Citation Nr: 1436512 Decision Date: 08/14/14 Archive Date: 08/20/14 DOCKET NO. 07-28 436 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a kidney disorder. 2. Entitlement to service connection for sleep apnea. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for a stomach disorder, to include gastroesophageal reflux disease (GERD). 5. Entitlement to service connection for diabetes mellitus, type II, to include as due to exposure to herbicides and/or asbestos. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Sherrard, Counsel INTRODUCTION The Veteran, who is the Appellant in this case, had active service from August 1964 to August 1968. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a November 2005 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). In June 2011, the Board remanded these claims for further development. The development requested having been completed, the case is now appropriate for appellate review. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. There was no event, disease, or injury resulting in a kidney disorder during active service, symptoms of a kidney disorder were not unremitting in service, symptoms of a kidney disorder have not been unremitting since service separation, nephritis did not manifest to a compensable degree during or within one year of active service, and there is no medical nexus between the current kidney disorders and active service. 2. There was no event, disease, or injury manifesting sleep apnea during active service, symptoms of sleep apnea were not unremitting in service, symptoms of sleep apnea have not been unremitting since service separation, and there is no medical nexus between the current sleep apnea and active service. 3. Other than acoustic trauma, there was no event, disease, or injury manifesting in hearing loss during active service, symptoms of hearing loss were not chronic in service, symptoms of hearing loss have not been chronic since service separation, hearing loss did not manifest to a compensable degree during or within one year of active service, and there is no medical nexus between the current hearing loss and active service. 4. There was no event, disease, or injury manifesting in GERD during active service, symptoms of GERD were not unremitting in service, symptoms of GERD have not been unremitting since service separation, and there is no medical nexus between the current GERD and active service. 5. The Veteran may have been exposed to asbestos during service, but was not exposed to herbicides; the Veteran does not have an asbestos-related disability; symptoms of diabetes mellitus were not chronic in service or since service separation, and diabetes did not manifest to a compensable degree either during service or within one year of service separation; and the current diabetes mellitus is not related to any in-service injury or disease, including in-service asbestos exposure. CONCLUSIONS OF LAW 1. The criteria for service connection for a kidney disorder are not met. 38 U.S.C.A. §§ 101, 1101, 1110, 1112, 1113, 5103(a), 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2013). 2. The criteria for service connection for sleep apnea are not met. 38 U.S.C.A. §§ 101, 1101, 1110, 5103(a), 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2013). 3. The criteria for service connection for a bilateral hearing loss disability are not met. 38 U.S.C.A. §§ 101, 1101, 1110, 1112, 1113, 5103(a), 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.385 (2013). 4. The criteria for service connection for a stomach disorder, to include GERD, are not met. 38 U.S.C.A. §§ 101, 1101, 1110, 5103(a), 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2013). 5. The criteria for service connection for type II diabetes mellitus have not been met, including as due to asbestos exposure or presumptively based on herbicide exposure. 38 U.S.C.A. §§ 101, 1101, 1110, 1112, 1113, 1116, 5103(a), 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition, such as nephritis, hearing loss, or diabetes mellitus, noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Unlike the claimed nephritis, hearing loss, and diabetes mellitus, the remainder of the conditions at issue are not "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.309(b) (requiring continuity of a condition after service if chronicity is not found in service) does not apply to those conditions. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as nephritis, organic diseases of the nervous system (e.g., sensorineural hearing loss), or diabetes mellitus, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The United States Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). In certain cases, service connection can be presumed if a veteran was exposed to an herbicide agent during active service. Under the current Code of Federal Regulations (C.F.R.), presumptive service connection is warranted for the following disorders: AL amyloidosis; chloracne or other acneform disease consistent with chloracne; Type II diabetes; Hodgkin's disease; chronic lymphocytic leukemia; multiple myeloma; non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); ischemic heart disease; Parkinson's disease; hairy cell leukemia; and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309€ (2013). Presumptive service connection for these disorders as a result of Agent Orange exposure is warranted if the requirements of 38 C.F.R. § 3.307(a)(6) are met. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.309€. The governing law provides that a "veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent . . . unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service." 38 U.S.C.A. § 1116(f). Pursuant to Section 3 of the Agent Orange Act of 1991, Pub. L. No. 102-4, 105 Stat. 11, the Secretary of Veterans Affairs (Secretary) entered into an agreement with the National Academy of Sciences (NAS) to review and summarize the scientific evidence concerning the association between exposure to herbicides used in Vietnam and various diseases suspected to be associated with such exposure. The NAS was to determine, to the extent possible, whether there was a statistical association between the suspect disease and herbicide exposure, taking into account the strength of the scientific evidence and the appropriateness of the methods used to detect the association; the increased risk of disease among individuals exposed to herbicides during the service in the Republic of Vietnam during the Vietnam era; and whether there is a plausible biological mechanism or other evidence of a causal relationship between herbicide exposure and the suspect disease. The NAS was required to submit reports of its activities every two years. The Secretary, under the authority of the Agent Orange Act of 1991 and based on studies by the NAS, has determined that there is no positive association between exposure to herbicides and any condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also Notice, 61 Fed. Reg. 41,442-449, and 61 Fed. Reg. 57,586-589 (1996); Notice, 64 Fed. Reg. 59,232-243 (Nov. 2, 1999); Notice, 67 Fed. Reg. 42,600-608 (June 24, 2002); Notice, 72 Fed. Reg. 32,395-407 (June 12, 2007); 74 Fed. Reg. 21,258-260 (May 7, 2009). When a disease is first diagnosed after service but not within an applicable presumptive period, service connection may nevertheless be established by evidence demonstrating that disease was in fact incurred during service. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). If there is no presumptive service connection available, direct service connection can be established if the record contains competent medical evidence of a current disease process with a relationship to exposure to an herbicide agent while in military service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303; Combee at 1043-44. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno, 6 Vet. App. At 469; 38 C.F.R. § 3.159(a)(2). The Court has emphasized that 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. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of a veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's 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 a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection for Kidney Disorder, Sleep Apnea, Hearing Loss and GERD The Veteran contends that his kidney disorder, sleep apnea, hearing loss, and stomach disorder (diagnosed as GERD) began either during or soon after active service. With regard to his kidney disorder, he contends that he had his first kidney stone (nephrolithiasis) shortly after he separated from service (1968 or 1969), and that they have recurred annually since then. He has undergone four lithotripsies, and was diagnosed with focal segmental glomerulosclerosis with nephrotic syndrome (FSGN) and chronic renal insufficiency in 2004. Next, he contends that his sleep disorder and GERD began in 1967, during active service, when he started waking up unable to breathe and also experienced heart burn. With regard to his hearing loss, he avers that his work station during active service was next to an aircraft elevator, and that the aircraft maintenance workers would test jet engines on the elevator. He stated the noise was so loud that he often had to leave. He requested ear protection but was told that his job did not qualify for hearing protection. He states that his ears started ringing all the time during service. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater, or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 26 decibels or greater, or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Also, the threshold for normal hearing is between 0 and 20 decibels, and higher threshold shows some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). After a review of all the evidence of record, lay and medical, the Board finds that the preponderance of the evidence demonstrates that there was no event, injury, or disease manifesting a kidney disorder, sleep apnea, hearing loss, or GERD during active service, and that the preponderance of the evidence demonstrates that symptoms of a kidney disorder, sleep apnea, hearing loss, or GERD were not chronic or unremitting in service. The July 1964 enlistment examination report shows normal clinical evaluations of the abdomen and genitourinary system, and no complaints of genitourinary, sleep, stomach, or hearing problems. The Veteran checked "no" next to "stomach, liver or intestinal trouble," "frequent indigestion," "kidney stone or blood in urine," and "frequent trouble sleeping" on his Report of Medical History. An audiogram conducted at enlistment in July 1964 revealed puretone thresholds of 15, 10, 10, 10, and 5 decibels in each ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hertz (Hz), demonstrating normal hearing. (Note: Prior to November 1, 1967, service department audiometric test results were reported in standards set forth by the American Standards Association (ASA). Since November 1, 1967, those standards have been set by the International Standards Organization (ISO)-American National Standards Institute (ANSI). In order to facilitate data comparison in this decision, for service department audiometric test results through October 31, 1967, the ASA standards have been converted to ISO-ANSI standards.) An August 1964 audiogram revealed puretone thresholds of 15, 15, 10, 15, and 15 decibels in the right ear, and 20, 15, 15, 15, and 15 decibels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. Although there was some threshold shift since enlistment, the results of the September 1964 audiogram still do not show a hearing loss disability under 38 C.F.R. § 3.385 or hearing loss under Hensley, as none of the puretone thresholds were above 20 decibels. Hensley, 5 Vet. App. at 157. The August 1968 separation examination report is negative for any report or findings of a kidney disorder, sleep apnea, hearing loss, or GERD. Clinical evaluations of the abdomen and genitourinary system were again marked as normal, and there were no complaints of genitourinary, sleep, stomach, or hearing problems. Although an audiogram was not conducted, the Veteran scored a 15 out of 15 on a whisper voice test, and the Veteran did not report any difficulty hearing or ringing in his ears. Thus, even if acoustic trauma during service is conceded, hearing loss, to any degree, was not demonstrated during active service. In sum, the Veteran's service treatment records are entirely negative for complaints, reports, symptoms, findings, treatment, or diagnoses of a kidney disorder, sleep apnea, hearing loss, or GERD. The Board next finds that the preponderance of the evidence demonstrates that symptoms of a kidney disorder, sleep apnea, hearing loss, or GERD have not been continuous or unremitting since separation from active service in August 1968. As noted above, the August 1968 separation examination report is negative for any report or finding of a kidney disorder, sleep apnea, hearing loss, or GERD. Following separation from service in August 1968, the evidence of record does not show any complaints, diagnosis, or treatment for a kidney problem until August 2001, when VA treatment notes indicate that the Veteran had a history of recurrent kidney stones since 1969. Nephropathy was assessed during the May 2005 Agent Orange examination at VA. The nurse practitioner-examiner noted that the Veteran was diagnosed with "a kidney problem" in 2004, while other VA treatment records show a diagnosis of protein losing nephropathy since 2004. Records from a private nephrologist, Dr. S., from 2005 to 2009 show a diagnosis of focal segmental glomerulosclerosis as early as January 2005. Concerning sleep apnea, the first post-service documentation of the disorder is also from August 2001, when it was noted that the Veteran had had sleep apnea and had been using a CPAP machine for five years, placing its inception in 1996, still 28 years after service separation. With regard to his GERD, VA treatment notes from October 2002 indicate a history of GERD, but do not state when the disorder began. A March 2008 VA treatment note indicates that he had GERD for "a long time." Finally, hearing loss was first documented following service separation at the Agent Orange examination in May 2005, when it was noted that the Veteran had hearing loss that was worse in the left ear. He was referred to an audiologist the same month, and he reported gradual hearing loss for several years, placing inception of the hearing loss symptoms more than three decades after service separation. He stated that he had difficulty understanding speech in noise, he turned up the television volume too loudly for others, and he had difficulty understanding female voices. It was noted that "a history of noise exposure is frequently present." The medical evidence indicates that there was some question as to the validity of the Veteran's hearing loss complaints throughout the years. For instance, an August 2001 treatment note indicated that the Veteran had "selective hearing." In addition, a May 2008 VA audiology consultation note indicates that the Veteran had a score of 36 on the Hearing Handicap Inventory for the Elderly, indicating a severe self-perceived hearing handicap. Further, in September 2010, a VA audiologist noted a significant threshold shift since the previous evaluation in 2008. However, the audiologist further noted that, during testing, initial responses were not given until levels approaching 50 to 60 decibels, but that with repeated instructions and effort, these were eventually reduced to levels that were within normal limits. However, the audiologist still suspected that the puretone thresholds were suprathreshold. While the audiologist believed that the Veteran had a degree of high frequency hearing loss, without better cooperation and reliable responses, it was impossible for him to make any recommendations regarding amplification. In any case, at the earliest, hearing loss complaints were first documented in 2001, more than three decades after service separation. Moreover, notably, an actual hearing loss disability as defined by VA regulations was not recorded until 2011 at the VA examination. The absence of post-service complaints, findings, diagnosis, or treatment for the claimed disorders for at least 28 years after service separation until 1996 and later is one factor that tends to weigh against a finding of chronic or unremitting symptoms of a kidney disorder, sleep apnea, hearing loss, or GERD after service separation. See Buchanan, 451 F.3d 1336 (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Additional evidence demonstrating that symptoms of a kidney disorder, sleep apnea, hearing loss, or GERD have not been chronic or unremitting since service separation include, as noted above, the Veteran's own history of symptoms provided for treatment purposes. For instance, in 2001, the Veteran reported a five year history of sleep apnea, and in 2005, he reported several years of gradual hearing loss, placing inception of sleep apnea and hearing loss many years after service separation. These statements provide highly probative evidence against his claim, as it is assumed that he would provide an accurate history of symptoms in the context of seeking treatment for these disorders. The Board also finds that the preponderance of the evidence demonstrates that nephritis and hearing loss did not manifest to a compensable degree within one year of service separation. The preponderance of the evidence demonstrates no nephritis or hearing loss symptoms during the one year period after service, and no diagnosis or findings of nephritis or hearing loss of any severity during the one year post-service presumptive period. See 38 C.F.R. § 4.85, 4.86, 4.115b, Diagnostic Codes 6100, 7502 (2013). Indeed, the evidence does not demonstrate a diagnosis or complaints of nephritis or hearing loss until 2001 at the earliest. For these reasons, the Board finds that nephritis and hearing loss did not manifest to a compensable degree within one year of service separation; therefore, the presumptive provisions for nephritis and hearing loss are not applicable in this case. 38 C.F.R. §§ 3.307, 3.309 (2013). With regard to the Veteran's recent assertions made in the context of the current disability claim of unremitting kidney disorder, sleep apnea, hearing loss, and GERD symptoms since service, the Board finds that these more recent assertions are outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and are not reliable. See Charles v. Principi, 16 Vet. App. 370 (2002). The Board finds that the Veteran's assertions of unremitting kidney disorder, sleep apnea, hearing loss, and GERD symptoms after service are not accurate because they are outweighed by other evidence of record that includes the more contemporaneous service treatment records, including the separation examination report, which are negative for any signs, symptoms, complaints, treatment, or diagnoses of a kidney disorder, sleep apnea, hearing loss, or GERD; the history of symptoms provided by the Veteran in 2001 and 2005 regarding the inception of sleep apnea and hearing loss several decades after service separation, as outlined above; and the lack of any documentation of reports or treatment for a kidney disorder, sleep apnea, hearing loss, or GERD until at least 1996. As such, the Board does not find that the evidence sufficiently supports chronic or unremitting kidney disorder, sleep apnea, hearing loss, or GERD symptomatology since service, so as to warrant a finding of a nexus between the current disorders and active service. The Board acknowledges the Veteran's statement as recorded in the August 2001 VA treatment note that he had experienced kidney stones since 1969. However, notably, he did not state that his kidney stones began during active service, nor do service treatment records record any kidney problems. Thus, even if the Veteran's statements as to his kidney stones beginning shortly after service are credible, his statements alone do not establish a medical nexus. Indeed, while the Veteran is competent to provide evidence regarding matters that can be perceived by the senses, he is not shown to be competent to render medical opinions. See Jandreau, 492 F.3d 1372; see also Barr, 21 Vet. App. 303 (lay testimony is competent to establish the presence of observable symptomatology). As such, as a lay person, he is without the appropriate medical training and expertise to offer an opinion on a medical matter, including the etiology or causation of a specific disability. The question of causation, in this case, involves a complex medical issue that the Veteran is not competent to address. Jandreau. Moreover, the Board finds that no competent medical opinions are of records which support a relationship between the Veteran's kidney disorder, sleep apnea, hearing loss, or GERD and active service. Here, the Veteran was afforded VA examinations with regard to each of his claimed disabilities in October 2011. First, with regard to the kidney disorder, the VA examiner noted diagnoses of nephrolithiasis, diagnosed in 1968 according to the Veteran, FSGN, and chronic renal insufficiency. The Veteran reported that he had his first kidney stone late in the year after he got out of service, and that the stones kept recurring. He also reported an onset of FSGN in 2004, and completed treatment for that in 2007, although he was still monitored for recurrence. The October 2011 VA examiner concluded that it would be only with resort to mere speculation to opine whether or not the Veteran's current FSGN, chronic renal insufficiency, and nephrolithiasis were caused or aggravated by his military service. Moreover, the VA examiner stated he could not opine as to the precise degree of contribution to the current FSGN and chronic renal insufficiency from each of his diabetes, hypertension, and other factors without resort to mere speculation. The examiner noted, however, that the service treatment records were silent for any kidney or renal disease or nephrolithiasis symptoms, findings, treatment, or diagnoses, including the separation examination report. Moreover, the examiner stated there was no objective evidence that the current FSGN, chronic renal insufficiency, or nephrolithiasis were caused or aggravated to any degree by military service. The VA examiner reasoned that a number of conditions may contribute to or cause FSGN, including the Veteran's diabetes, hypertension, and contributions from the immune system. Therefore, the examiner stated it was not possible to objectively determine from the currently available evidence the precise contribution from each of the potential factors, reiterating that there was no evidence that the FSGN and chronic renal insufficiency were caused or aggravated by military service. Next, with regard to sleep apnea, the VA examiner noted that sleep apnea was diagnosed and confirmed with a sleep study in 1997. The VA examiner stated that it would be only with resort to mere speculation to opine whether or not the sleep apnea was caused or aggravated by military service. However, as above, the examiner noted that service treatment records were silent for any sleep apnea symptoms, treatment, or diagnoses, including the separation examination report, and there was no current objective evidence that the current sleep apnea was caused or aggravated by military service. At the October 2011 VA audiology examination, an audiogram demonstrated a bilateral hearing loss disability as defined by VA regulations. 38 C.F.R. § 3.385. Notably, this is the first time a hearing loss disability was demonstrated by the evidence. The Veteran reported gradual bilateral hearing loss, with post-service noise exposure including 30 years of weapons training as a conservation ranger, without hearing protection for the first 20 years, and hunting without hearing protection. After reviewing the Veteran's claims file, the VA examiner stated that he could not provide a medical opinion regarding the etiology of the hearing loss without resorting to mere speculation. The VA examiner noted that hearing was normal at the time of enlistment, but that the whisper voice test conducted at separation is too insensitive to high frequency hearing loss, the type of hearing loss most commonly caused by noise exposure, and was not reliable evidence of either normal hearing or hearing impairment. The examiner cited to a September 2005 Institute of Medicine Report on noise exposure in the military which concluded that if documentation of the existence of hearing loss at discharge from the military was missing, it is nearly impossible to determine whether hearing loss later in life is the result of noise exposure during prior military service. Thus, since no valid hearing test was conducted at separation, the Veteran reported gradual hearing loss and did not report onset of hearing loss during service, and there were other potential etiologies for hearing loss, including age, hypertension, use of potentially ototoxic medications, long-term occupational noise exposure, much without hearing protection, and recreational gunfire without hearing protection, the VA examiner stated he could not resolve the issue of etiology without resort to mere speculation. Further, it would be speculative to allocate a portion of the current hearing loss to military noise exposure or to each of the other potential etiologies, and the etiology of the hearing loss cannot be determined to a reasonable degree of medical certainty. Finally, at the GERD VA examination, the Veteran stated his symptoms began in 1968 when he would wake up in the middle of the night with reflux. He stated that he tried soda water, Tums, and other medications including Zantac, but still had constant symptoms. The VA examiner stated that it would be only with resort to mere speculation to opine whether or not the current GERD was caused or aggravated to any degree by military service. However, the examiner noted that service treatment records were silent for any GERD symptoms, treatment, or diagnoses, including the separation examination report, and there was no current objective evidence that the current GERD was caused or aggravated to any degree by military service. The Board acknowledges that the VA examiners stated that they could not provide a nexus opinion without resort to mere speculation. However, the examiner did not relate the Veteran's current kidney disorders, sleep apnea, hearing loss, or GERD to active service, and, in fact, stated that there was no objective evidence to support such a relationship. Indeed, the examiners explained that the lack of evidence was precisely why a nexus opinion could not be provided "without resort to mere speculation." In effect, the examiners opined that a relationship between service and the claimed disability is unlikely. Moreover, there were no physicians who related the Veteran's kidney disorders, sleep apnea, hearing loss, or GERD to his active service, and the Veteran's own statements (particularly with regard to the kidney problems, sleep apnea, and hearing loss) indicate that the problems began after service. Based on the evidence of record, the weight of the competent evidence demonstrates no relationship between the Veteran's kidney disorders, sleep apnea, hearing loss, or GERD and his military service, including no credible evidence of unremitting symptoms of the claimed disorders during active service, unremitting symptomatology of the claimed disorders following service separation, or competent medical evidence establishing a link between the Veteran's kidney disorders, sleep apnea, hearing loss, or GERD and active service. Therefore, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for a kidney disorder, sleep apnea, hearing loss, and GERD, and outweighs the Veteran's more recent contentions regarding in-service unremitting symptoms and unremitting post-service symptoms. For these reasons, the claims must be denied. Because the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for Diabetes Mellitus The Veteran has filed a claim for service connection for diabetes mellitus, to include as due to herbicide and/or asbestos exposure. With regard to herbicide exposure, he contends that when the USS Independence was off the shores of Vietnam, he was exposed to herbicides while working with aircraft that had flown through herbicide-contaminated air and landed on the ground in Vietnam. He has not contended that he ever set foot on the ground in Vietnam or traveled in in-country waters. Having considered the Veteran's contentions and statements, and after a review of all the evidence of record, the Board finds that the weight of the evidence demonstrates that the Veteran did not have any in-country service in the Republic of Vietnam at any time during the regulatory period from January 1962 to May 1975. The Veteran was in active service from August 1964 to August 1968 of the Vietnam period, and served on the USS Independence for nearly three-and-a-half years, from March 1965 to August 1968. The National Personnel Records Center (NPRC) confirmed that the USS Independence was in the official waters of Vietnam during the time that the Veteran was serving on the ship, but was unable to determine whether the Veteran had any in-country service in Vietnam. Moreover, his service personnel records do not document any service on land in Vietnam or in the in-land waterways, nor do his service treatment records document treatment for any injuries in Vietnam. His DD Form 214 reflects a military occupational specialty (MOS) of boatswain's mate. Thus, his assigned duties, as documented in his service personnel records, do not indicate in-country service in Vietnam. A May 2009 Memorandum of record indicates that proper development for Vietnam service and/or herbicide exposure was completed, and it was determined that the information necessary to determine if the Veteran qualifies for the presumption of exposure to herbicides is not available. Again, the Veteran has not contended that he had in-country service in Vietnam, nor has he submitted any documentation or evidence of in-country service. The Board finds that the Veteran's service personnel records and the findings of the NPRC, which do not reflect in-country service in Vietnam, to be probative evidence against the Veteran's contention of herbicide exposure. While the Board acknowledges the Veteran's contentions regarding herbicide exposure via close contact with aircraft that had been contaminated by herbicides, the law provides that the presumption of herbicide exposure is warranted for service only if the conditions of service involved duty or visitation in the Republic of Vietnam (meaning on land or in-land waterways). 38 C.F.R. § 3.307(a)(6)(iii) (2013); see also Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008), cert. denied, 129 S. Ct. 1002 (2009). In addition, a Memorandum for the Record entitled "Herbicide use in Thailand during the Vietnam Era" states that if a veteran's claim is based on servicing or working on aircraft that flew bombing missions over Vietnam, there is no presumption of "secondary exposure" based on being near or working on aircraft that flew over Vietnam or handling equipment once used in Vietnam. For these reasons, the Board finds that the weight of the evidence is against a finding of herbicide exposure during active service, and presumptive service connection for diabetes mellitus based on exposure to herbicides is not warranted. Thus, even though the Veteran has been diagnosed with diabetes mellitus, which is specifically listed among the Agent Orange-related diseases enumerated in 38 C.F.R. § 3.309(e), a medical nexus may not be presumed as a matter of law because the Veteran does not meet the requirements of 38 C.F.R. § 3.307(a)(6) or herbicide exposure. Notwithstanding the inapplicability of the Agent Orange presumptive service connection regulations, the Board is obligated to fully consider the Veteran's service connection claim on a direct basis. See Combee, 34 F.3d at 1043-1044. In doing so, the Board will also consider the Veteran's claim that he was exposed to asbestos via insulation while in the dry docks in Norfolk, Virginia in 1967, and that this exposure caused his diabetes mellitus. There is no specific statutory guidance with regard to asbestos related claims, nor has the VA Secretary promulgated any specific regulations in regard to such claims. However, VA has issued a circular on asbestos-related diseases. DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988) provides guidelines for considering compensation claims based on exposure to asbestos. The information and instructions from the DVB Circular were included in the VA Adjudication Procedure Manual, M21-1 (M21-1), Part VI, para. 7.21. In December 2005, M21-1, Part VI was rescinded and replaced with a new manual, M21-1MR, which contains the same asbestos-related information as M21-1, Part VI. See M21-1MR, Part IV, Subpart ii, Chapter 1, Section H, Topic 29, entitled "Developing Claims for Service Connection for Asbestos-Related Diseases," and Part IV, Subpart ii, Chapter 2, Section C, Topic 9, entitled "Service Connection for Disabilities Resulting from Exposure to Asbestos." The Court has held that VA must analyze an appellant's claim to entitlement to service connection for asbestosis or asbestos-related disabilities under the administrative protocols provided in the DVB Circular guidelines. See Ennis v. Brown, 4 Vet. App. 523 (1993); McGinty v. Brown, 4 Vet. App. 428 (1993). Subpart ii of M21-1MR Part IV lists some of the major occupations involving exposure to asbestos including mining, milling, work in shipyards, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, manufacture and installation of roofing and flooring materials, asbestos cement and pipe products, and military equipment. M21-1MR, Part IV Subpart ii, Chapter 2, Section C, Topic 9, see also M21- 1MR Part IV, Subpart ii, Chapter 1, Section H, Topic 29. VA's Manual 21-1MR, Part IV, subpart ii, Chapter 2, Section C in essence 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). Notably, diabetes mellitus is not one of the disease listed as being related to asbestos exposure. With respect to claims involving asbestos exposure, VA must determine whether or not military records demonstrate evidence of asbestos exposure during service, develop whether or not there was pre-service and/or post-service occupational or other asbestos exposure, and determine whether there is a relationship between asbestos exposure and the claimed disease. M21-1MR, Part IV, Subpart ii, Chapter 1, Section H, Topic 29; DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988). VA satisfied the above requirements by obtaining the Veteran's service personnel records and asking the Veteran questions specific to his claimed asbestos exposure in its August 2012 letter. It should be noted that for many asbestos related diseases, the latency period varies from ten to forty-five or more years between first exposure and development of disease. M21-1MR, Part IV, Subpart ii, Chapter 2, Section C, Topic 9(d). In this case, the Veteran's MOS as a boatswain's mate, performing duties all over the ship, is likely an occupation involving exposure to asbestos. See VA Adjudication Manual M21-MR, Part IV.ii.2.C.9. Thus, affording reasonable doubt in favor of the Veteran, the Board does not dispute that the Veteran may have been exposed to asbestos during active service. In addition to finding the Veteran had in-service exposure to asbestos, competent evidence is required for a determination that the Veteran has an asbestos-related disability, and that asbestosis or another asbestos-related disorder is etiologically related to asbestos exposure in service. After a review of the evidence, lay and medical, the Board finds that the Veteran does not have an asbestos-related disorder that is due to any in-service injury or disease, including in-service asbestos exposure. After a review of all the evidence of record, lay and medical, the Board finds that the weight of the evidence demonstrates that no relevant injury or disease manifesting in diabetes mellitus occurred during service, and that the weight of the evidence demonstrates that symptoms of diabetes mellitus were not chronic in service. Both the July 1964 enlistment and August 1968 separation examination reports are negative for any report, complaints, or diagnosis of symptoms of diabetes, and clinical evaluation of the endocrine system was marked as "normal" on both occasions. In short, the service treatment records are negative for any signs, symptoms, complaints, history, report, treatment, or diagnoses of diabetes mellitus. If there is no showing of a chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). The Board next finds that the weight of the evidence demonstrates that diabetes mellitus symptoms have not been continuous since service separation in August 1968. As mentioned above, the August 1968 service separation examination report is negative for any history, complaints, treatment, or findings of diabetes mellitus. Following separation from service in August 1968, the evidence of record shows no complaints, diagnosis, or treatment for diabetes until January 2004, when VA treatment notes indicate he had been diagnosed with diabetes mellitus. A March 2008 VA treatment note indicates that diabetes was diagnosed in 2000, although VA treatment notes prior to 2004 are negative for any indication of treatment or diagnosis of diabetes, and, in fact, the Veteran specifically denied having diabetes in October 2002. For these reasons, the Board finds that diabetes did not manifest to a compensable degree within one year of service separation; therefore, the presumptive provisions for diabetes are not applicable in this case. 38 C.F.R. §§ 3.307, 3.309 (2013). In any case, the absence of post-service complaints, findings, diagnosis, or treatment for more than 30 years after service is one factor that tends to weigh against a finding of continuous symptoms of diabetes mellitus after service separation. See Buchanan, 451 F.3d 1336 (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Other evidence of record showing that symptoms of diabetes mellitus have not been continuous since service separation include the VA treatment records from 2001 to 2004 that are negative for any findings, symptoms, treatment, or diagnosis of diabetes, as noted above, as well as the Veteran's specific denial of having diabetes in October 2002, also noted above. The Veteran has not contended that his diabetes mellitus began in service or that his symptoms have continued while in service and following service. However, to the extent that his current statements can be interpreted as such, the Board finds that, while the Veteran is competent to report the onset of his diabetes mellitus symptoms, any recent report of continuous symptoms since service is outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and is not credible. See Charles, 16 Vet. App. 370. The Board finds that any statements as to diabetes mellitus symptoms in service and continuous diabetes mellitus symptoms after service are not credible because they are outweighed by other evidence of record that includes the absence of in-service complaints or symptoms of diabetes mellitus; the negative clinical examination at the August 1968 service separation examination at which no symptoms of diabetes mellitus were reported or diagnosed; and the absence of any post-service history, complaints, symptoms, diagnosis, or treatment of diabetes mellitus for more than 30 years after service until 2004. Further, as noted above, VA treatment notes from October 2002 specifically indicate that the Veteran did not have diabetes. The Board has considered the Veteran's contention that his current diabetes mellitus is related to active service. However, while the Veteran is competent to provide evidence regarding matters that can be perceived by the senses, he is not shown to be competent to render medical opinions. See Jandreau; see also Barr. As such, as lay person, he is without the appropriate medical training and expertise to offer an opinion on a medical matter, including the diagnosis of a specific disability. Furthermore, the question of causation, in this case, involves a complex medical issue that the Veteran is not competent to address. Jandreau. In this regard, the treatment records fail to note any conditions associated with asbestos exposure and the Veteran himself simply lacks all qualification to opine on the question of etiology of his diabetes mellitus. Moreover, no physician has stated or indicated that the Veteran's current diabetes is related to asbestos exposure or otherwise to active service. There is simply nothing in the record to indicate a medical nexus between the current diabetes mellitus and asbestos exposure almost one-half of a century ago. Based on the evidence of record, the weight of the competent evidence demonstrates no relationship between the Veteran's current diabetes mellitus and his military service, including no credible evidence of continuity of symptomatology of diabetes mellitus or in-service herbicide exposure which would serve either as a nexus to service or as the factual basis for a favorable medical nexus opinion. Moreover, the weight of the evidence is against a finding of a medical nexus between possible asbestos exposure during active service and the current diabetes mellitus. Therefore, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for diabetes mellitus. For these reasons, the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a timely March 2005 letter, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection, what information and evidence must be submitted by the Veteran, and what information or evidence VA will attempt to obtain. The letter requested information specific to the Veteran's claimed herbicide exposure. In addition, a March 2009 letter described how VA determines disability ratings and effective dates, and an August 2012 letter requested information regarding the Veteran's claimed asbestos exposure. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, service personnel records, post-service VA and private treatment records, VA examinations and opinions with regard to the kidney disorder, sleep apnea, hearing loss, and GERD claims, and the Veteran's statements. VA opinions were obtained in October 2011 with regard to the question of whether the Veteran's current kidney disorders, sleep apnea, hearing loss, and GERD are related to active service. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr at 312. The Board finds that the October 2011 VA examinations and opinions obtained in this case are adequate. The opinions were predicated on a full reading of the private and VA medical records in the Veteran's claims file. The VA examiners considered all of the pertinent evidence of record, to include VA treatment records, comprehensive physical examinations, and the statements of the Veteran. The Board acknowledges that the examiners stated they were unable to provide nexus opinions without resorting to speculation; however, as was explained in the merits section above, the examiners essentially explained that the claimed conditions were unlikely to be related to service. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the kidney disorder, sleep apnea, hearing loss, and GERD claims has been met. 38 C.F.R. § 3.159(c)(4). The Board acknowledges that the Veteran has not been afforded a VA medical examination specifically geared to the claimed service connection for diabetes; however, the Board finds that a VA examination is not necessary in order to decide this issue. Two pivotal Court cases exist that address the need for a VA examination. Those are Duenas v. Principi, 18 Vet. App. 512 (2004) and McLendon v. Nicholson, 20 Vet. App. 79 (2006). In McLendon, the Court held that in disability compensation claims, the Secretary must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurring symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on a claim. In Duenas, the Court held that a VA examination is necessary when the record: (1) contains competent evidence that the veteran has persistent or recurrent symptoms of the claimed disability, and (2) indicate that those symptoms may be associated with her active military service. In this case, the Veteran's service treatment records are negative for any complaints of or treatment for diabetes. Thus, the weight of the evidence demonstrates that the Veteran did not sustain an injury, disease, or event relating to diabetes in service, and there is no duty to provide a VA medical examination. See Bardwell v. Shinseki, 24 Vet. App. 36, 40 (2010) (holding that that where the evidence has failed to establish an in-service injury, disease, or event, VA is not obligated to provide a medical examination). As explained in this decision, the Board also finds that the weight of the evidence demonstrates no chronic symptoms of diabetes in service and no continuity of symptoms of diabetes since service separation. Because there is no in-service injury or disease to which a competent medical opinion could relate the current disability, there is no reasonable possibility that a VA examination or opinion could aid in substantiating the current claim for service connection for diabetes. See 38 U.S.C.A. § 5103A(a)(2) (VA "is not required to provide assistance to a claimant . . . if no reasonable possibility exists that such assistance would aid in substantiating the claim"); 38 C.F.R. § 3.159(d) (VA to discontinue assistance where there is "no reasonable possibility that further assistance would substantiate the claim"). The Board has considered the decision in Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); however, in the absence of evidence of an in-service disease or injury, referral of this case to obtain an examination and/or an opinion as to the etiology of the Veteran's diabetes would in essence place the examining physician in the role of a fact finder, would suggest reliance on an inaccurate history of occurrence of an in-service injury or disease, and could only result in a speculative opinion or purported opinion of no probative value. In other words, any medical opinion which purported to provide a nexus between the Veteran's diabetes and military service would necessarily be based on an inaccurate history regarding what occurred in service, so would be of no probative value. The Court has held on a number of occasions that a medical opinion premised upon an unsubstantiated account of a claimant is of no probative value. See, e.g., Swann v. Brown, 5 Vet. App. 229, 233 (1993) (generally observing that a medical opinion premised upon an unsubstantiated account is of no probative value, and does not serve to verify the occurrences described); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (the Board is not bound to accept a physician's opinion when it is based exclusively on the recitations of a claimant that have been previously rejected). The holding in Charles was clearly predicated on the existence of evidence of an in-service injury, disease, or event and a current diagnosis. Referral of this case for an examination or to obtain a medical opinion would be a useless act. The duty to assist by providing a VA examination or opinion is not invoked in this case because there is no reasonable possibility that such assistance would aid in substantiating the diabetes claim. See 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d). Notably, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Service connection for a kidney disorder is denied. Service connection for sleep apnea is denied. Service connection for bilateral hearing loss is denied. Service connection for a stomach disorder, to include gastroesophageal reflux disease (GERD), is denied. Service connection for diabetes mellitus, type II, including as due to herbicide and/or asbestos exposure, is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs