Citation Nr: 1804944 Decision Date: 01/25/18 Archive Date: 02/05/18 DOCKET NO. 15-41 172A ) DATE Advanced on the Docket ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder. 2. Entitlement to service connection for a thoracolumbar spine disorder. 3. Entitlement to service connection for a cervical spine disorder. 4. Entitlement to service connection for a bilateral shoulder disorder. 5. Entitlement to service connection for a bilateral knee disorder. 6. Entitlement to service connection for bilateral hearing loss. 7. Entitlement to service connection for tinnitus. 8. Entitlement to service connection for hypertension. 9. Entitlement to service connection for hyperlipidemia. ORDER Service connection for an acquired psychiatric disorder is denied. Service connection for a thoracolumbar spine disorder is denied. Service connection for a cervical spine disorder is denied. Service connection for a bilateral shoulder disorder is denied. Service connection for a bilateral knee disorder is denied. Service connection for bilateral hearing loss is denied. Service connection for tinnitus is denied. Service connection for hypertension is denied. Service connection for hyperlipidemia is denied. FINDINGS OF FACT 1. The Veteran does not have a psychosis; the diagnosed psychiatric disorders are not listed among the diseases for which the presumption of service connection for certain chronic diseases, and the provisions regarding chronicity in service and continuity of symptomatology after service must be considered; an acquired psychiatric disorder is not related to injury or disease in service. 2. Thoracolumbar spine arthritis did not become manifest to a degree of 10 percent or more within 1 year of service separation; a thoracolumbar spine disorder is not related to injury or disease in service. 3. Cervical spine arthritis did not become manifest to a degree of 10 percent or more within one year of service separation; a cervical spine disorder is not related to injury or disease in service. 4. Shoulder arthritis did not become manifest to a degree of 10 percent or more within 1 year of service separation; the diagnosed non-arthritic shoulder pathology is not listed among the diseases for which the presumption of service connection for certain chronic diseases, and the provisions regarding chronicity in service and continuity of symptomatology after service must be considered; a bilateral (or unilateral) shoulder disorder is not related to injury or disease in service. 5. Knee arthritis did not become manifest to a degree of 10 percent or more within 1 year of service separation; the diagnosed non-arthritic knee joint pathology is not listed among the diseases for which the presumption of service connection for certain chronic diseases, and the provisions regarding chronicity in service and continuity of symptomatology after service must be considered; a bilateral (or unilateral) knee disorder is not related to injury or disease in service. 6. Organic disease of the nervous system, to include bilateral hearing loss, did not become manifest to a degree of 10 percent or more within 1 year of service separation; non-neurological ear pathology, to include a ruptured tympanic membrane, is not listed among the diseases for which the presumption of service connection for certain chronic diseases, and the provisions regarding chronicity in service and continuity of symptomatology after service must be considered; a bilateral (or unilateral) hearing loss disability is not related to injury or disease in service. 7. Organic disease of the nervous system, to include tinnitus, did not become manifest to a degree of 10 percent or more within 1 year of service separation; tinnitus is not related to injury or disease in service. 8. Cardiovascular-renal disease, to include hypertension, did not become manifest to a degree of 10 percent or more within 1 year of service separation; hypertension is not related to injury or disease in service. 9. Hyperlipidemia is not a disability. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder was not incurred in service; a psychosis is not presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 4.125 (2017). 2. A thoracolumbar spine disorder was not incurred in service; arthritis is not presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 3. A cervical spine disorder was not incurred in service; arthritis is not presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 4. A bilateral (or unilateral) shoulder disorder was not incurred in service; arthritis is not presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 5. A bilateral (or unilateral) knee disorder was not incurred in service; arthritis is not presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 6. Bilateral (or unilateral) hearing loss was not incurred in service; an organic disease of the nervous system is not presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2017). 7. Tinnitus was not incurred in service; an organic disease of the nervous system is not presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 8. Hypertension was not incurred in service; cardiovascular-renal disease is not presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 9. The basic service connection criteria for the claimed hyperlipidemia have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a veteran (the Veteran) who had active duty service from October 1956 to October 1957. This appeal comes before the Board of Veterans' Appeals (Board) from an April 2015 rating decision of the RO in San Juan, the Commonwealth of Puerto Rico. VA law provides that, for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during a period of war, or other than a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation, except if the disability is a result of the veteran's own willful misconduct or abuse of alcohol or drugs. 38 U.S.C. §§ 1110, 1131 (West 2014). Entitlement to service connection on a direct basis requires (1) evidence of current nonservice-connected disability; (2) evidence of in-service incurrence or aggravation of disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current nonservice-connected disability. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For specific enumerated diseases designated as "chronic" there is a presumption that such chronic disease was incurred in or aggravated by service even though there is no evidence of such chronic disease during the period of service. In order for the presumption to attach, the disease must have become manifest to a degree of 10 percent or more within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Presumptive service connection for the specified chronic diseases may alternatively be established by way of continuity of symptomatology under 38 C.F.R. § 3.303(b). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a) Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 ('sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer'); 38 C.F.R. § 3.159(a)(2). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104(a) (West 2014). When there is an approximate balance of 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 claimant. 38 U.S.C. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2017). A VA claimant need only demonstrate an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert at 54. The National Personnel Records Center indicates that the Veteran's service treatment records had been destroyed by fire and could not be located. In these circumstances, VA's duties to assist, to provide reasons and bases for its findings and conclusions, and to consider carefully the benefit-of-the-doubt rule are heightened. Milostan v. Brown, 4 Vet. App. 250, 252 (1993) (citing Moore v. Derwinski, 1 Vet. App. 401, 406 (1991) and O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991)). The Board will address compliance with these provisions below. Entitlement to service connection for an acquired psychiatric disorder. The Veteran filed a claim for nonservice-connected pension in April 1997. Among the problems listed was a nervous condition. VA problem lists reveal initial diagnosis of "panic" on March 27, 1998, and initial diagnosis of agoraphobia with panic and depressive disorder on December 17, 2001. The first record of psychiatric treatment comes on July 19, 2002. A VA Mental Health Note of that date reveals that the Veteran reported that he was feeling more or less well. He was having anxiety attacks which were controlled with Paxil. The examiner found him psychiatrically stable and dealing well with his current personal situation. The assessment was panic disorder (VBMS record 04/02/2015). An April 14, 2014, Private Medical Report from C. Mora-Quesada, MD, states that the Veteran complained of nervousness, anxiety, increased irritability, difficulty in adapting to stressful circumstances, inability to establish and maintain effective work and social relationships, disturbances of motivation and mood, depressed mood, isolation episodes, easy crying, and insomnia. He was in psychological therapy with poor control of symptoms. Diagnoses included generalized anxiety disorder, major depression disease, and a sleep disorder. The examiner opined that, these psychiatric disorders where, more probable than not, secondary to his "military service performance." The report of an April 2015 VA Mental Examination reveals the diagnosis of unspecified depressive disorder. The examiner opined that this mental disorder was less likely than not (less than 50% probability) incurred in or caused by an in-service injury, event or illness. The rationale was that the Veteran denied ever receiving mental health referrals, personal requests, findings, diagnoses, or treatment for a mental disorder while in the military service. The Veteran told the examiner that he began psychiatric treatment around 1990 and was treated for anxiety due to family problems. He was in treatment for about one year. He also stated that he was in treatment in the San Juan VA Mental Hygiene clinic from 1997 to 2008 with diagnoses of depression, panic attacks, and past alcohol abuse, also due to family problems. The examiner concluded that the Veteran began psychiatric treatment 33 years post-military service, so there is no temporal relationship between military service and initial presentation of symptoms. The examiner also addressed the letter from Dr. Mora Quesada, noting that Dr. Mora Quesada is an internal medicine specialist, not a psychiatrist/psychologist/mental health specialist, and is not qualified to evaluate, diagnose, and/or treat mental disorders. In addition, he sees veterans on a one time basis, does not do a mental status exam, and writes basically the same letter with same diagnoses for all veterans; he does not provide a rationale for his diagnoses; and, he charges a hefty fee for his letters. After a review of all of the evidence, the Board finds that the Veteran's current psychiatric disorders are not related to service. For purposes of the presumptive provisions, the term "psychosis" is defined as any of the following disorders listed in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition of the American Psychiatric Association (DSM-5): (a) Brief Psychotic Disorder; (b) Delusional Disorder; (c) Psychotic Disorder Due to Another Medical Condition; (d) Other Specified Schizophrenia Spectrum and Other Psychotic Disorder; (e) Schizoaffective Disorder; (f) Schizophrenia; (g) Schizophreniform Disorder; and (h) Substance/Medication-Induced Psychotic Disorder. See 38 C.F.R. § 3.384 (2017). As the Veteran does not have a diagnosis of a psychosis, the presumption of service connection is not for application. While the record contains a nominally favorable opinion regarding the asserted a nexus between the current psychiatric disorders and service, the opinion is completely unexplained in terms of how this conclusion was reached. It does not address the evidence of record in any meaningful way, and it provides no discussion of generally accepted medical principles with respect to the incurrence of psychiatric disorders. The opinion is therefore deemed conclusory and of reduced probative weight. In contrast, the opinion of the VA physician is explained in terms of the evidence of record, including the opinion of Dr. Mora Quesada, and including the Veteran's specific statements made to the examiner. The Board accords greater probative weight to the VA opinion and finds that, while there are current psychiatric diagnoses, the crucial element of nexus, between the current disabilities and service, is not substantiated. The Board has considered the Veteran's assertions in support of his claim; however, the Board finds that establishing the etiology of a psychiatric disorder is not the equivalent of relating a broken bone to a concurrent injury to the same body part (Jandreau, at 1377). Such an opinion requires specialized training and knowledge and is not capable of lay observation. Accordingly, the Veteran's lay statements are not competent evidence of an etiologic relationship between the claimed psychiatric disorders and service. In light of these findings, the Board concludes that service connection for the claimed psychiatric disorders is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Entitlement to service connection for a thoracolumbar spine disorder. Entitlement to service connection for cervical spine disorder. Entitlement to service connection for a bilateral shoulder disorder. Entitlement to service connection for a bilateral knee disorder. The Veteran filed a claim for nonservice-connected pension benefits in April 1997. Among the claimed disorders was generalized arthritis. VA problem lists show initial diagnosis of rotator cuff rupture and acromioclavicular sprain on December 17, 2001. A March 24, 2006, MRI of the left knee reveals calcifications, small knee effusion, associated Hoffa's fat pad tear, and a medial meniscus posterior horn tear (VBMS record 03/04/2014). A December 20, 2007, Emergency Department Note reveals complaint of left knee pain. The Veteran reported no trauma associated with this complaint. A December 3, 2012, X-ray report shows mild degenerative changes of the right knee (VBMS record 03/04/2014). An April 14, 2014, Private Medical Report from Dr. Mora Quesada states that the Veteran complains of neck and high back pain with numbness, tingling, sensorial loss, cramps and weakness of both shoulders. He also complains of severe low back pain with numbness, tingling, sensorial loss, cramps and weakness radiating to the hips and lower limbs, with severe knee pain, left greater than right, and instability. He was advised to use a one-point cane for stability. Diagnoses included chronic myositis, para-cervical spine muscles, bilateral shoulders osteoarthritis, chronic myositis of the para-lumbar spine muscles, and osteoarthritis of the bilateral knees. Dr. Mora Quesada opined that the Veteran's musculoskeletal disorders are more probable than not secondary to his "military service performance." A June 19, 2014, private report from R. Munoz, MD, states that a right shoulder ultrasound revealed torn supraspinatus, infraspinatus and biceps tendons, subacromial subdeltoid bursitis, and arthritis. The report of a March 2015 VA Joints Examination reveals the diagnoses of cervical and lumbar myositis and arthritis of the bilateral shoulders and knees. The examiner opined that these conditions were less likely than not (less than 50% probability) incurred in or caused by an in-service injury, event or illness. The rationale of the VA examiner with respect to the neck and back was that the Veteran reported that his neck and back pain developed over the last several years. He served in the Army more than 50 years ago and no medical link was found between his complaint of neck and back pain and his years in the military service. There are no civilian or military records found in the claim folder other than the medical letter by Dr. Mora Quesada, more than 50 years after his military service, and the comments by Dr. Mora Quesada (neck and back) are not seen to reflect any review of past medical records seen by him. The Veteran admitted pain in these areas only during the past several years. Therefore, the present neck and back condition are at least as likely as not due to his natural process of aging and less likely as not due to his military service. The rational with respect to the shoulders and knees was that, it is very well documented in medical literature that knee and shoulder osteoarthritis are considered part of the normal aging process in patients older than 40 years old. The Veteran was released from active service more than 50 years ago. The etiology of shoulder and knee osteoarthritis is due to the normal aging process. There is no evidence in the medical records that he received treatment for the conditions claimed, at least within 5 years after being released from active service. After a review of all of the evidence, the Board finds that the Veteran's current disorders of the neck, back, bilateral shoulders, and bilateral knees, are not related to service. Regarding the presumption of service connection for arthritis, in order for lumbar spine arthritis to have become manifest to a degree of 10 percent, there must be evidence to substantiate that (1) forward flexion of the thoracolumbar spine is limited to 85 degrees, or (2) that combined range of motion of the thoracolumbar spine is limited to 235 degrees, or (3) there must be a diagnosis "established by X-ray findings" and "satisfactory evidence of painful motion." See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5242 (2017). In order for cervical spine arthritis to have become manifest to a degree of 10 percent, there must be evidence to substantiate that (1) forward flexion of the cervical spine is limited to 40 degrees, or (2) that combined range of motion of the cervical spine is limited to 335 degrees, or (3) there must be a diagnosis "established by X-ray findings" and "satisfactory evidence of painful motion." See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5242 (2017). In order for shoulder arthritis to have become manifest to a degree of 10 percent on the basis of limited motion, (1) there must be evidence to substantiate that abduction or flexion are limited at least to shoulder level, or (2) there must be a diagnosis of arthritis "established by X-ray findings" and "satisfactory evidence of painful motion." See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5201 (2017). In order for knee arthritis to have become manifest to a degree of 10 percent, there must be evidence to substantiate that (1) flexion of the knee is limited to 45 degrees, or (2) that extension is limited to 10 degrees, or (3) there must be a diagnosis "established by X-ray findings" and "satisfactory evidence of painful motion." See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2017). In this case, while the Veteran has arthritis with respect to each of these claims, the evidence does not demonstrate any manifestation of arthritis to a degree of 10 percent or more within 1 year of service separation. For each claim, to have become manifest, there must be X-ray evidence. While the record contains a nominally favorable opinion regarding the asserted nexus between each current musculoskeletal disability and service, as with the psychiatric claim, the opinions are completely unexplained in terms of how the conclusions were reached. They do not address the evidence of record in any meaningful way, and they provide no discussion of generally accepted medical principles with respect to the incurrence of arthritis and other joint pathology. Dr. Mora Quesada discusses recent X-ray evidence, but does not explain how the acknowledged presence of current arthritis provides a link to service. The opinions are therefore deemed conclusory and of reduced probative weight. In contrast, the opinions from the VA physician are explained in terms of the evidence, including the opinion of Dr. Mora Quesada, and including the Veteran's specific statements made to the examiner regarding the onset of symptoms. The Board accords greater probative weight to the VA opinions and finds that, while there are current diagnoses for each of the claims, the crucial element of nexus, between the current disabilities and service, is not substantiated. The Board has considered the Veteran's assertions in support of his claims; however, the Board finds that establishing the etiology of the disease process of arthritis is not the equivalent of relating a broken bone to a concurrent injury to the same body part (Jandreau, at 1377). Such an opinion requires specialized training and knowledge and is not capable of lay observation, particularly where the asserted injury is temporally remote from the onset of the disability. Accordingly, the Veteran's lay statements are not competent evidence of an etiologic relationship between the claimed arthritis and service. Regarding the non-arthritic joint pathologies, as noted by the VA examiner, the Veteran has described post-service onset of these conditions. In light of these findings, the Board concludes that service connection for the claimed disorders of the neck, back, shoulders, and knees is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Entitlement to service connection for bilateral hearing loss. Entitlement to service connection for tinnitus. Service connection for impaired hearing shall only be established when hearing status as determined by audiometric testing meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels) over a range of frequencies (in Hertz). Hensley v. Brown, 5 Vet. App. 155, 158 (1993). Impaired hearing will be considered to be a "disability" when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 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. VA problem lists indicate that the Veteran sustained a total perforation of the left tympanic membrane on July 19, 1995 (VBMS record 04/10/2015 at 173). The Veteran filed a claim for nonservice-connected pension in April 1997. Among the problems listed was hearing loss. The Veteran asserted that the hearing loss began in 1956. An April 14, 2014, Private Medical Report from Dr. Mora Quesada states that, since his military service, the Veteran refers earaches, vertigo, tinnitus, and hearing loss secondary to high noises during military operations. He has undergone a left ear surgical procedure with poor results. Diagnoses included tinnitus and bilateral deafness. Dr. Mora Quesada did not provide an etiology opinion regarding hearing loss or tinnitus. The report of a March 2015 VA Audio Examination reveals pure tone thresholds as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 25 45 60 70 LEFT 100+ 100+ 105+ 105+ 105+ Speech recognition was 92 percent in the right ear and 0 percent in the left ear. The examiner opined that the claimed hearing loss and tinnitus were less likely than not (less than 50% probability) incurred in or caused by an in-service injury, event or illness. The rationale was that the current audiological evaluation shows mild to severe hearing loss in the right ear and profound hearing loss in the left ear. However, there is no medical evidence in the file that shows evidence of complaints of hearing loss and tinnitus for the period of active duty. In addition, this was a young veteran with no history of ear/hearing related health problems when he enrolled in the US Army. In this case, this Veteran worked in the construction area for many years in his civilian occupation and he was exposed to high impact noise. Therefore, it is reasonable, to conclude that the hearing loss and tinnitus are less likely than not related to the military noise exposure in the period of active duty. After a review of all of the evidence, the Board finds that the Veteran's current bilateral hearing loss and tinnitus are not related to service. Regarding the presumption of service connection, in order for sensorineural hearing loss for a single service-connected ear to have become manifest to a degree of 10 percent, there must be a diagnosis that conforms to 38 C.F.R. § 3.385 for that ear, and such combination of auditory threshold measurements and speech recognition scores (or auditory threshold measurements alone in the case of an exceptional pattern) as would produce Level X hearing in the service-connected ear, as combined with Level I hearing for the nonservice-connected ear, under Table VII of 38 C.F.R. § 4.85 (2017). In order for sensorineural hearing loss as a bilateral condition to have become manifest to a degree of 10 percent, there must be a diagnosis that conforms to 38 C.F.R. § 3.385, and such combination of auditory threshold measurements and speech recognition scores (or auditory threshold measurements alone in the case of an exceptional pattern) as would produce a 10 percent rating under Table VII of 38 C.F.R. § 4.85 (2017). There are many classifications of tinnitus some of which at least imply neurologic etiology. See Dorland's Illustrated Medical Dictionary 1956 (31st ed. 2007) (identifying "sensorineural" tinnitus as synonymous with subjective tinnitus). Organic disease(s) of the nervous system, which might include tinnitus, is included among the enumerated chronic diseases. The United States Court of Appeals for Veterans Claims (Veterans Court) has held that the presumptive diseases include tinnitus, at a minimum where there is evidence of acoustic trauma, as an organic disease of the nervous system. See Fountain v. McDonald, 27 Vet. App. 258 (2016). The Board notes that the term "acoustic trauma" was not defined by the Veterans Court in Fountain, nor is it defined under VA statutes or regulations. The term was used, but was not defined, in the rating schedule for tinnitus prior to 1999. Accordingly, it is appropriate to use a generally accepted medical definition. The University of Maryland Medical Encyclopedia defines acoustic trauma as "injury to the hearing mechanisms in the inner ear[...] due to very loud noise." See http://umm.edu/health/medical/ency/articles/ acoustic-trauma. In order for tinnitus to have become manifest to a degree of 10 percent, there must be competent evidence establishing the existence of the condition. 38 C.F.R. § 4.87, Diagnostic Code 6260. In this case, there is no manifestation of hearing loss or tinnitus to a degree of 10 percent or more within 1 year of service separation. The Board acknowledges that the Veteran has asserted his hearing loss began in 1956. He did not mention tinnitus in that statement. While tinnitus may be subject to lay observation, a hearing loss disability is not, nor is the degree of such disability once established. Establishing a hearing loss disability, and establishing the degree of such disability, requires medical evidence. 38 C.F.R. §§ 3.385, 4.85(a). There is no medical opinion that purports to relate hearing loss or tinnitus to service. While Dr. Mora Quesada provided diagnoses of these conditions, his opinion did not address them. The Board finds that, while there are current diagnoses for each of the claims, the crucial element of a nexus between the current disabilities and service is not substantiated. In light of these findings, the Board concludes that service connection for the claimed hearing loss and tinnitus is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Entitlement to service connection for hypertension. Entitlement to service connection for hyperlipidemia. VA outpatient treatment records reveal a diagnosis of high blood pressure on April 11, 2001 (VBMS record 04/02/2015). These also show that the diagnosis of "essential" hypertension. VA problem lists show initial diagnosis of hyperlipidemia on December 17, 2001. An April 14, 2014, Private Medical Report from Dr. Mora Quesada states the Veteran had poor blood pressure control. He also receives treatment for high serum cholesterol levels. Diagnoses included hypertension and hyperlipidemia. The examiner opined that his "cardiovascular disorders" are more probable than not secondary to his "military service performance." The report of a March 2015 VA Hypertension Examination reveals a diagnosis of hypertension in March 2008. The examiner opined that the Veteran's hypertension is less likely as not (less than 50/50 probability) incurred, aggravated or diagnosed during military service. The rationale was that hypertension was first diagnosed on March 3, 2008. There is no evidence of any symptom or diagnosis during military service or during one year after being released from military service. After a review of all of the evidence, the Board finds that the Veteran's current hypertension is not related to service. Regarding the presumption of service connection, in order for hypertension to have become manifest to a degree of 10 percent, there must be evidence to substantiate that diastolic pressure is predominantly 100 or more; or, that systolic pressure is 160 or more; or, that there is a history of diastolic pressure predominantly 100 or more and that continuous medication for control is required. See 38 C.F.R. § 4.104, Diagnostic Code 7101. For VA rating purposes, hypertension means that diastolic blood pressure is predominately 90 mm. or greater; isolated systolic hypertension means that the systolic blood pressure is predominately 160 mm. or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 (2017). Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. In this case, there is no manifestation of hypertension to a degree of 10 percent or more within 1 year of service separation. While the record contains a nominally favorable opinion regarding the asserted nexus between the current hypertension and service, the opinion is completely unexplained in terms of how this conclusion was reached. It does not address the evidence of record in any meaningful way, and it provides no discussion of generally accepted medical principles with respect to the incurrence of hypertension. The opinion is therefore deemed conclusory and of reduced probative weight. In contrast, the opinion of the VA physician is explained in terms of the evidence, including the Veteran's specific statements made to the examiner. Moreover, the characterization of the Veteran's hypertension as "essential" means that it occurs without discoverable organic cause. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 909 (31st ed., 2007). The Board accords greater probative weight to the VA opinion and finds that, while there is a current diagnosis of hypertension, the crucial element of a nexus between the current disability and service is not substantiated. Therefore, the Board concludes that service connection for the claimed hypertension is not warranted. The Board has considered the Veteran's assertions in support of his hypertension claim; however, the Board finds that establishing the etiology of vascular hypertension, where, as here, the onset is temporally remote from the alleged cause, is not the equivalent of relating a broken bone to a concurrent injury to the same body part (Jandreau, at 1377). Such an opinion requires specialized training and knowledge and is not capable of lay observation. While the Veteran may be competent to take his blood pressure, he has not described having done so in service or within the presumptive period, nor has he described being told by a doctor during this time that he had hypertension. Accordingly, the Veteran's lay statements are not competent evidence of an etiologic relationship between the claimed hypertension and service. Hyperlipidemia is a laboratory finding and is not a disability in and of itself for which VA compensation benefits are payable. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (Diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities. They are, therefore, not appropriate entities for the rating schedule). Service connection may not be granted for a laboratory finding, standing alone. In the absence of proof of present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Heightened Duties In addressing the Board's heightened duty to provide reasons and bases for its findings and conclusions, and to consider carefully the benefit-of-the-doubt rule, the Board finds that, while there is a current disability with respect to each claim, even to the extent that there might, hypothetically, have been symptoms or treatment in service, which might have been substantiated by the missing service treatment records, the crucial element of a nexus between the current disabilities and service is not substantiated. In other words, there is not an approximate balance of the evidence on this element. A preponderance of the evidence is against the element of nexus to service in light of the noted problems with the opinions of Dr. Mora Quesada, and the lack of an opinion with respect to several of the claims. Therefore, the Board concludes that the absence of the service treatment records is not likely prejudicial regarding any of the claims. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD L. Cramp, Counsel Department of Veterans Affairs