Citation Nr: 20067664 Decision Date: 10/19/20 Archive Date: 10/19/20 DOCKET NO. 18-12 165 DATE: October 19, 2020 ORDER Entitlement to service connection for a back disability is denied. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is denied. Entitlement to service connection for gastroesophageal reflux disease/Barrett's Syndrome is denied. Entitlement to service connection for irritable bowel syndrome (IBS) is denied. REMANDED Issue of entitlement to service connection for hypertension, to include on a secondary basis, is remanded. FINDINGS OF FACT 1. The Veteran had slight scoliosis at entrance into service but there is virtually no inservice or postservice evidence of any increase in scoliosis at any time; and even assuming that the Veteran injured his back in combat-related helicopter jumps a chronic back disorder, including arthritis, did not manifested until many years after active service and is not demonstrated to be of service origin. 2. The Veteran’s was found to have had juvenile asthma on examination for entrance into active service and it did not undergo an increase in severity during service; and, after many years of smoking tobacco he developed COPD and emphysema. 3. Barrett's syndrome is not clinically demonstrated, and GERD first manifested many years after service, and many years after smoking tobacco, and is not caused or aggravated by service-connected PTSD. 4. IBS first manifested many years after service; is unrelated to military service; and is not caused or aggravated by service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for a back disability are not met. 38 U.S.C. §§ 1110, 1112, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2019). 2. The criteria for service connection for COPD are not met. 38 U.S.C. §§ 1110, 1111, 1116, 1153, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2019). 3. The criteria for service connection for GERD/Barrett's Syndrome, to include on a secondary basis, are not met. 38 U.S.C. §§ 1110, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2019). 4. The criteria for service connection for IBS, to include on a secondary basis, are not met. 38 U.S.C. §§ 1110, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who was born in October 1942, served on active duty from October 1963 to October 1966, to include service in the Republic of Vietnam from March 1964 to January 1965. His military decorations, as stated on his DD 214, include the “Armed Forces Expeditionary Medal (Air Medal (1 OLC), RVN Campaign Medal with device, Aircraft Crewman Badge, Good Conduct Medal (1st Award) National Defense Service Medal.” His military occupational specialty was Air Traffic Controller. This appeal to the Board of Veterans’ Appeals (Board) arose from a December 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In August 2018, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge, a transcript of which is of record. In pertinent part, a November 2018 Board decision found that there was new and material evidence to reopen claims for service connection for tinnitus; bilateral hearing loss; posttraumatic stress disorder (PTSD); IBS; hypertension; GERD/Barrett’s Syndrome; and a back condition. That decision granted service connection for tinnitus and bilateral hearing loss. Claims for a rating in excess of 10 percent for diabetes mellitus type II (DMII) and in excess of 30 percent for coronary artery disease (CAD), status-post bypass grafting (CABG) and myocardial infarction (MI), were denied. Upon reopening, the claims for service connection for PTSD; IBS; hypertension; GERD/Barrett’s Syndrome; and a back condition, as well as an original claim for service connection for COPD, were remanded for further development. A May 2020 rating effectuated the Board’s grants of service connection for tinnitus and bilateral hearing loss, assigning initial 10 percent and noncompensable ratings, respectively. Subsequently, a June 2020 rating decision granted service connection for PTSD, which was assigned an initial 30 percent disability evaluation. In July 2020 the Veteran initiated an appeal as to the initial assignment of a 30 percent rating for PTSD by filing VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) in which he requested a hearing with a Veterans Law Judge (VLJ) and the opportunity to submit additional evidence in support of that appeal within 90 days after that hearing. By letter of September 2020 the Veteran and his attorney were notified of the receipt of VA Form 10182 and were informed that a letter from the Board would be received when the hearing was scheduled and that he had the option to add new evidence during your hearing or within 90 days after your hearing. However, the matter of the initial rating for PTSD is not now before the Board. After the hearing is conducted and any additional evidence is received, this claim will be addressed in a separate Board decision. The Veteran is service-connected for: coronary artery disease (CAD), status post (SP) coronary artery bypass graft (CABG) and myocardial infarction (MI), rated 30 percent; PTSD, rated 30 percent; tinnitus, rated 10 percent; diabetes mellitus, type II, rated 10 percent; and noncompensable ratings are assigned for postoperative (PO) CABG scar of the sternum, and bilateral hearing loss. Veterans Claims Assistance Act of 2000 (VCAA) After filing his claim for disability compensation in February 2006, by letters in March and April 2006 the Veteran was informed of how to substantiate his claims, the elements required for granting service connection, and the assistance VA would provide in evidentiary development, and what he was to provide, as required under the VCAA. See 38 U.S.C. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With respect to the claim for hypertension as associated with herbicide, i.e., dioxin, exposure, he was requested to provide scientific or medical evidence, e.g., scientific or medical journal articles, showing that it was medically associated with dioxin exposures, including any physician’s clinical treatment records and medical opinion. The Veteran never provided such information. In conjunction with a February 2013 claim for service connection for ischemic heart disease, the Veteran reported having been treated by Dr. J. Isaac from 1996 to 2013 and by Dr. M. Arsenian from 1997 to 2013. By letter that same month the RO informed him that those records had been requested but that ultimately it was his responsibility to see that VA received such records. Dr. Isaac executed an Ischemic Heart Disease (IHD) Disability Benefits Questionnaire (DBQ) in April 2013. Moreover, extensive records from Dr. Isaac have been received. In August 2015 the Veteran’s application to reopen claims for, in part, Barrett’s syndrome, IBS, GERD, back problems, and hypertension, as well as an initial claim for service connection for COPD, was received. In an attachment, the Veteran’s attorney reported that the Veteran had received treatment, in pertinent part, from (a) the Massachusetts General Hospital, (b) Beverly Hospital, (c) Addison Gilbert Hospital, (d) Beth Israel Deaconess Medical Center, (e) Jay Isaac, M.D., (f) Asthma and Allergy Affiliates, and (g) Sports Medicine North. In October 2015 the Veteran executed a release to obtain record from the sources listed in the attachment to his August 2015 claim. In an RO letter that same month he was notified that those records, including records of “Melrose-Wakerfield Hospital” had been requested. He was notified that ultimately it was his responsibility to submit relevant evidence. Subsequently, a response was received indicating that records of Melrose-Wakerfield Hospital were unavailable, having been destroyed. Also, responses were received from the Massachusetts General Hospital and Beth Israel Deaconess Medical Center that no records were found. In October 2015 the Veteran was informed by the RO that there had been no response to a request for records from Beverly Hospital and the Sports Medicine North and that a second request was being made but, ultimately, it was his responsibility to submit relevant evidence. In December 2015 the Veteran’s attorney was provided, as requested, a complete copy of his claim file. In September 2019 and June 2020 authorization forms were received to obtain private clinical records. In June 2020 the Veteran and his attorney were notified that, after having received authorization forms, records had been requested from Addison Gilbert Hospital, Asthma and Allergy Affiliates, Massachusetts General Hospital, Melrose Wakefield Hospital, Beverly Hospital, Dr. Jay J Isaac, Sports Medicine North Peabody, North Shore Ear Nose and Throat Associates, and Beth Israel Deaconess Medical Center. June 2020 Reports of Contact reflects that the Beth Israel Deaconess Medical Center and Sports Medicine North Peabody would not provide records unless a fee was paid. Also, in June 2020 a response was received stating that the Veteran had not been seen at the Melrose Wakefield Hospital. Following the videoconference, in September 2018, the Veteran’s attorney submitted voluminous (over 1,000 pages) private clinical records in support of the claims on appeal. And, after the Board’s November 2018 remand to assist in obtaining private clinical records, as recently as July 2020 additional private clinical records were submitted which included treatment for multiple health problems in 2020. There is no argument or contention that all available clinical records have not been associated with the record. Additionally, in light of the argument and testimony at the August 2018 videoconference, following the November 2018 remand of the claims addressed herein, VA medical opinions were obtained addressing the service connection claims. There has been no argument that the medical opinions are in any way inadequate. Accordingly, the Board concludes that there has been full compliance with the mandate of the VCCA and with the November 2018 Board remand. Factual Background On an April 1963 examination for enlistment it was noted that the Veteran had mild seasonal hay fever; an “[u]ndocumented history of bronchial asthma, last attack age of 10. Chest clear Juvenile asthma”; and slight scoliosis to the left. On examination his heart, vascular system, and abdomen and viscera were normal. His blood pressure was 122/78. In an adjunct medical history questionnaire he reported having or having had hay fever, and asthma. He had a history of treatment for hepatis and mononucleosis at the Massachusetts Salem Hospital, Salem Massachusetts. It was noted that there were no sequelae of his infectious hepatitis and infectious mononucleosis 4 years earlier. In December 1963 the Veteran had nasal coryza, sore throat, and headache. On examination his lungs were clear, and the impression was that he had an upper respiratory infection (URI). On general examination for overseas assignment in February 1964 the Veteran’s his lungs and chest, heart, vascular system, abdomen and viscera, and spine were normal. His blood pressure was 122/68. A routine chest X-ray in March 1964 was normal. A July 1964 examination for “ATC” School noted that the Veteran had an anterior nasal deflection to the left with partial, 25%, obstruction, which was not considered disqualifying. On examination his lungs and chest, heart, vascular system, abdomen and viscera, and spine were normal. Three blood pressure readings were 120/80, 118/70, and 122/78. In the summary of defects it was also noted that he had a history of allergic rhinitis, mild only, which was not considered disqualifying. At the time of an EKG, which was within normal limits, his blood pressure was 118/80. In an adjunct medical history questionnaire he reported having or having had asthma, and stomach, liver or intestinal trouble. It was noted that he had a history of “Hapatitus and mononucleosis Salem Hospital, Salem Mass. 1959.” It was also reported that he had a history of juvenile asthma, with the last attack having been at the age of 10. He had mild seasonal hay fever. There were no sequelae from having had infectious hepatitis 5 years ago. A chest X-ray in September 1964 was normal. The information recorded on that clinical record does not reflect and current or history of signs or symptoms of any kind. In April 1965 the Veteran was in a vehicular accident, in which his vehicle rolled over. His only complaint was a headache but on examination he was neurologically intact, and a skull X-rays series was negative. The impression was that no injury was found. On examination for flight class in October 1965 the Veteran’s lungs and chest, heart, vascular system, abdomen and viscera, and spine were normal. His blood pressure was 120/70. A chest X-ray revealed no active disease. In an adjunct medical history questionnaire he reported having or having had hay fever, asthma, and stomach, liver or intestinal trouble. It was noted that he had had childhood asthma and hay fever, which were now inactive. He had had a good recovery from his earlier hepatitis. On examination for flying in April 1966 the Veteran’s lungs and chest, heart, vascular system, abdomen and viscera, and spine were normal. Three blood pressure readings were 120/70, 115/68, and 118/70. A chest X-ray was within normal limits. In an adjunct medical history questionnaire he reported having or having had asthma, and stomach, liver or intestinal trouble. It was reported that he had had hay fever and asthma in childhood but had no problems at present. He had no sequelae from hepatitis with jaundice in 1959. A September 1966 examination for separation from service the Veteran’s lungs and chest, heart, vascular system, abdomen and viscera, and spine were normal. His blood pressure was 120/70. In an adjunction medical history questionnaire he reported having or having had hay fever; asthma; and stomach, liver or intestinal trouble. The Veteran first applied for VA education benefits in December 1966, and received such benefits through 1977. Records of the Massachusetts General Hospital in 1998 show that in July 1998 the Veteran underwent a CABG for CAD. The discharge summary reflects that associated diagnoses were unstable angina, hypertension, elevated cholesterol, GERD, and old MI. He had had an MI in 1997. He had previously been hospitalized in 1997 for an MI. He had a 25 pack year history of smoking. The Veteran’s initial claim for disability compensation, VA Form 21-526, Application for Compensation or Pension, was received in February 2006, in which he claimed service connection for (a) bilateral hearing loss, (b) tinnitus, (c) IBS, (d) Barrett’s syndrome, (f) PTSD, (g) hypertension, (h) GERD, (i) back disorder, and (j) sleep apnea. He claimed that hypertension was due to herbicide exposure in Vietnam. Records from Sports Medicine North from 2007 to 2015 were received. These show that in October 2007 it was reported that the Veteran had a 20 year history of lower and upper back pain, which had been intermittent but worsened with prolonged standing. He had not had previous treatment for back pain. The diagnosis was myofascial low back pain with lumbar spondylosis. In February 2013 it was noted that he had had bilateral hip replacements 3 years earlier. In January 2015 he reported having had low back pain for “quite some time and possible for years.” Records of North Shore ENT of 2008 and 2015 reflect treatment for rhinitis and sinusitis. In June 2008 the Veteran had sinus surgery. Also, in that month it was noted that he had a history of CAD, hypertension, and COPD. In December 2008 it was noted that he had had an upper respiratory tract infection (URTI), and that any viral URTI would exacerbate his pulmonary condition and should be treated aggressively. In June 2013 it was noted that he had resolving sinusitis and pneumonia. He had recently been hospitalized for a COPD exacerbation. Records of the Addison Gilbert Hospital from 2010 to 2015 are on file. These reflect that cervical spine X-rays in April 2010 revealed degenerative changes at the C5-6 level. A chest X-ray in June 2011, taken for a complaint of chest pain, revealed no acute abnormality. X-rays in June 2011 revealed that both hips had been replaced. A study in April 2012 revealed a sliding hiatal hernia without evidence of reflux, esophagitis or stricture, and a small bowel series was normal. A chest X-ray in May 2013, taken for SOB with respiratory failure, when compared to X-rays earlier that month revealed a marked interval worsening, with pulmonary vascular congestion, and a chest X-ray the next day revealed findings that favored pulmonary edema although an underlying pneumonia was not excluded, and the findings suggested pulmonary edema. A May 2013 transthoracic echocardiogram revealed mild hypertrophy of the left ventricle, borderline left atrial enlargement, and mild pulmonary hypertension. Chest X-rays in June 2013 found slightly improved aeration in the left lower lobe, consistent with a resolving infiltrate. In October 2013 he was evaluated for diabetes and hypercholesterolemia. In an Ischemic Heart Disease (IHD) Disability Benefits Questionnaire (DBQ) in March 2013 by a physician’s assistant of the office of Dr. Arsenian it was reported that the Veteran had been diagnosed as having coronary artery disease (CAD) in 2008, a myocardial infarction (MI) in 2005, and had had a coronary artery bypass graft (CABG) in 2005. Additional diagnoses included hypertension, which had been diagnosed in 2005, and diabetes which had been diagnosed in 2008. Hypercholesterolemia had been diagnosed in 2005. He had dyspnea and fatigue on exertion. In an Ischemic Heart Disease (IHD) Disability Benefits Questionnaire (DBQ) in April 2013 by Dr. Isaac it was reported that in 1997 the Veteran had been diagnosed as having CAD, MI, and had had a CABG. There was evidence of hypertrophy or dilatation. He had dyspnea on exertion, for which he took Nitroglycerin. Records of the Asthma and Allergy Affiliates in 2014 and 2015 are on file. These reflect that pulmonary function testing (PFT) in June 2014 revealed a mild restrictive ventilatory defect. He had chronic rhinosinusitis for which he took Prednisone. He had been a smoker for about 30 years, and stopped in 1994. He had known hypertension. His COPD was associated with coughing, wheezing, and shortness of breath (SOB). He had GERD. He had osteoarthritis, and a history of GERD and irritable bowel disease (IBD). He had had a left hip replacement, and a right hip replacement. It was reported that PFT had revealed moderate obstruction. PFT in July 2014 revealed a mild restrictive ventilatory defect, and the possibility of a superimposed early obstructive pulmonary impairment. PFT in October 2014 revealed a moderate restrictive ventilatory defect, and the possibility of a superimposed early obstructive pulmonary impairment. In April 2015 PFT revealed a mild restrictive ventilatory defect, and the possibility of a superimposed early obstructive pulmonary impairment. Records of the Addison Gilbert Hospital show that in January 2014 pulmonary function testing “(overnight oximetry)” was abnormal with a clinical suspicion for obstructive sleep apnea. In May 2014, when evaluated for chronic sinusitis, it was reported that he had numerous medical problems, including “COPD related to past smoking” and sleep apnea, hypertension, CAD, GERD, diverticulitis, and osteopenia. In July 2014 he was evaluated for a left ankle injury but he denied “any other areas of pain or injury such as his back.” In August 2014 a transthoracic echocardiogram revealed mild left ventricular hypertrophy and mild dilatation of the left atrium but no pulmonary hypertension. In October 2014, when evaluated for diabetes, laboratory studies yielded findings which indicated he probably had nephrosclerosis related to hypertension or his cholesterol for his kidney issues. It was also noted that he had a “lot of arthritis.” Voluminous records from J. Isaac, M.D. are on file. These show that in April and August 2010 the Veteran had a history of CAD, CABG done in 1998, hypertension, COPD with bronchospasm, sleep apnea, GERD, and diverticulitis. A May 2012 colonoscopy, conducted due to a history of melena, revealed a small polyp and diverticulosis. A July 2012 esophagogastroduodenoscopy, done for a history of heartburn of many years as well as a history of reflux esophagitis and bile reflux gastritis, revealed Grade I GERD, esophageal dysmotility, and bile reflux gastritis. In June 2013 it was reported that he had back pain, and the assessment was that the back pain was likely related to coughing. In September 2013 he was evaluated for diabetes mellitus, type II, with vascular complications and hypertension. In March 2015 it was noted that an MRI, taken for a complaint of back pain, revealed diffuse degenerative joint disease (DJD). In April 2015 it was reported that he had hypertensive cardiovascular disease. Included were records of the New England Surgery Center that show that in April 2015 he had a lumbar steroid injection on the right due to lumbar radiculopathy. Records from Dr. Issacs also show that in October 2011 a lumbar MRI revealed stable slight multilevel degenerative changes but no evidence of disc herniation or stenosis. In May 2013 he was hospitalized for difficulty breathing. He had a history of COPD and CABG, with compromising pneumonia. In April 2014 he had an infection of his sinuses and lungs. In a December 2015 Initial PTSD Disability Benefits Questionnaire (DBQ) it was reported that the Veteran had a diagnosis of Other Specified Trauma- and Stressor-Related Disorder, which was at least as likely as not a result of fear of hostile military or terrorist activity in Vietnam. It was noted that in high school he had had Hepatitis C and mononucleosis. His MOS involved flight operations and he was sent to Vietnam, and his duties included flight operations, door gunner with exposure to incoming fire, and rappelling out of helicopter. He reported having quit smoking around 1994. A December 2015 Report of General Information reflects that upon being contacted the Veteran was asked about serving as a door gunner during combat missions, and why his DD214 has his MOS as an air traffic controller. His response was that he received the Armed Forces Expeditionary Medal and the Aircraft Crewman Badge, and he believed those to be specific to his combat activity in Vietnam. He was informed that those awards were not on the list of combat medals that allowed VA to concede due to combat activity. On VA cardiovascular examination in May 2017 the diagnoses were: acute, subacute, or old myocardial infarction, date of diagnosis: June 1997; CAD, date of diagnosis June 1997; unstable angina, date of diagnosis July 1998; ventricular arrhythmia, date of diagnosis June 1997; and CABG, date of diagnosis July 1998. He reported progressive limitations in function as his COPD, back pain and left ankle pain had progressed. It was noted that he had had his first MI in June 1997, and a CABG in July 1998. It was reported that “[t]he veteran believes his diagnoses of hypertension and hyperlipidemia date back approximately 35 years to the early 1980s. He is a former 1-2 pack per day smoker for 34 years (quit 1994). He is currently limited functionally by chronic obstructive pulmonary disease and back/ankle pain.” It was noted that his CAD qualified as being within the generally accepted medical definition of ischemic heart disease (IHD). With respect to the etiology of each of the Veteran's heart conditions, including the relationship/causality to other heart conditions, particularly the relationship/causality to the Veteran's IHD conditions, it was reported that the etiology of the MI was the Veteran’s CAD. The etiology of his CAD was hypertension, hyperlipidemia, obesity, and tobacco use. A May 2017 Diabetes DBQ yielded an opinion that the Veteran more likely than not has a true diagnosis of diabetes. His medical records reflected this as a confirmed diagnosis dating back to at least 2013 (although the original labs used to make the diagnosis were unavailable). Since that time, he has actively adopted weight loss strategies and a diabetic diet in order to avoid requiring medications for management of diabetes. At the August 2018 videoconference the record was held open for 20 day to submit additional evidence. The Veteran’s attorney asserted that medical literature supported the belief that the Veteran’s GERD and IBS were associated with or due to his anxiety (from the subsequently service-connected PTSD). See page 5 of the transcript. It was not contended that either GERD or IBS or hypertension were incurred during service. Page 33. The Veteran testified that he had flare-ups of IBS consistent with his flare-ups of PTSD. Page 15. The attorney asserted that there was a higher incidence of hypertension among veterans with combat experience, but that it was not contended that hypertension had its onset during service. Rather, it was contended that it was due to the service-connected CAD, with stent implacements, and (the subsequently service-connected) PTSD. Page 5. The Veteran testified that his hypertension had been diagnosed when he was in his mid-twenties, and he had been 22 and 23 years of age while in Vietnam. Page 16. The Veteran testified that he served in Vietnam with the 119th Aviation Attack Helicopter Company. Page 6. His job had been the maintaining process and recording of information of daily sortie but he was also a helicopter gunner, firing a variety of weapons. Page 7. He testified that he had impaired breathing which he believed was due to Vietnam herbicide exposure. Page 10. He had some problems with his memory which might be due to aging or his PTSD. Page 12. The Veteran’s attorney asserted that the Veteran had had an inservice chest X-ray in September 1964 (while in Vietnam) was consistent with his having breathing difficulties at that time. Page 33. The Veteran’s attorney also suggested that at that time the Veteran had “a full pulmonary test.” Page 33. Also as to the claimed COPD, the Veteran testified that he first received treatment for it “[p]robably in the Army probably.” He testified that as to treatment for COPD he believed it had first been treated while in the Army. Page 19. At that time it was asthma, and not COPD, and now he had a combination of asthma and emphysema. He was first treated in the Army after returning from Vietnam. Page 20. He also referenced inservice exposure to Agent Orange. Page 21. However, he also testified that he had “had trouble breathing pretty much my whole life and the military didn’t help any.” He believed his inservice respiratory problems were due to multiple exposures while in Vietnam to smoke, fuels and fumes, as well as the heat and humidity in Vietnam, and he had no such exposures after service. Page 22. The Veteran testified that he hurt his back jumping out of helicopters. Page 23. In particular, he recalled two back injuries that occurred in combat. He had probably not been treated for his back at that time, but he believed he probably did later during service while attending air traffic school, after service in Vietnam. Page 24. He had continuously received treatment for his back after service. Page 25. Following the videoconference the Veteran’s attorney submitted voluminous (over 1,000 pages) private clinical records in September 2018 reflecting treatment for a great many disabilities. The much of these are duplicate of records previous on file. A 1999 esophagogastroduodenoscopy yielded clinical impressions of esophageal dysmotility, questionable Barrett’s esophagus, diffuse gastritis, and mild duodenitis. A colonoscopy in December 2004 yielded a diagnosis of diverticulosis. In January 2006 he was evaluated at Northeast Hospital Corporation for his hypercholesterolemia and questionable hypertension. When hospitalized in February 2008, at that facility, a chest X-ray revealed hyperinflated lungs, and it was reported that he had a history of mild obstructive emphysema. These records also show that July 2012 clinical record from the Northeast Hospital Corporation reflect that the Veteran had a history of chronic heartburn dating back to prior to 1999. A May 2012 colonoscopy revealed a polyp and diverticulosis. Private clinical records also show that lumbar X-rays in 2012 revealed degenerative changes. He received treatment in 2014 for bilateral radiculopathy. A September 2015 record of Lahey Health shows that the Veteran was evaluated for complaints of memory loss. A March 2017 record of Sports Medicine North shows that the Veteran’s complaints of pain on walking long distances was consistent with neurogenic claudication which, along with lumbar radiculopathy, was the clinical impression. On VA hypertension DBQ in September 2019 the Veteran’s VA electronic claim file and medical records were reviewed. The Veteran reported his history of an MI, CAD, and CABG. The examiner noted that the service records were negative for hypertension during service. The Veteran now had hypertension, for which he took medication. The examiner opined that hypertension was less likely than not proximately due to the service-connected CAD. The rationale was that the service treatment records (STRs) were silent for hypertension during active duty service and that he had cardiac risk factors, including a history of tobacco abuse, having quit smoking in 1994 after having smoked one pack per day for 30 years; hyperlipidemia; and a family history of CAD. The examiner cited an Internet source in support of the opinion and noted that the source stated that although epidemiological data indicated a strong and consistent link between hypertension and CAD this did not mean that hypertension was the cause of CAD. Less than a quarter of the risk of developing CAD could be attributed to raised blood pressure. The examiner also opined that it was less likely than not that the Veteran's hypertension had been aggravated beyond its natural progression by his CAD. The rationale was that the STRs were silent for hypertension during active duty service and that he had cardiac risk factors, including a history of tobacco abuse, having quit smoking in 1994 after having smoked one pack per day for 30 years; hyperlipidemia; and a family history of CAD. The examiner cited the same Internet source in support of the opinion. The examiner also opined that it was less likely than not that the Veteran's hypertension had been caused by or aggravated beyond its natural progression by his PTSD. The rationale stated by the examiner was that in addition to the STRs being silent for hypertension, there was no nexus to connect hypertension to an acquired psychiatric disorder because these were two separate conditions. On VA respiratory DBQ in September 2019 the Veteran’s VA electronic claim file and medical records were reviewed. It was reported that he had been diagnosed as having COPD, for which he now took medication. The examiner noted that the service records were negative for COPD during service but his service records noted a history of childhood hay fever and asthma, with the last asthma attack having been at the age of 10. It was further stated that the Veteran now required continuous oxygen therapy. Pulmonary function testing was done which found a mild mixed obstructive/restrictive ventilatory defect. The Veteran did not have multiple respiratory conditions. The examiner opined that the claimed respiratory disorder clearly and unmistakably existed prior to service. The rationale was that the entrance examination documented a history of juvenile bronchial asthma, with the last attack being at the age of 10, and mild seasonal hay fever. As to the query of whether there was clear and unmistakable evidence that the disorder was aggravated by service (i.e., worsened beyond its natural progression) the examiner opined that it was “less likely than not that the Veteran's claimed COPD/respiratory condition was not [sic] aggravated beyond its natural progression during service.” The examiner also opined that it was less likely than not (less than 50% probability) that the claimed COPD/respiratory condition was incurred during service. The rationale was that the STRs were silent for COPD or a respiratory condition and/or treatment prior to or during active service. On VA spinal DBQ in September 2019 the Veteran’s VA electronic claim file and medical records were reviewed. After a physical examination the diagnosis was that he had a lumbar strain. The Veteran reported having been in a vehicular accident during service, in which the vehicle rolled over. He now had constant low back pain, and had had physical therapy, acupuncture, and chiropractic adjustments but no surgery. His history of slight scoliosis to the left having been found at service entrance was noted. The examiner opined, after noting a review of the claim file and VA treatment records as well as the Veteran's lay statements, obtained history, and conducting a physical examination related to the claimed back condition, that it was less likely than not (less than 50% probability) that the claimed back disorder was incurred in or caused by service. It was noted that the entrance examination found only slight scoliosis to the left and that the STRs were silent for a back disorder, including no treatment, and the separation examination was negative. As to a back disorder, in April 2020, response to a request for an addendum opinion addressing the Veteran's lay statements regarding his combat-related helicopter jumps, accepting such accounts as credible, the 2019 examiner opined that after a thorough review of all available medical records, and Veteran's lay statement regarding his combat-related helicopter jumps, his obtained history, and a physical examination related to the claimed back condition, that it was less likely than not (less than 50% probability) that the claimed back disorder was incurred in or caused by service. The rationale was the claimed back condition was directly related to his occupational and lifestyle activities. Although the enlistment examination found slight scoliosis to the left, the STRs were silent for a back condition and/or treatment regarding his combat-related helicopter jumps during service, and after service the Veteran worked for many years, having retired in 1999 and then working at another job for a further 5 years. As to COPD, in April 2020, response to an addendum addressing the Veteran's lay statements regarding exposure to helicopter fuel and fumes and shortness of breath, as well as the Veteran's presumed exposure to herbicide agents, the 2019 examiner opined that after a thorough review of all available medical records, and Veteran's lay statements as to various exposures, it was less likely than not (less than 50% probability) that the claimed respiratory condition was incurred in or caused by during service. Rather, the claimed respiratory condition was directly related to his occupational and lifestyle activities. The rationale the STRs were silent for the claimed COPD/respiratory condition and/or treatment regarding exposure to helicopter fuel and fumes and shortness of breath. Also, the Veteran had a history of tobacco abuse, having smoked 1 pack per day for 30 years, until quitting in 1994. He was diagnosed with COPD several years after separation from service. A May 2020 VA DBQ for esophageal conditions reflects that the VA electronic records were reviewed. The Veteran was not examined because of the COVID-19 pandemic. The diagnosis was GERD and it was reported that this disorder had been diagnosed in 2011, when he had reflux. It was noted that a July 2012 upper endoscopy had confirmed the presence of GERD. There was no objective evidence to support claim for Barrett's Syndrome. Therefore, no diagnosis of Barrett's Syndrome was warranted. With respect to a relationship to PTSD, it was opined that the conditions of GERD and PTSD were not medically related. GERD was not caused or aggravated by PTSD. The GERD was a separate entity entirely from PTSD and unrelated to it. There was no objective evidence found to support claim that GERD was aggravated by PTSD. Citation was made to a medical source on the Internet, maintained by the Mayo Clinic, and it was stated that the causes of GERD were multifactorial. According to medical literature GERD was caused by frequent acid reflux. Risk factors for GERD included obesity. Factors that could aggravate acid reflux included smoking. Thus, a nexus was not established because a thorough review of medical literature failed to demonstrate a causal relationship. A May 2020 VA DBQ for intestinal conditions, including IBS, reflects that the VA electronic records were reviewed. The Veteran was not examined because of the COVID-19 pandemic. The diagnosis was IBS and it was reported that this disorder had been diagnosed in 2009. With respect to a relationship to PTSD, it was opined that the conditions of IBS and PTSD were not medically related. Rather, IBS was a separate entity entirely from PTSD and unrelated to it. There was no objective evidence that IBS was aggravated beyond its natural progression by PTSD. IBS was not caused or aggravated by PTSD. Citation was made to a medical source on the Internet, maintained by the Mayo Clinic, noting that IBS could develop from bacterial or viral infections of the intestines and that research indicated that microflora in people with IBS might differ from microflora in healthy people. Thus, a nexus was not established because a thorough review of medical literature failed to demonstrate a causal relationship. Received in June 2020 were records of North Shore Ear, Nose and Throat Associates dated in 2019 and none of which are material to the claims now before the Board, dealing primarily with vestibular problems. Received in June 2020 were records of Addison Gilbert Hospital in 2020 which includes a January 2020 record of Lahey Health Outpatient Physical Therapy that reflects therapy for vestibular problems and that the Veteran’s past medical history included chronic kidney disease. Received in June 2020 were records of the Beverly Hospital reflecting, in pertinent part, treatment in 2020 for COPD. Received in June 2020 were records of the Massachusetts General Hospital reflecting, in pertinent part, treatment in 2018 and 2019 for vestibular and upper respiratory problems. Records of Asthma and Allergy Affiliates show treatment and evaluation in 2018 for allergic rhinitis and COPD. Pulmonary function testing in July 2018 revealed severe obstruction. The assessments were COPD, seasonal and perennial allergic rhinitis, and hypertension, unspecified type. In August 2018, when seen for nasal symptoms, revealed an obstructive component which had been stable over time. Records of J. Isaac, M.D. of Blackburn Primary Care from 2015 to 2020 were received. A January 2015 CT low does lung screening revealed extensive emphysematous changes, bilaterally, most pronounced in the upper lobes. In April 2015 he had a transforaminal epidural lumbar steroid injection at L3/4 and L4/5 on the right at the New England Surgery Center because of a preoperative diagnosis of lumbar radiculopathy which caused leg pain. A lumbar MRI in November 2015 revealed lumbar degenerative disc disease and facet arthropathy, with minor disc bulging at L5-S1. In June 2017, at the time of an abdominal CT scan, it was noted that prior imaging revealed a history of diverticulitis; and current imaging revealed colonic diverticulosis without evidence of acute diverticulitis. Records of J. Isaac, M.D. of Blackburn Primary Care also reflect that a January 2018 laboratory study revealed his “BUN” was 26 mg/dl (with normal being from 8 to 28). A May 2018 laboratory study revealed his “BUN” to be normal at 18 mg/dl (with normal being from 7 to 24). In October 2018 a laboratory study revealed his “BUN” to be high at 27 mg/dl (with normal being from 7 to 24). Chest X-rays in June 2018 revealed hyperinflation of the lungs and flattening of the diaphragm indicating COPD, as well as emphysematous change preferentially involving the upper lobes. At an October 9, 2018 office visit it was reported that the Veteran had diabetes mellitus type II with renal and vascular complications. Imaging in November 2018, compared to a CT of the abdomen and pelvis in June 2017, revealed a “hyperechoic focus at the upper pole” of the right kidney” which likely reflected a “angiomyolipoma” and “a well-circumscribed anechoic cyst at the midpole.” In 2018 his past medical history was noted to include hypertension, diabetes mellitus type II with vascular complications, hypertensive cardiovascular disease, COPD with bronchospasm, obstructive sleep apna (OSA), GERD, diverticulitis, and osteoporosis. Records of J. Isaac, M.D. of Blackburn Primary Care show that a report of a November 1, 2018 office visit yielded assessments of COPD “former smoker” and hypertensive cardiovascular disease “bp [blood pressure] is not ideal. likely from active pulmonary process.” A January 2019 a laboratory study revealed his “BUN” to be 22 mg/dl (with normal being from 7 to 24). A July 2019 spirometry revealed a moderate restrictive defect. An October 2019 VAOPT record shows that the Veteran had a cardiology consultation. It was noted, in pertinent part, that he had a history of hypertension, degenerative joint disease (DJD), and COPD. Principles of Service Connection Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C. § 1110; 38 C.F.R. §3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Service connection may be granted for any disease diagnosed after discharge, when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain conditions, arthritis, and peptic ulcers which are either gastric or duodenal, will be presumed to have been incurred in service if manifested to a compensable degree within 1 year after service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. However, not every manifestation of joint pain, or any cough, during service will permit service connection for arthritis or pulmonary diseases first shown as a clear-cut clinical entity at some later date. 38 C.F.R. § 3.303(b). Service connection may be established under 38 C.F.R. § 3.303(b) by evidence of (a) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) which requires (i) a sufficient combination of manifestations for disease identification, and (ii) sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “chronic” and (iii) subsequent manifestations of the same chronic disease, or (b) if chronicity in service is not established, as above, by evidence of continuity of symptomatology which requires that (i) a condition was ‘noted’ during service, and (ii) evidence of postservice continuity of the same symptomatology, and (iii) medical or lay evidence of a nexus between the present disability and the postservice symptomatology.” See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Service connection will be granted on a secondary basis for disability that is proximately due to or the result of, or permanently aggravated by, an already service-connected condition. 38 C.F.R. § 3.310(a) and (b). This requires (1) evidence of a current disability; (2) a service-connected disability; and (3) evidence establishing a nexus between the service-connected disability and the claimed disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran served in the Republic of Vietnam during the Vietnam Conflict and is presumed to have been exposed to herbicide agents. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309. The list of diseases that are deemed associated with herbicide exposure does not include asthma, COPD, GERD, Barrett’s syndrome, or irritable bowel syndrome. The Board must find whether the preponderance of the evidence is against the claim. If so, it is denied, but if the preponderance supports the claim or the evidence is in equal balance, the claim is allowed. 38 U.S.C. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1365-66 (Fed. Cir. 2001); 38 C.F.R. § 3.102. If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. 1. The claim for service connection for a back disability The Veteran had slight scoliosis to the left at service entrance but this was not shown to be productive of disability and he was admitted into active service despite this abnormality. Moreover, there is no evidence of record that there was any increase in the scoliosis during military service or even thereafter. Accordingly, the Veteran was in sound condition at service entrance and the matter before the Board is whether any other low back disability was incurred during active service or whether arthritis, as a chronic disease, of the lower spine manifested within one year of service. In this regard, as a clinical entity arthritis is not demonstrated merely by complaints of pain but must be shown by radiological, X-ray, studies. In this case, it is neither shown nor contended that the Veteran developed arthritis during his active service in the 1960s or within one year of his October 1966 discharge from active service. The Veteran testified that he injured his low back on two occasions during combat operations while jumping out of helicopters but did not recall having immediately sought treatment, although he thought he might have at some later date during service. In this regard, the service treatment records (STRs) are silent for treatment for a back injury. As to this, at the 2019 evaluation he reported having injured his back in an inservice vehicular accident and now had constant low back pain. However, the STRs are quite clear that roll-over vehicular accident, in April 1965 and after his return from Vietnam, did not cause any back injury. To the contrary, the STRs are quite explicit that the Veteran then reported only having a headache and, equally significant, the clinical impression at that time was that there was no injury. In other words, although the Veteran’s testimony suggests that after combat in Vietnam he sought treatment for combat-related back injuries, the evidence demonstrates otherwise. Rather, he sought treatment after being in Vietnam when he was in a vehicular accident during service but not for combat-related back injuries and at that time it was reported that other than having a headache he had no injury from the vehicular accident. Thus, while the Veteran may have injured his back during combat, and here the Board need not make any specific determination that he did, the passage of many years and his demonstrated impairment of his memory, which he acknowledged at the hearing, of events many years earlier has led to some confusion in his recollection of past events. Unfortunately, this diminishes his credibility. Also, the Board must point out that the earliest contemporary clinical evidence pertaining to any disability of his back is in 2007, he had not had prior treatment for his back pain, which is in direct contrast to, and contradicts, his testimony that he had continuously received treatment for his back after service. In assessing varying clinical histories related in the evidentiary record, the Board looks to the clarity with which the clinical histories were reported, the depth of details related, the consistency between the clinical history related in each document, and whether examinations were conducted in light of the history reported. Lay evidence does not have to be corroborated by contemporaneous competent medical evidence and does not, by itself, render lay evidence not credible but the lack of such medical evidence is a factor in weighing and considering lay evidence. 38 C.F.R. §§ 3.303(a), 3.307(b). For example, lay statements may be of slight probative value when there is a significant time delay between the affiant’s observations and the date the statement is made or if there are conflicting statements or bias or self-interest. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed.Cir. 2006); see also Smith v. Derwinski, 2 Vet. App. 147, 148 (1992) (citing Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). By this, the Board does not confuse the requirement of continuity of symptomatology with continuity of treatment, and only the former and not the latter is required. As to this, the earliest contemporary clinical evidence pertaining to any disability of his back is in 2007 at which time it was reported that he had only a 20 year history of back pain. This antedates the onset of his back pain to only 1987, which is a point in time more than 20 years after his discharge from active service. Thus, continuity of symptomatology is now shown and the Veteran’s testimony of continuity of postservice treatment is refuted by the contemporary clinical evidence. The evidence since the Veteran initially sought treatment for his back in 2007 shows that he has developed osteopenia. “Osteopenia is reduced bone mass. DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1202 (28TH ed. 1994).” Moore v. West, 17 Vet. App. 238 (Table), No. 98-195, slip op. (U.S. Vet. App. Oct. 26, 1999); 1999 WL 1023754 (Vet.App.). The evidence also shows that he has developed osteoporosis. Osteoporosis is an age-related condition characterized by decreased bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fractures— especially of the vertebral bodies of the spine, the hip (particularly the neck and intertrochanteric regions of the femur), and the wrist (distal radius). It is ordinarily asymptomatic until a fracture occurs. Joint manifestations are not always present; vertebral fractures, for example, may result primarily in neurologic complications. 68 Fed. Reg. 7007 (February 11, 2003). In this regard, in 2014 and 2015 it was clinically reported that he had extensive or diffuse arthritis, but this was at a time when he was 70 years of age or older. The 2019 official spinal evaluation and addendum are to the effect that even assuming as credible the Veteran’s reports of injury from combat-related helicopter jumps, his current back disability, diagnosed as a lumbar strain, was not related to his military service. Rather, the medical opinion was that his current disability was related to his occupational and lifestyle activities. Equally important, there is no contrary medical opinion of record, nor medical records which would antedate current disability of the back to the Veteran’s military service. For these reasons and bases, the Board finds that the preponderance of the evidence is against the claim for service connection for a back disorder and, so, there is no doubt to be resolved in favor of the Veteran. 2. The claim for service connection for COPD When no preexisting medical condition is upon entrance into service, a veteran is presumed to have been in sound condition. 38 U.S.C. § 1111. The burden is on VA to rebut the presumption of soundness by clear and unmistakable evidence that a disability was both preexisting and not aggravated by service, and the latter may be demonstrated by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or (2) any increase in disability was due to the natural progression of the condition. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991); Quirin v. Shinseki, 22 Vet. App. 390, 397 (2009); and Horn v. Shinseki, 25 Vet. App. 231 (2012). If there is an increase in a pre-existing disability during active service aggravation is presumed and the burden shifts to the government to show a lack of aggravation by a specific finding established by clear and unmistakable evidence that the increase in disability is due to the natural progress of the disease. See Townsend v. Derwinski, 1 Vet. App. 408, 410 (1991); see also Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004) (citing 38 U.S.C. § 1153) and 38 C.F.R. § 3.306(b)). On the other hand, if a disability is found on the service entrance examination for entrance, the presumption of soundness does not apply and the burden is on the Veteran to establish that the disability was aggravated during service, i.e., underwent an increase in severity during service. Here, the service entrance examination revealed the Veteran’s history of asthma which had existed prior to service. Although it was then noted, and noted on several other occasions during service, that the last attack of asthma had been at the age of 10, the 2019 respiratory evaluator found that the Veteran’s respiratory disability, which has subsequently been diagnostically classified as COPD, clearly and unmistakably pre-existed service, primarily because it was noted on the entrance examination. This higher level of evidentiary proof (clear and unmistakable evidence) is not required when the disorder is found on the entrance examination but, nevertheless, the 2019 evaluator was certain that it did pre-exist military service. As to the question of inservice aggravation the 2019 evaluator reported that it was “less likely as not” that the respiratory condition “was not aggravated beyond its natural progression during service.” While this use of a double negative (“less likely as not” and “not aggravated”) is at best inartful, the meaning of the opinion, when taken in context and as used in the report as a whole, makes it clear that the evaluator found that there was no aggravation, i.e., increase, beyond a natural progression. This is corroborated by the fact that during service the Veteran was not seen or treated for a respiratory ailment, other than the acute and transitory URI in 1963. The Board has also considered the Veteran’s lay speculation that inservice exposure to herbicides, heat, humidity, fuels, and fumes somehow played a role in his development of chronic respiratory disability. However, while not doubting that he had such exposures, the Board is not required to accept the Veteran’s lay interpretation of medical evidence because the Veteran lacks the education, experience, and training to make such interpretations. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). While competent medical evidence is not always required in a claim for service connection, and competent lay evidence may suffice in an appropriate circumstance, competent evidence of some kind, either medical or lay evidence, is required. Posited against the Veteran’s interpretation of the evidence, which is not supported by the actual medical evidence on file, is the opinion of the 2019 evaluator that the claimed exposures were less likely as not the cause of the claimed respiratory disability. In this regard, the evaluator stated that the STRs were negative for an active respiratory disability. As to this, the Veteran’s attorney asserted at the hearing that a September 1964 chest X-ray was consistent with the Veteran’s then having had breathing difficulties. However, the report of that X-ray contains no such clinical notation or history and, equally significant, the STRs of the Veteran’s remaining two (2) years of military service are also negative for signs, symptoms, complaints, history, treatment or diagnosis of a respiratory disorder during active service. Moreover, that chest X-ray was more than nine (9) months after the acute URI in December 1963. While posited as lay evidence, the Veteran’s belief that inservice exposure to a variety of allegedly causative factors, i.e., herbicides, heat, humidity, fuel, and fumes, was the cause or a precursor of his respiratory disorder, it is actually a medical opinion in the guise of lay evidence and, as such, is not competent because respiratory disorders can have many causes and so medical expertise is necessary to resolve the question. The Board is not required to accept the Veteran’s lay interpretation of medical evidence because the Veteran lacks the education, experience, and training to make such interpretations. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). While competent medical evidence is not always required in a claim for service connection, and competent lay evidence may suffice in an appropriate circumstance, competent evidence of some kind, either medical or lay evidence, is required. Here, there is neither competent medical evidence nor lay evidence which is both competent and credible that establishes the required nexus between the inservice exposures of the sort alleged and the current respiratory disorder or even an increase in severity during service of the pre-existing respiratory disorder. As to continuity of symptomatology, because the respiratory disorder pre-existed active service, the fact that the Veteran continued to have respiratory problems after service is not persuasive that there was an inservice increase in his pre-existing respiratory disorder. In other words, the very fact that he had this disability at entrance into service would mean that he was likely to continue to have this respiratory disability even after service. This is particularly true considering the observation of the 2019 evaluator of the Veteran’s long history of smoking tobacco prior to eventually quitting in 1994. The fact that he quit smoking in 1994, prior to there being diagnoses of COPD and evidence of emphysema, does not mean that he could smoke for many, many years without subsequent adverse medical and health consequences. Thus, the Board finds that the record as a whole and in particular the probative opinion of the recent VA evaluator outweighs, for the reasons explained, the credibility of the Veteran’s statements and testimony of the inservice onset of chronic respiratory disability and the putative continuity of symptomatology. For these reasons, the Board finds that even after consideration of the doctrine of the favorable resolution of doubt and the claim must be denied. 3. The claim for service connection for GERD/Barrett's Syndrome, to include on a secondary basis Barrett’s syndrome is also called Barrett’s esophagus. “‘Barrett’s esophagus involves ‘peptic ulcer of the lower esophagus, often with stricture, due to the presence of columnar-lined epithelium in the esophagus (sometimes containing functional mucous cells, parietal cells, or chief cells) instead of the normal squamous cell epithelium. It is sometimes premalignant, followed by esophageal adenocarcinoma.’ DORLAND'S at 1848.” Trull v. Shinseki, No. 08-1892, slip op. (U.S. Vet. App. Jan 21, 2010) (nonprecedential memorandum decision). Gastroesophageal reflux is the “reverse flow of material from stomach to esophagus.” Cox v. Brown, 5 Vet. App. 95, 97 (1993). Gastroesophageal reflux is the most disabling manifestation of a hiatal hernia. 76 Fed.Reg. 39160, 39174 (July 5, 2011). Although the Veteran had, and completely recovered from, an episode of hepatitis prior to military service, the STRs are negative for upper gastrointestinal signs, symptoms, complaints, treatment, history or diagnosis of either Barrett’s syndrome or GERD. Similarly, there is no evidence of Barrett’s syndrome, in the form of ulcer disease, within one year after military service. In fact, the earliest contemporary evidence of GERD or Barrett’s syndrome does not antedate 1998, and an esophagogastroduodenoscopy yielded clinical impressions of esophageal dysmotility, questionable Barrett’s esophagus, diffuse gastritis, and mild duodenitis. This is further supported by the clinical histories that were subsequently recorded that the Veteran’s upper gastrointestinal disability(ies) had had an onset in 1999. Moreover, at the hearing it was asserted that GERD and Barrett’s syndrome were due to the Veteran’s service-connected PTSD. The record is otherwise negative for any evidence of continuity of symptomatology following service and, because the claim is premised upon an association with service-connected PTSD, the absence of any evidence, clinical or lay, of continuity of symptomatology is not required to prove entitlement based on secondary service connection, i.e., either causatively or secondarily. The Veteran, and his attorney, asserted at the hearing that the Veteran has GERD and Barrett’s syndrome due to his service-connected PTSD. However, no supporting evidence, lay or clinical, has been submitted nor has there been any citation to any medical literature. The Veteran’s belief that the claimed disorders are due to PTSD is actually a medical opinion in the guise of lay evidence and, as such, is not competent because gastrointestinal disorders may have many causes and so medical expertise is necessary to resolve the question. The Board is not required to accept the Veteran’s lay interpretation of medical evidence because the Veteran, and his attorney, does not have the education, experience, and training to make such interpretations. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). While competent medical evidence is not always required in a claim for service connection, and competent lay evidence may suffice in an appropriate circumstance, competent evidence of some kind, either medical or lay evidence, is required. Here, there is neither medical evidence nor lay evidence which is both competent and credible that establishes the required nexus between the service-connected PTSD and any current upper gastrointestinal disorder, including any GERD or Barrett’s syndrome. Rather, the only competent evidence of record is the medical opinion rendered in 2020. Although that evaluator may have incorrectly stated that GERD had been diagnosed in 2011, when the Veteran had reflux, this is only because in 1998 GERD and in 1999 there was some evidence of esophageal dysmotility and questionable Barrett’s syndrome. However, repeated studies have never confirmed the presence of any form of peptic ulcer disease at any time. The 2020 evaluator concluded that the Veteran did not have Barrett’s syndrome, which as noted is a form of peptic ulcer of the lower esophagus. With respect to any association of GERD and PTSD, the 2020 evaluator concluded that there was none. The rationale was comprehensive, stating that the two disorders were separate and unrelated, and that GERD was not caused or aggravated by PTSD. Likewise, it was opined that there was no objective evidence found to support claim that GERD was aggravated by PTSD. Equally significant, the evaluator relied upon and cited to an accepted medical source in noting that the causes of GERD were multifactorial, with frequent acid reflux being the physical cause, and the risk factors included obesity, with a risk factor for aggravation including smoking. In this regard, the Board notes that the Veteran had a long history of smoking tobacco prior to the advent of his GERD. In sum, the 2020 evaluator concluded that a nexus was not established between GERD and service-connected PTSD because a thorough review of medical literature failed to demonstrate a causal relationship. This medical opinion is unrebutted by any opposing medical evidence and far outweighs the lay speculation of the Veteran and his attorney because such lay opinions simply are not competent to establish the required nexus. For these reasons and bases, the Board must conclude that even after considering the doctrine of resolving any doubt in favor of the Veteran that service connection for GERD and Barrett's syndrome is not warranted. 4. The claim for service connection for IBS, to include on a secondary basis Although the Veteran had, and completely recovered from, an episode of hepatitis prior to military service, the STRs are negative for lower gastrointestinal signs, symptoms, complaints, treatment, history or diagnosis of either IBS or diverticulitis. In fact, the earliest contemporary evidence of IBS or diverticulitis does not antedate a time which is several decades after the Veteran’s military service. This is further supported by the statements at the hearing that it was not contended that IBS was incurred during service. Moreover, at the hearing it was asserted that IBS was due to the Veteran’s service-connected PTSD. The record is otherwise negative for any evidence of continuity of symptomatology following service and, because the claim is premised upon an association with service-connected PTSD, the absence of any evidence, clinical or lay, of continuity of symptomatology is not required to prove entitlement based on secondary service connection, i.e., either causatively or secondarily. The Veteran, and his attorney, asserted at the hearing that the Veteran has IBS due to his service-connected PTSD. However, no supporting evidence, lay or clinical, has been submitted nor has there been any citation to any medical literature. The Veteran’s belief that his IBS is due to PTSD is actually a medical opinion in the guise of lay evidence and, as such, is not competent because gastrointestinal disorders may have many causes and so medical expertise is necessary to resolve the question. The Board is not required to accept the Veteran’s lay interpretation of medical evidence because the Veteran, and his attorney, does not have the education, experience, and training to make such interpretations. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). While competent medical evidence is not always required in a claim for service connection, and competent lay evidence may suffice in an appropriate circumstance, competent evidence of some kind, either medical or lay evidence, is required. Here, there is neither medical evidence nor lay evidence which is both competent and credible that establishes the required nexus between the service-connected PTSD and any current lower gastrointestinal disorder, including any IBS or diverticulitis. Rather, the only competent evidence of record is the medical opinion rendered in 2020. Although that evaluator stated that IBS had been diagnosed in 2009, the clinical records show that diverticulitis found at the time of at 2004 colonoscopy. Both disorders affect the lower gastrointestinal tract. However, service connection is not claimed for diverticulitis. With respect to any association of IBS and PTSD, the 2020 evaluator concluded that there was none. The rationale was comprehensive, stating that the two disorders were separate and unrelated, and that IBS was not caused by PTSD and that there was no objective evidence that IBS was aggravated beyond a natural progression by PTSD. Equally significant, and as to the contention and testimony at the hearing that there was a consistency between flare-ups of PTSD and flare-ups of IBS, the evaluator relied upon and cited to an accepted medical source in noting that the cause of GERD could be of an infectious origin, either bacterial or viral, with the microflora of those with IBS differing from healthy individuals. No argument or contention has been offered as to how flare-ups of PTSD affect microflora of those with IBS such as to cause a flare-up of IBS. In sum, the 2020 evaluator concluded that a nexus was not established between IBS and service-connected PTSD because a thorough review of medical literature failed to demonstrate a relationship. This medical opinion is unrebutted by any opposing medical evidence and far outweighs the lay speculation of the Veteran and his attorney because such lay opinions simply are not competent to establish the required nexus. For these reasons and bases, the Board must conclude that even after considering the doctrine of resolving any doubt in favor of the Veteran that service connection for IBS is not warranted. REASONS FOR REMAND 1. The claim for service connection for hypertension, to include on a secondary basis, is remanded. At the August 2018 videoconference the Veteran’s attorney conceded that it was not contended that hypertension was incurred during service. Page 33. The attorney asserted that there was a higher incidence of hypertension among veterans with combat experience, but that it was not contended that hypertension had its onset during service. Rather, it was contended that it was due to the service-connected CAD, with stent emplacements, or (the subsequently service-connected) PTSD, or both. Page 5. The Veteran testified that his hypertension had been diagnosed when he was in his mid-twenties, and he had been 22 and 23 years of age while in Vietnam. Page 16. He did not testify that he had hypertension during service or within one year after service. However, negative VA nexus opinions have been obtained as to a relationship between the claimed hypertension and the Veteran’s service-connected PTSD and service-connected CAD (a form of ischemic heart disease). It has not been contended that the Veteran’s hypertension is due to or aggravated by his inservice exposure to herbicides. However, it is undisputed that the Veteran served in Vietnam during the Vietnam Conflict and VA regulations provide a presumption of herbicidal agent exposure and a presumption that certain listed diseases in those so exposed shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service. This list of diseases, at 38 C.F.R. § 3.309(e), includes ischemic heart disease but does not include hypertension. Specifically, Note 2 to 38 C.F.R. § 3.309(e) provides that “[f]or the purposes of this section, the term ischemic heart disease does not include hypertension ….” Nevertheless, notwithstanding the presumptive provisions, service connection for claimed residuals of exposure to herbicides may also be established by showing that a disorder resulting in disability is, in fact, causally linked to the exposure. See Brock v. Brown, 10 Vet. App. 155, 162-64 (1997); Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir.), citing 38 U.S.C. §§ 1113 and 1116, and 38 C.F.R. § 3 In this regard, the National Academy of Sciences had earlier issued a statement that there is only limited or suggestive evidence of a relationship between herbicide exposure and the development of hypertension. However, the National Academy of Sciences in 2018 had changed the classification from limited or suggestive evidence of a relationship to “sufficient” evidence of an association. The duty to assist requires VA to provide a medical opinion when the evidence “indicates” that there “may” be a nexus between the in-service injury and current disability. See McLendon v. Nicholson, 20 Vet. App. 79, 83 2996). Accordingly, a medical opinion should be obtained as to whether the National Academy of Sciences 2018 change of the classification from limited or suggestive evidence of a relationship to “sufficient” evidence of an association warrants finding that the Veteran’s hypertension is due to his conceded inservice herbicide exposure. Also, it has not been contended that the Veteran’s hypertension is due to or aggravated by his now service-connected diabetes mellitus, type II. However, because the Veteran is now service-connected for diabetes mellitus, type II, and because there is also some evidence that his diabetes may have caused renal (kidney) complications, a medical opinion should be obtained as to whether the Veteran’s hypertension has been either caused or aggravated his service-connected diabetes mellitus or, if it exists, diabetic nephropathy. Accordingly, the claim for service connection for hypertension is remanded for the following: An appropriate clinician should be requested to opine whether the National Academy of Sciences 2018 change of the classification from limited or suggestive evidence of a relationship to “sufficient” evidence of an association between herbicide exposure and the development of hypertension warrants finding that it is as likely as not that the Veteran’s hypertension is due to his conceded inservice herbicide exposure. The clinician is also requested to opine, in light of the above, as to whether it is as likely as not that the Veteran’s hypertension is aggravated (having undergone an increase in severity) by his conceded inservice herbicide exposure. The clinician is requested to opine whether it is as likely as not that the Veteran’s hypertension is proximately due to or caused by service-connected diabetes mellitus, type II or, if it exists, any diabetic nephropathy. The clinician is also requested to opine as to whether it is as likely as not that the Veteran’s hypertension is aggravated (having undergone an increase in severity) by his diabetes mellitus, type II or, if it exists, any diabetic nephropathy. As to the latter two opinions, the clinician is requested to comment upon the significance, if any, of the private clinical records indicating that the Veteran has diabetes mellitus with renal complications as well as the significance, if any, of any abnormal findings as to the Veteran’s “BUN” in recent private laboratory studies. The matter of whether an additional in-person examination should be conducted if left to the discretion of the opining clinician. If no examination is scheduled and conducted it will be assumed that the opining clinician deemed an examination to be unnecessary. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Fussell, 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.