Citation Nr: 21002069 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 16-14 696 DATE: January 12, 2021 ORDER Service connection for a bilateral hearing loss disability, to include as secondary to service-connected tinnitus, is denied. Service connection for benign prostatic hypertrophy (BPH), to include as secondary to service-connected posttraumatic stress disorder (PTSD), is denied. Service connection for hypertension, to include as secondary to service-connected PTSD, is denied. Service connection for nephrolithiasis, to include as secondary to service-connected PTSD, is denied. FINDINGS OF FACT 1. The Veteran’s bilateral hearing loss disability did not have its onset during service and is not otherwise related to service, including in-service noise exposure. 2. The Veteran’s BPH is unrelated to service, to include the service-connected PTSD. 3. The Veteran’s hypertension did not have its onset during service, was not shown to a compensable degree within the first post-service year, and is not otherwise shown to be related to disease or injury in service, including service-connected PTSD. 4. The Veteran’s nephrolithiasis was not caused by or incurred in service, to include the service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral hearing loss disability, including as secondary to service-connected tinnitus, have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 2. The criteria for service connection for BPH, to include as secondary to service-connected PTSD, have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 3. The criteria for service connection for hypertension, to include as secondary to service-connected PTSD, have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 4. The criteria for service connection for nephrolithiasis, to include as secondary to service-connected PTSD, have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1969 to December 1971, including service in the Republic of Vietnam. This case is before the Board of Veterans’ Appeals (Board) on appeal from a November 2014 Department of Veterans Affairs (VA) Regional Office (RO) rating decision that denied the above service connection claims. The Veteran timely appealed to the Board by submitting a November 2014 Notice of Disagreement (NOD); and, a March 2016 VA Form 9 following the RO’s February 2016 Statement of the Case. In August 2019, the Veteran testified at a video conference hearing (Hearing) at the RO before the undersigned Veterans Law Judge (VLJ). A transcript of that testimony is of record. In December 2019, the Board remanded the claims for further development. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § § 1110, 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Additionally, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). VA has amended 38 C.F.R. § 3.310 to explicitly incorporate the holding in Allen, except that it will not concede aggravation unless a baseline for the claimed disability can be established with evidence created prior to any aggravation. 38 C.F.R. § 3.310(b). Also, if a veteran was exposed to an herbicide agent (to include Agent Orange) during active military, naval, or air service, certain diseases shall be presumed to be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even if there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied; i.e. unless there is affirmative evidence of non-exposure. 38 C.F.R. § 3.309(e). 1. Entitlement to service connection for a bilateral hearing loss disability The Veteran contends that his current bilateral hearing loss disability is the direct result of noise exposure during service. Specifically, he reports that he was exposed to loud noises during service, including from demolitions, exploding objects, heavy equipment, helicopters, and missile fire. See November 2014 VA Examination report. Sensorineural hearing loss (an organic disease of the nervous system), may be presumed to have been incurred or aggravated during service if it becomes disabling to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303 (b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the purpose of applying the laws administered by VA, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels (dB) or greater; or when the auditory threshold for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. When audiometric test results at separation from service do not meet the regulatory requirements for establishing a “disability” at that time, a veteran may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155, 160 (1993). The threshold for normal hearing is from 0 to 20 decibels. Id. at 157. Initially, the Veteran has a current hearing loss that meets the criteria for a disability for VA purposes pursuant to 38 C.F.R. § 3.385. See November 2014 VA Examination report. Therefore, the Veteran has met the current disability element of service connection. 38 C.F.R. §§ 3.303, 3.385. The Veteran’s Form DD 214 indicates a Military Occupational Specialty (MOS) of combat engineer, which has a high probability of noise exposure. The Veteran is competent to describe what he experienced while in military service, including exposure to loud noises from demolitions, exploding objects, heavy equipment, helicopters, and missile fire. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The record does not include evidence that would discount the Veteran’s claimed noise exposure. Based on the foregoing, the Veteran’s statements regarding in-service noise exposure are credible and noise exposure is conceded. Thus, the Veteran has met the in-service injury or event element. Accordingly, the dispositive issue is whether there is a nexus between the Veteran’s bilateral hearing loss disability and the in-service noise exposure. Service Treatment Records (STRs) are silent as to complaints, treatment, or diagnosis of hearing loss or tinnitus during service. The Veteran’s hearing was tested at a July 1968 pre-entrance audiological evaluation and at a December 1971 separation audiological evaluation. Historically, when interpreting audiometric data from STRs, it is important to note that Service Departments changed from using American Standards Association (ASA) standards, to using International Standards Organization – American National Standards Institute (ISO-ANSI) standards when providing audiograms beginning at some point between approximately January 1, 1967 and December 31, 1970, however, the conversion date was not consistent between all branches of the Armed Forces. Accordingly, if the standard used is not clearly indicated on the Service Department audiogram(s), it is presumed that prior to January 1, 1967 the ASA standard was used. For in-service audiograms conducted between January 1, 1967 and December 31, 1970, where the standard used is unclear, the data under both ASA and ISO-ANSI standards will be considered. For in-service audiograms conducted after December 31, 1970, it is presumed that the ISO-ANSI standard was used. As it relates to VA examinations and VA records, audiological reports were routinely converted from ISO-ANSI results to ASA units until the end of 1975 because the regulatory standard for evaluating hearing loss was not changed to require ISO-ANSI units until September 9, 1975. In this case, because it is unclear whether the July 1968 audiological testing results were recorded using American Standards Association (ASA) units or International Standards Organization-American National Standards Institute (ISO-ANSI) units, the recorded metrics are considered under both standards, relying on the unit measurements most favorable to the Veteran’s appeal. Converting from ASA standards to ISO-ANSI requires the following amounts be added to the recorded ASA audiological results: 15 dB at 500 Hz, 10 dB at 1000 Hz, 10 dB at 2000 Hz, 10 dB at 3000 Hz, and 5 dB at 4000 Hz. The Veteran’s July 1968 audiometric testing revealed the following pure tone thresholds (in dB), with the conversion to ISO listed in parentheses next to each number: HERTZ 500 1000 2000 3000 4000 RIGHT 15 (30) 15 (25) 10 (20) 10 (20) 30 (35) LEFT 5 (20) 0 (10) -10 (0) 0 (10) 15 (20) The Veteran’s December 1971 separation audiometric testing, presumably using the ISO standard, revealed the following pure tone thresholds (in dB): HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 - 0 LEFT 0 0 0 - 5 Accordingly, the Veteran’s hearing tested within normal limits at entrance except at 4000 Hz in the right ear, which puretone threshold (30 dB) indicated mild hearing loss. When converting, the July 1968 audiogram indicates mild hearing loss at the 500 Hz, 1000 Hz, and 4000 Hz frequencies in the right ear (30 dB at 500 Hz, 25 dB at 1000 Hz, 35 dB at 4000 Hz, albeit not considered a disability by VA regulation) and hearing within normal limits in the left ear, as the examiner noted in her opinion. Additionally, as noted by the discharge audiogram, hearing was within normal limits in all frequencies bilaterally when the Veteran left service. In November 2014, a VA examiner opined that the Veteran’s hearing loss was less likely than not related to service. However, that opinion was based on an inaccurate factual premise—the examiner discussed a February 1976 audiogram of a different Veteran—and carries no probative weight. The Veteran had another VA examination in January 2020. The examiner conducted an in-person examination; audiometric testing revealed the following puretone thresholds (in dB): HERTZ 500 1000 2000 3000 4000 RIGHT 35 40 75 75 85 LEFT 45 50 80 95 100 Speech discrimination (Maryland CNC word list) testing was 80 percent in the right ear, and 72 percent in the left ear. Then, the examiner reviewed the STRs, including the July 1968 entrance examination which showed non-permanent mild hearing loss at 4000 Hz in the right ear and normal hearing in the left ear; and, the December 1971 separation examination which showed normal hearing in both ears. The examiner acknowledged the Veteran’s report of exposure to gunfire, explosives, aircraft noises, and other service-related noise exposure, as well as his report that he did not use hearing protection during service. The examiner noted no permanent positive threshold shift greater than normal measurement variability, from the July 1968 to the December 1971 examination, at any frequency relevant for VA purposes in either ear. The examiner noted the absence of any complaint or treatment for hearing decrease in the STRs or at separation, and though acknowledging that there is a relationship of noise to auditory damage and hearing loss, opined that the hearing loss is less likely than not caused by the Veteran’s in-service noise exposure. The examiner further noted that hearing loss did not exist prior to service. Importantly, the examiner addressed the mild hearing loss shown at 4000 Hz in the right ear on the entrance examination, and noted the normal hearing in the right hear. The examiner could not determine why there was non-permanent hearing loss, but specifically characterized the hearing loss shown on the entrance examination as non-permanent. The examiner further indicated that although the Veteran has bilateral, constant tinnitus which has reportedly continued since service, and although the medical literature indicates that tinnitus may be so loud as to interfere with hearing ability, tinnitus cannot cause hearing loss. Therefore, the bilateral hearing loss is less likely than not caused by the tinnitus. Based on the foregoing, the weight of the evidence is against finding that the Veteran’s bilateral hearing loss is related to service. The evidence in favor of the claim in that regard is the Veteran’s lay belief that the hearing loss began in service, and has worsened since then. While the Veteran is competent to report observable events such as instances during service when he was exposed to loud noise, he is not competent to opine as to whether such noise exposure is related to his current bilateral hearing loss, because such an issue is medically complex issue which requires specialized training and expertise which the Veteran does not possess, and as a result, the Veteran’s belief that there is a link between the two does not carry any probative value in that regard. Moreover, while the Veteran is competent to report observable symptoms such as a decrease in hearing acuity in service, any assertions in this regard are inconsistent with the objective findings in the STRs; and, they are inconsistent with the Veteran’s specific denial of hearing loss on a report of medical history at the time of discharge from service. The January 2020 VA examiner reviewed the Veteran’s medical file, including STRs, and conducted an in-person interview with the Veteran at which the Veteran laid out a history of his noise exposure during and after service. The examiner addressed the mild hearing loss shown on the July 1968 examination, the examiner suggested that the July 1968 testing results showed non-permanent hearing loss (when reviewed in conjunction with the audiogram at discharge) which could have been the result of factors such as a noisy testing environment or recent hazardous noise exposure. Accordingly, irrespective of what the 1968 audiogram showed, the Veteran’s hearing was normal at the time of discharge, and therefore, it logically follows that any potential hearing loss noted at entry could not have been permanent. When considered along with the December 1971 examination, which serves as objective evidence that there was no permanent hearing auditory damage during service, the evidence demonstrates that there is no link between any in-service noise exposure and the current bilateral hearing loss disability. Additionally, the examiner’s opinion concerning a link between the tinnitus and hearing loss considers the Veteran’s specific reports as to the onset and continuity of tinnitus; the medical relationship between the two conditions; and the relevant medical literature concerning the issue. In sum, the examiner’s opinions are based on thoroughly reasoned rationales which set out the basis for each opinion in clear language. As so, the opinions carry substantial probative weight. In light of the foregoing, the most probative evidence is against finding the bilateral hearing loss disability is related to service, to include the in-service noise exposure and/or tinnitus. There is no reasonable doubt to resolve in the Veteran’s favor, and the claim is denied. 2. Entitlement to service connection for BPH, to include as a result of in-service herbicide exposure and/or secondary to service-connected PTSD The Veteran claims entitlement to service connection for BPH on a direct basis as due to exposure to Agent Orange during service in Vietnam, or in the alternative, as secondary to his service-connected PTSD. The Veteran has a current disability of BPH. See, e.g. VA treatment records dated April 2017. Exposure to Agent Orange is presumed for veterans who served in the Republic of Vietnam during the period from January 9, 1962 to May 7, 1975. 38 C.F.R. § 3.307 (a)(iii). As the Veteran’s military personnel records confirm service in the Republic of Vietnam from September 1969 to September 1970, exposure to herbicide agents is presumed. BPH is not among those disabilities identified in 38 C.F.R. § 3.309(e) as subject to presumptive service connection based on exposure to herbicide agents in Vietnam, service connection may still be established on a direct or secondary basis. The Veteran has a service-connected disability of PTSD. As a result, the dispositive issues are whether the BPH is (i) related to in-service herbicide exposure, or (ii) related to, or aggravated by, the service-connected PTSD. Service Treatment Records (STRs) are silent as to any complaint, treatment, or diagnosis of BPH, and the Veteran does not assert that his BPH had its onset during service. Private urology treatment records show an October 2000 diagnosis of prostatitis. VA treatment records show that the Veteran currently receives treatment for BPH, and has done so since at least March 2012. The Veteran was afforded a VA male reproductive organs examination in January 2020. After conducting a review of the Veteran’s file and an in-person examination, the examiner noted a diagnosis of BPH from January 2010. The examiner noted that while the Veteran reported symptoms caused by the diseases, such as increased frequency in urination, an objective examination was normal and there as no objective evidence of a chronic condition. Moreover, BPH is not a condition which is presumed to be due to Agent Orange exposure. As so, the examiner opined that the BPH is less likely than not incurred in or caused by service, including Agent Orange exposure. Then, the examiner opined that the BPH is less likely than not due to or the result of the service-connected PTSD, because the conditions are not medically related. Specifically, the BPH is a “separate entity entirely from the [PTSD] and unrelated to it.” The examiner cited to the medical literature, which does not support a medical relationship, and that PTSD is a mental health disorder while BPH is more likely than not an age-related disease. The examiner cited no pathophysiological process through which PTSD can cause or lead to BPH. The examiner also opined that the PTSD does not aggravate the BPH beyond the natural progression of the disease, because the medical evidence is not sufficient to show a baseline level of severity of the BPH, and because PTSD does not aggravate BPH. Furthermore, the examiner noted that the BPH has not progressed beyond its natural progression; there is no connection between the two conditions so as to cause aggravation; and the diseases are “separate conditions.” Based on the foregoing, the weight of the evidence is against finding that the BPH is (i) caused by or related to service, including in-service Agent Orange exposure; (ii) caused by the PTSD; or (iii) aggravated by the PTSD. On that issue, the record contains the January 2020 examiner’s opinion. The examiner formed the opinion as to each question after performing a review of the Veteran’s file and an in-person interview. The language of each opinion is clear, and each opinion is formed with consideration for the Veteran’s unique disability picture, the medical nature of the BPH as well as the nature of PTSD, and the medical literature. The examiner provided thorough rationales in support of each opinion, which are based on the examiner’s medical expertise and knowledge, as well as the medical literature. For those reasons, the opinions carry substantial probative value. While the Veteran sincerely believes that his BPH is related to Agent Orange exposure and/or is aggravated by PTSD, the record does not show that the Veteran has the requisite medical expertise to provide such an opinion, because the issue is complex in nature and requires specialized medical expertise, training, and skills. As a result, the Veteran’s lay belief that a link exists which would satisfy the “nexus” requirement of the service connection claim carries no probative value. For those reasons, the weight of the evidence is against finding that the nexus element of the service connection claim is met; there is no reasonable doubt to resolve in the Veteran’s favor, and the claim must be denied. 3. Entitlement to service connection for hypertension, to include as a result of in-service herbicide exposure and/or secondary to service-connected PTSD The Veteran claims entitlement to service connection for high blood pressure on a direct basis as due to Agent Orange exposure, or in the alternative, as secondary to his service-connected PTSD. The Veteran’s blood pressure was tested several times during service. At a July 1968 medical examination, his sitting blood pressure was 139/80 (systolic/ diastolic). At a December 1971 medical examination, his sitting blood pressure was 120/60. At an October 1997 private urology visit, the Veteran reported a family history of high blood pressure. A September 1999 private outpatient note shows blood pressure of 169/120, and a March 2003 note shows a past medical history that includes hypertension. A March 2001 private check up note shows that the Veteran was encouraged to see a primary car doctor for high blood pressure. At that time, he was already on “some medication,” and his private physician prescribed hydrochlorothiazide in hopes of blocking future kidney stones. A January 2005 private urology note shows that the Veteran had a history of hypertension for “approximately six to seven years.” VA primary care and nursing notes from as early as July 2009 show that the Veteran was treated for hypertension, including by prescriptions for amlodipine, hydrochlorothiazide, and metoprolol. At his August 2019 Board hearing, the Veteran indicated that he began taking medication for his high blood pressure at some point between approximately 1975 and the 1980s. The Veteran had a VA hypertension examination in January 2020. The examiner diagnosed hypertension. The examiner noted that the Veteran reported an onset of December 1974 for the hypertension when, the Veteran reported, “his blood pressure was noted to be high at 180/90 mmHg.” The Veteran reports that he was treated with lifestyle modifications and that his blood pressure was on different occasions either normal or low. Based on the Veteran’s report, the examiner noted June 1975 as the approximate date of diagnosis and first medication usage. The Veteran reported that he has been taking anti-hypertensive medication since June 1975. He reported that his blood pressure “kept on going up and sometimes was as high as 180/90 mmHg,” which required that his prescriptions be adjusted. The examiner noted current prescriptions for once daily doses of Losartan 150 mg, chlorthalidone 25 mg, amlodipine 5 mg, and Coreg 3.125 mg. The examiner noted a blood pressure measurement from December 2019 of 128/78 with a second reading of 125/65; and a later reading of 140/80 with a second reading of 112/64. A January 2020 blood pressure reading was 102/59 and a second reading was 128/64. At the examination, blood pressure measure at 128/72; 126/68 on a second reading; and 128/78 on a third reading. The examiner noted that he was unable to find records to meet the VA criteria of two blood pressures on the same day for three different days at which diastolic pressure was at least 90 mmHg or isolated systolic pressure was at least 160 mmHg. However, after reviewing the Veteran’s file, the examiner rendered the hypertension diagnosis based on sufficient documentation of elevated blood pressures and continued treatment for hypertension over the years. The examiner opined that the hypertension is less likely than not caused by in-service Agent Orange exposure, because while herbicide exposure is linked to several medical conditions, there is no link to hypertension. Then, the examiner opined that the hypertension is less likely than not caused or aggravated by the PTSD. In so opining, the examiner noted that PTSD and stress can aggravate hypertension beyond its natural progression, and that PTSD is one of the risk factors for blood pressure to increase. However, the examiner noted that he was able to establish a baseline level of severity, based on the medical evidence, of the hypertension; and, that the current severity of the hypertension was not greater than the baseline. Moreover, the examiner found that there is no medical evidence in the claims file to suggest that the Veteran’s hypertension is aggravated beyond its natural progression by the service-connected PTSD. Turning to whether the nexus element of the service connection claim is met, the record contains a single opinion – that of the January 2020 VA examiner. The examiner’s negative opinions as to whether there is a link between the hypertension and (i) service, including Agent Orange exposure, or (ii) service-connected PTSD are set out in clear language, and addresses each theory of entitlement. The examiner provided rationales for each opinion which are based upon a thorough review of the Veteran’s claims file, including STRs, and after conducting an in-person interview at which the Veteran was able to describe his history of hypertension. Then, the examiner supported the opinions by addressing the nature of hypertension; the unique history of the Veteran’s hypertension disability picture; the absence of any medical evidence which supports a relationship between hypertension and service; the medical literature, which indicates that PTSD cannot cause hypertension; and the absence of any medical evidence indicating that the PTSD did, in fact, aggravate the hypertension. For those reasons, the opinion carries substantial probative weight. In addition, the record does not show that the Veteran’s hypertension had its onset during service, or, that it manifested to a compensable degree within the first post-service year. Accordingly, service connection based on in-service onset, and/or the presumption thereof, is not warranted. While the Veteran sincerely believes that there is a link between the hypertension and in-service herbicide exposure and/or the service-connected PTSD, the Veteran does not possess the requisite medical expertise to provide such an opinion, because each issue is medically complex in nature and requires specialized medical expertise, training, and skills in order to competently link them to service. As a result, the Veteran’s lay beliefs regarding a link, from the (i) in-service Agent Orange exposure or the (ii) service-connected PTSD, to the Veteran’s hypertension, carry no probative value. In light of the foregoing, the weight of the evidence is against finding that the “nexus” element of the hypertension service connection claim is met. As there is no reasonable doubt to resolve in the Veteran’s favor, the claim must be denied. 4. Entitlement to service connection for nephrolithiasis (kidney stones), to include as due to in-service herbicide exposure and/or secondary to service-connected PTSD The Veteran seeks entitlement to service connection for nephrolithiasis on a direct basis as due to his presumed Agent Orange exposure in Vietnam; or in the alternative, as secondary to his PTSD; or in the alternative, as secondary to his hypertension. The Veteran has a current disability of nephrolithiasis, and as indicated above, presumed in-service Agent Orange exposure. See, e.g. VA treatment records dated April 2017. However, nephrolithiasis is not among those disabilities identified in 38 C.F.R. § 3.309(e) as subject to presumptive service connection based on exposure to herbicide agents in Vietnam; therefore, no further analysis concerning entitlement to service connection on that basis is necessary. For the reasons set out in the analysis above, the Veteran does not have a service-connected disability of hypertension; as a result, no further analysis is necessary as to whether secondary service connection is warranted on that basis. An October 1970 STR shows that the Veteran reported that he had been treated for kidney disease prior to October 1970; STRs are otherwise silent as to any complaint, treatment, or diagnosis of nephrolithiasis during service. The Veteran did not report any kidney disorder at the time of entry, or at the time of discharge. Private urology notes show that the Veteran was first diagnosed with kidney stones at a urology appointment in October 1997. At the appointment, the Veteran reported a family history of kidney stones; he also reported pain related to the kidney stones that had begun three weeks before, and reported that he had previously passed a stone. As noted above, in March 2005 the Veteran’s private physician prescribed hydrochlorothiazide in hopes of blocking future kidney stones. Private urology notes from January 2005 show that the Veteran was treated for kidney stones. VA treatment notes show that the Veteran has been treated, or complained of, kidney stones since as early as February 2010. The Veteran reported a history of kidney stones in August 2010, noting that he had previously passed a stone approximately ten years before. See August 2010 VA primary care nursing note. The Veteran had a VA kidney conditions examination in January 2020. The examiner diagnosed nephrolithiasis (kidney stones) and renal disease, chronic. The examiner stated that the cause of the disease is hypertension, and that the onset was July 1995 based on the Veteran’s report of his blood pressure staying high for “some time[],” which caused his kidney injury. The examiner described a course of the disease since onset that included the Veteran having been told several times that he has kidney damage secondary to high blood pressure; that his serum creatinine was 1.5 on December 30, 2017; and that his last serum creatinine was 3.27 mg/dl on March 2, 2019, before he was admitted to the hospital after having a stroke. The examiner opined that the kidney stones were less likely than not caused or incurred during service, including as a result of Agent Orange exposure. The examiner stated that while the Veteran was treated for a kidney condition in service, the condition was acute, and there is no evidence of chronicity of care. The examiner noted that there is no connection between Agent Orange exposure and kidney stones, and therefore, a nexus on that basis could not be established. Regarding a link with the service-connected PTSD, the examiner opined that the kidney stones are less likely than not caused or aggravated by the PTSD. The examiner noted that the two conditions are not medically related and that the kidney stones are a separate and unrelated entity to the PTSD, which is a psychiatric condition. The examiner further noted that there is no medical connection to support a finding that the PTSD had aggravated the kidney stones; and, no medical link from Agent Orange to kidney stones which would aggravate the condition. In sum, the record contains a single medical opinion concerning whether the nephrolithiasis is related to service, including the service-connected PTSD. The January 2020 VA examiner formed the opinions as to each question after performing a review of the Veteran’s file, including the STRs, and after an in-person interview. The language of the opinions is clear, and each opinion is supported by a thorough rationale which was formed in light of the Veteran’s unique disability picture based on the medical records; the medical nature of nephrolithiasis; the relationship, or lack thereof, between PTSD and nephrolithiasis; and the medical literature. For those reasons, the opinions carry substantial probative value While the Veteran sincerely believes that there is a link between the nephrolithiasis and service, including a link between the nephrolithiasis and service-connected PTSD, he is not shown to possess the requisite medical expertise to provide such an opinion, because the issue is medically complex in nature and requires specialized medical expertise, training, and skills in order to provide a competent opinion. As a result, the Veteran’s lay belief that a link exists which would satisfy the “nexus” requirement of the service connection claim carries no probative value. Based on the foregoing, the weight of the evidence is against finding that the “nexus” element of the nephrolithiasis service connection claim is met. As there is no reasonable doubt to resolve in the Veteran’s favor, the claim must be denied. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. KAYS HUKILL 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.