Citation Nr: 1315042 Decision Date: 05/07/13 Archive Date: 05/15/13 DOCKET NO. 06-10 876A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for Type II Diabetes Mellitus. 2. Entitlement to service connection for an eye disorder, claimed as ocular hypertension. 3. Entitlement to service connection for a heart disorder, claimed as coronary artery disease. 4. Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Harold A. Beach, Counsel INTRODUCTION The Veteran served on active duty (AD) from May 1969 to January 1973. He also had extensive service after that in the U. S. Naval Reserves from January 1973 to April 1975 and from February 1978 to May 1993. In the Reserves, he had numerous periods of active duty for training (ACDUTRA), including from May 22-June 3, 1978; September 24-October 6, 1979; June 9-20, 1980; March 5-21, 1984; February 25-March 11, 1985; June 1-13, 1986, February 26-March 21, 1987; April 16-May 21, 1988; May 21-August 19, 1989; and August 18-September 29, 1990. He also had active training from May 29-June 22, 1991; January 18, 1992-May 21, 1992; and from May 21-June 27, 1992. His awards and decorations include the Vietnam Service Medal and the Republic of Vietnam Campaign Medal, as well as the Armed Forces Expeditionary Medal. This appeal to the Board of Veterans' Appeals (Board/BVA) is from a January 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In June 2010 and again in May 2012, the Board remanded these claims to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development and consideration. This additional development included verifying the times when the Veteran was on ACDUTRA and inactive duty training (INACDUTRA) and having him undergo a VA compensation examination for medical nexus opinions concerning the nature and etiology of his diabetes, eye disorder, heart disorder, and hypertension, if first confirmed he has these alleged conditions, but particularly insofar as whether they are related or attributable to his military service - either directly, presumptively, or secondarily. Following that requested development, the AMC confirmed and continued the denial of these claims and returned them to the Board for further appellate consideration. In January 2013, however, because still additional comment was needed regarding the etiologies of these conditions, the Board requested an advisory medical opinion from the Veterans Health Administration (VHA). The designee, who is the Chief of the Endocrinology Section of the VA Medical Center (VAMC) in Durham, NC, also an Associate Professor of Medicine, Division of Endocrinology, Metabolism and Nutrition at Duke University Medical Center, provided her response opinion later in January 2013. A copy of the opinion was provided to the Veteran and his representative in February2013, and in response the representative submitted additional argument in April 2013. FINDING OF FACT The most persuasive medical and other evidence of record indicates the Veteran's diabetes, eye disorder, heart disorder, and hypertension did not originate or incept during a qualifying period of active military service, or within the required time after, and are not shown to otherwise have been caused or permanently exacerbated by any qualifying period of active military service or a service-connected disability. CONCLUSION OF LAW The Veteran's diabetes, eye disorder, heart disorder, and hypertension are not the result of disease or injury incurred in or aggravated by his active military service, may not be presumed to have been incurred during his service, and are not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. §§ 101 (22) - (24), 1101, 1110, 1112, 1113, 1116, 1131, 1137, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.6(a), (c), (d), 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103A, 5107, 5126 (West 2002 & Supp. 2012), prescribes several requirements as to VA's duties to notify and assist a claimant with the evidentiary development of a pending claim for compensation or other benefits. Implementing regulations were codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326 (2012). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must, upon receipt of a complete or substantially complete application for benefits, inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is expected to provide; and (3) that VA will obtain on his behalf. See also Quartuccio v. Principi, 16 Vet. App. 183 (2002). A regulatory amendment effective for claims pending as of or filed after May 30, 2008, removed the so called "fourth" requirement that VA also specifically request that he provide any evidence in his possession pertaining to the claim. 73 Fed. Reg. 23,353-56 (Apr. 30, 2008), codified later at 38 C.F.R. 3.159(b)(1). The U. S. Court of Appeals for Veterans Claims (Court/CAVC) further held in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), that these 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: 1) Veteran status, 2) existence of a disability, 3) a connection between the disability and military service, but also concerning the "downstream" 4) disability rating and 5) effective date for the award if service connection is granted. Ideally, this notice should be provided prior to initially adjudicating the claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, it was not or the notice provided was inadequate or incomplete, then VA need only provide all necessary notice, give the Veteran ample opportunity to submit additional evidence and/or argument in response, and then readjudicate the claim, including in a statement of the case (SOC) or supplemental SOC (SSOC). This rectifies ("cures") the timing defect in the provision of the notice because the intended purpose of the notice is still preserved in that he is given meaningfully opportunity to participate effectively in the adjudication of his claim. Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006). In Shinseki v. Sanders, 129 S. Ct. 1696 (2009), the U. S. Supreme Court made clear that VCAA notice and assistance errors, even when shown to have occurred, are not presumptively prejudicial, instead, must be judged on an individual case-by-case basis. Moreover, as the pleading party attacking the agency's decision, the Veteran, not VA, has this burden of proof of not only establishing error but also, above and beyond that, of showing how it is unduly prejudicial - meaning outcome determinative of his claim. Here, in October 2003, VA received the Veteran's claims, and there is no issue as to providing an appropriate application form or completeness of the application. Following the receipt of that application, VA notified him of the information and evidence necessary to substantiate and complete his claims, including the evidence to be provided by him and notice of the evidence VA would attempt to obtain for him or on his behalf. VA informed him of the criteria for service connection, as well as those for rating disabilities once determined to be service connected and insofar as assigning an effective date should service connection be granted. So he has received all required notice concerning his claims. VA also fulfilled its duty to assist him with his claims by obtaining all identified and available evidence that is potentially relevant. VA obtained or ensured the presence of his service treatment and personnel records; records and reports reflecting his treatment from July 1985 through January 1986 at the Family Practice Center of the University of Alabama in Birmingham; records and reports reflecting his treatment by M. A. R., D.O, from August 1994 to December 1998; records and reports reflecting his treatment by D. G. D.O., from June 1998 to July 2003; records and reports reflecting his treatment at North Jefferson Internal Medicine from April 1999 to August 2004; records and reports reflecting his treatment at Carraway Methodist Medical Center from April 1999 to October 2004; records and reports reflecting his treatment by S. E. P., M.D., from May 1999 to February 2001; records and reports reflecting his treatment by R. J. T., M.D., from June 1999 to April 2004; the September 2003 report of a VA Agent Orange protocol examination; and the January 2013 VHA advisory medical opinion. In June 2010, so even before obtaining that VHA advisory medical opinion, VA also had had him undergo a VA compensation examination for other medical comment concerning the nature and etiology of any diabetes mellitus, eye disorder, heart disorder, or hypertension found to be present, but particularly in terms of the likelihood these claimed conditions are related or attributable to his military service. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). The VA examination report and the VHA advisory medical opinion shows the examiners reviewed the Veteran's medical history, in the case of the compensation examination also interviewed and examined him personally, documented his current medical conditions, and rendered diagnoses and etiological opinions consistent with the remainder of the evidence of record. This evidence is responsive to the determinative issues of causation and aggravation, both in terms of any direct or presumptive relationship between these claimed conditions and the Veteran's military service and any secondary relationship to a service-connected disability. Therefore, the Board concludes that the VA examination report and VHA advisory medical opinion provide the level of information needed to fairly decide these claims such that still additional comment is not needed. See 38 C.F.R. § 4.2; see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion in response to a claim of entitlement to service connection, even if not statutorily obligated to, it must ensure the examination or opinion is adequate). In July 2011 and September 2012, the VA physician who had performed the June 2010 VA compensation examination reviewed the Veteran's claims file and rendered additional opinions as to the nature and etiology the Veteran's diabetes mellitus, eye disorder, heart disorder, and hypertension. But also, as already alluded to, in January 2013 the Board additionally obtained the advisory opinion from the VHA medical expert. The RO also scheduled the Veteran for a July 2009 hearing before a local Decision Review Officer (DRO). However, the Veteran did not report for the hearing and did not offer any good-cause reason or explanation for his absence. He also has not requested his hearing be rescheduled; and, therefore, the Board is proceeding as if he no longer wants to have a hearing. He has received all essential notice and assistance with his claims, has had a meaningful opportunity to participate effectively in the development of his claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). So, in summary, it is difficult to discern what additional guidance VA could have provided him regarding what further evidence he should submit to substantiate his claims. See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances when a remand would not serve any useful or meaningful purpose or result in any significant benefit to the Veteran). This is especially true in this instance, considering there already have been remands of these claims in June 2010 and May 2012, an even since the obtaining of the VHA advisory medical opinion. In deciding these claims, the Board has reviewed all of the evidence in the Veteran's claims files, both his physical claims file and electronic ("Virtual VA") claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by him or obtained on his behalf be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Merits of the Appeal Service connection is granted for current disability resulting from a disease contracted or an injury sustained in the line of duty during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for a disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Active military service includes any period of active duty (AD) or active duty for training (ACDUTRA) during which the Veteran was disabled from disease or injury and any period of inactive duty training (INACDUTRA) during which the Veteran was disabled from injury - though not disease - or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident that occurred during such training. 38 U.S.C.A. §§ 101(21), (22), (23), (24), 106, 1110, 38 C.F.R. §§ 3.6(a), (d), 3.303(a). See also Harris v. West, 13 Vet. App. 509, 511 (2000); Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); and Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). Certain diseases are considered chronic, per se, including diabetes, heart disease and its precursor hypertension, and therefore will be presumed to have been incurred in service if manifested to a compensable degree of at least 10-percent disabling within one year after service. This presumption, however, is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). It also does not apply to claims predicated on ACDUTRA and INACDUTRA service, only AD, and there equally are no presumptions of soundness and aggravation concerning claims premised on ACDUTRA and INACDUTRA service. See Biggins, 1 Vet. App. at 477-78; Smith v. Shinseki, 24 Vet. App. 40 (2010). Reserve and National Guard service generally means ACDUTRA and INACDUTRA. ACDUTRA is full time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c). Basically, this refers to the two weeks of annual training, sometimes referred to as "summer camp," which each Reservist or National Guardsman must perform each year. It can also refer to the Reservist's or Guardsman's initial period of training. INACDUTRA includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505. 38 U.S.C.A. § 101(23); 38 C.F.R. § 3.6(d). Basically, this refers to the twelve four-hour weekend drills that each Reservist or National Guardsman must perform each year and is often referred to as "weekend warrior" training. These drills are deemed to be part-time training. So to the extent the Appellant is alleging he has disability as a result of injury or disease incurred or aggravated during his time in the reserves, it must be remembered that only "Veterans" are entitled to VA compensation under 38 U.S.C.A. §§ 1110, 1131 and 38 C.F.R. § 3.303(a). Thus, to establish his status as a "Veteran" based upon a period of ACDUTRA, he must establish that he was disabled from disease or injury incurred or aggravated in the line of duty during that period of ACDUTRA. 38 C.F.R. § 3.1(a), (d); Harris v. West, 13 Vet. App. 509, 511 (2000); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). The same is true for establishing his entitlement to compensation for disability from injury, though not disease, incurred or aggravated during his INACDUTRA. Id. So service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection also may be granted on a secondary basis for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). In addition, a claimant is entitled to service connection on a secondary basis when it is shown that a service-connected disability has chronically aggravated a nonservice-connected disability. 38 C.F.R. § 3.310(b). See also Allen v. Brown, 7 Vet. App. 439 (1995). Under the current version of § 3.310(b), the regulation provides that any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service connected. Service connection on a direct-incurrence basis requires competent and credible evidence showing: (1) the Veteran has the alleged disability or, at the very least, indicating he has at some point since the filing of his claim; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002). Also of application to claims for direct service connection is the principle that where a chronic disease is shown during service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. On the other hand, continuity of symptomatology is required where the condition noted during service is not shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. In this circumstance, a showing of continuity of symptomatology since service is required establish chronicity of disease or injury in service and in turn link current disability to service. 38 C.F.R. § 3.303(b). However, the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court) since has clarified in Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), that this notion of continuity of symptomatology is limited to where involving those specific diseases denoted as "chronic" (and for which presumptive service connection is otherwise available) under 38 C.F.R. § 3.309(a). In cases where a Veteran asserts entitlement to service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C.A. § 1154(b) and its implementing regulation, 38 C.F.R. § 3.304(d), are applicable. This statute and regulation ease the evidentiary burden of a combat Veteran by permitting the use, under certain circumstances, of lay evidence to establish the occurrence of the claimed disease, injury or event in service. If the Veteran engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of his service. Id. The U.S. Court of Appeals for the Federal Circuit (Federal Circuit Court) has held that, in the case of a combat Veteran, not only is the combat injury presumed, but so too is the disability due to the combat injury in service. See Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). To establish entitlement to service connection, however, there must be the evidence of a current disability and a causal relationship between the current disability and the combat injury. Id. (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). The Board is required to apply the section 1154(b) presumption to whether the claimed injury occurred as well as the separate issue of whether the Veteran suffered the claimed ensuing disability while on active duty. For example, a Veteran would then only have to show that the disability he or she incurred in service was a chronic condition that persisted in the years following active duty. This basically establishes that the in-service injury resulted in permanent disability. See generally Reeves. In Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), the Federal Circuit Court recognized lay evidence as potentially competent to support the presence of the claimed disability during service, even where not corroborated by contemporaneous medical evidence such as actual treatment records (STRs, etc.). The Federal Circuit Court also has cautioned that negative evidence, meaning actual evidence weighing against a party, must not be equated with the absence of substantive evidence. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc). In cases involving combat-related injury, VA is prohibited from drawing a negative inference from silence in the STRs. But in cases where this inference is not prohibited [i.e., non-combat scenarios], the Board may use silence in the STRs as contradictory evidence if the alleged injury, disease, or related symptoms ordinarily would have been recorded in the STRs. Kahana v. Shinseki, 24 Vet. App. 428 (2011). See also Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (For non-combat Veterans providing non-medical related lay testimony regarding an event during service [or when the event did not occur in combat], Buchanan is distinguishable; the lack of documentation is service records must be weighed against the Veteran's statements.). In this circumstance, the Board must make two preliminary findings in order to rely on this inference (see Kahana): (a) First, the Board must find that the STRs appear to be complete, at least in relevant part. If the SMRs are not complete in relevant part, then silence in the STRs is merely the absence of evidence and not substantive negative evidence. (b) If the STRs are complete in relevant part, then the Board must find that injury, disease, or related symptoms ordinarily would have been recorded had they occurred. In making this determination, the Board may be required to consider the limits of its own competence on medical issues. It further deserves mentioning, however, that the Federal Circuit Court went on to indicate in Buchanan that the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. So the Board does not have to blindly accept the Veteran's allegations as credible, including in the face of contradictory medical evidence. See Buchanan, 451 F.3d at 1336 ("Nor do we hold that the Board cannot weigh the absence of contemporaneous medical evidence against the lay evidence of record."). The Federal Circuit Court has recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Ultimately, the Board must consider all the evidence relevant to the claim, including the availability of medical records, the nature and course of the disease or disability, the amount of time that has elapsed since military service, and any other pertinent facts. Cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact-finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). The determination as to whether the requirements for service connection are met is based on an analysis of all the relevant evidence of record, medical and lay, and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). All reasonable doubt material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 3.102. Generally, lay statement evidence may have direct relevance to establishing underlying components of a claim for service connection. Lay testimony where found credible is also competent to establish the presence of continuity of symptomatology for a claimed disability during and since separation from military service (again, subject to the limitation that a "chronic" disease is involved as defined under 38 C.F.R. § 3.309(a)). See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The Federal Circuit Court has further held in Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010) and in Waters v. Shinseki, 601 F.3d 1274, 1278 (2010), that it is error to suggest that lay evidence can never be sufficient to satisfy the requirement of 38 U.S.C.A. § 5103A(d)(2)(B) that there be a nexus between military service and a claimed condition. But as also observed by the Federal Circuit Court, lay evidence must "demonstrate some competence." See King v. Shinseki (Fed. Cir. 2012) (citing 38 U.S.C.A. § 5107(b) and 38 C.F.R. § 3.307(b)) (internal quotation marks omitted). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). The evaluation of evidence generally involves a three-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 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether the 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. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Baldwin v. West, 13 Vet. App. 1, 8 (1999). 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(a)(2). 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). In ascertaining the competency of lay evidence, the Courts generally have 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 competent with regards 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 also have been found not competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). In Colantonio, 606 F.3d at 1382, the Federal Circuit Court recognized that in some cases lay testimony "falls short" in proving an issue requiring expert medical knowledge. Similarly, in Waters, 601 F.3d at 1278, the Federal Circuit Court concluded that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger VA's duty to obtain a medical opinion on the issue. 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). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza at 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). Indeed, even if lay testimony is competent, should VA find it to be mistaken or lacking credibility, the Board may reject it as unpersuasive and, thus, not ultimately probative. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). See also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between 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")); and Rucker v. Brown, 10 Vet. App. 67 (1997) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). The Board may find a lack of credibility in, for example, conflicting medical statements or witness biases. Buchanan at 1337. The lack of contemporaneous medical evidence is also relevant; however, the mere lack of such evidence may not constitute the sole basis for discrediting the lay evidence. Id. As concerning AD service, though not also ACDUTRA and INACDUTRA, there is a presumption of soundness when there has been an induction examination during which the disability about which the Veteran later complains was not detected ("noted"). See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulations provide expressly that the term "noted" denotes "[o]nly such conditions as are recorded in examination reports," 38 C.F.R. § 3.304(b), and that mere "[h]istory of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions." Id., at (b)(1). To rebut this presumption of soundness absent this notation when entering service, VA is required to show by clear and unmistakable evidence both that the condition at issue preexisted service and that it was not aggravated during or by the Veteran's service beyond its natural progression. VAOPGCPREC 3-2003 (July 16, 2003); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). If, on the other hand, a pre-existing disability is noted upon entry into service, then the Veteran cannot bring a claim for service connection for that disability, only instead a claim for service-connected aggravation of that disability. And in this alternative circumstance, § 1153 applies and the burden falls on him to establish aggravation. Wagner, 370 F.3d at 1096; Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). Moreover, independent medical evidence generally is needed to support a finding that the pre-existing disorder increased in severity during service beyond its natural progression. See Paulson v. Brown, 7 Vet. App. 466, 470-471 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1994). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306; Falzone v. Brown, 8 Vet. App. 398, 402 (1995). See also Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); and Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). (all holding that mere temporary or intermittent flare-ups of a pre-existing injury or disease during service are insufficient to be considered "aggravation in service", unless the underlying condition, itself, as contrasted with mere symptoms, has worsened). Moreover, in Verdon v. Brown, 8 Vet. App. 529 (1996), the Court held that the presumption of aggravation does not attach even where the pre-existing disability has been medically or surgically treated during service and the usual effects of treatment have ameliorated disability so that it is no more disabling than it was at entry into service. Only if the Veteran somehow manages to show a chronic worsening of his pre-existing disability during his service would the presumption of aggravation apply and, in turn, require VA to then show by clear and unmistakable evidence that the worsening was not beyond the condition's natural progression. The presumption of aggravation applies only when pre-service disability increases in severity during service. Beverly v. Brown, 9 Vet. App. 402, 405 (1996); Browder v. Derwinski, 1 Vet. App. 204, 206-207 (1991). Also noteworthy is that, according to 38 C.F.R. § 3.303(c), in regards to pre-service disabilities noted in service, there are medical principles so universally recognized as to constitute fact (clear and unmistakable proof), and when in accordance with these principles existence of a disability prior to service is established no additional or confirmatory evidence is necessary. Section 3.303(c) goes on to indicate this determination includes situations where the manifestation of symptoms of chronic disease from the date of enlistment, or so close thereto, that the disease could not have originated in so short a period will establish pre-service existence thereof. Type II Diabetes Mellitus The Veteran contends that his diabetes is primarily the result of his exposure to Agent Orange. He states that he served aboard a ship that was close to shoreline and exposed to windblown contaminants from Agent Orange. He also contends that he was exposed to Agent Orange while the ship was in port in the Philippines. In addition, he notes that, while the ship was in port, he participated in a number of ship overhauls that exposed him to other noxious substances, including asbestos. He maintains that his exposure to those multiple contaminants and toxins in service led to his eventual development of diabetes. This claim therefore is predicated on both direct and presumptive service connection, and in adjudicating this claim the Board must consider all potential bases of entitlement. See Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). VA has a duty to address all arguments put forth by a claimant and/or theories under which entitlement to benefits sought may be awarded. See Robinson v. Peake, 21 Vet. App. 545, 552 (2008) (noting that the Board is required to consider all issues raised either by the claimant or reasonably by the evidence of record), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009); Buckley v. West, 12 Vet. App. 76, 83 (1998) (noting that where the RO and the Board have failed to address an argument reasonably raised by a claimant in support of a claim over which the Court (CAVC) has jurisdiction by virtue of a Notice of Disagreement (NOD) satisfying Veterans Judicial Review Act (VJRA) § 402, the Court will remand the claim with directions that the Board address the particular argument(s) in support thereof). This includes the duty to address arguments a Veteran has specifically made as it relates to the adequacy of any given VA examination. In deciding this claim, the Board must weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others and other evidence. Schoolman v. West, 12 Vet. App. 307, 310-11. The Board is mindful that it cannot make its own independent medical determination, and that there must be plausible reasons for favoring one medical opinion over another. Evans v. West, 12 Vet. App. 22, 31 (1998). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings. The probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). In this regard, generally speaking, contemporaneous evidence has greater probative weight than a history reported by the Veteran long after the fact. Curry v. Brown, 7 Vet. App. 59, 68 (1994). However, medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993). There is no disputing the Veteran has Type II Diabetes Mellitus, as this diagnosis is apparent from the medical records in the file. So the determinative issue instead is whether his diabetes is directly or presumptively related to his military service, and in particular to the type of activity he cites as the source or cause of it. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). A review of the evidence discloses that his STRs and the reports of his March 1969 service entrance examination and January 1973 service separation examination are unremarkable for any complaints or clinical findings of diabetes or of laboratory findings suggestive of the imminence of this condition, such as the presence of sugar in his urine (elevated glucose level). And because diabetes is diagnosed based on the results of this type of laboratory testing and objective data, it is not the type of "simple" condition that is readily amenable to probative lay comment regarding its diagnosis and etiology. Thus, the fact that his STRs do not suggest this condition's presence tends to refute any notion that it was directly incurred during his initial AD service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). There equally is no suggestion of this condition's presence, certainly not to the required minimum compensable degree of at least 10-percent disabling, within one year of his discharge from service to warrant presuming it was incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Type II Diabetes mellitus also is among a group of diseases that VA presumes to be the result of exposure to herbicides in service such as Agent Orange, provided that, with certain exceptions not relevant here, they are manifested to a degree of at least 10-percent disabling at any time after service. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.309(e). The Veteran's diabetes has become manifest to a degree of at least 10-percent disabling, see 38 C.F.R. § 4.119, Diagnostic Code 7913, albeit well after expiration of the one-year presumptive period just mentioned immediately following the conclusion of his service to otherwise warrant presuming it was incurred in service. Therefore, the more determinative question is whether it is the result of exposure to Agent Orange. It is presumed that Veterans who served in the Republic of Vietnam during the Vietnam era were exposed to Agent Orange 38 C.F.R. § 3.307(a)(6)(iii). There also is this presumption for Veterans who served in other areas at specified times, such as along the Korean Demilitarized Zone (DMZ). Veterans who were otherwise exposed to such herbicides also may take advantage of the presumptive health effects. However, unlike Vietnam Veterans or those who served elsewhere in areas acknowledged to have had Agent Orange used or sprayed there, they are required to prove that they were, in fact, exposed to herbicides during their military service. That is, they do not have the benefit of a presumption of exposure as do Vietnam and similarly situated Veterans. Thus, service connection may be presumed for residuals of Agent Orange exposure by satisfying two requirements. First, a Veteran must show that he served in the Republic of Vietnam during the Vietnam War era or elsewhere outside of Vietnam where Agent Orange was used or sprayed. See 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6). Second, the Veteran must have a diagnosis of one of the specific diseases listed in 38 C.F.R. § 3.309(e). See Brock v. Brown, 10 Vet. App. 155, 162 (1997). However, the availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a Veteran from alternatively establishing entitlement to service connection with proof of direct causation linking his claimed disability to his military service. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); see, too, McCartt v. West, 12 Vet. App. 164, 167 (1999) (indicating the principles set forth in Combee, which, instead, concerned exposure to radiation, are equally applicable in cases involving Agent Orange exposure to establish direct causation). But as regarding presumptive service connection, which is the only possibly viable means still available to the Veteran since it is not shown that his diabetes was directly incurred in service, according 38 C.F.R. § 3.307(a)(6)(iii), in order for the presumption of herbicide exposure to apply, qualifying service in the Republic of Vietnam must have involved service on the landmass of Vietnam (often referred to as service "in country") or, at the very least, on the inland waterways ("brown water"), but does not include mere service on a deep-water naval vessel in the waters offshore ("blue water"). See Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008); cert denied, 77 U.S.L.W. 3267 (Jan. 21, 2009) (No. 08-525); VAOPGCPREC 27-97. What constitutes "inland waterways" is not defined in VA regulations; however, VA Adjudication Procedure Manual provides interpretive guidance. The Manual indicates that inland waterways include rivers, canals, estuaries, and delta areas, such as those on which the Vietnam "brown water" Navy operated. VA Adjudication Procedure Manual M21-1MR, pt. IV, subpt. ii, ch. 2, § C.10.k. However, the Manual clearly states that service aboard a ship that merely anchored in an open deep-water harbor, such as Da Nang, Vung Tau, or Cam Ranh Bay, along the Vietnam coast, does not constitute inland waterway service or qualify as docking to the shore to establish presumptive exposure to herbicides. Id. The Manual does note an exception regarding veterans who served as a coxswain. So service in the Republic of Vietnam means that the Veteran actually set foot within the land borders of Vietnam. Service in the Vietnam coastal waters without ever having gone ashore is not enough. Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008), cert. denied, 77 U.S.L.W. 3267 (Jan. 21, 2009) (No. 08-525). In his April 2006 Substantive Appeal (on VA Form 9), the Veteran acknowledged that he had never actually set foot in Vietnam, and there is no competent and credible evidence suggesting otherwise. And although he claims that he was exposed to Agent Orange while his ship was in port in the Philippines, there is no probative evidence corroborating that assertion either. With respect to the contention that, due to his close proximity to the Vietnam coast, he was exposed to Agent Orange through the air or through his drinking water, he is, in essence, attempting to expand the statutory presumption to waters offshore Vietnam. This matter has been finally settled by Haas. Indeed, in upholding VA's requirement that a Veteran must have been present within the land borders of Vietnam, the Federal Circuit Court essentially reaffirmed the VA's discretion to maintain a "bright line" rule against those claiming presumptive exposure to herbicides via runoff into the sea or spray drift in the air off the coast. Accordingly, the Board rejects the argument that alleged exposure to herbicides via wind or sea water off the coast of Vietnam should be presumed. In addition to Agent Orange, the Veteran contends that he was exposed to numerous other noxious substances and toxins in service. For example, he states that he was exposed to asbestos during major overhauls of his ship. With regards to the necessary development of this alternative theory of entitlement, there is no statute specifically dealing with service connection for asbestos-related diseases, nor has the Secretary of VA promulgated any specific regulations. In 1988, however, VA issued a circular on asbestos-related diseases providing guidelines for considering asbestos compensation claims. See Department of Veterans Benefits, Veterans Administration, DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988). The information and instructions contained in the DVB Circular since have been included in VA Adjudication Procedure Manual, M21-1, part VI, para. 7.21 (January 31, 1997) (hereinafter "M21-1"). Also, an opinion by VA's Office of General Counsel discussed the development of asbestos claims. VAOPGCPREC 4-2000 (April 13, 2000). VA must analyze the Veteran's claim for service connection for asbestos-related disease under these administrative protocols. Ennis v. Brown, 4 Vet. App. 523, 527 (1993); McGinty v. Brown, 4 Vet. App. 428, 432 (1993). Recognizing this, with asbestos-related claims, the Board must determine whether the claim development procedures applicable to such claims have been followed. Ashford v. Brown, 10 Vet. App. 120, 124-125 (1997) (while holding that the Veteran's claim had been properly developed and adjudicated, the Court indicated the Board should have specifically referenced the DVB Circular and discussed the RO's compliance with the Circular's claim-development procedures). VA Adjudication Procedure Manual Rewrite (M21-1MR) provides that, where asbestos exposure is alleged, VA must determine whether military records demonstrate evidence of asbestos exposure during service, develop whether there was pre-service and/or post-service occupational and other asbestos exposure, and determine whether there is a relationship between asbestos exposure and the claimed disease. M21-1MR, at IV.ii.2.C.9. VA's Manual 21-1MR, Part IV, subpart ii, Chapter 2, Section C essentially acknowledges that inhalation of asbestos fibers can result in fibrosis and tumors, and produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of the pleura and peritoneum, and cancer of the lung, gastrointestinal tract, larynx, pharynx and urogenital system (except the prostate), with the most common resulting disease being interstitial pulmonary fibrosis (asbestosis). Regarding the M21-1MR's exclusion of prostate cancer from urogenital cancers that may result from inhalation of asbestos fibers, VA's General Counsel determined that the M21-1MR provisions discussing asbestos and asbestos-related diseases generally are not substantive rules, and there is no presumption that a Veteran was exposed to asbestos in service. Dyment v. West, 13 Vet. App. 141, 145 (1999), aff'd, Dyment v. Principi, 287 F. 3d 1377 (Fed. Cir. 2002); VAOPGCPREC 4-2000. Some of the major occupations involving exposure to asbestos include mining, milling, shipyard work, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products (such as clutch facings and brake linings), and manufacture and installation of products such as roofing and flooring materials, asbestos cement sheet and pipe products, and military equipment. M21-1MR, IV.ii.2.C.9.f. Again, however, there is no probative evidence tending to support the notion the Veteran developed diabetes as a result of exposure to asbestos, even accepting that diseases attributable to asbestos exposure often do not fully develop or manifest until many years later, sometimes not until anywhere from 10-45 years after exposure, thus even accepting this acknowledged latency. Moreover, there has to be radiographic confirmation of a disease typically resulting from asbestos exposure, and diabetes is not among the conditions so recognized. Because there is no competent and credible evidence of diabetes during the Veteran's period of AD or during the first year after his separation from AD, and because there is no competent and credible evidence of a nexus or link between his eventually diagnosed diabetes and any event, injury or disease during his service, including exposure to Agent Orange, his diabetes does not meet the criteria for associating this condition either directly or presumptively with his AD military service. Therefore, service connection on these bases is not warranted. However, that does not end the inquiry In the alternative, he contends that his diabetes first manifested during an examination in conjunction with his additional service in the Naval Reserves and that service connection therefore is warranted on this other basis. In July 1985, he was examined at the Military Entrance Processing Station at Gunter Annex, Maxwell Air Force Base, in Montgomery, Alabama. The purpose of that examination was to determine whether he was medically qualified to be a commissioned officer in the Naval Reserves. A urinalysis was negative for sugar. However, it did show the presence of albuminaria. Later in July 1985, he went to the Family Practice Center at the University of Alabama, Birmingham. He stated that he had been through a military physical examination in Montgomery that had shown the presence of glycosuria. He noted that such a finding would preclude him from becoming a commissioned officer. At his request, additional tests were performed at the Family Practice Center: a urinalysis, 24-hour urine for creatinine clearance and total protein, and a 5-hour glucose tolerance test (GTT) to confirm or rule out diabetes. He related that his glycosuria had been 1, 2, and 4+ on serial measurements on his testing in Montgomery. In August 1985, following an analysis of the additional laboratory test results, the examiner felt that the Veteran definitely had glucose intolerance. During a March 15, 1986 annual examination for the Naval Reserves, a urinalysis revealed the Veteran's sugar was 250 mg/dL. The positive albumin test from his July 1985 examination was noted. However, it was reported that he had no history of diabetes or visual problems. With respect to his March 15, 1986 examination, there is some question in the record as to whether it was performed on March 15, 1985. If so, that would have been 4 days after returning from a period of ACDUTRA from February 25 to March 11, 1985. Although the front of report of the Medical Examination (Standard Form 88) is dated March 15, 1985, the evidence strongly suggests that the date of the examination was March 15, 1986. Not only does the Medical Examination report show a history of diabetes testing in July 1985, the back of the form shows that a urinalysis performed on March 16, 1986 was negative for sugar. Moreover, it is noted that the examination was administratively reviewed for completeness and accuracy on March 16, 1986. Finally, the Report of Medical History (Standard Form 93) accompanying the Report of Medical Examination shows that it was completed and signed by the examining physician on March 15, 1986. For these reasons, the Board concludes that the Veteran's examination for the Naval Reserves was on March 15, 1986 not March 15, 1985. Accordingly, the Board finds that his diabetes did not become manifest 4 days after a period of ACDUTRA from February 25 to March 11, 1985. Rather, it was first reported during the July 1985 examination. In any event, there is no presumptive service connection for ACDUTRA service or even INACDUTRA service, only instead AD. Furthermore, he was examined by VA in June 2010 to determine the etiology of this disorder, seeing as though its diagnosis since has been confirmed. During the June 2010 VA examination, the examiner confirmed the presence of diabetes. The Veteran reported the onset as being in the 1990s. However, the examiner erroneously presumed it to be the result of the Veteran's exposure to Agent Orange in Vietnam. The VA examiner suggested that it was first manifested during the Veteran's military medical examination in 1985. For these reasons, she found it at least as likely as not related to service. In light of the erroneous information, the claims file was returned to her in July 2011 and September 2012 for further review and supplemental comment. Following her July 2011 review, the VA examiner found that the Veteran did not have the requisite service in Vietnam and that his diabetes could not be presumed to be the result of his claimed exposure to Agent Orange. The VA examiner also noted that the Veteran's diabetes was not manifested until Reserve service in 1985, and that such onset conflicted with his report of onset as being in the 1990s. Therefore, she concluded that his diabetes was unrelated to his service. In September 2012, she reaffirmed her opinion that the onset of his diabetes had been after service, not during. But in order to further clarify the date of onset of the Veteran's diabetes, the claims folder was referred for an expert opinion to the Chief of the Endocrinology Service at the VAMC in Durham, North Carolina. Following her review of the claims folder, the VHA medical expert found that the first indication of any sign that the Veteran had glucose intolerance was the report of his March 15, "1985" military medical examination. The VHA medical expert stated that it was not possible to determine precisely when that problem arose and that no other tests or information which could be gathered would make such a determination possible. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (noting the Board need not obtain further medical evidence where the medical evidence "indicates that determining the cause is speculative"). She noted that Type II diabetes mellitus was a chronic condition that, generally, developed over long periods of time and that there was no particular day, week, or month during which a patient clearly transitioned from being normal to having diabetes. Rather, the VA medical expert noted that individuals had had up to 10 years of deteriorating glucose control and insulin secretory ability by the time they were diagnosed with Type II diabetes. Thus, she found it likely that the Veteran likely had a continuous worsening of glucose metabolism for an extended period prior to the initial detection of glucose in his urine. Following further review, the VHA medical expert opined that it was unlikely that the Veteran had experienced the initial manifestation of Type II diabetes during any period of ACDUTRA. Although it was noted, erroneously, that diabetes had first been manifested on March 15, "1985", 4 days after a period of ACDUTRA, the VHA medical expert nonetheless found no evidence that diabetes could have or should have been found during any period of ACDUTRA. In so saying, she reiterated that the chronicity of diabetes developed over an extended period of time and did not support the contention that it would have occurred specifically during a period of ACDUTRA. In addition to these conclusions, the VHA medical expert further opined that it was physiologically unlikely that the Veteran's diabetes had been aggravated by or during any period of ACDUTRA. Indeed, she stated, specifically, that there was no evidence to support such a contention. In Owens v. Brown, 7 Vet. App. 429, 433 (1995), the Court held that VA may favor the opinion of one competent medical authority over another when decision makers give an adequate statement of reasons and bases. See also Wray v. Brown, 7 Vet. App. 488, 493 (1995) (holding that the adoption of an expert medical opinion may satisfy the Board's statutory requirement of an adequate statement of reasons and bases if the expert fairly considered the material evidence seemingly supporting the Veteran's position). Here, the only evidence of record to the contrary is the Veteran's own unsubstantiated lay opinion. However, he has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation regarding the likely time of inception of his diabetes. To reiterate, this is not a simple condition, rather, one that necessarily is medically complex. Accordingly, his unsubstantiated lay opinion does not constitute competent and credible evidence of the type needed to support his claim. His lay opinion lacks probative value both in terms of when a diagnosis of diabetes was warranted and when it initially manifested. In so concluding, the Board is not dismissing his lay opinions out of hand. Rather, it simply finds the preponderance of the evidence, including the VA medical expert's opinion, more probative. Accordingly, service connection is not warranted for this condition, so his appeal of this claim is denied. Eye Disorder The Veteran does not contend, and the evidence does not otherwise suggest, that his eye disorder, claimed as ocular hypertension, was first manifested during his period of AD. Although he has demonstrated refractive error since his March 1969 service entrance examination, such a disorder is not considered to be a disease or injury within the meaning of the law and regulations applicable to service connection. 38 C.F.R. § 3.303(c). While service connection may be granted, in limited circumstances, for disability due to aggravation of a constitutional or developmental abnormality by superimposed disease or injury, such disease or injury was not demonstrated during his period of AD. See Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993). The primary thrust of his contentions, instead, is that his eye disorder was first manifested during a period of ACDUTRA or that it is primarily related to his diabetes, i.e., a complication. However, after carefully considering the claim in light of the record and the applicable law, the Board finds that the preponderance of the evidence is against this claim, so it, too, must be denied. Eye disorders, diagnosed as bilateral hypertensive retinopathy and cataracts, were first manifested in May 1999 during the Veteran's treatment by D. G., O.D. There was no evidence of ocular hypertension. In July 2003, the Veteran's visual symptoms reportedly worsened due to his cataracts. The diagnoses of hypertensive retinopathy and cataracts were well after the Veteran left AD and service in the Naval Reserves, and there is no objective evidence that either disorder is in any way related to that service. In fact, during her January 2013 review of the claims file, the VHA medical expert found no recent evidence of retinopathy. Although the VHA medical expert noted the presence of cataracts could be due to diabetes, she also noted that they could occur with aging as well. While the Veteran contends that his cataracts are primarily the result of diabetes, it must be emphasized that service connection has been denied for that disorder. Therefore, service connection for cataracts is not available on a secondary basis inasmuch as this other disorder, itself, meaning the diabetes, has not been shown to be related or attributable to his military service. For these reasons and bases, the Board finds that the preponderance of the evidence is against a finding of service connection, either on a direct or secondary basis for an eye disorder, diagnosed as hypertensive retinopathy and cataracts. Therefore, the Veteran does not meet the criteria for service connection for a eye disorder. Accordingly, service connection is not warranted, and this portion of the appeal also is denied. Heart Disorder The primary thrust of the Veteran's contentions is that his heart disorder, diagnosed primarily as coronary artery disease, was first manifested during a period of ACDUTRA or that it is related to his diabetes. However, after carefully considering this claim in light of the record and the applicable law, the Board finds that the preponderance of the evidence is against this claim. Therefore, this claim also must be denied. The Veteran's STRs from his period of AD service, as well as those from his periods of ACDUTRA, are unremarkable for any complaints or clinical findings of coronary artery disease. This disease was first discovered during his hospitalization at the Carraway Methodist Medical Center from April to May 1999. At that time, he consequently underwent a 2-vessel coronary artery bypass graft. Not only were the initial manifestations of coronary artery disease many years after his separation for AD, but they also were several years after his release from the United States Naval Reserves. Moreover, the preponderance of the evidence is against a finding that his heart disease is in anyway related to his period of AD service or reserve duty on ACDUTRA. In this regard, the Board notes that coronary artery disease is also a presumptive result of exposure to Agent Orange. As noted above, however, the preponderance of the competent and credible evidence of record is against finding that the Veteran was ever exposed to herbicides. Moreover, there is no competent and credible evidence on file that his coronary artery disease underwent an increase in the underlying pathology during any period of ACDUTRA. For these reasons and bases, the Board concludes that he does not meet the criteria for service connection on a direct or presumptive basis or on the basis of aggravation. Again, however, that does not end the inquiry. The primary thrust of his contentions is that his coronary artery disease is proximately due to or the result of his diabetes or aggravated by it, so as to in turn warrant the granting of secondary service connection. The evidence, such as the report of his June 2010 VA examination and the January 2013 opinion from the VHA medical expert, strongly suggests that the Veteran's coronary artery disease is related to his Type II Diabetes Mellitus. However, more importantly, it must be emphasized that service connection has not been established for the Type II Diabetes Mellitus. Thus, service connection for coronary artery disease is not warranted on a secondary basis because this condition cannot be attributed to the Veteran's military service where, as here, the condition used to provide this pathway, his diabetes, itself has not been attributed to his service. In sum, the preponderance of the evidence shows that the Veteran's hypertension was first manifested in July 1985, many years after his separation from AD and not during a period of ACDUTRA. The preponderance of the competent and credible, so probative, evidence of record is also against a finding that his heart disease was aggravated during or by a period of ACDUTRA, certainly not beyond its natural progression. Hypertension Finally, the Veteran seeks entitlement to service connection for hypertension. The primary thrust of his contentions is that his hypertension was manifested by elevated blood pressure readings measured during a period of ACDUTRA. Therefore, he maintains that service connection is warranted on that basis. In the alternative, he contends that his hypertension is related to his diabetes and that service connection is warranted on a secondary basis. However, after carefully considering this claim in light of the record and the applicable law, the Board finds that the preponderance of the evidence is against this claim of entitlement to service connection for hypertension. Accordingly, the appeal of this claim must be denied. A review of the Veteran's treatment records from his period of AD, as well as the reports of his service entrance and separation examinations, is unremarkable for any complaints or clinical findings of hypertension. His first demonstrated an elevated blood pressure of 154/92 on July 30, 1985, during treatment at the Family Practice Center at the University of Alabama in Birmingham. During a March 1988 annual/reenlistment examination for the Naval Reserves, his blood pressure was also elevated at 130/90. Though not considered disqualifying for further service, hypertension was first clinically reported during his annual service examination in February 1989. Since that time, he has been diagnosed with chronic, identifiable hypertension; however, the STRs are negative for any findings that it is etiologically related to any period of his service. In this regard, the Board notes no evidence of any increase in the underlying pathology during any period of ACDUTRA. In order to clarify the date of onset of the Veteran's hypertension, the claims folder was referred for an expert opinion to the Chief of the Endocrinology Service at the VA Medical Center in Durham, North Carolina. In January 2013, following her review of the claims folder, the VHA medical expert confirmed that the first indication of any sign that the Veteran had hypertension was the report of his July 30, 1985 treatment at the Family Practice Center at the University of Alabama in Birmingham. As with the Veteran's diabetes, the VHA medical expert stated that it was not possible to determine precisely when the Veteran's hypotension arose. In this regard, she noted that there were no other tests or information that could be gathered which would make such a determination possible. She noted that essential hypertension was a chronic condition which, generally, developed over long periods of time and that there was no particular day, week, or month during which a patient clearly transitioned from being normal to becoming hypertensive. Rather, the VHA medical expert noted that individuals had had up to 10 years of deteriorating glucose control and insulin secretory ability by the time they were diagnosed with Type II diabetes. Following further review, the VA medical expert opined that it was unlikely that the Veteran experienced the initial manifestation of hypertension during any period of ACDUTRA. Indeed, the VHA medical expert found no evidence of hypertension prior to the elevated blood pressure reading on July 30, 1985. She noted that all previous blood pressure readings had been unremarkable and that there was no evidence that hypertension could have or should have been diagnosed during any period of ACDUTRA. In so saying, she reiterated that the chronicity of hypertension had developed over an extended period of time and did not support the contention that it would have occurred specifically during a period of ACDUTRA. In addition, the VHA medical expert opined that it was physiologically unlikely that the Veteran's hypertension had been aggravated by or during any period of ACDUTRA. Indeed, she stated, specifically, that there was no evidence to support such a contention. The only evidence of record to the contrary is the Veteran's own opinion. However, he has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Accordingly, this lay evidence does not constitute competent and credible evidence and lacks probative value. In so concluding, the Board is not dismissing his opinion out of hand. Rather, it simply finds the preponderance of the evidence, including the VHA medical expert's opinion, more probative. Additional Considerations In arriving at the foregoing decisions, the Board has considered the doctrine of reasonable doubt. Reasonable doubt is doubt that exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. The reasonable doubt doctrine is also applicable even in the absence of official records, particularly if the basic incident allegedly arose under combat, or similarly strenuous conditions, and is consistent with the probable results of such known hardships. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996); Brown v. Brown, 5 Vet. App. 413, 421 (1993) (Observing that under the "benefit-of-the-doubt" rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the claimant shall prevail upon the issue). In this case, however, the preponderance of the evidence is against the Veteran's claims. Therefore, the doctrine of reasonable doubt is not applicable. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). ORDER Entitlement to service connection is denied for Type II Diabetes Mellitus. Entitlement to service connection is denied for an eye disorder, claimed as ocular hypertension. Entitlement to service connection is denied for a heart disorder, claimed as coronary artery disease. Entitlement to service connection is denied for hypertension. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs