Citation Nr: 19149350 Decision Date: 06/25/19 Archive Date: 06/24/19 DOCKET NO. 11-22 873 DATE: June 25, 2019 ORDER Service connection for diabetes mellitus is denied. Service connection for peripheral neuropathy of the right upper extremity is denied. Service connection for peripheral neuropathy of the left upper extremity is denied. Service connection for peripheral neuropathy of the right lower extremity is denied. Service connection for peripheral neuropathy of the left lower extremity is denied. Service connection for a right knee disability, diagnosed as degenerative joint disease, is granted. Service connection for a left knee disability, diagnosed as degenerative joint disease, is granted. Service connection for arthritis throughout the body, other than degenerative joint disease of the right knee and left knee, is denied. REMANDED Entitlement to service connection for hypertension is remanded. FINDINGS OF FACT 1. The Veteran does not current have diabetes mellitus. 2. The Veteran’s peripheral neuropathy of the right upper extremity was not present during service, or for many years thereafter, and was not caused by any incident of service, including Agent Orange exposure. The Veteran also claims service connection for peripheral neuropathy of the right upper extremity secondary to diabetes mellitus, but he is not currently service-connected for diabetes mellitus. 3. The Veteran’s peripheral neuropathy of the left upper extremity was not present during service, or for many years thereafter, and was not caused by any incident of service, including Agent Orange exposure. The Veteran also claims service connection for peripheral neuropathy of the left upper extremity secondary to diabetes mellitus, but he is not currently service-connected for diabetes mellitus. 4. The Veteran’s peripheral neuropathy of the right lower extremity was not present during service, or for many years thereafter, and was not caused by any incident of service, including Agent Orange exposure. The Veteran also claims service connection for peripheral neuropathy of the right lower extremity secondary to diabetes mellitus, but he is not currently service-connected for diabetes mellitus. 5. The Veteran’s peripheral neuropathy of the left lower extremity was not present during service, or for many years thereafter, and was not caused by any incident of service, including Agent Orange exposure. The Veteran also claims service connection for peripheral neuropathy of the left lower extremity secondary to diabetes mellitus, but he is not currently service-connected for diabetes mellitus. 6. A right knee disability, diagnosed as degenerative joint disease, had its onset during service. 7. A right knee disability, diagnosed as degenerative joint disease, had its onset during service. 8. The Veteran’s claimed arthritis throughout the body, other than degenerative joint disease of the right knee and left knee, was not present during service, or for many years thereafter, and was not caused by any incident of service. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 2. The criteria for service connection for peripheral neuropathy of the right upper extremity have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 3. The criteria for service connection for peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 4. The criteria for service connection for peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 5. The criteria for service connection for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 6. The criteria for service connection for a right knee disability, diagnosed as degenerative joint disease, have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 7. The criteria for service connection for a left knee disability, diagnosed as degenerative joint disease, have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 8. The criteria for service connection for arthritis throughout the body, other than degenerative joint disease of the right knee and left knee, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from February 1969 to July 1970, including in the Republic of Vietnam. In February 2017, the Veteran appeared at a Board videoconference hearing before the undersigned Veterans Law Judge. In June 2017, the Board remanded the issues of entitlement to service connection for a psychiatric disorder, to include PTSD and a generalized anxiety disorder; hypertension; diabetes mellitus; peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; peripheral neuropathy of the left lower extremity; and for arthritis throughout the body, for further development. An August 2018 RO decision granted service connection and a 30 percent rating for other specified trauma and a stressor related disorder (claimed as a psychiatric disorder, to include PTSD and a generalized anxiety disorder), effective August 31, 2009. Therefore, the issue of entitlement to service connection for a psychiatric disorder, to include PTSD and a generalized anxiety disorder, is no longer before the Board. 1. Diabetes Mellitus Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). A veteran who served in the Republic of Vietnam during the Vietnam era is presumed to have been exposed during such service to certain herbicide agents (e.g., Agent Orange). In the case of such a veteran, service incurrence for the following diseases will be presumed if they are manifest to a compensable degree within specified periods, even if there is no record of such disease during service: chloracne or other acneform diseases consistent with chloracne, type 2 diabetes, Hodgkin’s disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin’s lymphoma, acute and sub-acute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, and trachea), and soft-tissue sarcomas. 38 U.S.C. § 1116; 38 C.F.R. § 3.307 (a)(6), 3.309(e). Effective August 31, 2010, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina), is included as a disease associated with herbicide exposure under 38 C.F.R. § 3.309 (e). (Under 38 C.F.R. § 3.309 (e), the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of Ischemic heart disease. 38 C.F.R. § 3.309 (e) (Note 3.). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran’s demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). The Veteran contends that he has diabetes mellitus that is related to service, to include as due to Agent Orange exposure. The Veteran reports that he has symptoms of being hungry, frequent urination, and a drastic weight loss, which may be indicative of pre-diabetes mellitus or diabetes mellitus. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Veteran served on active duty in the Army from February 1969 to July 1970, including in the Republic of Vietnam. Therefore, his exposure to Agent Orange is conceded. The Veteran’s service treatment records do not show treatment for diabetes mellitus. Post-service VA treatment records, including examination reports, do not show treatment for diabetes mellitus. Post-service private treatment records include a diagnosis of diabetes mellitus on one occasion. An August 2010 general medical examination report reflects that the claims file was reviewed. The examiner reported that there were no records indicating that the Veteran had diabetes mellitus. The examiner stated that the Veteran’s serum glucose was 98 in May 2010 and that it was 93 in November 2009. It was noted that the Veteran had not been told that he had diabetes. The examiner indicated that, therefore, a diabetes mellitus examination had not been performed. A January 2013 treatment report from Cardiology Now notes that the Veteran was seen for a history of lower extremity edema and that he had multiple risk factors for coronary atherosclerosis. As to a past medical history, it was noted that the Veteran had disorders, including borderline diabetes mellitus. The impression included diabetes mellitus. There was no indication that laboratory tests were performed at that time. An August 2018 VA diabetes mellitus examination report includes a notation that the Veteran’s claims file was reviewed. The examiner reported that there was not an official diagnosis of either diabetes mellitus, type I, or diabetes mellitus, type II. The examiner stated that the Veteran’s most recent A1C was 5.4 in February 2017, and that his most recent fasting plasma glucose was 91 in February 2018. The diagnosis was impaired fasting glucose. The examiner indicated that Veteran did not meet the criteria for a diagnosis of diabetes mellitus. The examiner stated that the Veteran had no diagnosis of diabetes mellitus and that his most recent blood glucoses and hemoglobin A1C had been within normal limits. The examiner indicated that the Veteran did not have a diagnosis of diabetes mellitus. The requirement for service connection that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to the Secretary’s adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). However, Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110; 1131. In the absence of proof of present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328 (1997) (38 U.S.C.A. § 1131 requires existence of present disability for VA compensation purposes). The Board notes that the evidence indicates no presently diagnosed diabetes mellitus and, thus, service connection for such disorder is not warranted. The Board notes that a January 2013 treatment report from Cardiology Now notes that the Veteran had a past medical history that included borderline diabetes mellitus. The impression included diabetes mellitus. The Board observes that although the impression included diabetes mellitus, there was no indication that any laboratory tests were performed at that time. The Board also notes that there is no indication that the examiner, pursuant to the January 2013 treatment report from Cardiology Now, reviewed the Veteran’s claims file. Although claims file review is not necessary, the probative value of a medical opinion is based on its reasoning and its predicate in the record so that the opinion is fully informed. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). There is simply no other evidence of record of a diagnosis of diabetes mellitus, and an August 2018 VA examination report, in which the examiner reviewed the claims file, found that the Veteran did not have diabetes mellitus. Therefore, the Board finds that the diagnosis of diabetes mellitus, pursuant to the January 2013 treatment report from Cardiology Now, is not probative in this matter. The Board notes that the August 2018 VA diabetes mellitus examination report relates a diagnosis of impaired fasting glucose. The examiner, following a review of the claims file, indicated that Veteran did not meet the criteria for a diagnosis of diabetes mellitus. The examiner specifically reported that the Veteran had no diagnosis of diabetes mellitus and that his most recent blood glucoses and hemoglobin A1C had been within normal limits. The Board notes that the examiner, pursuant to the August 2018 VA diabetes mellitus examination report, reviewed the Veteran’s claims file, discussed his recent laboratory results, and provided a rationale for her opinion. Additionally, the examiner’s determination that the Veteran did not meet the criteria for a diagnosis of diabetes mellitus is more consistent with the evidence of record. Therefore, the Board finds that examiner’s determination that the Veteran did not have diabetes mellitus, pursuant to the August 2018 VA diabetes mellitus examination report, is the most probative in this matter. See Wensch v. Principi, 15 Vet. App. 362 (2001). The Veteran essentially asserts that he has diabetes mellitus as a result of Agent Orange exposure during his period of service. The Board observes that the Veteran is competent to report symptoms he thought were due to diabetes mellitus during service, or after service, but, as a lay person, he does not have the education, training and experience to offer a medical diagnosis or an opinion as to the onset or etiology of this condition. See Kahana, see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (holding that “[l]ay evidence can be competent and sufficient to establish a diagnosis when... a lay person is competent to identify the medical condition” and providing, as an example, that a layperson would be competent to identify a condition such as a broken leg, but would not be competent to identify a form of cancer); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a veteran’s lay belief that his schizophrenia aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary’s duty to seek a medical opinion on the issue). The preponderance of the evidence is against the claim for entitlement to service connection for diabetes mellitus, to include as due to Agent Orange exposure. The evidence does not reflect that the Veteran has diabetes mellitus. As there is no doubt to be resolved, service connection is not warranted. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Peripheral Neuropathy of the Right and Left Upper Extremities and Peripheral Neuropathy of the Right and Left Lower Extremities The Veteran is currently service-connected for other specified trauma and a stressor-related disorder. He is also service-connected for psoriasis; bilateral hearing loss; and for tinnitus. As discussed below, the Board has also granted service connection for a right knee disability, diagnosed as degenerative joint disease, and for a left knee disability, diagnosed as degenerative joint disease. The Veteran contends that he has a peripheral neuropathy of the right and left upper extremities, and peripheral neuropathy of the right and left lower extremities, that are all related to service, to include as due to Agent Orange exposure. The examiner further asserts that his peripheral neuropathy of the right and left upper extremities, and his peripheral neuropathy of the right and left lower extremities, are secondary to diabetes mellitus. See Scott, 789 F.3d at 1375. The Veteran served on active duty in the Army from February 1969 to July 1970, including in the Republic of Vietnam. Therefore, his exposure to Agent Orange is conceded. The Veteran’s service treatment records do not show treatment for peripheral neuropathy of the right and left upper extremities, or for peripheral neuropathy of the right and left lower extremities. Post-service private and VA treatment records, including examination reports, show treatment for peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and peripheral neuropathy of the left lower extremity (neuropathy, peripheral sensory neuropathy, etc.). A July 2014 VA Agent Orange Peripheral Neuropathy Review Checklist report, signed by a VA physician, indicates that no evidence of early onset peripheral neuropathy was found during the Veteran’s Vietnam service, or within one year of his separation from service. The examiner specifically reported that the Veteran’s peripheral neuropathy was not early onset peripheral neuropathy. A June 2018 VA peripheral nerves conditions examination report includes a notation that the Veteran’s claims file was reviewed. The Veteran reported that approximately two to three years ago, he had tingling, numbness, and swelling to the bilateral lower extremities, as well as painful cramps at nighttime. He stated that about eight months ago, the bilateral lower extremity tingling, numbness, swelling, and cramps had worsened. The Veteran indicated that he also would have tingling and numbness of the bilateral upper extremities from his forearm to his fingers. He maintained that he would occasionally drop items. The diagnosis was peripheral sensory neuropathy. The examiner indicated that it was less likely than not that the Veteran’s peripheral sensory neuropathy was related to his exposure to Agent Orange during his military service. The examiner reported that the Veteran developed his peripheral neuropathy symptoms years after his exposure to Agent Orange, and that such was chronic peripheral neuropathy. It was noted that acute peripheral neuropathy was a presumptive illness to Agent Orange exposure. The examiner stated that VA presumes that veterans’ early-onset peripheral neuropathy was related to their exposure to Agent Orange or other herbicides during service when the disease appeared within one year of exposure. The examiner stated that the Veteran’s peripheral neuropathy was at least as likely as not related to his degenerative disc disease of the cervical spine and of the lumbar spine. The Board observes that although exposure to Agent Orange is conceded due to the Veteran’s service in Vietnam, his peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of right lower extremity; and peripheral neuropathy of the left lower extremity, are not among the diseases listed as presumptively associated with Agent Orange exposure. The evidence specifically indicates that the Veteran does not have acute and sub-acute peripheral neuropathy. Thus, the Veteran is not entitled to service connection on a presumptive basis. 38 C.F.R. § 3.309(e). The Veteran may, nonetheless, establish service connection if the evidence shows that his current peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of right lower extremity; and peripheral neuropathy of the left lower extremity, were, in fact, caused by exposure to Agent Orange or some other incident of service. See Combee v. Brown, 34 F.3d at 1039 (Fed. Cir. 1994). The Board notes that the probative evidence of record does not suggest that the Veteran’s peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of right lower extremity; and peripheral neuropathy of the left lower extremity, are related to his period of service. In fact, the probative evidence of record is against this finding, indicating that the Veteran’s present peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of right lower extremity; and peripheral neuropathy of the left lower extremity, began many years after service, without relationship to service, to include any Agent Orange exposure. A VA examiner, pursuant to a June 2018 VA peripheral nerves conditions examination report, following a review of the claims file, specifically found that the Veteran’s peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of right lower extremity; and peripheral neuropathy of the left lower extremity, were not related ot his Agent Orange exposure during service, and were related to his degenerative disc disease of the cervical spine and of the lumbar spine. There are no positive etiological opinions of record. The Veteran has asserted that his peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of right lower extremity; and peripheral neuropathy of the left lower extremity, had their onset during his period of service. While the Veteran is competent to report that he had symptoms that he thought were due to peripheral neuropathy of the right and left upper extremities, and peripheral neuropathy of the right and left lower extremities, during service or since service, he is not competent to diagnose his currently claimed peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of right lower extremity; and peripheral neuropathy of the left lower, as related to service, to include as due to exposure to Agent Orange. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms at the time supports a later diagnosis by a medical professional); Buchanan v. Nicholson, 451 F.3d. 1331 (Fed. Cir. 2006) (lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself). Similarly, the Veteran is not competent to provide a nexus, and a medical opinion from a medical professional has not related his peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of right lower extremity; and peripheral neuropathy of the left lower extremity, to his period of service. Thus, the Veteran’s lay assertions are not competent or sufficient. Additionally, the Veteran is also attempting to establish service connection for peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of right lower extremity; and peripheral neuropathy of the left lower extremity, as secondary to diabetes mellitus. However, secondary service connection presupposes the existence of an established service-connected disability. The Board notes that diabetes mellitus is not service-connected, and thus, secondary service connection for any condition allegedly due to diabetes mellitus is not warranted. The preponderance of the evidence is against the claims for entitlement to service connection for peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of right lower extremity; and peripheral neuropathy of the left lower extremity, to include as due to Agent Orange exposure; there is no doubt to be resolved; and service connection for peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of right lower extremity; and peripheral neuropathy of the left lower extremity, is not warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. 3. Right Knee Arthritis and Left Knee Arthritis The Veteran essentially contends that he has arthritis of the right knee and arthritis of the left knee that are related to service. See Scott, 789 F.3d at 1375. The Veteran’s service treatment records show treatment for right knee and left knee problems. On a medical history form at the time of a May 1968 pre-induction examination, the Veteran checked that he had swollen and painful joints, and a tricked or locked knee. The reviewing examiner indicated that the Veteran reported that his knees would swell. An objective May 1968 pre-induction examination report notes that the Veteran had subjective knee complaints. There was also a notation that his lower extremities were normal. A May 1968 statement from C. W. McGavran, II, M.D., associated with the Veteran’s service treatment records, notes that the Veteran was examined in May 1968. Dr. McGavran stated that the Veteran had early degenerative arthritis of both knees, which did not require intermittent therapy at that stage of the disease. Dr. McGavran indicated that he felt that it would be detrimental to the Veteran’s health to be subject to military training. There is no indication that Dr. McGavran performed x-ray studies as to the Veteran’s knees. A July 1968 statement from W. H. Hauser, M.D., also associated with the Veteran’s service treatment records, notes that the Veteran was referred to his office for an orthopedic examination in July 1968. Dr. Hauser reported that the Veteran stated that he had difficulty with both knees. It was noted that the Veteran indicated that he injured both of his knees playing football and that he had re-injured his knees on several occasions since that time. Dr. Hauser related that the Veteran maintained that he had undergone x-rays of both knees and that treatment was recommended by his family doctor. Dr. Hauser reported that the Veteran indicated that his right knee was worse than his left, that it would swell up, and that it would be sore in bad weather or if he twisted it. It was noted that the Veteran also reported that his right knee did not lock and that he would have a squeaking noise at times in the joint with motion. Dr. Hauser stated that the Veteran maintained that his left knee would hurt with twisting or in bad weather, and that it would have a squeaking noise on motion, but that it did not lock or swell. Dr. Hauser indicated that the Veteran had normal range of knee motions, with no tenderness, effusion, or capsular thickening. It was noted that the Veteran’s medial and lateral collateral ligaments, as well as his posterior cruciate ligaments, were stable. Dr. Hauser reported that there was no atrophy measure five inches above the patella, and that the McMurry’s test was negative. Dr. Hauser indicated that x-rays, as ot the lateral right and left knee, were within normal limits, bilaterally. As to an impression, Dr. Hauser stated that the Veteran was fit for military service. An April 1969 treatment entry notes that the Veteran complained of pain in the tibias of both knees. The examiner reported that there was no swelling or erythema, and that he had full range of motion. The impression was stress pains. A July 1970 objective separation examination report includes a notation that lower extremities were normal. Post-service private and VA treatment reports, including examination reports, show treatment for variously diagnosed right and left knee complaints, including chronic knee pain; mild tricompartmental osteoarthritis of the left knee; right knee discomfort (etiology uncertain); degenerative joint disease of the right knee; and degenerative joint disease of the left knee. An August 2010 VA general medical examination report includes a notation that the Veteran’s claims file was reviewed. The Veteran reported that he had suffered bilateral knee pain for many years. He denied that he suffered any injury or trauma during service. The Veteran indicated that approximately two years earlier, he sought treatment for knee pain. He maintained that he had pain in both knees that was sharp and dull. It was noted that the Veteran rated the bilateral knee pain as an eight or nine out of ten. The Veteran reported that his provocative factors were prolonged walking, and that his palliative factors were nonsteroidal anti-inflammatory drugs and Vicodin. The examiner reported that prior to service, the Veteran’s physician indicated that he had early degenerative arthritis of both knees. The examiner stated that current x-rays, as to the Veteran’s right knee and left knee, relate impressions of a normal right knee and a normal left knee. The diagnosis was a normal knee examination. The examiner indicated that there was a question regarding the development of early degenerative joint disease of both knees prior to the Veteran’s period of service. The examiner stated that radiographs were normal at that time. The examiner stated that current radiographs were also completely normal as well. It was noted that there was no current evidence of degeneration. The examiner indicated that the Veteran had no permanent residual or chronic disability subjective to service connection as shown by the service treatment records or the evidence following service. A June 2018 VA neck conditions examination report includes a notation that the Veteran’s claims file was reviewed. The diagnosis was spinal stenosis of the cervical spine. The examiner specifically noted that the according to the Veteran’s service treatment records, he had degenerative joint disease to the bilateral knees. A June 2018 VA back conditions examination report, by the same examiner who performed the June 2918 VA neck conditions examination report, includes a notation that the Veteran’s claims file was reviewed. The diagnosis was degenerative arthritis of the lumbar spine. The examiner also referred to degenerative disc disease of the lumbar spine. The examiner reported that according to the Veteran’s service treatment records, he had degenerative joint disease of the bilateral knees. The service treatment records show treatment for possible right knee and left knee problems. On a medical form at the time of a May 1968 pre-induction examination the Veteran checked that he had swollen and painful joints and a tricked or locked knee, and the reviewing examiner indicated that the Veteran reported that his knees would swell. An objective May 1968 pre-induction examination report notes that the Veteran had subjective knee complaints, but there was also a notation that his lower extremities were normal. Additionally, a May 1968 statement from Dr. McGavran indicates that the Veteran had degenerative arthritis of both knees. The Board notes, however, that a subsequent July 1968 statement from Dr. Hauser indicates that x-rays, as to the Veteran’s lateral right knee and left knee, were within normal limits, bilaterally, and that the Veteran was fit for military service. The Board observes, therefore, that the Board cannot conclude that the Veteran had preexisting right knee or left knee disabilities prior to service. An April 1969 treatment entry, during the Veteran’s period of service, notes that he complained of pain in the tibias of both knees and that the impression was stress pains. The Board notes that an August 2010 VA general medical examination report indicates that the Veteran complained of bilateral knee pain for many years. The examiner, following a review of the claims file, found that the Veteran had a normal knee examination. The Board observes, however, that subsequent private and VA treatment records show treatment for variously diagnosed right knee and left knee disabilities, including osteoarthritis of the left knee. Additionally, a VA examiner, pursuant to a June 2018 VA neck conditions examination report and a June 2018 VA back conditions examination report, and following a review of the claims file, indicated that according to the Veteran’s service treatment records, he had degenerative joint disease to the bilateral knees. Therefore, the Veteran is currently diagnosed with a right knee disability, diagnosed as degenerative joint disease, and with a left knee disability, diagnosed with degenerative joint disease. Additionally, a VA examiner, pursuant to a June 2018 VA neck conditions examination report and a June 2018 VA back conditions examination report, has specifically found that the Veteran had degenerative joint disease to the bilateral knees during service. Resolving any doubt in the Veteran’s favor, the Board finds that the evidence is at least in equipoise regarding whether the current right knee disability, diagnosed as degenerative joint disease, and left knee disability, diagnosed as degenerative join disease, commenced during his period of service. In light of the evidence of record, the Board cannot conclude that the preponderance of the evidence is against granting service connection for a right knee disability, diagnosed as degenerative joint disease, and a left knee disability, diagnosed as degenerative joint disease. Therefore, service connection for a right knee disability, diagnosed as degenerative joint disease, and for a left knee disability, diagnosed as degenerative joint disease, is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As the Board has granted direct service connection in this matter, it need not address other theories of service connection. 4. Arthritis throughout the Body, other than Degenerative Joint Disease of the Right Knee and Left Knee As discussed above, the Board has granted service connection for a right knee disability, diagnosed as degenerative joint disease, and for a left knee disability, diagnosed as degenerative joint disease. Therefore, the Board will address the issue of entitlement to arthritis throughout the body, other than degenerative joint disease of the right knee and left knee. The Veteran essentially contends that he has arthritis throughout the body, other than degenerative joint disease of the right knee and left knee, that is related to service. See Scott, 789 F.3d at 1375. The service treatment records refer to possible back and shoulder complaints. Such records do not refer to arthritis throughout the body or to any other joint problems, other than the already service-connected bilateral knee disabilities. On a medical history form at the time of a May 1968 pre-induction examination, the Veteran checked that he had swollen and painful joints. He also checked that he had back trouble. The Veteran reported that his shoulder would not let him reach very high after he suffered an injury. He also stated that his back muscle would pull out of place. The reviewing examiner reported that the Veteran had a back sprain a couple years ago, which was not tender presently. The objective pre-induction examination report includes notations that his upper extremities; lower extremities; and spine and other musculoskeletal systems, were all normal. The objective July 1970 separation examination report includes notations that the Veteran’s upper extremities; lower extremities; and spine and other musculoskeletal systems, were all normal. Post-service private and VA treatment records, including examination reports, do not show treatment for arthritis throughout the body. Such records do show treatment for spinal stenosis of the cervical spine; degenerative disc disease and degenerative joint disease of the lumbar spine; acute right and left shoulder pain; and right hip radiculopathy. A June 2018 VA neck conditions examination report includes a notation that the Veteran’s claims file was reviewed. The diagnosis was spinal stenosis of the cervical spine. The examiner stated that the Veteran’s cervical degenerative disc disease (arthritis) was less likely as not related to, or had its onset during, his period of service. The examiner indicated that according to the Veteran’s service treatment records, he did have degenerative joint disease of the bilateral knees. The examiner referred to a medical treatise and stated that degenerative joint disease did not spread to other parts of the body, and that the development of degenerative joint disease affecting other parts of the body depended on how active a lifestyle a person had. It was noted that degenerative joint disease was a common condition that affected most adults older than fifty. The examiner stated that degenerative disc disease was characterized by ongoing deterioration of the discs of the spine and was often due to genetic factors such as age and lifestyle changes. The examiner indicated that the Veteran’s degenerative disc disease of the cervical spine was more likely than not related to the normal aging process. A June 2018 VA back conditions reflects that the Veteran’s claims file was reviewed. The diagnosis was degenerative joint disease of the lumbar spine. The examiner stated that the Veteran’s lumbar spine arthritis was less likely as not related to, or had its onset, during his period of service. The examiner reported that the Veteran did not experience any injury to the low back during his military service and he was not diagnosed with any arthritis of the low back. The examiner indicated that according to the Veteran’s service treatment records, he did have degenerative joint disease of the bilateral knees. The examiner referred to a medical treatise and stated that degenerative joint disease did not spread to other parts of the body, and that the development of degenerative joint disease affecting other parts of the body depended on how active a lifestyle a person had. The examiner indicated that degenerative joint disease of the lumbar spine was a relatively common condition in aging adults, and that it was a normal aging process. The examiner commented that the Veteran’s degenerative disc disease of the lumbar spine was more likely than not related to the normal aging process. A June 2018 VA hand and finger conditions examination report reflects that the Veteran’s claims file was reviewed. The examiner reported that the Veteran not have a current diagnosis associated with any hand and finger conditions. A June 2018 VA foot condition examination report includes a notation that the Veteran’s claims file was reviewed. The diagnosis was bilateral flat foot. The examiner reported that she was unable to find a diagnosis of arthritis of the feet in the medical records or any significant injury in the service medical records. A November 2018 VA non-degenerative arthritis and dysbaric osteonecrosis examination report includes a notation that the Veteran’s claims file was reviewed. The examiner indicated that the Veteran did not have a diagnosis of arthritis throughout the body. The examiner indicated that the Veteran’s alleged inflammatory, autoimmune, crystalline, or infectious arthritis, or dysbaric osteonecrosis diagnoses, were less likely as not incurred in, caused by, or related to, and/or had their onset during, his period of service. The examiner reported that the Veteran’s service treatment records were silent in regard to inflammatory, autoimmune, crystalline, or infectious arthritis, or dysbaric osteonecrosis diagnoses. The examiner stated that there was no medical evidence of chronic, progressive complaints of inflammatory, autoimmune, crystalline, or infectious arthritis, or dysbaric osteonecrosis diagnoses. A November 2018 VA wrist conditions examination report reflects that the Veteran’s claims file was reviewed. The examiner indicated that the Veteran did not have a current diagnosis associated with any claimed bilateral wrist arthritis. The examiner stated that the Veteran’s alleged bilateral wrist arthritis was less likely as not incurred in, caused by, or related to, or had its onset during, his service. The examiner stated that the service treatment records were silent in regard to bilateral wrist conditions or arthritis. It was noted that the Veteran’s available records were also silent in regard to a bilateral wrist condition or arthritis. The examiner stated that there was no medical evidence of chronic, progressive complaints of bilateral wrist arthritis. The examiner reported that the Veteran did have subjective bilateral wrist symptoms, but no established diagnoses. A November 2018 VA elbow and forearm conditions examination report reflects that the claims file was reviewed. The examiner reported that the Veteran did not have a current diagnosis associated with any arthritis of the bilateral elbows. The examiner stated that the Veteran’s alleged bilateral elbow arthritis was less likely as not incurred in, caused by, related to, or had its onset during, his period of service. The examiner reported that the Veteran’s service treatment records were silent in regard to bilateral elbow conditions or arthritis, and his available medical records were also silent in regard to bilateral elbow conditions or arthritis. The examiner indicated that there was no medical evidence of chronic, progressive complaints of bilateral elbow arthritis. It was noted that the Veteran did have subjective bilateral elbow symptoms, but no established diagnoses. A November 2018 VA shoulder and arm conditions examination report includes a notation that the Veteran’s claims file was reviewed. The diagnosis was acute shoulder pain of both shoulders. The examiner reported that the Veteran’s alleged bilateral shoulder arthritis or acute shoulder pain are less likely as not incurred in, caused by, related to, or had their onset during, his period of service. The examiner stated that the Veteran’s service treatment records and medical records were silent in regard to bilateral shoulder arthritis. The examiner related that there was no medical evidence of chronic, progressive complaints of bilateral shoulder arthritis. It was noted that the the Veteran did have subjective bilateral shoulder symptoms, but no established diagnoses. The examiner commented that the Veteran’s medical records did indicate that he was treated for acute shoulder pain in 2015, but that condition had resolved, and any new subjective complaints was a new and separate condition. A November 2018 VA hip and thigh conditions examination report reflects that the Veteran’s claims file was reviewed. The diagnosis was right hip radiculopathy. The examiner stated that the Veteran’s alleged bilateral hip arthritis, or right hip radiculopathy, were less likely as not incurred in, caused by, related to, or had their onset during, his period of service. The examiner reported that the Veteran’s service treatment records and medical records were silent in regard to bilateral hip arthritis. It was noted that there was no medical evidence of chronic, progressive complaints of bilateral hip arthritis. The examiner stated that the Veteran did have subjective complaints of bilateral hip problems, but no established diagnoses. The examiner indicated that the Veteran’s medical records did note an episode of right hip radiculopathy, which would be from his lumbar condition. A November 2018 VA ankle conditions examination report includes a notation that the Veteran’s claims file was reviewed. No diagnoses were provided. The examiner indicated that the Veteran’s alleged bilateral ankle arthritis was less likely than not incurred in, caused by, related to, or had its onset during, his period of service. The examiner reported that the Veteran’s service treatment records and medical records were silent in regard to bilateral ankle conditions or arthritis. It was noted that there was no medical evidence of chronic, progressive complaints of bilateral ankle arthritis. The examiner stated that the Veteran did have subjective bilateral ankle symptoms, but no established diagnoses. The Board observes that the probative medical evidence does not suggest that the Veteran’s claimed arthritis throughout the body, other than degenerative joint disease of the right knee and left knee, is related to his period of service. In fact, the probative evidence of record is against this finding, indicating that the Veteran’s claimed arthritis throughout the body, other than degenerative joint disease of the right knee and left knee, began many years after service, without relationship to service. The Board observes that the VA examination reports discussed above show that the Veteran does not have currently diagnosed arthritis of the hands and fingers; inflammatory, autoimmune, crystalline, or infectious arthritis, or dysbaric osteonecrosis diagnoses; arthritis of the bilateral wrists; arthritis of the bilateral elbows; arthritis of the bilateral shoulders; arthritis of the bilateral hips; or arthritis of the bilateral ankles. The examiner, pursuant to June 2018 VA neck conditions and back conditions examination reports, also found that the Veteran’s degenerative joint disease of the cervical spine and lumbar spine were not related to his period of service. There are no positive etiological opinions of record. The Veteran has asserted that his claimed arthritis throughout the body, other than degenerative joint disease of the right knee and left knee, had their onset during his period of service. The Board observes that while the Veteran is competent to report that he had joint symptoms that he felt were related to arthritis throughout the body, other than degenerative joint disease of the right knee and left knee, during service or since service, he is not competent to diagnose his claimed arthritis throughout the body, other than degenerative joint disease of the right knee and left knee as related to service. See Jandreau, 492 F.3d at 1372 (lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms at the time supports a later diagnosis by a medical professional); Buchanan, 451 F.3d. at 1331 (lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself). Similarly, the Veteran is not competent to provide a nexus, and a medical opinion from a medical professional has not related his claimed arthritis throughout the body, other than degenerative joint disease of the right knee and left knee, to his period of service. Thus, the Veteran’s lay assertions are not competent or sufficient. In sum, the preponderance of the evidence is against the claim for entitlement to service connection for arthritis throughout the body, other than degenerative joint disease of the right knee and left knee; there is no doubt to be resolved; and service connection is not warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. REASONS FOR REMAND This case was remanded in February 2017, partly to afford the Veteran a VA examination to determine the onset and/or etiology of his claimed hypertension. The examiner was to indicate whether it was at least as likely as not that any currently diagnosed hypertension was related to and/or had its onset during the service, to include presumed exposure to Agent Orange during service. The February 2017 Board remand specifically directed the examiner to consider that the National Academy of Sciences Institute of Medicine had concluded that there was “limited or suggestive evidence of an association” between herbicide exposure (e.g. Agent Orange) and hypertension. The Veteran was afforded a VA hypertension examination in June 2018. The diagnosis was hypertension. The examiner opined that the Veteran’s hypertension was less likely than not related to his Agent Orange exposure. The examiner stated that hypertension was not a presumptive illness related to Agent Orange, and the Veteran developed hypertension after his discharge from military service. The Board observes that the examiner did not address the conclusion by the National Academy of Sciences Institute of Medicine that there was “limited or suggestive evidence of an association” between herbicide exposure (e.g. Agent Orange) and hypertension, as requested in the February 2017 Board remand. Additionally, the Board observes that an article in the November 2016 Journal of Occupational and Environmental Medicine entitled Herbicide Exposure, Vietnam Service, and Hypertension Risk in Army Chemical Corps Veterans suggests that herbicide exposure history and Vietnam service status were significantly associated with hypertension risk. See https://www.publichealth.va.gov/epidemiology/studies/vietnam-army-chemical-corps.asp. Moreover, the Veteran is service-connected for other specified trauma and a stressor related disorder. A VA study indicates a possible link between a psychiatric disorder (specifically PTSD), and heart disease. See http://www.research.va.gov/currents/spring2015/spring2015-8.cfm. Additionally, in November 2018, the National Academy of Sciences upgraded hypertension to the “sufficient” category from “limited or suggestive,” indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure.” In light of the foregoing, the Board finds that this issue must be remanded for another medical opinion. The matter is REMANDED for the following action: 1. Ask the Veteran to identify all medical providers who have treated him for hypertension since August 2017. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Schedule the Veteran for a VA examination to determine the onset and/or etiology of his hypertension. The claims file must be reviewed by the examiner. The examiner must specifically indicate whether the Veteran has diagnosed hypertension. The examiner must opine as to whether it is at least as likely as not that any currently diagnosed hypertension is related to and/or had its onset during service, to include presumed exposure to Agent Orange during service. The examiner’s opinion must include consideration that the National Academy of Sciences has upgraded hypertension to the “sufficient” category from “limited or suggestive,” indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure.” Additionally, the opinion must also include consideration that in a study among U.S. Army Chemical Corps Veterans, VA researchers, found an association between both hypertension risk and exposure to herbicides, and hypertension risk and service in Vietnam. The examiner must further opine as to whether the Veteran’s service-connected other specified trauma and a stressor related disorder (to include any medications taken for that condition), or any other service-connected disabilities, caused or aggravated any diagnosed hypertension. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. D. Regan, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.