Citation Nr: 21064061 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 19-24 230 DATE: October 18, 2021 ORDER Service connection for a cardiovascular disability, to include hypertension, atherosclerosis, and a thoracic aortic aneurysm, is denied. Service connection for a gastrointestinal disability, to include diverticulosis, episodes of diverticulitis with rectal bleeding, epiploic appendagitis, and gastroenteritis, is denied. FINDINGS OF FACT 1. The Veteran has diagnoses of hypertension, atherosclerosis, and a thoracic aortic aneurysm; he has not been diagnosed with any other cardiac condition, including arrythmia. 2. The Veteran's hypertension, atherosclerosis, and thoracic aortic aneurysm have not been linked to disease or injury incurred or aggravated in active service. 3. The Veteran has been diagnosed with diverticulosis with past episodes of diverticulitis and rectal bleeding, and epiploic appendagitis; he has not been diagnosed with gastroenteritis during the pendency of this claim. 4. The Veteran's diverticulosis with rectal bleeding, epiploic appendagitis, or any other gastrointestinal conditions manifested by abdominal pain, are not linked to disease or injury incurred or aggravated in active service. CONCLUSIONS OF LAW 1. The criteria for service connection for a cardiovascular disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 2. The criteria for service connection for a gastrointestinal disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1965 to May 1969 These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in April 2021. A transcript of the hearing is of record. Service Connection Service connection generally will be awarded when a veteran has a 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 may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection on a direct basis, the evidence must show: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a link between the current disability and the disease or injury incurred or aggravated in service (the "nexus" element). Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). For the chronic diseases listed in 38 C.F.R. § 3.309(a), including cardiovascular-renal disease, which encompasses hypertension, service connection may alternatively be established with evidence of chronicity of the disease during service or during a presumptive period following service separation. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012). For conditions noted during service (or in the presumptive period) but not shown to be chronic at the time, a continuity of symptomatology after service is required to support the claim. 38 C.F.R. § 3.303(b). When chronicity or continuity is established, subsequent manifestations of the same chronic disease at any later date, no matter how remote in time from the period of service, will be service connected unless clearly attributable to causes unrelated to service ("intercurrent" causes). Id. In addition, where a veteran served continuously for 90 days or more during a period of war, or after December 31, 1946, there is a presumption of service connection for cardiovascular-renal disease such as hypertension if the disease manifested to a degree of 10 percent or more within one year from the date of separation from service, even if there is no evidence of the disease during the service period itself. 38 U.S.C. § § 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). This presumption may be rebutted by affirmative evidence to the contrary. 38 C.F.R. § 3.307(d). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see Lynch v. McDonough, 999 F.3d 1391, 1395 (Fed. Cir. 2021) (holding that if the positive and negative evidence is in approximate balance, which includes but is not limited to equipoise, the claimant receives the benefit of the doubt). Cardiovascular Disability The Veteran initially filed a claim for "syncope secondary to arrhythmia." See March 2018 VA Form 21-4138. The claim has since been expanded to include any cardiovascular condition, including diagnosed hypertension. For the following reasons, the Board finds that service connection is not established. The service treatment records show that the Veteran had several episodes of falling in 1967 and 1968, with associated symptoms including dizziness and headaches. An August 1967 entry reflects that he was seen for dizziness and having passed out. A neurological examination was negative. The clinical impression was that "skull disease" needed to be ruled out. In this regard, the May 1965 report of medical history at entrance into service notes that when the Veteran was about one year old, he fell three stories and fractured his skull. An August 2013 VA treatment record provides a similar account, and states he was hospitalized for six months at the time. According to this record, he stated he feels dizzy once in a while. This medical history places in context the August 1967 impression that skull disease needed to be ruled out. The August 1967 service treatment record reflects that the Veteran was referred for a skull x-ray. An entry dated a few days later reflects that a spinal fluid sample was also taken. The service treatment records do not indicate that either the skull x-ray or the spinal fluid sample were found to be abnormal. The service treatment records show that a week later, he passed out again. Thereafter, they show he was treated after several falls. An October 1967 record notes he developed a queasy feeling shortly after a fall, and that after eating supper he started to vomit. A service treatment record dated in early November 1968 states that the Veteran reported experiencing episodes of dizziness with weakness and syncope at times during the past year. The dizziness was usually followed by a severe headache. For the past two days he had been having dizziness and frequent headaches. He requested further workup. The clinician agreed that such work-up was needed. This record also notes at the outset that the Veteran related a history of trouble with his ears, and that they were "giving him trouble" again. He stated that he had some form of growth in his ears, but this was not evident on examination. The Board notes that post-service treatment records show that he had a history of multiple cholesteatomas that were surgically treated, and experienced associated headaches described as left-sided occipital head pain. See, e.g., June 2017 Private Treatment Record. A May 2021 VA treatment record states that the Veteran related that he "mostly suffers from 'dizzy spells[]" because he had [eight] tumors removed from [his] ears." The Board assumes that by "tumors" the Veteran meant cholesteatomas. It is not evident whether a "form of growth" in his ears mentioned in the November 1968 entry is related to the subsequent history of cholesteatomas with associated headaches and dizziness, and this issue is not encompassed by the claim for a heart condition. The same day as the above November 1968 record, the Veteran was referred for a consultation. The consultation request states that the Veteran had a two-year history of dizziness, headaches, and periodic syncopal attacks which had become more serious recently. The consultation report itself, which is on the same form as the November 1968 request, was filled out in late November 1968, on the day the Veteran was admitted to the hospital. In this regard, he was admitted because the day before he became unconscious while sitting in a chair. His pulse was 112, and he had an irregular heartbeat. He was brought to the sick bay ward. He was shivering and shaking, and conscious. His blood pressure was 142/92. He was covered with blankets to keep warm. About thirty minutes after becoming unconscious, his heartbeat was regular. His pulse was 82. His blood pressure was 128/84. He was then calm with a pulse of 76. His headache was still present, but not "very bad." He was completely stable but it was felt further workup was needed immediately because he was a danger to others and himself. As noted, the bottom half of the November 1968 consultation request was filled out on the date of the Veteran's hospital admission. The report reiterates that the Veteran again had an attack of syncope, and that further workup was needed. In different handwriting, there is a notation that the Veteran was admitted, and the diagnosis was "syncope due to arrythmia." The hospital discharge summary reflects that the Veteran was admitted on November 25, 1968 and discharged on December 17, 1968. The admission diagnosis was syncope due to arrhythmia. The narrative states that the Veteran's first episode began about two years prior to admission. The episodes were characterized initially by a pounding feeling in the retrosternal area, followed by a true vertigo, nausea, weakness in the legs, and a high-pitched, ringing noise in both ears, with a right frontal and occipital headache. He often had a feeling that he was unable to get a good deep breath at these times, and experienced paresthesias in his circumoral and peripheral extremity areas. He was usually able to sit down or lie down for a few minutes, and the sensation subsided; however, there were occasions where he had fallen. During the hospitalization, a complete neurological examination was normal. The neurologist felt that the etiology of the Veteran's episodes was hyperventilation syndrome. An attempt was made to precipitate the arrhythmia, without any results. The discharge diagnosis was hyperventilation syndrome. The service treatment records thereafter do not mention subsequent falls, fainting episodes, episodes of dizziness or syncope, or an irregular heart beat. The May 1969 separation examination report reflects that the Veteran's heart (including rhythm) and vascular system were evaluated as normal. The service treatment records do not reflect findings that the Veteran had high blood pressure or hypertension. The Board notes that, for rating purposes, VA regulation defines hypertension as diastolic blood pressure predominantly 90 mm. or greater; isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. The service treatment records show occasional blood pressure readings that are at or above these thresholds. For example, a September 1965 record shows that when the Veteran was seen for treatment following being kicked in the abdomen, he had a blood pressure reading of 160 systolic blood pressure and 98 diastolic. In August 1967, when he was seen for dizziness and passing out, his diastolic blood pressure was initially 97, and systolic blood pressure 115. However, a second reading showed diastolic blood pressure of 76, and systolic blood pressure of 115. In November 1968, when he was initially seen after having passed out and exhibiting an irregular heartbeat, his diastolic blood pressure was 92, and systolic blood pressure 152. However, about thirty minutes later, the diastolic blood pressure was recorded as 84, and the systolic blood pressure as 128. When he was admitted to the hospital, his diastolic blood pressure was 84, and systolic blood pressure 140. The May 1969 separation examination report reflects that diastolic blood pressure was 82, and systolic blood pressure 115. In sum, while the Veteran occasionally had isolated blood pressure values during service that were abnormally high, and which, under VA's regulatory definition, would satisfy the thresholds for hypertension if these were shown "predominantly," he did not have them consistently, let alone predominantly; indeed, they reverted to normal when retesting was done the same day. Moreover, he was not noted in these records to have high blood pressure, his blood pressure on re-reading fell below the thresholds for hypertension, and his blood pressure was normal at separation. The Board further observes that the high blood pressure readings were recorded in the context of treatment for an injury (being kicked in the bladder) or for his episodes of dizziness and fainting, and not because of symptoms suspected to be indicative of high blood pressure. Accordingly, the service treatment records do not show that hypertension manifested in service as a chronic disease, or was noted in service. The Veteran separated from service in May 1969. There are no post-service medical records in the file dated before 2008. The private treatment records show that in June 2008, a computerized tomography (CT) scan of the abdomen and pelvis, which was performed due to abdominal pain, showed coronary artery calcification. It was noted that there was atherosclerotic disease, with calcification of the abdominal aorta and bifurcation. The impression, in relevant part, was "atherosclerotic disease and coronary artery calcification." A general physical examination reflects that, with regard to the heart, there was a regular rhythm, without murmurs or rubs. The VA treatment records reflect that the Veteran was seen as a new patient at VA in June 2012. He related that he had not seen a doctor in five years. In a review of his medical history and symptoms, it was noted with regard to the cardiovascular system that he denied chest pain. A blood pressure reading showed 138 systolic blood pressure and 80 diastolic blood pressure. A general examination was conducted. With regard to the heart, the Veteran had a regular S1 and S2 rhythm. There were no gallops or rubs. A July 2012 record reflects that the Veteran reported occasional chest pain on the left side. An August 2013 record reflects a general review of symptoms, and states with regard to the heart that he had no chest pain and no palpitations. A February 2013 blood pressure reading was 139/86. An October 2013 blood pressure reading was 138/80. A November 2014 VA treatment record reflects a blood pressure reading of 142/100. In early January 2015, an electrocardiogram (EKG) study was performed as part of a routine test for a colonoscopy which showed abnormal findings. The Veteran was referred to his doctor. He stated he felt fine. He had one episode of chest pain a few days earlier which lasted one minute and resolved. He stated he has had these sharp pains infrequently which last one minute and resolve on their own. A repeat EKG was normal. He was referred to cardiology. The January 2015 cardiology consultation record states that the Veteran was seen for chest pain. He stated that about ten years earlier he had one episode of chest pain which caused him to collapse to the ground. He calmed down, slowed down his heart rate, and was able to resume his activity. Since then, he had occasional chest discomfort associated with left arm numbness and tingling. He also had longstanding vertigo and balance issues "due to his [history of] ear issues and craniotomies." He did not have syncope or palpitations. The cardiologist noted that the chest pain was atypical of cardiac chest pain, but did have some "typical aspects." On examination, an automated reading of the Veteran's blood pressure was 154 systolic over 94 diastolic. On manual reading, it was 152 systolic over 85 diastolic. The cardiologist concluded that in light of the EKG changes, the Veteran's elevated cholesterol, elevated blood pressure, and family history, there was a concern he had coronary artery disease (CAD). The plan was for the Veteran to undergo a nuclear stress test to evaluate his high risk of CAD. The cardiologist also noted that the Veteran would benefit from blood pressure management, but was not currently taking medications. In this regard, the cardiologist noted that this was his second elevated blood pressure reading. Presumably, the cardiologist was referring to the November 2014 reading. The cardiologist recommended initiation of blood pressure medications with the next elevated blood pressure recording. Private treatment records dated in October 2015 show that the Veteran was admitted overnight for left-sided weakness and numbness/tingling. It was noted that he had a history of hypertension, possibly hyperlipidemia, smoking, and chronic obstructive pulmonary disease (COPD) who presented with six weeks of on-and-off left-sided weakness and numbness, which that day became more pronounced and included left facial droop and weakness in the left arm and leg with difficulty walking. The symptoms had mostly resolved by the time he was seen. He reported a history of hypertension and hyperlipidemia, but was not on medications. A general physical examination was conducted, with a cardiac examination showing normal S1, S2 and regular rhythm. Based on laboratory testing and diagnostic imaging including a CT scan of the head, he was assessed with a possible transient ischemic attack (TIA) or a cerebral vascular accident (CVA). The following day, the Veteran was seen for a neurological consultation. The consultation report states that he had a chief complaint of "spells." He related that for the past six weeks he had been having "spells" characterized by sharp pain in the right posterior parietal region followed twenty minutes to two hours later by "an electrical tingling" in the entire left side of his head, face, and neck, left upper extremity, and left lower extremity. He had associated decreased sensation and heaviness in the left upper extremity and left lower extremity and intermittent dizziness with imbalance. It was noted that he had multiple left ear surgeries for multiple cholesteatomas, with the last in 2002. He had left-sided deafness and decreased hearing on the right. He had chronic imbalance. On examination, his heart was normal. The impression was transient ischemic attacks. The October 2015 discharge summary for the Veteran's overnight hospitalization reflects diagnoses of a transient ischemic attack and untreated hypertension. The summary notes that he was monitored on the telemetry, which showed no acute arrhythmia. A bilateral carotid duplex ultrasound showed no significant stenosis. An EKG was still pending. On discharge, his heart had a regular rate and rhythm. The October 2015 EKG report reflects findings that included normal systolic function, Grade 1 diastolic dysfunction, and concentric left ventricular hypertrophy. The aortic valve was normal in structure and function, and opened well. There was no significant valvular aortic stenosis. There was mild aortic regurgitation. The VA treatment records reflect that in December 2015, the Veteran was seen for follow-up by cardiology. It was noted that he had not undergone the nuclear stress test previously ordered. He had been admitted to a private hospital and diagnosed with a transient ischemic attack (as summarized by the Board above). He had been taking Amlodipine (a medication for "blood pressure/heart," according to subsequent medication lists) and aspirin since his admission. He denied any significant recurrence of his atypical chest pain. He had recently undergone a CT scan which showed an ascending aortic aneurysm. He did not have syncope or palpitations. An automated blood pressure reading was 154/91. A manual reading was 118/70. The cardiologist's assessment was chest pain. The cardiologist noted the Veteran was taking daily aspirin and a statin, and that his blood pressure was well controlled. A June 2017 private treatment record reflects that the Veteran presented with multiple medical issues, including hypertension. He had an elevated blood pressure reading greater than 200/100, but without acute symptoms. He was not taking the Amlodipine. He was given a dose of that medication and advised to follow up with his doctor. He stated that a Troponin test gives him a rapid heart rate, and the treating physician noted that the Veteran had some mild tachycardia from the ipratropium which should resolve that night. An EKG did not show acute ischemic findings. His laboratory work was "benign." Private treatment records dated in March 2018 reflect that the Veteran fell, and initially reported a syncopal episode while walking outside. However, he then reported he fell while walking, and was "adamant" he did not have a syncopal episode. He denied dizziness or lightheadedness. In addition to other testing, an EKG was performed; the findings included a normal sinus rhythm ("NSR") and nonspecific ST and T wave abnormality. There were no acute changes when compared to the June 2017 EKG. A VA examination was performed in April 2018 as part of the development of this claim. The examiner diagnosed "hypertensive heart disease" with a date of diagnosis of 2018, and arrhythmia, with a date of diagnosis of 1968. The report reflects that the Veteran related having symptoms of "feeling like his heart thumping" which had been "ongoing since his service in the Navy." He complained of continued symptoms of a thumping sensation, which did not occur "that often." The last such episode occurred three or four weeks earlier. The episodes lasted about ten or fifteen seconds. He did not have symptoms of chest pain or shortness of breath. He stated he had an episode of syncope around 2010 while he was working. He went to pick up an item and passed out. He was not taken to the hospital at that time, and not evaluated any further. He had experienced six to seven such episodes over the last five years. However, he had not had any hospitalizations or medical evaluations after these episodes. A May 2021 VA treatment record reflects an active problem list that includes essential hypertension, hyperlipidemia, and atypical chest pain. No other diagnoses pertain to the cardiovascular system. The Veteran denied a history of coronary artery disease. He stated he had a "leaky valve." He stated he mostly suffers from "dizzy spells" because he had "8 tumors removed from [his] ears," which the Board assumes was in reference to the cholesteatoma surgeries. A May 2021 VA treatment record reflects that the Veteran was seen in cardiology for follow-up treatment. It was noted that he had been initially referred to cardiology by his primary care physician due to atypical chest pain (as discussed above with regard to the January 2015 cardiology treatment). He denied further chest pain or chest pounding. He did not have palpitations, dizziness, or syncope. Most of his issues were related to his pulmonary condition. Based on a review of past EKGs and laboratory testing, the cardiologist determined that the Veteran had "no active cardiac issue." He was diagnosed with a thoracic aortic aneurysm ("TAA")with respect to which it was advised he have an annual chest CT scan or echocardiogramand hypertension. A VA examination as part of the development of this claim was performed in July 2021. The examination report reflects that the Veteran related that during service he was moving a generator when he got a tightness in his chest. About two months later it occurred again and he passed out. He stated he was admitted to the hospital and told he had a mild heart attack. He stated that ever since that time he had recurrent episodes. These were described as a pounding in the chest and associated tightness. He stated he had been checked over the years but had not had any formal diagnosis. He stated he was told he needed a pacemaker. He added that he "can't remember anything now." An EKG performed in late June 2021 showed normal left ventricular cavity size with mild upper discrete atrophy. The left ventricular ejection fraction was normal. There was Grade 1 diastolic dysfunction. There was mild aortic insufficiency. There were no significant changes compared with the prior EKG. The severity of the aortic regurgitation appeared similar. In an August 2021 VA medical opinion, the clinician who conducted the above examination found that the Veteran had been diagnosed with hypertensive heart disease, atherosclerosis, and thoracic aortic aneurysm, and that these conditions were less likely than not related to an in-service disease, injury, or event. In this regard, the examiner noted the Veteran's in-service hospital admission for a syncopal episode with a final diagnosis of hyperventilation syndrome. The examiner explained that this is not an arrhythmia or cardiac condition, and occurred typically due to stress; its etiology was psychological in nature. There was no documented arrythmia in the medical records and no diagnosis of that condition. The examiner noted that the Veteran was found to have a small thoracic aortic aneurysm many years after service on CT scan in 2015. The examiner explained that this is a slight ballooning of the aorta in the chest commonly from atherosclerosis, hypertension, and tobacco use (the examiner here noted the Veteran's well-documented history of tobacco use). The examiner stated that the aneurysm, hypertension, and atherosclerosis would not be related to service, and developed over many years. The examiner noted that the Veteran had a long history of smoking and continued to smoke, which was a known cause of hypertension and atherosclerosis. The examiner further stated that the Veteran also had genetic factors that led to his hypertensive heart disease and thoracic aneurysm. Regarding the Veteran's TIA, the examiner explained that this is a transient neurologic condition and not a heart condition. There was no medical evidence that any of these conditions "would have an etiology within one year of service," and basic medical knowledge would go against that possibility since hypertensive heart disease and atherosclerotic disease take years to develop, according to the examiner. Regarding the Veteran's "leaky valve," the examiner explained that this was noted on echocardiogram as mild aortic regurgitation, and was not the cause of the Veteran's symptoms or related to his service. At the April 2021 Board hearing, when asked if he had been experiencing problems with his heart thumping ever since separation from service, the Veteran responded in the affirmative. He stated it did not occur that often anymore because he could sense when the symptoms were coming on and he was able to sit down, relax, and try to breathe so as to prevent the symptoms from occurring. He added that when these episodes first occurred, he experienced them as his heart stopping and a pounding beat in his chest. He testified that he was first diagnosed with heart disease in 1970 at a medical facility in Scotland, shortly after service separation. He stated that when he returned to the U.S., he was treated at medical facilities which have since closed down, and was diagnosed with arrhythmia. He stated he also found out he had a leaky valve, and that "the Navy had said that," but that the Navy could not be positive regarding that diagnosis without conducting an operation. When asked if any of the doctors indicated that his current heart problems are the same condition that he had in service, he responded in the affirmative. He stated it was a doctor at one of the medical facilities which had since closed, and that he was unsuccessful in getting medical records from those hospitals. The record shows that the Veteran has not been found to have an arrythmia. An arrythmia has not been diagnosed during the pendency of this claim. On the contrary, heart examinations conducted over several years have uniformly shown a normal rate and rhythm. Thus, as there is no current disability with regard to that condition, service connection cannot be established. See Holton, 557 F.3d at 1366. The Board finds the Veteran's statements regarding his cardiac history at the April 2021 hearing and July 2021 VA examinations lack credibility, as will be explained. In general, there must be a proper foundation to draw adverse inferences against the credibility of testimony from silence in the record. Fountain v. McDonald, 27 Vet. App. 258, 272 (2015); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011). Such a foundation may be established by finding that the fact being claimed would ordinarily have been recorded in the available records had it occurred. Id. Thus, the Board may not rely on an absence of treatment without explaining "why the appellant would reasonably have been expected to report his symptoms to medical providers." Fountain, 27. Vet. App. at 273. The Board must also consider whether it is qualified to make that determination, or whether independent medical evidence is required. Kahana v. Shinseki, 24 Vet. App. 428, 434-35 (2011) (holding that the Board improperly found that a claimed injury would have been documented at the time, as there was no independent medical evidence to support that determination.) In determining whether a claimant's statements are credible, the Board may consider their internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). In this case, the Board finds the Veteran's statements regarding his cardiac history lack credibility not because of silence in the record, but because they conflict with other, more probative evidence, and are inconsistent with earlier statements he made in the context of treatment. More specifically, at the April 2021 hearing, the Veteran stated he was diagnosed with heart disease in 1970, shortly after separation from service, and that the Navy found he had a leaky valve. He also stated he was diagnosed with an arrythmia in earlier post-service treatment records that are no longer available. He responded in the affirmative when asked if any doctor had found that his current heart problems were the same as the condition he had in service. In his hearing testimony and at the VA examinations, he also related or endorsed experiencing recurrent episodes of his heart pounding or thumping ever since service. However, the VA treatment records contradict these statements. They show he denied a history of heart conditions when providing his medical history in the context of treatment at VA when seen as a new patient. These records are more reliable, and thus more probative, than his later statements proffered in support of a claim for benefits (the VA examinations were conducted as part of the development of this claim, and not for treatment purposes). In the latter context, he had an incentive to misrepresent that history, while in the former he had an incentive to provide an accurate medical history, or at least did not have an incentive to misrepresent it. Moreover, the service treatment records show he was not found to have a leaky valve or any other heart condition. When hospitalized for a fainting episode in November 1968, he was initially assessed with an irregular heartbeat or arrythmia, but his heart subsequently had a normal rate and rhythm, including when clinical attempts were made to precipitate an arrythmia, and the diagnosis was revised to hyperventilation syndrome. The August 2021 VA medical opinion explains that hyperventilation syndrome is not due to a heart condition. Indeed, the Veteran also stated at the July 2021 VA examination that he was diagnosed with a heart attack during service, which is contradicted by the service treatment records. At the Board hearing, he stated that the Navy found he had a leaky valve, which is also contradicted by the service treatment records. The fact that he misrepresented that history, either purposefully or unknowingly, further detracts from the reliability of his other statements regarding his cardiac history, which are otherwise in conflict with what the contemporaneous treatment records show. The Board also notes that the Veteran stated at the July 2021 VA examination that he was having memory difficulties ("I can't remember anything now"), which further detracts from the reliability of his statements regarding a medical history going back several decades. Accordingly, the Veteran's testimony that he had been diagnosed with an arrythmia in earlier post-service treatment records, and with heart disease in 1970, is not credible, not because of silence in the record as to that history, but because more probative evidence directly conflicts with it. Even if he was sincere in relating that history, it is contradicted by the more probative treatment records, including his earlier statements recorded in those records, as explained above; moreover, he was referring to treatment and symptoms that would have occurred decades earlier, while he has recently stated that he "can't remember anything now." The Veteran's statements that he has experienced a sensation of his heart thumping or pounding in his chest associated with tightness ever since service also lack credibility. The VA treatment records show that he generally denied heart palpitations. He reported he occasionally experienced chest pain, but did not report a history of pounding or thumping in his chest. Moreover, the January 2015 VA cardiology consultation record states that the Veteran reported an episode of chest pain about ten years earlier which caused him to collapse to the ground. He calmed down, slowed down his heart rate, and was able to resume his activity. While it is possible he was only describing a more severe episode of chest pain, that record indicates he did not have recurrent chest pain ever since service, but rather than his first such episode occurred ten years before that record. In addition, the service treatment records generally do not show complaints of chest pain. Rather, they show that his symptoms associated with the episodes of syncope and occasional fainting were described as dizziness, headaches, nausea, and ringing in his ears. When he was hospitalized for a fainting episode in November 1968, he did state that these episodes were preceded by a brief sensation of pounding in the retrosternal area, but did not describe chest pain. The Board also observes that his hypertension, atherosclerosis, and aortic aneurysm are not manifested by that symptom, as explained in the August 2021 VA medical opinion, and that symptom has not otherwise been found to be associated with a cardiovascular condition. With regard to the Veteran's in-service syncopal and fainting episodes, which were described at the time as associated with symptoms of headaches, nausea, weakness in the legs, and ringing in his ears, the Veteran has not stated that he experienced similar episodes ever since service. When he was hospitalized for "spells" in October 2015, which were diagnosed as transient ischemic attacksa neurological condition as explained in the August 2021 VA medical opinion he described the symptoms as including head pain, left facial droop, weakness in the left upper and lower extremities, "an electrical tingling" in the entire left side of his head, face, and neck, left upper extremity, and left lower extremity, and intermittent dizziness with imbalance, and stated they had been occurring for the past six weeks. He has not stated that he has experienced syncopal episodes with symptoms similar to those that manifested in servicedizziness, weakness, nausea, headaches, ringing in the earsever since service. As discussed above, the record also shows a history of recurrent cholesteatomas with associated left-sided headaches and dizziness. Thus, those symptoms are not manifestations of a heart condition. The issue of whether his cholesteatomas may be related to service is not encompassed by this claim. The Veteran's currently diagnosed cardiovascular conditions are not otherwise shown to be linked to his active service. As explained above, he had a few isolated high blood pressure readings in service which were not reproduced when re-readings were conducted the same day, and which were not found at the time to be indicative of high blood pressure or hypertension. The post-service treatment records show that he was not found to have high blood pressure or hypertension until early 2015. He had a blood pressure reading of 142/100 in November 2014; otherwise, the blood pressure readings from 2012 through 2013 do not show findings of high blood pressure. In the August 2021 VA medical opinion, the examiner found that the Veteran's hypertension was not related to his service and did not manifest within a year of his service, but instead developed over many years due to factors unrelated to service such as his history of smoking and genetics. The examiner also noted that hypertension and atherosclerosis generally take years to develop. The examiner also found that a heart condition did not manifest in service. Consistent with what the service treatment records show, the examiner explained that while the Veteran was initially assessed with an arrythmia when hospitalized in November 1968, this assessment was revised to hyperventilation syndrome, which did not have a cardiac origin. The medical records did not otherwise show that a heart condition manifested in service. With regard to the Veteran's thoracic aortic aneurism, the examiner explained that this condition was not found until 2015, and was commonly due to atherosclerosis, hypertension, and tobacco use. It was not related to his service. The examiner also found that the "leaky valve" or aortic regurgitation was not the cause of the Veteran's symptoms or related to his service. The record does not indicate otherwise. The record does not show that the Veteran had a transient ischemic attack prior to 2015, and the August 2021 VA medical opinion explains that this is a neurological condition; it is thus not cardiac in nature. The VA medical opinion is probative, as it was rendered by a medical professional based on examination of the Veteran and review of his medical history, and is supported by a thorough explanation that is sufficient for the Board to make a fully informed decision. Accordingly, because a link between the Veteran's current cardiovascular conditions and an in-service disease or injury is not established, the criteria for direct service connection are not satisfied. See 38 C.F.R. § 3.303(a); Holton, 557 F.3d at 1366. As a cardiovascular condition, including hypertension, did not manifest until years after the Veteran's service, service connection also cannot be established under the presumptive provisions applicable to chronic diseases, including based on continuity of symptomatology. See 38 C.F.R. §§ 3.303(b), 3.307. The Board also notes that most of the Veteran's cardiovascular conditions, including hypertension, atherosclerotic disease, and aortic aneurysm, have been attributed to intercurrent causes, namely his history of smoking and genetic factors. In any event, the probative evidence shows that these conditions were not noted in service or within a year of separation, and did not manifest until years after service. As the preponderance of the evidence is against the claim, there is not an approximate balance of positive and negative evidence; therefore, the benefit-of-the-doubt rule does not apply. See Lynch, 999 F.3d at 1395; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 U.S.C. § 5107. Gastrointestinal Disability The Veteran claims service connection for a gastrointestinal disability, including gastroenteritis and diverticulitis, which he states was caused by an injury to his bladder during service, as discussed in more detail below. See March 2018 VA Form 21-4138; April 2021 Hearing Transcript. For the reasons that follow, the Board finds that service connection is not established. The service treatment records show that in September 1965, the Veteran was hospitalized for about ten days after being kicked in the lower abdomen. He reported gross hematuria, described as seeing spots of blood in his urine. He had gross hematuria on two occasions after that without pain. During his hospitalization, a Foley catheter was passed into the bladder and left indwelling. His urine became clear within twenty-four hours. The catheter was left in. His abdomen remained soft and nontender. An intravenous pyelogram was within normal limits. He was cystoscoped and had a cystogram performed; these were within normal limits except for some bullous edema at the dome of the bladder, which was felt to be probably due to catheter reaction. He was left on catheter drainage for one week, and after removal of the catheter he voided well without difficulty. It "was felt that he had only had a bladder contusion and nothing more serious than this." The hospital discharge diagnosis was contusion of the bladder. The service treatment records further show that in January 1967a year and several months after the September 1965 bladder injurythe Veteran reported an onset of abdominal cramps and diarrhea that morning, followed by vomiting. He denied a previous history of abdominal pain. He did not have genitourinary symptoms. He had a mild upper respiratory condition the last few days. On examination, there was slight right abdominal tenderness. A rectal examination showed slight tenderness on both sides. He was admitted to the sick list and placed on bed rest and intravenous supplements ("IV's"). He was to take nothing by mouth ("NPO"). His gastrointestinal symptoms slowly improved. However, a throat culture revealed strep throat, and he was prescribed a ten-day course of Penicillin. He was diagnosed with gastroenteritis and pharyngitis. Thereafter, the service treatment records do not show subsequent complaints or treatment for gastrointestinal symptoms or abdominal pain. The May 1969 separation examination report reflects a normal clinical evaluation of the abdomen and viscera, genitourinary system, anus and rectum; it does not record abnormal findings with regard to the gastrointestinal system. There are no post-service treatment records dated in the file prior to 2008. Private treatment records show that in June 2008, the Veteran was seen in the emergency room with a chief complaint of abdominal pain for the past eight days. The pain began in the epigastric area and became generalized. It first started when he was lifting a heavy object, and he felt a pop in the substernal epigastric area, with an acute onset of pain. In the past twenty-four hours he had developed some diarrhea, and was concerned he may have a recurrence of his diverticulitis. In a review of symptoms, the Veteran denied left lower quadrant pain. The pain increased with certain positions and with bending. He felt as if there were some swelling in his epigastric area after the initial injury. His past medical history included diverticulitis and gastroenteritis. Based on physical examination, laboratory testing, and diagnostic imaging, the impression was that the Veteran had undifferentiated abdominal pain, which may be related to an abdominal muscle strain, as described by him. It was noted that he may also have gastroenteritis developing. The private treatment records show that a June 2008 CT scan of the Veteran's abdomen and pelvis was performed the following day due to his complaint of abdominal pain. The CT scan findings included the bladder being within normal limits and colonic diverticulosis without evidence of diverticulitis. The impression was stated as follows: "No acute abnormality. Atherosclerotic disease and coronary artery calcification. Degenerative changes of the lumbar spine." A July 2012 VA treatment record reflects that the Veteran reported breathing issues and occasional chest pain; all other systems were negative. A January 2015 VA treatment record reflects a reported history that included "rectal bleeding/diverticulosis." The private treatment records show that in September 2015, the Veteran was hospitalized overnight with a chief complaint of left lower quadrant abdominal pain. On admission, he reported a history of recurrent diverticulitis over the last thirty years. He stated that the left lower quadrant abdominal pain was the same as previous diverticulitis flares. He did not have vomiting, diarrhea, or constipation. The admitting team thought the abdominal pain was due to diverticulitis. However, on further discussion with the radiologist and after consultation with general surgery, "it was clear" that the Veteran had epiploic appendagitis and not diverticulitis. In this regard, a September 2015 CT scan of the abdomen and pelvis showed findings most consistent with severe epiploic appendagitis of the mid to distal descending colon. There was also severe diffuse colonic diverticulosis. The September 2015 surgical consultation report states that epiploic appendagitis is a self-limiting, benign entity, which would likely resolve in one to two weeks, and should be treated with simple pain control and anti-inflammatories. In April 2018, a VA examination was performed as part of the development of this claim. The examination report reflects that the Veteran stated his symptoms started in 1966 after being kicked in the bladder. He described the symptoms as sharp pain in the suprapubic region. It was accompanied by diarrhea or constipation, and associated with increased frequency of micturition. The VA treatment records reflect that in April 2019, the Veteran was seen in the gastroenterology department for a consultation. The reason for the consult was a history of infraumbilical abdominal pain that was intermittent and had been present for the last several years, without nausea or vomiting. There was also intermittent rectal bleeding. He related sustaining a bladder injury in service when he was kicked in the bladder. The record states he he still notes blood from the bladder, but further down the page states that the Veteran was not having any difficulty with urinating, pain on urination, or blood in the urine. He stated that a year later he started to have lower abdominal pain, and had been hospitalized ten times for the pain. He stated the pain starts right above the bladder. He stated that when he has the pain, he also passes some blood from the rectum. The results of a CT scan were reviewed, which showed diverticulosis without evidence of diverticulitis. There was no CT scan explanation for the abdominal pain. The treating physician stated that the differential diagnosis included "any [genitourinary] injury since the pain started after injury to the bladder[,] although [the Veteran] does not have any dysuria." The physician added that adhesion pain was "possible" from the prior injury. Possible diagnoses also included ischemic colitis or inflammatory bowel disease, but this was unlikely due to the fact that there was no change in bowel habits. The physician recommended a colonoscopy for further evaluation, but noted that the Veteran would "hold off" on that procedure for now. The Veteran was also seen in urology in April 2019 for "infraumbilical pain" and a history of a bladder "rupture" in 1965. The Veteran stated that his present pain was "intestinal pain" (quotes in original). The diagnosis was non-urologic abdominal pain; altered pelvic anatomy due to prior bladder rupture; and possible adhesions. The Veteran was again advised to undergo a colonoscopy. A September 2020 VA treatment record reflects that the Veteran was seen for a general check-up. It was noted that the Veteran had a "50+ year history of unexplained lower abdominal pain possible related to [a] bladder injury in the service." A VA examination as part of the development of this claim was performed in July 2021. According to the examination report, the Veteran stated that he has had recurrent suprapubic pain since the in-service injury to his bladder. He stated that his doctors told him his diverticulitis is related to that injury. In an August 2021 medical opinion, the July 2021 VA examiner found that the Veteran's gastrointestinal pain is less likely than not related to his in-service bladder injury. The examiner noted that the Veteran had been diagnosed with recurrent diverticulitis in the setting of severe diverticulosis. The examiner further noted that the service treatment records showed that the Veteran had gastroenteritis, which is a self-limiting viral or bacterial infection of the intestines, and would not cause any chronic condition or lead to his current diverticular disease. The examiner considered the service treatment record reflecting that the Veteran had slight tenderness of the rectum when examined during the episode of gastroenteritis, and that a December 2015 VA treatment record shows a complaint of rectal bleeding. The examiner stated that from a clinical standpoint, the note in 1967 and the note in 2015 have no clinical relevance. The acute process of gastroenteritis in 1967 would not cause any long-term sequalae of abdominal pain. The examiner also considered the in-service bladder contusion, but found no "sequelae" in the service treatment records. The examiner stated that there was no medical literature that would support a finding that a bladder injury would lead to diverticulosis. Thus, the Veteran's diverticulosis was unrelated to the bladder injury. Regarding the diagnosis of epiploic appendagitis, the examiner explained that this is a separate entity and would have no relation to the Veteran's service, since it was diagnosed in 2015. Moreover, it was also self-limiting. The examiner concluded that there is no clinical evidence that the Veteran's bladder injury or in-service complaints would lead to his current diverticular disease, which was the likely cause of his current symptomatology. At the April 2021 Board hearing, the Veteran testified that he has had "diverticulitis-type symptoms" ever since his in-service bladder injury. The Board finds that the preponderance of the evidence weighs against a link between the Veteran's in-service bladder injury and episode of gastroenteritis, and his current gastrointestinal conditions. As an initial matter, the record does not show diagnoses of gastroenteritis during the pendency of this claim. The Veteran has not stated otherwise. Thus, as a disability associated with gastroenteritis is not established, the criteria for service connection are not satisfied with regard to that condition. See Holton, 557 F.3d at 1366. The Board does not find it credible that the Veteran has had abdominal symptoms ever since service. As explained above, the Board may not weigh silence in the record against the Veteran's statements without laying a proper foundation based on competent evidence to draw adverse inferences from that silence against the credibility of his statements. See Fountain, 27 Vet. App. at 272-73. In this case, the Board does not base its adverse credibility finding on silence in the record, but on what the available evidence affirmatively shows. It shows that when the Veteran sustained a bladder contusion in 1965 from being kicked in the bladder, his symptom was gross hematuria. During his hospitalization for that injury, no abnormalities were found; his abdomen was nontender. More than a year later, he was treated for an episode of gastroenteritis with symptoms completely different from gross hematuria and involving a different part of his body. He had abdominal cramps and diarrhea, followed by vomiting. He denied a previous history of abdominal pain. He did not have genitourinary symptoms. Moreover, the September 2015 private hospitalization record reflects that the Veteran reported a history of recurrent diverticulitis over the last thirty years. A period of thirty years indicates that its onset would have been around 1985, about fifteen years after the Veteran's separation from service. He also described his diverticulitis flares at that time as left lower quadrant abdominal pain without vomiting, diarrhea, or constipation. When he was treated for gastroenteritis during service, in September 1967, he had right abdominal tenderness on examination, not left lower quadrant pain, and also had symptoms of diarrhea and vomiting. As noted, the service treatment records do not otherwise show abdominal pain, including when the Veteran was treated for the bladder contusion in 1965. The Veteran's later statements asserting that he had abdominal symptoms for the past fifty years, and which had been present ever since service are contradicted by the above evidence. These statements were generally made in the context of supporting a claim for benefits. While the history he related in the April 2019 VA gastroenterology consultation record was ostensibly in the context of treatment, his Notice of Disagreement regarding the denial of service connection for this claim was pending further action at that time. Thus, unlike in the earlier records, he had an incentive to misrepresent his medical history in support of the claim. Accordingly, the earlier records are more reliable, and thus more probative, than these later statements. Accordingly, given these inconsistencies and conflicts, the Board finds that the Veteran's statements that he experienced abdominal pain ever since service are not credible. See Caluza, 7 Vet. App. at 511. With regard to the slight rectal tenderness on examination noted in the September 1967 service treatment record, the records dated during the pendency of this claim do not reflect rectal tenderness. Rather, they reflect that he had rectal bleeding associated with left lower quadrant pain. The August 2021 VA medical opinion explains that his current symptoms are not related to his in-service episode of gastroenteritis, which was self-limiting and had no sequalae. The August 2021 VA medical opinion constitutes probative evidence weighing against a link between the Veteran's in-service bladder injury or episode of gastroenteritis and his current diverticulosis with recurrent diverticulitis, epiploic appendagitis, or symptoms of recurrent abdominal pain with rectal bleeding. The examiner explained that a bladder injury would not lead to diverticulosis or diverticular disease, which was the cause of his current symptomatology. The examiner also explained that the Veteran's in-service gastroenteritis was a self-limiting condition that had no sequalae during service, meaning that it resolved, and would not cause any chronic condition or lead to his current diverticular disease. It was thus not related to the Veteran's subsequent gastrointestinal conditions. Similarly, the examiner found that the Veteran's epiploic appendagitis is a self-limiting condition that is distinct from the other conditions and not shown until 2015. As the opinion is based on examination of the Veteran and review of his medical history, and is supported by a thorough explanation sufficient for the Board to make a fully informed decision, it is probative. The statements by the treating physician in the April 2019 VA gastroenterology record that the differential diagnosis included "any [genitourinary] injury since the pain started after injury to the bladder," and "adhesion pain possible from the prior injury" are discounted as lacking probative value. There is no indication that the physician reviewed the Veteran's service treatment records, which would have shown that he did not have abdominal pain until more than a year after the bladder injury, that the pain occurred in the context of gastroenteritis and was accompanied by nausea and vomiting, and that the symptoms were completely distinct from the hematuria associated with the bladder contusion. The statement by the April 2019 gastroenterologist does not account for that evidence. It is also based on the assumption that the Veteran had recurrent abdominal pain ever since service, while the credible evidence shows it did not manifest until around 1985, as explained above. Further, the words "differential" and "possible" underscore the speculative nature of these observations, which also detracts from their probative value. See, e.g., Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996) (holding that a "generic statement about the possibility of a link" to service is "too general and inconclusive" to be probative) (emphasis in original). Finally, the statements by the April 2019 gastroenterologist do not account for the fact that the Veteran's in-service abdominal pain occurred in the context of gastroenteritis with diarrhea and vomiting, as well as an upper respiratory infection, and that the tenderness on examination was in the right abdomen at that time; by contrast, the post-service treatment records show that the Veteran's abdominal symptoms have been characterized by left lower quadrant pain. Accordingly, given the deficiency in the rationale provided, the April 2019 statement by the gastroenterologist is discounted. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (holding that the probative value of a medical opinion comes from its reasoning, and that critical pieces of information from a claimant's medical history can lend credence to the opinion of a medical expert who considers them, and detract from the medical opinions of experts who do not). It is outweighed by the August 2021 VA medical opinion. For the same reason, the notation in the April 2019 VA urology consultation record that the Veteran had "infraumbilical pain" and a history of a bladder "rupture" in 1965 does not support a relationship between the two. The treating physician did not indicate a finding that the two were related, and noted that the Veteran's present pain was "intestinal pain" and "non-urologic." The Board further observes that the Veteran did not sustain a bladder "rupture" during service, but rather a contusion. The Board also notes that the urologist's diagnosis of "altered pelvic anatomy due to prior bladder rupture" is not supported by an explanation, does not account for the fact that the Veteran had a bladder contusion and not a rupture, that this was not surgically treated, and that he did not have an "altered pelvic anatomy" at the time apart from some swelling ("edema") at the dome of the bladder, which was thought to be a reaction to the catheter and has not subsequently been shown. In any event, the present claim is not for a genitourinary condition, but for abdominal symptoms. These symptoms have not been attributed to the Veteran's genitourinary system, but rather to diverticulitis and epiploic appendagitis. The only other abdominal pain documented in the records is the June 2008 emergency treatment at a private facility. The records pertaining to that treatment show abdominal pain that was not located in the left lower quadrant, but note that the Veteran's pain had its onset upon lifting a heavy object eight days earlier and experiencing a "pop" in the substernal epigastric area at the time. The impression was that it may be due to an abdominal strain. As the Veteran also reported that he had experienced some diarrhea in the past twenty-four hours, it was noted that he may also have some gastroenteritis developing. However, this was not confirmed, and the August 2021 VA medical opinion explains that the gastroenteritis during service was self-limiting with no sequelae, and thus would not lead to a chronic condition. The Board here again notes that the Veteran has not been diagnosed with gastroenteritis during the pendency of this claim. Diagnostic workup at the time of the June 2008 treatment, including a CT scan, did not show findings of diverticulitis. Rather, the abdominal CT scan showed "no acute abnormality." There is thus no indication that this abdominal pain is related to the in-service episode of gastroenteritis, or his bladder contusion. The Board has considered the Veteran's statement recorded in the April 2018 VA examination report that his symptoms consist of sharp pain in the suprapubic region and are accompanied by diarrhea or constipation and increased frequency of micturition. Regardless of whether that may be the case, this alone does not support a relationship to service. As explained in the August 2021 VA medical opinion, the Veteran's in-service bladder contusion is not related to his current gastrointestinal problems, and his in-service episode of gastroenteritis resolved without sequelae, meaning it was not causally related to any subsequent episodes or a chronic condition. The Board also again observes that the Veteran has not been diagnosed with gastroenteritis during the pendency of this claim. In general, in the context of treatment, the Veteran has stated that his diverticulitis is associated with left lower quadrant pain and rectal bleeding, but not has reported associated diarrhea, constipation, urinary frequency, or vomiting. Whatever the case may be, the preponderance of the evidence weighs against a relationship to service, for the reasons discussed above. The July 2021 VA examination report reflects the Veteran's statement that his doctors told him his diverticulitis is related to his in-service bladder injury. To the extent the Veteran was referring to the April 2019 gastroenterology record discussed above, the Board has explained why any findings in that record as to a possible link to the in-service bladder injury are not probative and outweighed by the August 2021 VA medical opinion. If other doctors told him his diverticulitis was related to his in-service injury, such findings are not of record. More weight is given to the August 2021 VA medical opinion actually before the Board for review, and which is supported by an explanation grounded in review of the Veteran's medical records. Indeed, the Veteran also stated at the July 2021 VA examination that he has had recurrent suprapubic pain ever since service. The Board has explained why that statement is not credible. Its lack of credibility also casts doubt on the reliability of his unsupported assertion that doctors have told him his diverticulitis is related to his in-service bladder injury. As a lay person in the field of medicine, the Veteran does not have the medical expertise to render a competent medical opinion as to whether his current abdominal issues are related to his in-service bladder injury, as this is a determination that is too complex to be made based on lay observation alone given the amount of time that has elapsed and the different symptoms involved. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). Thus, his own opinion on the issue is not probative. See Layno v. Brown, 6 Vet. App. 465, 470-71 (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration). Moreover, it is based on a premise which is not established, namely that he has had recurrent abdominal pain ever since that injury, or ever since service. His opinion is discounted on that basis too. It is outweighed by the August 2021 VA medical opinion. In sum, a link between any current gastrointestinal conditions, including diverticulosis with recurrent diverticulitis and epiploic appendagitis, and an in-service disease or injury is not established. Therefore, the criteria for service connection are not satisfied. See Holton, 557 F.3d at 1366. (Continued on next page) As the preponderance of the evidence is against the claim, there is not an approximate balance of positive and negative evidence; therefore, the benefit-of-the-doubt rule does not apply. See Lynch, 999 F.3d at 1395; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 U.S.C. § 5107. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Rutkin, 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.