Citation Nr: 1340218 Decision Date: 12/05/13 Archive Date: 12/20/13 DOCKET NO. 07-20 731A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for residuals of cold injury of the upper and/or lower extremities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD J. W. Loeb INTRODUCTION The Veteran served on active military duty from March 1983 to March 2003. These matters are before the Board of Veterans' Appeals (Board) on appeal from March 2006, October 2006 and June 2007 rating decisions of the Department of Veterans Affairs (VA) Regional Office in St. Petersburg, Florida (RO). The March 2006 rating decision denied service connection for residuals of cold injuries. The October 2006 rating decision denied service connection for PTSD. The June 2007 rating decision denied service connection for hypertension. These matters were before the Board in May 2009 when they were remanded to the RO for additional development. The case was again remanded by the Board in April 2012 to obtain VA addendum opinions on the etiology of the disabilities at issue on appeal. VA addendum opinions were obtained in May 2012 and added to the record. As the requested actions have been complied with, there has been substantial compliance with the April 2012 remand instructions. Stegall v. West, 11 Vet. App. 268 (1998) (Holding that a remand by the Court or the Board confers on the Veteran or other claimant, as a matter of law, the right to compliance with the remand orders). The Veteran testified at a personal hearing before an undersigned Veterans Law Judge (VLJ) of the Board in Washington, D.C., in October 2008, and a transcript of the hearing is of record. The Veteran testified at a second personal hearing before an undersigned Veterans Law Judge (VLJ) in Washington, D.C., in July 2013, and a transcript of the hearing is of record. During the July 2013 Board hearing, the Veteran waived his right to testify at a third hearing before a VLJ of the Board. 38 U.S.C.A. § 7102(a) (West 2002); 38 C.F.R. § 20.707 (2013); Arneson v. Shinseki, 24 Vet. App. 379 (2011). Private treatment records were received by VA and added to the claims folder in September 2013 along with a waiver of RO review. See 38 C.F.R. § 20.1304(c) (2013). FINDINGS OF FACT 1. The Veteran is not shown to have had combat with the enemy while serving on active duty. 2. The most probative evidence of record does not contain a diagnosis of PTSD based on a corroborated in-service stressor. 3. The most probative evidence of record does not demonstrate that the Veteran has an acquired psychiatric disorder that is causally related to his active military service. 4. The most probative competent evidence of record does not demonstrate that it is at least as likely as not that the Veteran currently has hypertension that was present in service, was present to a compensable degree within one year after service, or is otherwise related to service. 5. The most probative evidence of record does not demonstrate that it is at least as likely as not that the Veteran currently has residuals of cold injury of the upper and/or lower extremities that were present in service or are otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disability, to include PTSD, have not been met. 38 U.S.C.A. §§ 101, 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.1, 3.102, 3.303, 3.304 (2013). 2. Hypertension was not incurred in or aggravated by active duty; nor may it be presumed to have been incurred or aggravated therein. 38 U.S.C.A. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 3. Chronic residual disability of cold injury of the upper and/or lower extremities was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Board has considered the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 and Supp. 2012). The regulations implementing VCAA have been enacted. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. See also Quartuccio v. Principi, 16 Vet. App. 183 (2002). After having carefully reviewed the record on appeal, the Board has concluded that the notice requirements of VCAA have been satisfied. The notice and assistance provisions of VCAA should be provided to a claimant prior to any adjudication of the claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the RO sent the Veteran a letter in April 2005, prior to adjudication, which informed him of the requirements needed to establish entitlement to service connection for PTSD and residuals of cold injury. In accordance with the requirements of VCAA, the April 2005 letter also informed the Veteran what evidence and information he was responsible for and the evidence that was considered VA's responsibility. A January 2007 VA letter informed the Veteran of the information and evidence necessary to substantiate the claim for service connection for hypertension, as well as the division of responsibility between the Veteran and VA in obtaining such information and evidence. The Veteran was also informed in the January 2007 letter of the factors for consideration in the assignment of a disability rating and/or effective date in the event of award of service connection. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA has a duty to assist the claimant in obtaining evidence necessary to substantiate a claim. The record contains the Veteran's service treatment records and post service private and VA medical records. VCAA also requires VA to provide a medical examination when such an examination is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159. VA medical examinations and nexus opinions were obtained in 2011 and 2012. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations and nexus opinions obtained in this case are adequate, as they are predicated on a reading of relevant medical records in the Veteran's claims files. The examiners considered all of the pertinent evidence of record, examined the Veteran, and provided a rationale for the nexus opinions on file. There is adequate medical evidence of record to make a determination on the service connection issues decided in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion on the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Veteran has been given ample opportunity to present evidence and argument in support of his claims, including at his July 2013 hearing. The Board additionally finds that general due process considerations have been complied with by VA, and the Veteran has had a meaningful opportunity to participate in the development of the claim. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); 38 C.F.R. § 3.103 (2007). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court recently held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. The VA personnel must also ask questions to fully explore the bases for each claim. At the October 2008 and July 2013 Board hearings, the Veteran's representative and the VLJ's asked the Veteran questions about the bases for the service connection issues on appeal. A VLJ also indicated that consideration would be undertaken based on the testimony and evidence of record as to whether an additional examination would be useful to substantiate the claims. The hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate the claims. The VLJ's and the Veteran's representative solicited information to identify any outstanding relevant evidence. Based on the Veteran's request at the July 2013 hearing, he was given 90 days to submit additional evidence in support of his claims. Therefore, the Board finds that, consistent with Bryant, the VLJ's complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Analysis of the Claims Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2013). Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2013). In order to establish direct service connection for a disorder, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection may be presumed for certain chronic diseases, such as hypertension, that are manifested to a compensable degree within one year after separation from service. 38 U.S.C.A. §§ 1101, 1112 (West 2002); 38 C.F.R. § 3.307, 3.309(a) (2013). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1) (2012). There is evidence on file both for and against the Veteran's service connection claims. The Board has the authority to "discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Court has held that the Board may not reject medical opinions based on its own medical judgment. See Obert v. Brown, 5 Vet. App. 30 (1993). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider is weighed by such factors as its thoroughness and degree of detail, and whether there was review of the Veteran's claims file. Prejean v. West, 13 Vet. App. 444 (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. Bloom v. West, 12 Vet. App. 185 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379 (1998). See also Claiborne v. Nicholson, 19 Vet. App. 181 (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 (1998). In order for a medical opinion to be probative, the medical examiner must have correct information regarding the relevant facts of the case. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008), Guerrieri v. Brown, 4 Vet. App. 467 (1993) (observing that the evaluation of medical evidence involves inquiry into, inter alia, the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches); see Shipwash v. Brown, 8 Vet.App. 218 (1995); Flash v. Brown, 8 Vet.App. 332 (1995) (regarding the duty of VA to provide medical examinations conducted by medical professionals with full access to and review of the Veteran's claims folder); but see D'Aries v. Peake, 22 Vet. App. 97, 106 (2008) (holding that it is not necessary for a VA medical examiner to specify review of the claims folder where it is clear from the report that the examiner has done so and is familiar with the claimant's extensive medical history). Psychiatric disability, to include PTSD The Veteran seeks service connection for an acquired psychiatric disorder, to include PTSD, as due to several incidents that incurred in service. In hearing testimony and statements on file, the Veteran noted the following stressor events: being held against his will while in Korea; seeing a fellow soldier severely injured, and possibly killed, by a rotating helicopter blade while in Honduras; and a second incident in Honduras in which he was exposed to a grenade explosion in a combat situation with a rebel group that resulted in people being killed and injured. With regard to PTSD, requisite for a grant of service connection is medical evidence establishing a diagnosis of the disorder, credible supporting evidence that the claimed in-service stressors actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressors. 38 C.F.R. § 3.304. With regard to the second PTSD element, that of an in-service stressor, the evidence necessary to establish that the claimed stressor actually occurred varies depending on whether it can be determined that the Veteran "engaged in combat with the enemy," or it is related to the Veteran's fear of hostile military or terrorist activity. 38 U.S.C.A. § 1154(b); 38 C.F.R. 3.304(d) and (f). If it is determined through military citation or other supportive evidence that a veteran engaged in combat with the enemy, and the claimed stressors are related to combat, the Veteran's lay testimony regarding the reported stressors must be accepted as conclusive evidence as to their actual occurrence and no further development or corroborative evidence will be necessary. 38 C.F.R. § 3.304(f). VA regulations were recently amended to include that if a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3) (2013). Where a determination is made that the Veteran did not "engage in combat with the enemy," or the claimed stressor is not related to combat or hostile military or terrorist activity, the Veteran's lay testimony alone will not be enough to establish the occurrence of the alleged stressor. Moreau v. Brown, 9 Vet. App. 389, 395 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In such cases, the record must contain service records or other statements as to the occurrence of the claimed stressor. See West (Carlton) v. Brown, 7 Vet. App. 70, 76 (1994); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). Once independent verification of the stressor event has been submitted, the Veteran's personal exposure to the event may be implied by the evidence of record. A veteran need not substantiate his actual presence during the stressor event; the fact that the Veteran was assigned to and stationed with a unit that was present while such an event occurred may strongly suggest that he was, in fact, exposed to the stressor event. See Pentecost v. Principi, 16 Vet. App. 124 (2002); Suozzi v. Brown, 10 Vet. App. 307 (1997). Of particular pertinence to a claim for PTSD, it has been held that a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. See Moreau; Cohen v. Brown, 10 Vet. App. 128, 142 (1997). The Veteran's service treatment records do not reveal any complaints or clinical findings indicative of a psychiatric disorder. According to an April 1987 United States Naval Investigative Service Operations Report, the Veteran reported in March 1987 that, while on liberty in the Port City of Pohang, Republic of Korea, he was taken by two men to an unknown location and questioned about his military activities. According to this report, the Veteran's description of the location to which he was taken is consistent with local Korean drinking establishments called Soju Tents. The Veteran admitted being intoxicated prior to being questioned. It was noted that inquiries did not support any activity on the part of a hostile intelligence agency; rather, it appeared that the men who questioned the Veteran were Korean Nationals attempting to help him return to his unit. When subsequently contacted and apprised of the above information, the Chief of the Foreign Affairs Section of the Korean National Police (KNP) stated that there were no known hostile intelligence forces operating in the area, that the KNP routinely conduct surveillance on all foreign sailors in the Pohang area, excluding U.S. forces personnel; and that nothing suspicious had been noted. A U.S. Marine Corps "Narrative Summary" indicates that from July 1, 1989 to July 31, 1989, the Air Contingency Battalion (ACB) for the 1st Marine Expeditionary Force, participated in a month-long training exercise in the Republic of Honduras. The Veteran has been reported to have served with this unit. VA treatment reports dated in February 2005 reveal a notation of PTSD-like symptoms. Another February 2005 report contains a diagnosis of PTSD. The diagnoses in October 2005 include depression/anxiety/PTSD, improved on medication. Also on file is a June 2005 statement from the Veteran's wife, who has known him since July 1985, on his psychiatric problems. She noted that he was a changed man after his first incident in Honduras, acting paranoid and withdrawn, and was worse after the second incident in Honduras. According to a May 2006 statement from a VA psychologist, the Veteran met the full diagnostic criteria for PTSD stemming from combat-related experiences in service. VA treatment reports dated from May 2006 to October 2008 reveal that the Veteran reported in May 2006 that he had had PTSD symptoms since 1997. He indicated in December 2006 that his symptoms actually began in 1987. The diagnoses in September 2006 were PTSD, by history; panic disorder, without agoraphobia; and major depressive disorder, recurrent, rule out OCD. According to a January 2008 questionnaire from another VA psychologist, the Veteran has been diagnosed with PTSD related to service. Another statement from the Veteran's wife was received by VA in July 2009. A VA psychiatric evaluation, including review of the claims folder, was conducted in May 2011. The diagnoses included PTSD; major depressive disorder, recurrent, severe; and anxiety disorder, not otherwise specified. The examiner concluded that the Veteran did not meet the DSM-IV stressor criteria because there was no supporting documentation in the claims folder. Consequently, the Veteran's psychiatric symptoms could not be attributed to service. In response to the Board's April 2012 remand for additional development, a VA opinion was obtained by a VA psychologist in May 2012. After review of the claims folder, the reviewer diagnosed a mood disorder and concluded that the record did not support a diagnosis of PTSD. The reviewer noted that the prior assessment of PTSD appeared to have been made through the use of an "unstructured" interview with the Veteran for treatment purposes and was essentially based on the Veteran's self-reported history. The reviewer noted that the Veteran's account of the events related to his stressor in Korea had evolved over time, as a more recent reference to a woman's involvement in the incident was not in the Veteran's original written account of the incident dated in March 1987, and was not supported by the independent evidence in the claims file, such as the Naval Investigative Report. The reviewer concluded that merely being questioned by individuals about his military service is insufficient to meet the DSM-IV diagnostic criteria for a PTSD stressor. The reviewer also noted that the Veteran's contention of being in combat in Honduras was not supported by the record, as the evidence of record, including a Command Chronology for the Veteran's unit, indicated that the Veteran was sent to Honduras for training and did not show any combat operations or resulting wounded or killed. The reviewer opined that it was less likely than not that the Veteran's psychiatric condition was incurred in or caused by an in-service injury, event, or illness. According to an August 2013 medical report from Solace Behavioral Health, the Veteran was exposed to combat in the Persian Gulf. The diagnoses were prolonged PTSD; post-concussion syndrome; major depressive affective disorder, recurrent episode, severe. It was concluded that there was a direct correlation between the Veteran's military experience and the emergence of a major depressive disorder and PTSD. The Veteran's service personnel records do not show that he received medals or decorations to verify combat with the enemy. Further, the Veteran has not made any assertions that he has PTSD as a result of engaging in combat with the enemy or related to fear of hostile military or terrorist activity. As such, service connection for PTSD requires credible supporting evidence that a claimed inservice stressor actually occurred. 38 C.F.R. § 3.304(f). VA records in the Veteran's claims file contain a diagnosis of PTSD. The Board notes, however, that a diagnosis of PTSD, related to service, based on an examination which relied upon an unverified history, is inadequate. West v. Brown, 7 Vet. App. 70, 77 (1994). It must therefore be determined whether there exists a stressor which has been verified from official sources or if there is credible supporting evidence from another source that a stressor claimed by the Veteran occurred. While the question of whether a proven stressor is sufficient to support a diagnosis of PTSD is a medical question, the question of whether an alleged stressor actually occurred is a question for VA adjudicators. Cohen. Further, the matter of whether there is credible supporting evidence of a Veteran's account of a stressor is a question of fact and credibility to be determined by the Board. The Veteran has reported that the combat incident in Honduras occurred in July 1989 with the 2nd Battalion, 9th Marine, 1st Marine Division (REIN). According to a Command Chronology for the United States Marine Corps, 2d Battalion, 9th Marines, 1st Marine Division, for the period from July 1, 1989 to December 31, 1989, the unit was deployed on a month long training exercise in the Republic of Honduras with the Honduran Armed Forces. There is no mention in the Chronology of combat involving injuries or death. Because the evidence of record related to the incident in Korea does not show that the Veteran was actually kidnapped or in danger, this incident is not considered by the VA psychologist in May 2012 to support a diagnosis of PTSD. As for the Veteran's other asserted stressors, no other stressor has been adequately verified. Neither the helicopter incident nor the incidents in Honduras involve combat with the enemy, which means that lay testimony from the Veteran and his wife is not sufficient to establish the occurrence of the alleged stressors. Instead, the record must contain credible supporting evidence which corroborates the Veteran's testimony. The lack of sufficiently credible supporting evidence of a claimed stressor is the determinative factor in this case. In short, all of the requirements for service connection for PTSD have not been fulfilled, and, consequently, entitlement to service connection for PTSD is not established. Although the Veteran has contended that he was exposed to combat with a rebel group while in Honduras, the objective evidence discussed above does not show exposure to hostile military or terrorist activity. For purposes of the revised provision, "fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. The evidence also does not show that service connection for an acquired psychiatric disorder other than PTSD is warranted. There were no psychiatric complaints or clinical findings in service. The initial diagnosis of an acquired psychiatric disorder other than PTSD is no earlier than February 2005, which is almost two years after discharge, when PTSD-like symptoms were reported. A mood disorder was diagnosed in May 2012, but the opinion, which was based on a review of the claims folder, concluded that the condition was less likely than not due to service. Therefore, service connection for an acquired psychiatric disability, to include PTSD, is not warranted. Hypertension The Veteran seeks service connection for hypertension, which he contends is related to elevated blood pressure readings that began in service. As noted above, service connection may be granted for hypertension if the disorder is manifested to a compensable degree within one year following separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Under Diagnostic Code 7101 for hypertensive vascular diseases (hypertension and isolated systolic hypertension), a 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or: systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. NOTE (1): Hypertension or isolated systolic hypertension must be confirmed by readings taken two more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic pressure is predominately 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2013). The Veteran's service treatment records reveal multiple blood pressure readings, some of which are elevated and some of which are not. The Veteran's blood pressure was within normal limits on periodic service examination reports in June 1984, March 1986, and June 1997. The Veteran was seen in January 1995 with complaints of difficulty breathing through his nose; his blood pressure was 136/96. The assessments in January 1995 included increased blood pressure. When evaluated by VA in October 2004, the Veteran indicated that he had been told in 1996 that he had stress-related hypertension and that he had been told on other occasions that he had elevated blood pressure readings but hypertension was not diagnosed. His claims folder was not available to the examiner. Blood pressure readings in October 2004 were elevated at 144/92, 156/94, and 148/100. He was not taking medication for hypertension. The examiner concluded that it was as likely as not that the Veteran had hypertension in service but that he did not have any old medical records to review to confirm this conclusion. VA treatment reports for October 2005 reveal diagnoses that include controlled hypertension. A VA evaluation of the Veteran's hypertension, which included review of the claims folder, was obtained in July 2011. Blood pressure readings were 122/76, 114/71, and 112/60. The examiner concluded that hypertension is at least as likely as not "caused by or a result of shown during active duty." It was stated as rationale for the opinion that the Veteran's service treatment records show him being evaluated for increased blood pressure but not placed on any medication; he was advised to change his diet. Blood pressure reading on VA evaluation in May 2012 were 143/98, 142/96, and 143/100. It was noted that the Veteran had been monitored for 2-3 weeks in service and was told that his blood pressure had leveled off; he was not treated for the condition in service. He said that he started treatment for hypertension in 2004-2005. The examiner cited to evidence in the Veteran's service treatment reports and concluded that it was less likely as not that the Veteran's current hypertension that was diagnosed and for which he started treatment in 2005 was incurred in service because his blood pressure readings in service were within normal limits on his routine physical evaluations and were only elevated at times when he was in pain or discomfort. The Veteran testified at his October 2008 and July 2013 hearings that he was monitored for elevated blood pressure readings in service and that his current hypertension is related to his elevated blood pressure readings. His wife testified that he had problems with dizziness in service. Although there is medical evidence both for and against the claim for service connection for hypertension, the Board finds the VA opinion against the claim to be of more probative value, when considered along with the other evidence of record, than the opinions in favor of the claim. Although the Veteran's service treatment reports show some elevated blood pressure readings, these were interspersed with normal readings and hypertension was not diagnosed and treated until 2005, more than a year after service discharge. The October 2004 VA opinion in favor of the claim is not based on a review of the claims folder and does not include any rationale. Although the July 2011 VA opinion is based on a review of the claims folder, and provides a rationale for its conclusion, this opinion is somewhat confusing, as the examiner concludes that hypertension is at least as likely as not "caused by or a result of shown during active duty." Unlike the prior opinions, the May 2012 opinion is based on a review of the claims folder and includes a rationale based on a more complete reference to the evidence of record, as the Veteran was not treated for hypertension in service or within a year of discharge, and his elevated reading in service were considered to be related to instances when he was in pain or discomfort and not the result of a normal examination. Consequently, service connection for hypertension is not warranted. Residuals of Cold Injury The Veteran seeks service connection for residuals of cold injury of the upper and lower extremities, which he contends were incurred in service in Korea as a result of exposure to extreme cold without adequate protection. He is currently service connected for onychomycosis of the feet and hands as associated with tinea unguium. The Veteran's service treatment reports reveal that the Veteran complained in June 1992 of a needle-like pain under the right hallux toenail, for which he had been given antifungal medication; onychomycosis was diagnosed. He had pain in the right toenail in August 1995, and tinea unguium was diagnosed. His right great toenail was removed without incident in September 1995. His tinea unguium was reported to be resolving in June 1996. The Veteran complained in September 1996 of right shoulder pain with some tingling sensation to the arm and fingers; the assessment was rule out tendonitis of the right shoulder. He reported pain in the left shoulder to the elbow with a numbness/tingling sensation to the left 1st-3rd digits in August 1999; the assessment was left shoulder bursitis/muscle strain. The Veteran was seen in September 1999 with complaints of radiating pain in the left shoulder, with tingling to the left hand. It was noted in October 2002 that the Veteran had low back pain with left lower extremity weakness, intermittent. The Veteran complained on VA evaluation in July 2011 of numbness and tingling of the hands and feet due to exposure to the cold while in service. After review of the claims folder and examination of the Veteran, the diagnoses were tinea unguium, onychomycosis, and dyshidrotic eczematous dermatitis of the hands, fingers, and fingernails secondary to cold exposure; and tinea unguium and onychomycosis of the toenails associated with cold injury. The examiner noted that medical literature related that even though the immediate effects of having had a cold injury can heal or appear to be healed, cold injuries can cause, even much later in life, chronic health problems such as: fungal infections, hyperhidradenous, numbness, tingling, weakness in the feet and hands, sensitivity to cold weather or cold objects when touched, even if at the time of injury these symptoms were not apparent. A subsequent VA opinion was obtained in May 2012 based on a review of the claims folder. The reviewer noted that X-rays of the hands and feet in July 2011 were normal. According to this reviewer, the Veteran's current symptoms of tingling and numbness in the toes and hands are not documented except on VA evaluation in July 2011. The reviewer noted that the complaints in service of tingling in the left thumb and first two fingers of the right hand were associated with shoulder pain. The reviewer concluded that the July 2011 X-rays did not show changes consistent with cold injury residuals and that the current foot and hand condition claimed as cold injury residuals was more likely due to fungal infection, as documented in a May 2012 dermatology report in which the Veteran was seen for a fungal infection of the fingernails and toenails, for which he had been treated with clotrimazole solution for two years without improvement. The Veteran testified at his October 2008 and July 2013 hearings that he incurred cold injures to his hands and feet in Korea in 1987 when he was stationed outside without proper equipment as the weather turned much colder. According to an August 2013 neurology consultation report from M. I. Saleh, M.D., the Veteran complained of persistent numbness, tingling, and burning in the arms, hands, legs, and feet. An EMG/NCV study was obtained. The impression was polyradiculopathic changes with multiple nerve root irritations, a picture of spinal spondylosis/stenosis; and mild early signs of carpel tunnel. Dr. Saleh concluded that the Veteran's previous exposure to extremely cold temperature/cold injury more likely than not contributed to the numbness and burning, especially in the feet, which is an indication of small sensory fibers neuropathy. As previously noted, the Veteran is currently service connected for onychomycosis of the feet and hands as associated with tinea unguium. The issue that the Board must determine is whether there is separate disability of the hands and feet as a result of exposure to cold weather in service, to include any neurological disability. Based on the above evidence, the Board finds that the Veteran does not have residuals of cold injury of the upper and/or lower extremities due to service. The Veteran's service treatment reports do not reveal any complaints of problems due to exposure to cold weather. The initial post-service medical evidence of cold weather complaints and findings are on VA evaluation in July 2011, which is several years after service discharge. Although Dr. Saleh found a causal link between the Veteran's current complaints of extremity numbness and tingling and exposure to cold weather, Dr. Saleh does not appear to have reviewed the claims folder and does not provide a rationale with reference to medical evidence in service. Rather, he appears to base his opinion on the Veteran's subjective history. In contrast, the May 2012 VA opinion, which is based on a review of the relevant evidence, contains a rationale that refers to the medical evidence, to include that the Veteran's symptoms of tingling in service are shown to be related to shoulder pain, that post-service complaints of numbness and tingling are not shown until VA evaluation in July 2011, and that X-rays of the hands and feet in July 2011 are not consistent with cold injury residuals. Consequently, entitlement to service connection for residuals of a cold injury of the upper and lower extremities is not warranted. Additional Considerations Due consideration has been given to hearing testimony and the written statements on file in support of the Veteran's claims. The testimony and lay statements from the Veteran and his wife have been taken into consideration in this decision. Although the Veteran is competent to report his subjective symptoms, and the Veteran's wife is competent to report her observations, the Veteran, who has not been shown to have had medical training, is not competent to diagnose or opine that he has an acquired psychiatric disorder, to include PTSD, hypertension, or residuals of cold injury of the upper and/or lower extremities due to service. Laypersons are not competent to provide evidence in certain medical situations, such as in a case involving the etiology of complex medical matters such as psychiatric disability, hypertension or cold injury residuals. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Rather, the diagnosis of certain conditions, such as a psychiatric disability, to include PTSD, hypertension, and neurological residuals of a cold injury, and the determination of the etiology for each of these disabilities require medical expertise to determine. Although the Veteran's wife indicated that she is a field medical service technician in the United States Navy, she has not provided a medical nexus opinion as a medical professional based on a review of the relevant evidence. Rather she has testified as to her observations on the Veteran's conditions as a layperson. In reaching these decisions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claims for service-connection denied above, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for an acquired psychiatric disorder, to include PTSD, is denied. Service connection for hypertension is denied. Service connection for residuals of cold injury of the upper and lower extremities is denied. ________________________________ ______________________________ DENNIS F. CHIAPPETTA S. L. KENNEDY Veterans Law Judge Veterans Law Judge Board of Veterans' Appeals Board of Veterans' Appeals ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs