Veteran entered service fit for duty and that a GGT was ordered in 1979, and therefore the treatment provider determined that the Veteran had a "presumptive diagnosis of diabetes." The physician also noted that the Veteran's symptoms immediately following service were early signs of diabetes. In addition, the Veteran was noted to have a diagnosis of hypertension that was known to occur due to diabetes primarily due to weight gain, and the Veteran's records were noted not to contain a more likely etiology for the Veteran's current diabetes and secondary complications. A statement from the Veteran's employer and co-worker noted their observations of the Veteran's struggles with his diabetes mellitus and related complications such as diabetic diarrhea. A statement from the Veteran's niece noted that she remembered the Veteran upon his returned from service, because he stayed with her family. She observed symptoms such as frequent thirst and urination, as well as tingling and numbness in his feet and fingertips. She reported that these diabetes-related symptoms were present since his return from service in 1980. An April 2010 medical statement from the private physician provided an addendum opinion in response to the addition of these lay statements. It was noted that the niece's observations were consistent with the early phases of diabetes and corroborate his similar service-time symptoms of diabetes. It was noted that, since these symptoms were observed shortly after service, the opinion was that these were likely the same symptoms that he had in service and were all the first signs and symptoms of diabetes was confirmed. The medical statement also noted that the Veteran had discussed an August 1979 in-service treatment report regarding numbness in his arms. It was noted that making an assessment of alcoholic neuropathy at this point in service would have been impossible because it took many years for alcoholism to get to the point of causing neuropathy. Moreover, the medical statement noted that there were no other signs such as elevated liver enzymes, ascites, or abnormal liver ultrasounds that generally accompanied such a diagnosis. The reporting physician opined that the Veteran had diabetes in service and that the ordering of a GGT supported a presumptive diagnosis of diabetes. A July 2010 VA examination report noted that the Veteran was diagnosed with diabetes mellitus in 1992. The Veteran reported having trouble maintaining erections in 1999 with ineffective treatment. A diagnosis of erectile dysfunction, secondary to diabetes mellitus, was assigned. At a VA examination in August 2010, the examiner noted that she could not resolve the question of whether the Veteran's diabetes mellitus was due to service without resorting to speculation. In so stating, she noted that the August 1979 report reflected that the Veteran was a heavy drinker and that a GTT was ordered, but there was no documentation of elevated blood sugars or glucosuria either in service or in the next decade after he left the military. In the absence of these findings, she found it was not possible to state categorically that the Veteran had diabetes mellitus in service or shortly thereafter. In connection with a separate VA examination in August 2010, an examiner noted that he had reviewed the entire claims file, including service treatment records and the private treatment reports and opinions and observed that the Veteran presented in service with a history of numbness and tingling in his arms of about a day's duration, and to the examining physician, the Veteran admitted to drinking in the preceding day. Thus, the examining physician thought that it was related to alcohol use and a possible mechanism of this would have been if the Veteran while intoxicated had fallen asleep and put pressure on his arms, a bit of transient pressure palsy ensued. The VA examiner noted that that it was speculative and could not be said with certainty what caused the complaints but the doctor examining the Veteran at that time believed alcohol was an involved factor. He, for completeness, ordered a GGT test. The Veteran reported that he declined to have the GGT test. The Veteran told the examiner that a presumptive diagnosis of diabetes mellitus was made in service and that he should be given the benefit of the doubt and awarded service connection for this disability. The examiner noted that the doctor who evaluated the Veteran thought it was more likely that the Veteran's alcohol consumption proximate to the medical visit was more likely the cause of the numbness and that, for completeness, a diabetes test should be done, but his notes indicated that the doctor believed it less likely than not that diabetes was the cause. The Veteran also was noted to report that the in-service symptom of tingling lasted for one day, never recurred until he was diagnosed with diabetes mellitus and had been present for the last 10 years. The examiner noted that it had been proposed that certain behavioral changes in the years after service were related to diabetes, but there was no supporting medical evidence and this proposal was merely speculation and less likely than not. The examiner also noted that the Veteran underwent urinalyses in 1977 and 1978, which would have also measured glucose in the urine, but there was no report of any abnormality or follow-up test, and therefore it was more likely than not that the urine dipstick was negative for glucose and that he was not diabetic at the time. The Veteran denied undergoing any medical evaluations in the 1980s, and indicated that additional medical records would indicate that there was evidence of diabetes in the early 1990s, but no records of treatment were available. The examiner noted that the Veteran's and family members' reports of non-specific symptoms in the 1980s were merely speculative in indicating that the Veteran had diabetes mellitus at an earlier time. He noted that there was no objective medical information that demonstrated an abnormal glucose function in the 1980s, and the earliest glucose abnormalities were shown in the mid-to-late 1990s. In sum, the VA examiner opined that the Veteran's tingling in his arms in service was less likely than not a precursor for his current diabetes mellitus and related peripheral neuropathy. He found it was more likely than not that diabetes mellitus had developed in the mid-1990s. In an October 2010 addendum opinion, a private physician noted that the VA opinion did not make sense as the Veteran had signs and symptoms that supported diabetes mellitus in service. He also suggested that he was better qualified to render an opinion on the matter as the VA examiner was a neurologist and he was a radiologist who saw "the entire spectrum of all disease and thus [was] better equipped to analyze these issues." The physician also noted that the VA examiner's reliance on the lack of performance of a GTT in service was faulty. He indicated that he did not see anywhere in the record that the in-service physician indicated diabetes mellitus was less likely than not the cause of the Veteran's in-service numbness of the arms. In light of the findings of the August 2010 VA examination report, the Veteran's claims file was forwarded to another VA examiner for an opinion on the etiology of the claimed diabetes mellitus in January 2012. The examiner noted that she having reviewed the entire claims file, to include service treatment records, post-service records, and the opinions from private physician. After this review, she found the claimed diabetes mellitus was less likely than not incurred in service or caused by the claimed in-service event or illness. In so finding, the examiner noted that symptoms of being overly tired, irritable and thirsty with frequent urination, episodes of dizziness, and chronic hunger were common symptoms of diabetes mellitus, but these symptoms were also found in other diseases. She also found it was unclear as to whether these symptoms started in reference to his discharge from service in 1980. The VA examiner noted that symptoms could direct an evaluation-but, by themselves-were not sufficient to diagnose an illness. A review of the claims file was noted not to document any elevation of blood glucose or glucosuria. She added that, if the Veteran had symptoms such as he complained, one would assume that this presumptive diabetes was out of control-yet, he was not diagnosed or treated for over 10 years despite medical care by other physicians. The VA examiner also noted that he was seen for frequent urination in service and had negative urinalyses for glucosuria. In the absence of elevated blood sugars or glucosuria, she found it not possible to state categorically that the Veteran had diabetes mellitus in service or soon after his discharge from service. The VA examiner also noted that the August 1979 in-service treatment report reflected that the Veteran was seen for upper extremity neuropathy secondary to alcohol consumption and was treated with vitamins and thiamine. There was no documentation of diabetes mellitus in the claims file until the 1990s. Thus, she found that a relationship between the in-service findings and current diabetes mellitus was less likely than not. In July 2013, the Veteran's claims file was reviewed for a VHA advisory medical opinion. The physician who provided the requested opinion indicated that she was a professor of medicine in the division of endocrinology, diabetes and metabolism at the Diabetes Research Institute, University of Miami Miller School of Medicine, as well as the section chief of the Department of Endocrinology, Diabetes and Metabolism and Director of the Diabetes Management Program at the Miami VA Medical Center. She indicated that she had reviewed the Veteran's claims file in regards to whether it was at least as likely as not that the Veteran exhibited a combination of manifestations, as distinguished from isolated findings, sufficient to identify diabetes mellitus and/or related complications, including neuropathy and erectile dysfunction, and sufficient observation to establish chronic disease during his period of active service or to a degree of 10 percent or more during the one year after his discharge from service. She noted that she reviewed the Veteran's service treatment records, post-service treatment records, VA examination reports, private medical statements, and the Veteran's and his family members' lay statements. As regards the Veteran's service treatment records, the opinion provider noted that they contained a number of urinalyses, none of which showed any glucosuria. She found that this spoke against the diagnosis of untreated diabetes being present, because if it were, it was likely that the renal threshold for glucose would have been exceeded and glucose would have been present in the urine. With respect to the Veteran's report of numbness in both arms, the physician noted that diabetic neuropathy was not mentioned in the progress note, but given the Veteran's positive family history of diabetes, a glucose tolerance test was ordered. The physician noted that this suggested that diabetes was at least considered, though apparently the test was never done. Finally, the physician observed the Veteran's service treatment records included a medical report at the time of discharge where he checked "no" next to potential symptoms or conditions associated with diabetes, including high blood pressure, frequent urination, sugar or albumin in the urine, gain or loss of weight, and neuritis. The physician also found the retrospective statements by the lay family members to be very vague and not specific to a diagnosis of diabetes after discharge. She noted that there could have been such symptoms, but in her opinion there was no way for this to be proven. In addition, the medical specialist noted that the earliest objective glucose abnormalities are said to be in the mid-to-late 1990s, but the provided records did not contain any medical information from that time period to document such. She noted that a VA treatment report dated in March 2008 had 3 separate notations of a diagnosis of diabetes, with dates indicating when the problem was added to the list, which should represent the date of diagnosis: 5/19/99, type 2 without complications, 7/29/99, type 1 without complications, 9/21/99, type 2 without complications, though she indicated that the accuracy of this problem list was in question. She noted that it was estimated that most individuals who are diagnosed with type 2 diabetes had actually had the disorder for between 5 to 10 years prior to the diagnosis, and complications could typically develop from 5 to 15 years after onset. Dr. M. observed that, in 2003, the records reflected that there was no evidence of retinopathy, and in 2007 it was noted that he probably did not have diabetic nephropathy. Based on her examination of the records, reviewing medical specialist determined that it was not at least as likely as not that the Veteran exhibited a combination of manifestations, as distinguished from isolated findings, sufficient to identify diabetes mellitus and/or related complications, including neuropathy and erectile dysfunction, and sufficient observation to establish chronic disease during his period of active service or to a degree of 10 percent or more during the year following his discharge from service. In sum, the record in this case contains conflicting opinions as to whether the Veteran's current diabetes mellitus had its onset in or is otherwise etiologically related to an event or incident of his period of active service. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. See also Obert v. Brown, 5 Vet. App. 30 (1993); Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). A medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board has carefully reviewed all the opinions of records. In this case, the Board finds that opinion of the VHA medical specialist in July 2013 is more probative. In so finding, the Board notes that the July 2013 opinion is supported by a medical rationale-such as the fact that the Veteran had negative urinalysis findings in service and denied diabetes-related symptoms at discharge-and is consistent with the medical evidence of record, which does not reflect diagnosis or treatment of diabetes until many years after service. In addition, the reviewing medical specialist based her opinion on more than just the lack of contemporaneous evidence in service. She noted that a diagnosis of diabetes mellitus was not indicated until 1999, and that medical literature generally supports onset of the disease 5 to 10 years prior to the diagnosis with onset of related complications 5 to 15 years later, which would still date the onset of diabetes mellitus to time that was many years following the Veteran's discharge from service. She also indicated that the various lay statements of record regarding earlier symptomatology were vague and unsupported and could not substantiate an earlier diagnosis of diabetes. Moreover, the July 2013 opinion was rendered by a physician who specialized in endocrinology and diabetes mellitus. Therefore, she is clearly presumed to have significant expertise regarding the claimed diabetes mellitus and the likely etiology of this disability. Unlike the July 2013 VHA physician, the private physician failed to address relevant factors such as the number of years between the Veteran's alleged onset and the first indication of treatment and diagnosis over 10 years later. Moreover, the private physician provided no rationale for why the ordering of a GTT study equated to a presumptive diagnosis of diabetes mellitus in service. He did not address the possibility that the Veteran's symptoms could be attributable to another condition, nor did he address the fact that there were negative urinalyses in service or lack of diagnosis of diabetes until many years following service despite the Veteran's and family members' retrospective reports of serious symptoms for many years. Thus, the most persuasive opinion on the question of whether there exists a medical nexus between the Veteran's current diabetes mellitus and service weighs against the claim. The Board has also considered the other medical opinion that the Veteran probably had developed diabetes in the late 1970s. However, such information simply recorded by a medical examiner and unenhanced by any additional medical comment, and thus not adding any medico-evidentiary value to the lay history through medical expertise, does not constitute competent medical evidence. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995). The Board has also considered the Veteran's written statements, as well as those statements from his family members to the effect that his diabetes mellitus was first manifested in service by symptoms of hunger, thirst and frequent urination. The Veteran is competent to testify as to his observations, but this testimony must be weighed against the other evidence of record. See Jandreau, 492 F.3d at 1376-77; Buchanan, 451 F.3d at 1336. In this case, the Board finds the other evidence of record more probative. Moreover, the reviewing VA medical specialists considered the lay evidence in arriving at her opinion. Significantly, the separation examination report was normal with regard to the claimed diabetes mellitus, and there were no complaints with regard to the any diabetes-related complaints in service outside of the one complaint of arm numbness, or for many years thereafter. In fact, a diagnosis of diabetes mellitus was not noted at separation, and he denied a pertinent history at that time. The VA outpatient treatment reports document a diagnosis in the mid-to-late 1990s, and at the time of treatment he did not express continuous diabetes-related symptoms since service or indicate history of complaints in service. The Veteran advanced his own opinion of his medical condition indicating that his current diabetes mellitus was related to the alleged in service complaints, but the probative worth of the Veteran's general assertions in this regard is far outweighed by the probative value of the specific, reasoned opinion of the VA physician provided in July 2013. To the extent that he and the lay informants attempt to report continuity, such lay evidence is inconsistent with the actual service treatment records, the normal findings at separation, and his denial of pertinent pathology at separation. He and the lay informants are not credible for the purpose of establishing the presence of a chronic disease in service or a continuity of symptomatology referable to diabetes mellitus since service. The Board finds the Veteran's own statements made contemporaneous with service to be more credible than the lay evidence advanced in support of a claim for monetary benefits. The evidence also reflects that there was no diagnosis or manifestation of diabetes mellitus within one year of discharge from service. See 38 C.F.R. § 3.307(c); Traut v. Brown, 6 Vet. App. 495 (1994) (establishing service connection on a presumptive basis does not require that a chronic disease be diagnosed within the applicable time period; rather, symptoms that manifest within this time period may subsequently be determined to have been early manifestations of a chronic disease). Therefore, on this record, service connection for diabetes mellitus must be denied on a presumptive basis. Accordingly, on this record, the claim of service connection for diabetes mellitus must be denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine cannot be applied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As regards the claims neuropathy of the bilateral upper and lower extremities and erectile dysfunction, the record clearly reflects that these disabilities are secondary to the claimed diabetes mellitus. The evidence does not support that erectile dysfunction and peripheral neuropathy were incurred in service or are otherwise due to service. The Board acknowledges the report of numbing sensation in both arms in service. However, at that time, these complaints were associated with alcoholic neuropathy. There is no other evidence suggestive of a diagnosis of diabetic neuropathy in service. More importantly, there is no evidence of record discussing a relationship between the Veteran's erectile dysfunction and peripheral neuropathy and service. With respect to the claims of secondary service connection, there is no legal basis for granting service connection for the claimed conditions. Where, as here, service connection for the primary disability has been denied, the Veteran cannot establish service connection, pursuant to 38 C.F.R. § 3.310(a), for a secondary condition. Thus, the matters of service connection for peripheral neuropathy of the upper and lower extremities and erectile dysfunction as secondary to diabetes mellitus lack legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). ORDER Service connection for diabetes mellitus is denied Service connection for bilateral upper extremity neuropathy, to include as secondary to diabetes mellitus, is denied. Service connection for bilateral lower extremity neuropathy, to include as secondary to diabetes mellitus, is denied. Service connection for erectile dysfunction, to include as secondary to diabetes mellitus, is denied. REMAND In light of the August 2012 Joint Motion, the Board finds that further RO action on the remaining claims on appeal is required. With regard to the bilateral knee disorder, the Joint Motion pointed out that the August 2010 VA medical examiner appeared to have impermissibly relied on the absence of contemporaneous medical evidence to support his conclusion that the Veteran's bilateral knee disability was not related to service in contravention of Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). That examiner determined that the Veteran's bilateral knee disability was not due to service, as there was absolutely no mention of injury to the knees at the time of right groin injury in service. No other rationale was provided. Given the inadequacies of this opinion, another VA examination is necessary to address the nature and likely etiology of the claimed bilateral knee disorder. As regards the claimed head injury, the Veteran contends that he experiences residual disability related to trauma sustained in service as a result of boxing. The Board notes that a statement from Dr. S. of the Medical Eye Center included his opinion that the Veteran suffered from anisocoria most likely traumatic and secondary to a history of boxing while in service. While the August 2010 VA examiner noted that the Veteran had pupil asymmetries, he indicated that these might be a normal variance or secondary to diabetes. However, as pointed out in the Joint Motion, the VA treatment records documented a poorly reactive pupil and the absence of diabetic eye problems. The examiner went on to opine that the Veteran did not have a residual cognitive disability or central nervous system symptoms related to a mild traumatic brain injury. The examiner did not discuss whether the Veteran had an eye disability stemming from service, to include the Veteran's claimed head trauma stemming from boxing injuries. The Board also notes that a June 2011 VA outpatient treatment report reflects that the Veteran reported that his eyes had been dilated for years since his time in service as a boxer. A June 2012 VA outpatient treatment report also notes left eye pain possibly related to some nerve damage from his boxing days. Given that the August 2012 VA examiner failed to address all potential residuals of a head injury-in particular any disability related to the eyes-the Board must also remand this claim for opinion on the nature and etiology of the claimed residuals of a head injury. Accordingly, these remaining matters are REMANDED for the following action: 1. The RO should arrange to have the Veteran scheduled for a VA examination to determine the nature and likely etiology of the claimed bilateral knee disorder. The entire claims file must be made available to the examiner designated to examine the Veteran. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner should clearly identify all current knee disorders. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that a current bilateral knee disorder had its clinical onset during the Veteran's period of active service or is due to an event or incident of the Veteran's period of active service to service. The examiner is advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, to include the opinion of private physician Dr. B., in formulating the requested opinion. The examiner should note that he/she may not rely on the absence of contemporaneous medical evidence in service in formulating his/her opinion. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should clearly so state, and the reasons and bases for the inability to provide the opinion must be included in the examination report. 2. The RO also should arrange to have the Veteran scheduled for a VA examination to determine the etiology of the claimed residuals of a head injury. The entire claims file must be made available to the examiner designated to examine the Veteran. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner should clearly identify all residuals of head injury, to include whether the Veteran has a current eye disorder. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current residuals of head injury had their clinical onset during the Veteran's period of active service or is due to an event or incident of the Veteran's period of active service to service, to include as residual to head trauma claimed as a result of boxing in service. The examiner is advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, to specifically include the opinions of Dr. B. and the December 2007 eye report from Dr. S., in formulating the requested opinion. The examiner should note that he/she may not rely on the absence of contemporaneous medical evidence in service in formulating his/her opinion. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should clearly so state, and the reasons and bases for the inability to provide the opinion must be included in the examination report. 3. After completing all indicated development, the RO should readjudicate the claims remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs