Citation Nr: 21001220 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 16-23 491 DATE: January 7, 2021 ORDER Entitlement to a separate disability rating of 20 percent, but no higher, for frequent episodes of locking, pain, and effusion into the joint associated with chondromalacia left knee, effective August 27, 2014, is granted. Entitlement to a disability rating in excess of 10 percent for objective painful motion and limited flexion associated with chondromalacia left knee is denied. Entitlement to service connection for diabetes mellitus is denied. FINDINGS OF FACT 1. The Veteran’s chondromalacia left knee has manifested with frequent episodes of locking, pain, and effusion into the joint from August 27, 2014. 2. Throughout the entire appeal period, the Veteran’s chondromalacia left knee has manifested in consistent pain which resulted in objective functional loss; extension was not limited, and flexion was limited to no more than 45 degrees, with pain on motion. 3. The preponderance of the evidence is against a finding that diabetes is either etiologically related to service or is caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for a separate 20 percent rating for frequent episodes of locking, pain, and effusion into the joint associated with chondromalacia left knee have been met, effective August 27, 2014. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Codes 5258. 2. Throughout the entire appeal period, the criteria for a disability rating in excess of 10 percent rating for objective painful motion and limited flexion associated with chondromalacia left knee have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, and 4.71a, Diagnostic Codes 5256-5263. 3. The criteria for entitlement to service connection for diabetes have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1988 until May 1994. These matters come to the Board of Veterans’ Appeals on appeal from November 2014 and February 2015 Department of Veterans Affairs (VA) regional office (RO) rating decisions. The Board has remanded these claims twice previously. In its November 2018 and September 2019 decisions, the Board found that further development was necessary before adjudication of the claim. As the actions specified in the remand have been substantially completed, the matters have been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Board notes that the Veteran’s claim for entitlement to service connection for acid reflux was the subject of a separate October 2020 Board remand and is not currently before the Board. The Board additionally notes that the requested December 2020 VA examination was performed regarding the etiology of the Veteran’s acid reflux. As the RO is currently proceeding with development of that claim, the Board will not address it in this decision herein. Increased Ratings The Veteran generally asserts that his left knee disability is worse than his current evaluation reflects. The Veteran’s chondromalacia left knee is currently rated at 10 percent disabling under Diagnostic Code 5260. VA is required to evaluate the Veteran’s disability under the most appropriate rating criteria that will provide the most benefit to the Veteran. The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). With respect to disabilities of the knee, 38 C.F.R. § 4.71a, Diagnostic Codes 5256 through 5263 set forth the relevant provisions. However, in this case, the evidence does not demonstrate ankylosis of the knee (Diagnostic Code 5256), recurrent subluxation or lateral instability (Diagnostic Code 5257), symptomatic removal of semilunar cartilage (Diagnostic Code 5259), impairment of the tibia and fibula (Diagnostic Code 5262); thus, the Diagnostic Codes pertaining to such impairments are not applicable. Diagnostic Code 5258 provides for a 20 percent evaluation on the basis of dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. This is the only available evaluation under this diagnostic code. Diagnostic Codes 5260 and 5261 provide for ratings for limitation of motion of the knee. Limitation of flexion of the leg to 60, 45, 30, or 15 degrees are evaluated as 0, 10, 20, or 30 percent, respectively. Limitation of extension of the leg to 5, 10, 15, 20, 30, or 45 degrees are evaluated as 0, 10, 20, 30, 40, or 50 percent, respectively. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability, and incoordination. Where arthritis results in painful motion of the joint, the rating criteria allow for at least the minimum compensable evaluation for the joint. 38 C.F.R. § 4.59. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize painful, unstable, or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint.  Id.  The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided.  38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Moreover, when evaluating musculoskeletal disabilities, VA may, in addition to applying the schedular criteria, assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). Nonetheless, a rating higher than the minimum compensable rating is not assignable under any diagnostic code (relating to range of motion) where pain does not cause a compensable functional loss. The “pain must affect some aspect of ‘the normal working movements of the body’ such as ‘excursion, strength, speed, coordination, and endurance,’” as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. This is because “pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss.” Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). Section 4.59 does not require objective evidence of painful motion. The regulation does not speak to the type of evidence required when assessing painful motion and therefore certainly does not, by its own terms, restrict evidence to “objective” evidence. Petitti v. McDonald, 27 Vet. App. 415, 427 (2015). If credible, lay testimony may consist of a veteran’s own statements to the extent that the statements describe symptoms capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staging the ratings.” See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Entitlement to a disability rating in excess of 10 percent for chondromalacia left knee As stated above, the Veteran’s left knee disability is currently rated at 10 percent disabling under Diagnostic Code 5260. After a review of the evidence, the Board finds that the Veteran’s left knee disability is best rated at 10 percent under Diagnostic Code 5260 for the entire appeal period and an additional 20 percent under Diagnostic Code 5258 effective August 27, 2014. At an August 2014 VA examination, the Veteran reported that his left knee has “achiness and discomfort” and pain on motion. While no instability or flare-ups were noted, the VA examiner found arthritic changes in the Veteran’s left knee. The Veteran’s flexion was limited to 120 degrees with pain beginning at 120 degrees; extension was not limited. The Veteran reported using a cane regularly to ambulate. In an January 2015 addendum, the VA examiner stated that the Veteran’s newly developed left knee arthritic change is considered a progression of the Veteran’s chondromalacia and that pain, weakness, fatigability, or incoordination does not significantly limit functional ability either during flare-ups or when the left knee is used repeatedly over a period of time. In an August 2014 VA treatment note, the Veteran complained of bilateral knee pain and a medial meniscal tear. No effusion was noted, and the Veteran continued with conservative treatments for his left knee disability. A January 2016 VA treatment note indicates that the Veteran has a left discoid lateral meniscus. A May 2015 VA treatment note indicates that the Veteran’s knee pain “seems worse with ascending stairs and rising from chair.” The physician assistant also noted that there was “periodic effusion” and that the Veteran may have dislocated his left knee on a jump “but this is questionable.” In October and November 2015 lay statements, the Veteran stated that his left knee “swells and slips out of joint,” walks with an altered gait, and is limited to slow-paced walking with a cane and knee brace. He also stated that he experiences pain in his knees every day, and is unable to run, squat, bend, or walk for longer than 20 minutes. Further, the Veteran complained of his knees having “slipped out of joint plenty of times. I also have popping and crackling in my knees. My knees swell up once or twice a month.” Private treatment records submitted in May 2016 show that the Veteran has difficulty walking and standing, that it is “very difficult to bend his knees even a little,” and that he has “elevated knee pain with any knee bending or weight bearing.” A March 2016 physical therapy note shows that the Veteran has difficulty bending, dressing, sitting, standing, walking, bed mobility, climbing stairs, standing for more than 10 minutes, and walking for more than 15 minutes even with the use of his cane and knee braces. The Veteran reported his pain to be a 9 out of 10. The Veteran’s flexion was limited to 75 degrees and his extension was limited to -16 degrees. The physical therapist described the Veteran as “very guarded” with the range of motion measurements, that he always ambulates with a severely antalgic gait even with the use of assistive devices and has impaired balance control. In a December 2018 lay statement, the Veteran contended that his knees are “tender with pain, I sometimes have swelling, and I always have aching pain, when it gets cold it is even more painful.” At a January 2019 VA examination, the Veteran’s flexion was limited to 100 degrees; his extension was not limited. The Veteran reported flare-ups and functional loss after repeated use over time and described it as “more pain with use.” The VA examiner did not estimate the expected range of motion on flare-up or repeated use over time or the point where objective painful motion began on either flexion or extension. However, the VA examiner did indicate that the Veteran’s pain on motion caused functional loss, and that there was evidence of crepitus, pain on weight bearing and palpation of the knee. Recurrent effusion was noted. At an April 2019 VA examination, the Veteran did not report flare-ups but reported chronic pain and swelling with repeated use over time; the VA examiner did not estimate the expected range of motion loss due to this functional loss. However, the VA examiner did state that the elements of the Veteran’s functional loss include pain fatigue, and lack of endurance. The Veteran’s left knee flexion was limited to 100 degrees while his extension was not limited. The VA examiner noted pain with weight bearing and palpation, and crepitus. Recurrent effusion was noted. At a May 2019 VA examination, the Veteran reported flare-ups and functional loss with repeated use over time; the Veteran described these manifestations as more pain with use. His left knee flexion was limited to 90 degrees while his extension was not limited. Pain on weight bearing and palpation, and crepitus were noted. Upon flare-ups, the VA examiner estimated that the Veteran’s flexion to be limited to 45 degrees with pain, fatigue, and lack of endurance. The Board notes that the January 2019, April 2019, and May 2019 VA examinations were found not to comply with Sharp v. Shulkin, 29 Vet. App. 26 (2017). At a December 2019 VA examination, the Veteran reported flare-ups about 4 to 5 times per year with increased activity lasting 2 days; these flare-ups are relieved with a heating pad and total rest. The VA examiner estimated range of motion during a flare-up was expected to be flexion from 0 degrees to 45 degrees and extension from 45 degrees to 0 degrees and result in pain, fatigue, lack of endurance, swelling, and disturbance of locomotion. The Veteran also reported functional loss after repeated use over time, however, the VA examiner was unable to estimate the loss of range of motion or limited functional ability because she did not examine him “over time.” While there was evidence of pain in both weight and non-weight bearing and active and passive motion, the range of motion was the same. Recurrent effusion was noted. A May 2020 addendum was submitted which estimated the Veteran’s expected range of motion loss over repeated use to be flexion from 0 degrees to 45 degrees and extension from 45 degrees to 0 degrees. The addendum VA examiner also estimated that the Veteran’s functional loss over repeated use include pain, fatigue, and lack of endurance. In a separate September 2020 addendum, the VA examiner stated that he can only give a retrospective opinion on flare-ups and repeated use only for the December 2019 VA examination, and not the January 2019, April 2019, or May 2019 VA examinations, as he did not examine the Veteran at those times. Based on the evidence of record, the Board concludes that the Veteran is not entitled to an increased rating for his left knee chondromalacia under Diagnostic Code 5260 or 5261. Specifically, the objective evidence of record does not show that the Veteran’s left knee disability is manifested by flexion limited to 30 degrees or by extension limited to 15 degrees at any time during the period on appeal (compare the August 2014 VA examination—flexion limited to 100 degrees; extension not limited—with the December 2019 VA examination—flexion limited to 45 degrees; extension not limited). At worst, the Veteran’s left knee flexion was expected to be limited to 45 degrees, after repetitive use testing and flare-ups, with 0 extension. As such, the Veteran’s left knee disability is no more than 10 percent disabling under Diagnostic Code 5260 or 5261 for the entire period on appeal. The Board has also considered whether a higher rating on the basis of additional functional loss due to pain, weakness, excess fatigability, or incoordination. The Board notes that many of the VA examiner’s estimated that the Veteran experienced additional function loss due to increased pain, weakness, fatigability, or incoordination after repeated use or during flare ups. However, the Board cannot find any objective medical evidence to show that painful motion or additional functional loss causes such an effect as such that would approximate flexion limited to 30 degrees or extension limited to 15 degrees. As the Veteran’s subjective reports of pain and painful motion are already contemplated by his currently assigned 10 percent rating on the basis of limitation of flexion or extension, a higher rating under DeLuca is not warranted. See 38 C.F.R. §§ 4.40, 4.45. A higher rating is also not warranted under Diagnostic Code 5003. Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 20 percent is warranted for x-ray evidence of arthritis with evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. Here, because the Veteran is already in receipt of a 10 percent rating for his left knee disability on the basis of flexion, the Board is unable to assign a separate rating pursuant to Diagnostic Code 5003 under essentially the same manifestation of symptoms, as such would violate the rule against pyramiding in 38 C.F.R. § 4.14. However, resolving all reasonable doubt in favor of the Veteran, the Board finds that from August 27, 2014, his left knee disability warrants a separate 20 percent evaluation under Diagnostic Code 5258 for semilunar dislocated cartilage with frequent episodes of “locking,” pain and effusion into the joint. On that basis, the Board finds that the most favorable evidence during this appeal period is reflected in the clinical findings at an August 2014 VA treatment record indicating that the Veteran has a medical meniscal tear, his October and November 2015 lay statements that his left knee has “slipped out of joint plenty of times. I also have popping and crackling in my knees,” the January 2016 VA treatment record diagnosing him with a left discoid lateral meniscus, and the multiple VA examinations which show he has recurrent effusion into his left knee. For this reason, the Board finds that the available evidence is sufficient to establish that the Veteran’s left knee disability more closely approximates the rating criteria under Diagnostic Code 5258. Accordingly, the Board finds that from August 27, 2014, the date of his meniscal tear diagnosis, the Veteran’s left knee disability warrants an additional 20 percent evaluation. This is the only available evaluation under this diagnostic code. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran’s higher than 10 percent evaluation claim for left knee chondromalacia under Diagnostic Code 5260 or 5261 as his left knee flexion has not been limited to 30 degrees or by extension limited to 15 degrees at any time during the period on appeal. Therefore, the benefit-of-the-doubt rule does not apply, and the higher evaluation claim must be denied. However, resolving all reasonable doubt in favor of the Veteran, from August 27, 2014, a separate 20 percent evaluation, but no higher, under Diagnostic Code 5258 for frequent episodes of locking, pain, and effusion into the joint associated with chondromalacia left knee is granted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection requires competent evidence of (1) a current disability; (2) the incurrence or aggravation of a disease or injury during service; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310 (a). Secondary service connection may also be established for a disability which is aggravated by a service-connected disability. In order to prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509 (1998). Service connection for certain chronic diseases may be established based on a continuity of symptoms since discharge. 38C.F.R. §§3.303 (b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection for certain chronic diseases may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38U.S.C. §§1101, 1112, 1113, 1131, 1137;38C.F.R. §§3.307, 3.309(a). Diabetes is a chronic disease for which service connection may be established based on a continuity of symptoms or presumption. Obesity is not generally considered to be a disease or injury and therefore may not be directly connected to service. See VAOPGCPREC 1-2017 (Jan. 6, 2017). However, VA’s Office of General Counsel has opined that obesity may act as an “intermediate step” between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310(a). Id. In order to establish service connection on this basis, three criteria must be met: (1) the service-connected disease caused the veteran to become obese; (2) such obesity is a substantial factor in causing the disability for which service connection is sought; and (3) the disability for which service connection is sought would not have occurred but for obesity. Id. Entitlement to service connection for diabetes The Veteran contends that he developed his diabetes as a secondary result of his service-connected PTSD, to include as the result of the obesity that he alleges that he developed as a result of his PTSD. The Veteran was diagnosed with type I diabetes in May 2004 and type II diabetes in August 2012 and has a significant family history of diabetes (mother, father, brother, sister). A March 2016 private medical opinion was submitted which noted that recent studies in medical literature supported a correlation between PTSD and obesity, due to over-eating, lack of motivation, low energy levels, social isolation, and medications such as benzodiazepines. The weight gain was then noted to predispose and aggravate the glucose metabolic processes in a cyclical fashion, with glucose control issue related to the weight gain and the weight gain causing glucose control issues. The clinician noted that diabetes was a result of and/or aggravated by both of these factors. The clinician opined that the Veteran’s diabetes was at least as likely as not caused or aggravated by his service-connected PTSD. The Board notes that the November 2018 decision found that the March 2016 private medical opinion was insufficient to grant service connection because it failed to reflect that the clinician considered this specific Veteran’s medical history to an adequate degree as there were several deficiencies in the clinician’s argument (such as pointing out that the Veteran was not diagnosed with diabetes in 2014). September 2016 VA treatment records show that the Veteran’s obesity is related to a history of excessive energy intake and weight gain. At a May 2019 VA examination, the VA examiner opined that the Veteran’s diabetes was less likely than not caused or aggravated by his service-connected PTSD. The VA examiner reasoned that while the medical literature shows an association between diabetes and PTSD, there is no cause and effect relationship. The VA examiner ultimately opined that the Veteran’s diabetes was related to his obesity. In a July 2019 VA addendum opinion, the VA examiner noted that the medical literature does not support a causal relationship between PTSD and diabetes as there is no scientific evidence that PTSD causes or aggravates diabetes. Further, after review of the March 2016 private opinion, the VA internist stated that it relied on associations, and in the absence of scientific evidence that PTSD causes diabetes, the factors outlined in the March 2016 private opinion are irrelevant as “there is no scientific basis upon which to establish a causal connection between PTSD and diabetes.” At a January 2020 VA examination, the VA examiner opined that since the Veteran’s service treatment records are silent for diabetes, it is less likely than not that it was incurred in or caused by service. The VA examiner also opined that while current research shows that PTSD and obesity are both “complex and related to appetitive behaviors around food and other substances, establishing direct correlations remains elusive and challenging.” In other words, while PTSD confers added risk for obesity, science has been unable to isolate a direct cause and effect relationship between them. Int a July 2020 VA addendum opinion, the VA examiner reviewed the medical article submitted in August 2019 but opined that even though it found an association between PTSD and obesity, “association is not causation and it is insufficient to prove a causal relationship.” The VA examiner also clarified and stated that while the March 2016 private opinion describes risk factors and associations between PTSD and diabetes, it does not establish a causal relationship between them. Turning to an analysis of these facts, the Veteran is service connected for PTSD and has a current diagnosis of diabetes. However, the Board finds that the weight of the evidence is against a finding that the Veteran’s diabetes is caused or aggravated by his PTSD, to include the obesity that the Veteran associates with his PTSD. The Board places great probative weight in the May 2019 and July 2019 VA examiner’s conclusion that the Veteran’s diabetes less likely than not directly caused or aggravated his diabetes as there is no scientific evidence that PTSD causes or aggravates diabetes. These VA examinations were thorough and based on the current medical literature. Rodrigues-Nieves v. Peake, 22 Vet. App. 295 (2008). Likewise, the Board affords probative weight to the January 2020 and July 2020 VA examiner’s opinion that while PTSD confers added risk for obesity, science has been unable to isolate a direct cause and effect relationship between them. These examinations too were thorough and based on a reading of current medical literature. Rodrigues-Nieves v. Peake, 22 Vet. App. 295 (2008). Most importantly, even though the Veteran has been successful in showing a general link between his PTSD and obesity, he has not provided any evidence showing that the two are specifically connected in this case. Put differently, while the Veteran’s diabetes has been linked to his obesity (May 2019 VA examination), and the Veteran’s obesity is related to his history of excessive energy intake (September 2016 VA treatment records), the Veteran’s excessive energy intake – i.e., his large appetite – has not been shown to be caused by his PTSD. This portion is the missing link. The only evidence the Board can find is a June 2015 mental health note which indicates that the Veteran reports “being with good appetite and eating well.” While it shows that the Veteran has a good appetite and is eating well, it does not show, specifically, how his obesity was caused by his service-connected PTSD. See VAOPGCPREC 1-2017 (Jan. 6, 2017). For this reason, the Veteran’s argument fails. While the Board has carefully considered the March 2016 private opinion linking the Veteran’s PTSD to diabetes, the Board places relatively less probative weight in this opinion as it is based on a series of associations and failed to consider this Veteran’s medical history to an adequate degree. Regardless, it is outweighed by the probative and thorough May 2019, July 2019, January 2020, and July 2020 VA medical opinions. The Board has additionally considered the lay evidence in this case, in particular, the Veteran’s statements that he believes that his PTSD caused or aggravated his diabetes. However, this evidence is not competent evidence, as he is a layperson and lacks the training to provide adequate opinion regarding medical etiology. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Thus, although the Board has carefully considered the lay contentions of record suggesting that the Veteran’s diabetes is related to his PTSD, the Board affords the objective medical evidence of record, which weighs against finding such a connection, with greater probative weight than the lay opinions, because such evidence was provided by a medical professional and concerned the Veteran’s endocrine system, the internal functioning of which is not readily perceivable by the use of a person’s senses. While the Veteran has not specifically argued that his diabetes is directly related to his service, the Board finds that the weight of the evidence is against such a connection. The weight of the medical evidence, including the finding of the January 2020 examiner, is against such a connection. Furthermore, the Veteran did not show symptoms of diabetes during service or for many years thereafter; he was not diagnosed with type II diabetes until August 2012, about 18 years after separation from service. For this same reason, service connection is therefore unwarranted on either a presumptive basis or based upon a continuity of symptomatology. In sum, the preponderance of the evidence weighs against finding in favor of the Veteran’s service connection claim for diabetes on a direct, secondary, or presumptive basis. Therefore, the benefit-of-the-doubt rule does not apply, and the service connection claims must be denied. 38 U.S.C. § 5107(b). LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Finelli, Associate 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.