Citation Nr: 1754768 Decision Date: 11/30/17 Archive Date: 12/07/17 DOCKET NO. 13-09 279 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an initial evaluation in excess of 20 percent for diabetes mellitus type II. 2. Entitlement to an initial evaluation in excess of 10 percent for tinnitus. 3. Entitlement to an initial compensable evaluation for bilateral sensorineural hearing loss (SNHL). 4. Entitlement to service connection for persistent depressive disorder, with disturbances of mood (claimed as mania). 5. Entitlement to service connection for hypertension. 6. Entitlement to service connection for residuals of a traumatic brain injury (TBI). 7. Entitlement to service connection for a headache condition. 8. Entitlement to service connection for a blurred vision disorder. 9. Entitlement to service connection for benign prostate hyperplasia (BPH). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Christopher M. Collins, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1967 to June 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal of a December 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. The Board notes that in the December 2010 rating decision, the RO denied service connection for mania, distinct from his claim of service connection for PTSD. The Veteran directly appealed both issues, and during the pendency of the appeal his claim of service connection for PTSD was granted; however, the claim of service connection for mania remains on appeal. As a function of the Board's de novo review authority, the Board has characterized the Veteran's claim for mania as a claim for persistent depressive disorder, with disturbances of mood. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (VA has an obligation to consider whether possible mental disorders are service connected if those disorders are indicated by the evidence in the record even if a veteran's claim does not specifically identify those disorders and instead identifies a distinct but related mental disorder.). FINDINGS OF FACT 1. During the entire pendency of the appeal, management of the Veteran's service-connected diabetes mellitus type II required oral hypoglycemic agent and a restricted diet; however, it did not also require regulation of activities and insulin. 2. The Veteran's tinnitus has been assigned a 10 percent rating, which is the maximum schedular rating authorized under the applicable criteria; factors warranting an extraschedular rating are not shown. 3. During the entire pendency of the appeal the Veteran's bilateral SNHL was manifested by no more than Level IV hearing acuity in the right ear and Level I hearing acuity in the left ear. 4. The competent medical evidence of record demonstrates that the Veteran has a separately diagnosable persistent depressive disorder, with disturbances of mood, that is at least as likely as not etiologically related to service, to include as due to PTSD. 5. The competent evidence does not demonstrate that the Veteran's currently diagnosed hypertension is attributable to the Veteran's active service or any incident of service, to include as due to a service-connected disability. 6. The competent evidence does not demonstrate that the Veteran currently experiences any residuals of a TBI. 7. The competent evidence does not demonstrate that the Veteran has a headache condition that is attributable to his active service or any incident of service, to include as due to a service-connected disability. 8. The competent evidence does not demonstrate that the Veteran has a blurred vision disorder that is attributable to his active service or any incident of service, to include as due to a service-connected disability. 9. The competent evidence does not demonstrate that the Veteran has BPH that is attributable to his active service or any incident of service, to include as due to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 20 percent for the service-connected diabetes mellitus type II have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.20, 4.40, 4.119, Diagnostic Code 7913 (2017). 2. The criteria for a rating higher than 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.321(b), 4.1, 4.87, Diagnostic Code 6260 (2017); Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). 3. The criteria for a compensable disability rating for bilateral SNHL have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 4.85, Diagnostic Code 6100 (2017). 4. The criteria for service connection for persistent depressive disorder, with disturbances of mood, have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017); Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). 5. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017); Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). 6. The criteria for service connection for residuals of a TBI have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 7. The criteria for service connection for a headache condition have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017); Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). 8. The criteria for service connection for a blurred vision disorder have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017); Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). 9. The criteria for service connection for BPH have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017); Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As a preliminary matter, the Board has reviewed the claims file and finds that there exist no deficiencies in VA's duties to notify and assist that would be prejudicial and require corrective action prior to a final Board determination. See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159; Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (corrective action to cure a 38 C.F.R. § 3.159(b) notice deficiency); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004) (timing of notification). Legal Criteria for Increased Rating Claims Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In every instance where the rating schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Notably, entitlement to a total disability rating based upon individual unemployability is already in effect in this case. Diabetes Mellitus Type II The Veteran was initial granted service connection for diabetes mellitus type II in a December 2010 rating decision and was assigned a 20 percent rating effective April 12, 2010. He contends that he is entitled to a higher disability evaluation for his diabetes mellitus type II throughout the entire period of the appeal. The 20 percent evaluation was awarded pursuant to 38 C.F.R. § 4.119, Diagnostic Code 7913. Under this code section, diabetes mellitus type II requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet, is rated 20 percent disabling. 38 C.F.R. § 4.119. Diabetes mellitus type II requiring insulin, restricted diet, and regulation of activities, is rated 40 percent disabling. Id. Diabetes mellitus type II requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated, is rated 60 percent disabling. Id. Diabetes mellitus type II requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated, is rated 100 percent disabling. Id. The rating schedule in Note 1 also instructs to evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process. Pursuant to Note 1 of the code section, the Veteran is currently assigned separate ratings for peripheral neuropathy of the bilateral upper extremities as well as the bilateral lower extremity femoral and sciatic nerve; these matters are not currently on appeal. There is no evidence of nephropathy, retinopathy, cardiovascular disease, peripheral vascular disease, gastroparesis, or skin changes directly attributable to the Veteran's diabetes mellitus type II. At the outset, the Board acknowledges that the Veteran's diabetes mellitus type II has required the use of oral medications and a restricted diet for control, thus warranting the currently assigned 20 percent rating. What is still in question, however, is whether the Veteran's diabetes mellitus required the use of insulin as well as the restriction of activities, as would be necessary to warrant an increase of the disability evaluation to 40 percent. VA outpatient treatment records reveal that the Veteran was often encouraged to exercise regularly and pursue a diet low in carbohydrates. A December 2012 outpatient entry showed that the Veteran's ability to exercise was hindered by chronic fatigue and dyspnea; however, these limitations were later attributed to the Veteran's unrelated coronary artery disease for which he is also service-connected. In addition, treatment notes indicate that he is further limited in his activities due to degeneration of the lumbosacral intervertebral disk, again unrelated to his diabetes mellitus type II. The Board also notes that there is no indication that the Veteran requires insulin for management of his diabetes mellitus type II. No VA examiner has determined that the Veteran's diabetes mellitus type II mandates a regulation of his activities or requires insulin. Indeed, the June 2010, December 2012, December 2013, and February 2015 examiners each expressly found that the diabetes mellitus type II required no regulation of activities. The Board acknowledges that the February 2015 VA examiner did determine that the diabetes mellitus type II resulted in some intermittent shaking alleviated by ingesting fruit or fruit juice, but the examiner did not find that this symptomology warranted any regulation of activities. The Veteran has not submitted any evidence or argument to suggest that the diabetes mellitus type II mandates regulation of his activities or requires the use of insulin. Therefore, the Board finds that the preponderance of the evidence is against the claim of entitlement to a disability rating greater than 20 percent for diabetes mellitus type II during the entire pendency of the appeal. Consequently, the benefit-of-the-doubt doctrine does not apply, and the rating claim must be denied on a schedular basis. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Tinnitus The Veteran was granted a 10 percent schedular rating for his service-connected bilateral tinnitus in December 2010, effective April 12, 2010, pursuant to 38 C.F.R. § 4.87, Diagnostic Code 6260. He currently is still rated 10 percent for his tinnitus, and he seeks a rating in excess of that 10 percent. The criteria of Diagnostic Code 6260 were revised, effective June 13, 2003, in part to clarify existing VA practice that only a single 10 percent rating is assigned for tinnitus, regardless of whether tinnitus is found as being in one ear or in each ear or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note 2 (2006). In Smith v. Nicholson, 451 F.3d 1344, 1350-51 (Fed. Cir. 2006), the Federal Circuit affirmed VA's interpretation of Diagnostic Code 6260 allowing for the assignment of only a single 10 percent rating for tinnitus, whether or not the tinnitus is determined to exist unilaterally or bilaterally. In consideration of the clear language of Diagnostic Code 6260 and the direction of the Federal circuit in Smith, the Board concludes that the 10 percent schedular rating for the Veteran's tinnitus is the maximum rating assignable under Diagnostic Code 6260. The Veteran has not contended that his tinnitus results in his inability to obtain or maintain substantially gainful employment, not is there any evidence in the record to suggest it; thus a claim for an increased rating of the tinnitus on an extraschedular basis has not been raised in this instance. See Thun v. Peake, 22 Vet. App. 111 (2008). A review of the record indicates that during the most recent VA examination to evaluate the tinnitus in March 2015, the Veteran asserted that it bothered him and impacted his hearing. The examiner did not offer any finding suggesting that the tinnitus had any impact on the Veteran's occupational functioning. Similarly, on the December 2013 VA examination, the examiner found that the tinnitus did not impact on the ordinary conditions of daily life, to include the Veteran's ability to work. In short, the record does not suggest that the tinnitus causes marked interference with employment. Additionally, there is no evidence that his tinnitus has presented an unusual disability picture such as requiring frequent hospitalization. Therefore, there is no suggestion that tinnitus has resulted in an exceptional disability picture, and no referral for an extraschedular rating is required under 38 C.F.R. § 3.321(b)(1). Bilateral SNHL The Veteran was granted service connection for bilateral SNHL in December 2010, effective April 12, 2010, and was assigned a noncompensable rating pursuant to 38 C.F.R. § 4.85. He continues to have the initial noncompensable rating and he seeks a compensable rating. The Rating Schedule establishes 11 auditory hearing acuity levels based upon average puretone thresholds and speech discrimination. See 38 C.F.R. § 4.85. The severity of a hearing loss disability is determined by comparisons of audiometric test results with specific criteria set forth at 38 C.F.R. § 4.85. Evaluations of bilateral defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by puretone audiometry tests in the frequencies of 1,000, 2,000, 3,000, and 4,000 Hertz (cycles per second). The audiometric test results are then translated into a numeric designation ranging from Level I to Level XI, in order to evaluate the degree of disability from bilateral service-connected defective hearing. Id. Audiometric testing on the most recent VA audiology examination in March 2015 revealed the following pure tone thresholds: HERTZ 1000 2000 3000 4000 RIGHT 55 60 65 65 LEFT 35 65 65 65 The average pure tone threshold at 1,000, 2,000, 3,000, and 4,000 Hertz was 61 decibels for the right ear, and 57 decibels in the left ear. The speech recognition scores, using the Maryland CNC word list, were 100 percent bilaterally. As for the functional impact of the SNHL, the examiner detailed that the Veteran reported difficulties understanding people. Applying the results from the March 2015 audiology examination to the 38 C.F.R. § 4.85 shows Level II hearing acuity in the right ear and Level I hearing acuity in the left ear. See 38 C.F.R. § 4.85, Table VI, Diagnostic Code 6100. Applying these findings to 38 C.F.R. § 4.85, Table VII of the Rating Schedule results in a noncompensable evaluation for bilateral hearing loss under Diagnostic Code 6100. The Board has also reviewed the other available audiological examinations for the period on appeal, all of which showed stronger hearing acuity than the most recent VA audiological examination in March 2015. Although this shows some decrease in hearing acuity over time, the fact remains that the current pure tone thresholds do not warrant a compensable evaluation for the Veteran's bilateral SNHL. The Rating Schedule provides for rating exceptional patterns of hearing impairment. 38 C.F.R. § 4.86. Pursuant to 38 C.F.R. § 4.86a, where, as is the case with the right ear here, the puretone thresholds at each of the four specified frequencies is 55 decibels or more, VA is instructed to determine the Roman numeral disgniation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Accordingly, the Board has reassigned a Level IV hearing acuity for the right ear as it is the higher available numeral between Table VI and Table VIa. That being said, a level IV in the right ear paired with a Level I hearing acuity in the left ear still results in a noncompensable evaluation for bilateral hearing loss under Diagnostic Code 6100. In addition to the medical evidence above, the Board has considered the lay evidence provided by the Veteran, in which he generally contended that his disability should be rated higher. A layperson's testimony is competent evidence in regard to the symptoms he experiences. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). However, disability ratings for hearing impairment are derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). As such, the medical evidence is considered the most probative evidence with regard to the level of severity of the Veteran's service-connected hearing loss. Moreover, the examiners considered the functional effects of the Veteran's bilateral hearing loss during the examination. Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). Based on the foregoing discussion, evidence of record showed no distinct periods of time during the appeal period when the Veteran's service-connected bilateral hearing loss disability varied to such an extent that a compensable rating would be warranted. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). In summation, the preponderance of the evidence is against the Veteran's claim for a compensable disability rating on a schedular basis, and the claim must be denied. 38 C.F.R. § 4.7. Legal Criteria for Service Connection Claims Service connection for VA compensation purposes will be granted for a disability resulting from disease or personal injury incurred in the line of duty or for aggravation of a preexisting injury in the active military, naval or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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). Alternatively, service connection may be granted on a presumptive basis for certain chronic diseases as outlined in 38 C.F.R. § 3.309(a) if they are shown to be manifest to a degree of 10 percent or more within one year following the Veteran's separation from active military service. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309. Establishing that a purported injury or disease is connected to service, such that a veteran is entitled to potential benefits, requires competent and credible evidence of the following three things: (1) a current disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a causal relationship, i.e. a nexus, between the disease or injury in service and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). With regards to a showing of chronic disease in service, it is necessary for the Veteran to demonstrate a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Where the disease identity is established, there is no requirement of evidentiary showing of continuity. However, continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and certain diseases (e.g., cardiovascular and organic neurologic disorders) become manifest to a degree of 10 percent within one year from date of termination of such service, such diseases shall be presumed to have been incurred in service, even though there is no evidence of such diseases during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 C.F.R. §§ 3.307, 3.309. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Secondary service connection is permitted based on aggravation. Compensation is payable for the degree of aggravation of a nonservice-connected disability caused by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995). The Board, as fact finder, must determine the probative value or weight of the admissible evidence. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005) (citing Elkins v. Gober, 229 F.3d 1369, 1377 (Fed. Cir. 2000) ("Fact-finding in veterans cases is to be done by the Board")). VA must give due consideration to all pertinent medical and lay evidence in a case where a veteran is seeking service connection. 38 U.S.C. § 1154(a). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Mania The Veteran contends that he experiences episodes of hyperarousal secondary to his service-connected post-traumatic stress disorder (PTSD) which has manifested as a separately diagnosable disorder. Upon review of the most recent examination to evaluate the nature and etiology of any mental health disorder, dated in July 2015, the Board finds that the Veteran is entitled to service connection for a separately diagnosable depressive disorder manifested by disturbances of mood. As stated, the Veteran was afforded a new VA mental health examination in July 2015, to determine the nature and etiology of any diagnosable mental health condition. He was diagnosed with both PTSD and a persistent depressive disorder, and his symptoms were listed as depression, anxiety, suspiciousness, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing effective relationships, and difficulty in adapting to stressful circumstances. In detailing these symptoms, the examiner explicitly noted the history of the Veteran being diagnosed with and treated for bipolar disorder by VA since April 2014, and discussed the Veteran's apparently variable mood during the in-person interview. As for the interplay between the two disorders, the examiner stated that they share multiple symptoms, including sleep disturbance, impaired concentration, and negative cognitions and mood, but ultimately concluded that it was more likely than not that the depressive disorder developed as a result of the loss of functioning associated with the PTSD. This opinion was reiterated when the examiner later discussed the etiology of both disorders. The Board finds the July 2015 VA examiner's opinion, supported as it is by a thorough rationale that took into consideration the Veteran's entire mental health history and service record, to be highly probative of the issue at hand. Accordingly, the Board finds that the preponderance of the evidence is in support of a determination that the persistent depressive disorder, with disturbance of mood, is proximately due to the service-connected PTSD. Therefore, service connection for persistent depressive disorder, with disturbance of mood, is granted on a secondary basis. 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 439. Hypertension The Veteran contends that he developed hypertension as a result of service, or, in the alternative, that his hypertension is secondary to his diabetes mellitus type II. Upon review of the record, the Board finds that the preponderance of the evidence is against a determination that hypertension is attributable to service. A review of the Veteran's service treatment records does not reveal any complaints, findings, treatment or diagnoses relating to hypertension. On the July 1967 induction examination, the Veteran's blood pressure reading was 130/60, while on the June 1970 separation examination, the blood pressure reading was 120/80. There are no more blood pressure readings available in the Veteran's service treatment records. These two readings do not qualify for a diagnosis of hypertension for VA purposes. 38 C.F.R. § 4.104, Diagnostic Code 7101. Post-service VA treatment records indicate that he had been treated for hypertension beginning around 1999 or 2000, as was reported on a March 2007 outpatient record in which he reported being diagnosed with hypertension about eight years prior. The first actual mention of high blood pressure is on a November 2006 emergency room report, on which it was noted that the Veteran had severely elevated blood pressure. VA treatment records continue to show that the Veteran's hypertension is managed with medication. The Veteran was afforded a VA examination in June 2010 for the purposes of providing an opinion regarding the etiology of the condition. After confirming that hypertension was diagnosed around 1999, some ten years prior to the diagnosis of diabetes mellitus type II, the examiner opined that it was less likely than not that the hypertension was related to service, to include as secondary to diabetes mellitus type II. In support thereof, the examiner noted that there was no evidence of hypertension in service and also highlighted that it was diagnosed 10 years prior to diabetes mellitus type II. Similarly, on the most recent examination to evaluate the Veteran's diabetes mellitus type II, dated in March 2015, the examiner found that it was less likely than not that the Veteran had hypertension that was due to diabetes mellitus type II. Upon consideration of the record, the Board finds that the preponderance of the evidence is against a grant of service connection for hypertension, to include as secondary to service-connected diabetes mellitus type II. To begin, the evidence does not show, and the Veteran does not assert, that he incurred hypertension while in service or within a year of his discharge. Accordingly, neither direct service connection pursuant to 38 C.F.R. § 3.303(a) nor presumptive service connection for chronic conditions that develop within one year of service under 38 C.F.R. § 3.303(b) is warranted. The Board will thus focus its analysis on whether the Veteran's hypertension was aggravated beyond its normal progression by diabetes mellitus type II. Both the June 2010 and March 2015 VA examiners found that it was less likely than not that there was an etiological connection between hypertension and diabetes mellitus type II. In support thereof, the June 2010 examiner correctly noted that the Veteran had been treated for hypertension for ten years prior to being diagnosed with diabetes mellitus type II. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303 (2008) (a medical opinion must be supported by sufficient evidence and cannot necessarily rely solely on the claim file alone). While the March 2015 examiner did not offer a rationale in support of their conclusion, the very fact that they denied a connection between the two after reviewing the claims file is also probative. The Board notes that the Veteran has presented no medical or other competent evidence suggesting the contrary, that hypertension was aggravated by type II diabetes mellitus. The Board acknowledges that the Veteran has consistently maintained that his hypertension was caused by his diabetes mellitus type II, and that he is competent to report his symptoms of hypertension and diabetes mellitus type II and when those symptoms began to manifest. Layno v. Brown, 6 Vet. App. 465 (1994). However, there is no evidence in the record which indicates that the Veteran is competent enough through training or credentials to conclude that his hypertension is attributable to or aggravated by his diabetes mellitus type II. Jandreau v. Nicholson, 491 F.3d 1372 (Fed. Cir. 2007). In summation, the opinions of the June 2010 and March 2015 VA examiners are a more reliable indicator of whether the Veteran's hypertension is in any way related to the service-connected type II diabetes mellitus. Therefore, the preponderance of the evidence is against the Veteran's claim of service connection for hypertension on a secondary basis. 38 C.F.R. § 3.310.; Allen, 7 Vet. App. at 439 (1995). The Veteran may still be entitled to service connection if all of the evidence establishes that the hypertension was incurred in service. 38 C.F.R. § 3.303(d). Here, however, there is no competent evidence of incurrence in service, and there is nearly a 30 year gap between discharge and the first indication that the Veteran was diagnosed with hypertension in 1999. Thus, the Board concludes that the preponderance of the evidence weighs against a finding that the Veteran's hypertension is otherwise attributable to service. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection for hypertension under 38 C.F.R. § 3.303(d) is denied, and as such the Veteran's claim for hypertension in total must be denied. As the preponderance of the evidence is against the Veteran's claim of service connection for hypertension, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). Residuals of a TBI The Veteran asserts that he experienced a TBI in the summer of 1968 while in service, and that he continues to suffer symptoms attributable to that in-service TBI. Upon consideration of the record, the Board finds that the preponderance of the evidence is against a determination that service connection is warranted for residuals of a TBI. Service treatment records do not show that the Veteran reported experiencing a traumatic brain injury in service or that he ever received treatment for symptoms of a traumatic brain injury. The Veteran contends that the injury occurred when he was standing next to a 105 Howitzer and a muzzle blast from the artillery knocked him to the ground. He has stated that the injury resulted in a ruptured ear drum. According to him he did not receive any medical treatment for this injury and returned to duty the next day. Treatment records dated after the purported occurrence of the injury do not show that the Veteran ever complained of symptoms of the injury. He was evaluated as having no abnormalities on his discharge examination dated in June 1970. Post-service VA treatment records do not show any specific treatment for a TBI or residuals that were attributed to the TBI. An August 2007 outpatient record indicates that the Veteran had a CT scan which showed no acute findings in the brain. The examiner who administered the CT scan did comment that changes over the frontal convexities may relate to previous old subdural hematomas. The Veteran was afforded a VA examination in June 2010 to evaluate the nature and etiology of any residuals of the in-service TBI. He detailed the same circumstances that he believed led to his TBI, and again acknowledged that he did not receive any medical care for the injury while in service. He stated that he did have some minor confusion and disorientation immediately after the incident but soon recovered with no apparent side effects at the time. On the basis of the Veteran's self-reporting, the examiner found that he qualified for the occurrence of a mild TBI in service. However, with regards to residual conditions, the examiner found little evidence that there were any symptoms that could be traced back to the in-service TBI. The Veteran's TBI residuals were also evaluated as part of the accompanying mental health examination in June 2010. After acknowledging the Veteran's report of a history of headaches as well as neurobehavioral symptoms, memory impairment, and cognitive problems, the examiner administered a battery of tests which showed no evidence of neurobehavioral symptoms, memory impairment, or cognitive deficiencies. The examiner concluded by stating that the TBI did not appear to contribute to any functional impairment or confound the mental condition or stress symptoms the Veteran reported. The Board further notes that on both the December 2012 and July 2015 examinations to evaluate the PTSD, the examiners noted that there was no evidence of a TBI and each of them declined to discuss whether the Veteran's purported in-service TBI had any impact on his currently mental health symptomatology. Upon consideration of the record, the Board finds that the preponderance of the evidence is against a determination that service connection is warranted for residuals of a traumatic brain injury. As discussed, the Veteran's service treatment records do not show any complaints of or treatment for symptoms attributable to a traumatic brain injury, and the Veteran himself has consistently maintained that he never received any treatment for the purported TBI he suffered in service. Moreover, the Veteran was evaluated as having no abnormalities on his June 1970 separation examination. The Veteran generally contends that he experiences symptomatology, including headaches, intermittent dizziness, and cognitive and memory impairment that are all attributable in some manner to his purported in-service TBI. He is of course credible to report as to the incidence of this symptomatology as well as the circumstances that he believes led to a TBI in service. Layno, 6 Vet. App. at 465. However, the fact remains that there is no objective evidence to suggest that the Veteran actually incurred a TBI in service or that he experienced any symptomatology potentially attributable to a TBI while in service. The Veteran does not have the training or credentials necessary to state authoritatively that any reported symptomatology is attributable to an in-service TBI. Jandreau, 491 F.3d at 1372. Although the June 2010 VA examiner conceded that the Veteran may have experienced a TBI while in service as he has described, they dismissed any connection between an in-service TBI and any current symptomatology. Subsequent VA examiners have declined to accept even the occurrence of an in-service TBI and thus did not even discuss the possible connection between any of the Veteran's current mental health symptomatology and an in-service TBI. In summation, the Board finds that the preponderance of the evidence is against a determination that the Veteran experiences any residuals of his in-service TBI, even granting him the benefit of the doubt that it occurred as he described it. Accordingly, without any diagnosed conditions attributable to the TBI, service connection for residuals of a TBI must be denied. Brammer v. Derwinksi, 3 Vet. App. 223, 225 (1992). Headache Condition The Veteran asserts that he developed a headache condition after his discharge from service that is a residual of his in-service TBI. In the alternative, he contends that the headache condition is secondary to his hypertension and/or his service-connected PTSD. Upon consideration of the record, the Board finds that the preponderance of the evidence is against a determination that service connection is warranted for a headache condition. To begin, service treatment records do not show that the Veteran reported experiencing any symptoms of a headache condition while in service, and he was evaluated as having no abnormalities on his discharge examination dated in June 1970. Moreover, the Veteran during the June 2010 VA examination addressing the TBI stated that his headache symptoms began 14 years prior to the examination, i.e., around 1996, over 25 years after his discharge from service. Accordingly, the Board finds that service connection is not warranted for a headache condition on a direct basis pursuant to 38 C.F.R. § 3.303(a). Post-service VA treatment records do not show any specific treatment for headaches, either on their own or as a residual condition attributable to any other diagnosed conditions, to include sinusitis, a mental health disorder, or as a residual of an in-service TBI. On the June 2010 VA examination, the Veteran reported that he had onset of chronic headaches beginning around 14 years prior, which he related to a sinus condition. He also detailed that he would experience headaches once a week as due to hypertension. Furthermore, he described two other types of headaches that he would also experience regularly; one, a migraine headache, that would occur once a month for the past five to six years, and the other, a bitemporal stress headache, which would occur three to four times a month. After reviewing the Veteran's history of TBI, to include a fall injury that occurred several years after his discharge, the examiner found no evidence to connect the reported headache symptoms to the in-service TBI. In support thereof, the examiner noted the lack of reported symptoms in service and the fact that the headaches began around 15 years prior to the VA examination, which in itself was over 25 years removed from the occurrence of the in-service TBI. Furthermore, although the examiner acknowledged that the Veteran's headache symptoms had been linked in the past to stress, hypertension, and sinus problems, they found that there was no evidence that the Veteran's headaches were an ongoing chronic problem and thus could not be related to his military service. As discussed previously, secondary service connection is based on aggravation of the condition due to an underlying service-connected disability. 38 C.F.R. § 3.310.; Allen, 7 Vet. App. at 439. From the outset, the Veteran's theory of entitlement to service connection for a headache condition as secondary to hypertension fails as the Board has already found that service connection for hypertension is not warranted. As for the theory of the headache condition being secondary to the PTSD, the Board notes that no post-service treatment record documenting the Veteran's treatment for his PTSD has ever found headaches to be a condition associated with the PTSD and his stress symptoms. Although the Board acknowledges that the June 2010 VA examiner noted that the headache condition had been linked to stress in the past, there are no records documenting this determination. Moreover, on none of the VA examinations to evaluate the Veteran's PTSD has he ever reported headaches as a symptom he personally associated with his stress, and no VA examiner has ever found any association between the two conditions that amounts to aggravation. Accordingly, as there is no evidence that the Veteran has a chronic headache condition associated with his PTSD, and no VA examiner or medical treatment provider has ever found evidence that the Veteran has a chronic headache condition or that he experienced headaches that were permanently aggravated by his PTSD, the Board finds that service connection for a headache condition as secondary to PTSD is not warranted. The Board acknowledges that the Veteran has consistently maintained that his headache condition was caused by one or more of his service-connected disabilities, and that he is competent to report his symptoms of headaches and when those symptoms began to manifest. Layno, 6 Vet. App. at 465. However, there is no evidence in the record which indicates that the Veteran is competent through training or credentials to conclude that his headache condition is attributable to or aggravated by a service-connected disability. Jandreau, 491 F.3d at 1372. In summation, the opinion of the June 2010 VA examiner is a more reliable indicator of whether the Veteran's headache condition is in any way related to a service-connected disability. Therefore, the preponderance of the evidence is against the Veteran's claim of service connection for a headache condition on a secondary basis. 38 C.F.R. § 3.310.; Allen, 7 Vet. App. at 439 (1995). The Veteran may still be entitled to service connection if all of the evidence establishes that a headache condition was incurred in service. 38 C.F.R. § 3.303(d). Here, however, there is no evidence of incurrence in service, and there is a 25 year gap between discharge and when the Veteran first reported experiencing headaches around 1995. Furthermore, the Veteran's contentions that his headache condition was aggravated beyond its normal progression by service-connected PTSD, or that the headache condition is a residual of his in-service TBI, have both been shown to be wholly unsupported by the evidence of record. Thus, the Board concludes that the preponderance of the evidence weighs against a finding that the Veteran's headache condition is otherwise attributable to service. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection for a headache condition under 38 C.F.R. § 3.303(d) is denied, and as such the Veteran's claim for a headache condition in total must be denied. As the preponderance of the evidence is against the Veteran's claim of service connection for a headache condition, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). Blurred Vision Disorder The Veteran asserts that he developed blurred vision after his discharge from service as a separately diagnosable disorder attributable to his diabetes mellitus type II. In the alternative, he contends that the blurred vision is a residual of his in-service TBI. Finally, he has also set forth a theory that his blurred vision is secondary to his hypertension and/or his headaches. Upon consideration of the record, the Board finds that the preponderance of the evidence is against a determination that service connection is warranted for a blurred vision disorder. To begin, service treatment records do not show that the Veteran reported experiencing any issues with his vision while in service, and he was evaluated as having no abnormalities with his vision on his discharge examination dated in June 1970. He had 20/20 uncorrected distance vision in both eyes on his entrance examination and had 20/25 vision in the left eye and 20/50 vision in the right eye on his discharge examination. The Veteran was afforded a VA opthmological examination in June 2010 to evaluate whether he experienced any significant decrease in visual acuity attributable to service, to include as due to his diabetes mellitus type II. He reported worsening vision at near but no current medical treatment for his vision as well as no history of diagnoses or treatment for an eye disorder. Testing showed 20/50 near and 20/40 or better far uncorrected vision in both eyes, with corrected vision at 20/40 or better. The examiner declined to diagnose any eye disorder, and specifically dismissed the diagnosis of glaucoma. Furthermore, the examiner found no evidence that the in-service TBI resulted in the development of a residual eye condition, and noted the lack of any complaints of eye issues following the incidence of the TBI and for many years thereafter. The Veteran was afforded a new VA opthmological examination in December 2013 to again evaluate the nature and etiology of any diagnosable eye conditions. On this examination he reported that he had been diagnosed with glaucoma as due to his diabetes mellitus type II, but acknowledged that he was not currently on any medication to treat the glaucoma. Testing showed 20/80 near and 20/20 far uncorrected vision in both eyes, with corrected vision at 20/20. On the most recent VA examination to evaluate the severity of the diabetes mellitus type II dated in March 2015, the examiner found no evidence of diabetic retinopathy and no evidence of any eye conditions other than diabetic retinopathy, to include glaucoma. Post-service VA treatment records show that the Veteran was diagnosed with preglaucoma not otherwise specified as well as a refraction disorder, both in May 2007. Subsequent treatment records, however, do not document that the Veteran continued to receive treatment for either condition. The most recent available treatment records dating from 2015 show that the Veteran was prescribed artificial tears to be used daily to treat a dry eye condition. Upon consideration of the record, the Board finds that the preponderance of the evidence is against a determination that service connection is warranted for a blurred vision disorder. To begin, there is no evidence that the Veteran experienced any issues with his vision in service, and he has never stated as much. Accordingly, service connection for a blurred vision disorder on a direct basis pursuant to 38 C.F.R. § 3.303(a) is denied. As for service connection for a blurred vision disorder on a secondary basis, there is no evidence that the Veteran has a blurred vision disorder that was permanently aggravated by a service-connected disability. 38 C.F.R. § 3.310.; Allen, 7 Vet. App. at 439 (1995). From the outset, the Veteran is not service-connected for headaches or hypertension and so secondary service connection as due to a headache condition or hypertension is denied outright. As for the theory of the blurred eye condition being a residual condition of the TBI, the Board notes that the June 2010 examiner dismissed this theory and supported it by reference to the lack of complaints of eye issues immediately following the TBI and for many years afterward. As the opinion was supported by a thorough rationale, the Board finds it highly probative, and further finds that it far outweighs the Veteran's contentions regarding the association between the in-service TBI and the current eye disorder, especially in light of the complete lack of medical evidence showing any connection between the two. With regards to whether the Veteran's blurry vision disorder is a residual of his diabetes mellitus type II, the Board notes that none of the VA examiners who reviewed the file and evaluated the Veteran's medical history and testing results found any evidence that the Veteran experienced diabetic retinopathy or any other eye disorders attributable to diabetes mellitus type II. The Veteran has submitted no competent evidence in support of his contention that he has glaucoma that is attributable to his diabetes mellitus type II or was permanently aggravated by the diabetes. Without any competent supporting evidence, and in light of the highly probative opinions of the three VA examiners who evaluated the Veteran's diabetes mellitus type II, the Board finds that the preponderance of the evidence is against a finding that the Veteran has a blurry vision disorder that is secondary to his diabetes mellitus type II, and that therefore service connection for a blurry vision disorder on a secondary basis must also be denied. The Board acknowledges that the Veteran has consistently maintained that his blurred vision disorder was caused by one or more of his service-connected disabilities, and that he is competent to report his symptoms of blurred vision and when those symptoms began to manifest. Layno, 6 Vet. App. at 465. However, there is no evidence in the record which indicates that the Veteran is competent through training or credentials to conclude that his blurred vision disorder is attributable to or aggravated by a service-connected disability. Jandreau, 491 F.3d at 1372. In summation, the opinion of the June 2010 and December 2013 VA examiners is a more reliable indicator of whether the Veteran's blurred vision disorder is in any way related to a service-connected disability. Therefore, the preponderance of the evidence is against the Veteran's claim of service connection for a blurred vision disorder on a secondary basis. 38 C.F.R. § 3.310.; Allen, 7 Vet. App. at 439 (1995). Again, the Veteran may be entitled to service connection if all of the evidence establishes that a blurred vision disorder was incurred in service. 38 C.F.R. § 3.303(d). Here, however, there is no evidence of incurrence in service, and it is entirely unclear if the Veteran even has a blurred vision disorder, and if so, when symptoms of such a disorder began. Although the Veteran was diagnosed with preglaucoma in May 2007, he did not continue to receive treatment for the condition, and even granting that the Veteran did have preglaucoma at that time it still was diagnosed over 35 years after service. Furthermore, the Veteran's contention that his blurry vision disorder was aggravated beyond its normal progression by service-connected diabetes mellitus type II, or that the blurry vision disorder is a residual of his in-service TBI, have both been shown to be wholly unsupported by the evidence of record. Thus, the Board concludes that the preponderance of the evidence weighs against a finding that the Veteran's blurry vision disorder is otherwise attributable to service. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection for a blurry vision disorder under 38 C.F.R. § 3.303(d) is denied, and as such the Veteran's claim for a blurry vision disorder in total must be denied. As the preponderance of the evidence is against the Veteran's claim of service connection for a blurry vision disorder, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). BPH The veteran asserts that he developed BPH after his discharge from service as a separately diagnosable disorder attributable to his diabetes mellitus type II. Upon consideration of the record, the Board finds that the preponderance of the evidence is against a determination that service connection is warranted for BPH. To begin, service treatment records do not show that the Veteran reported experiencing any symptoms of a prostate condition while in service, and he was evaluated as having no abnormalities on his discharge examination dated in June 1970. Moreover, the Veteran during the June 2010 VA examination stated that his BPH symptoms began two or three years prior to the examination, i.e., around 2007 or 2008, over 35 years after his discharge from service. Accordingly, the Board finds that service connection is not warranted for BPH on a direct basis pursuant to 38 C.F.R. § 3.303(a). The Veteran was afforded a VA examination in June 2010 to evaluate the nature and severity of any prostate condition. As stated, he reported that he noticed symptoms of increased urinary frequency, terminal dribbling, hesitancy, and change in stream, all beginning about two or three years prior to the examination. The examiner evaluated the symptoms as suggestive of BPH, and associated it wholly with the Veteran's age. After reviewing the claims file, and noting the lack of reported prostate issues, the examiner found that it was less likely than not that the BPH was related to service. Post-service medical records do not show that the Veteran has ever been diagnosed with or specifically treated for a prostate condition. On the December 2012, December 2013 and March 2015 VA examinations, each administered for the purpose of evaluating the nature and severity of the diabetes mellitus type II, the examiners denied that the Veteran experienced any issues with his prostate that were attributable to his diabetes mellitus type II. Upon consideration of the record, the Board finds that there is insufficient evidence that the Veteran has a prostate condition that is related to service, to include his service-connected diabetes mellitus type II. The Board accepts that the Veteran has submitted research suggesting a connection between diabetes mellitus type II and the development of BPH. See Appellate Written Brief Presentation, October 6, 2017. However, while the subject of the submitted medical literature is sufficiently similar to the issue on appeal, generic information from a medical journal, treatise, or website is too "general and inconclusive" to establish a medical nexus to a disease or injury. Mattern v. West, 12 Vet. App. 222, 228 (1999) (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)). A medical article or treatise can provide support for a claim, but must be combined with an opinion of a medical professional and be reflective of the specific facts of a case as opposed to a discussion of generic relationships. Sacks, 12 Vet. App. at 316-17. Here, no such medical opinion has been associated with the record. Furthermore, the Veteran's general assertion that his BPH is attributable to his service-connected diabetes mellitus type II has been refuted by several distinct VA examiners who reviewed the record and concluded that there was insufficient evidence to establish that the Veteran had BPH that was caused or permanently aggravated by his diabetes mellitus type II. Those VA examiner opinions, supported as they are by a thorough rationale with reference to the Veteran's medical history, are highly probative of the issue at hand. Nieves-Rodriguez, 22 Vet. App. at 303. The Board acknowledges that the Veteran has consistently maintained that his BPH was caused by his service-connected diabetes mellitus type II, and that he is competent to report his symptoms of BPH and diabetes mellitus type II and when those symptoms began to manifest. Layno, 6 Vet. App. at 465. However, there is no evidence in the record which indicates that the Veteran is competent through training or credentials to conclude that his BPH is attributable to or aggravated by a service-connected disability. Jandreau, 491 F.3d at 1372. In summation, without any specific medical evidence in support of the Veteran's contentions regarding the etiology of his BPH, the Board finds that service connection is not warranted for BPH on a secondary basis pursuant to 38 C.F.R. § 3.310, nor is it warranted on an indirect basis pursuant to 38 C.F.R. § 3.303(d). As such, the Board finds that service connection for BPH is denied in total. As the preponderance of the evidence is against the Veteran's claim of service connection for BPH, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). ORDER An initial disability evaluation in excess of 20 percent for diabetes mellitus type II is denied. An initial disability evaluation in excess of 10 percent for tinnitus is denied. An initial compensable evaluation for bilateral SNHL is denied. Service connection for persistent depressive disorder, with disturbance of mood, is granted. Service connection for hypertension is denied. Service connection for residuals of a TBI is denied. Service connection for a headache condition is denied. Service connection for a blurry vision disorder is denied. Service connection for BPH is denied. ____________________________________________ A. C. MACKENZIE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs