Citation Nr: 21005601 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 15-22 781A DATE: February 2, 2021 ORDER Entitlement to service connection for retinopathy, to include as secondary to and/or aggravated by diabetes mellitus, type I, is granted. Entitlement to service connection for insulin reaction (previously claimed as adrenal cortical hypofunction and Addison’s Disease), to include as secondary to and/or aggravated by diabetes mellitus, type I, is denied. Entitlement to service connection for hypertension, to include as secondary to and/or aggravated by diabetes mellitus, type I, is denied. Entitlement to service connection for hyperthyroidism, to include as secondary to and/or aggravated by diabetes mellitus, type I, is denied. Entitlement to service connection for arteriosclerotic heart disease, to include coronary artery disease, to include as secondary to and/or aggravated by diabetes mellitus, type I, is denied. FINDINGS OF FACT 1. The objective medical evidence shows retinopathy is proximately due to, a result of or made worse beyond its natural progression by diabetes mellitus, type I. 2. The objective medical evidence shows insulin reaction (previously claimed as adrenal cortical hypofunction and Addison’s Disease), is not caused by an event, injury. or illness during active service, nor is it proximately due to, a result of or made worse beyond its natural progression by service-connected diabetes mellitus, type I. 3. The objective medical evidence shows hypertension is not caused by an event, injury. or illness during active service, it is not proximately due to, a result of or made worse beyond its natural progression by service-connected diabetes mellitus, type I, nor did it manifest to a compensable degree within one year of separation from active service. 4. The objective medical evidence shows hyperthyroidism is not caused by an event, injury. or illness during active service, it is not proximately due to, a result of or made worse beyond its natural progression by service-connected diabetes mellitus, type I, nor did it manifest to a compensable degree within one year of separation from active service. 5. The objective medical evidence shows arteriosclerotic heart disease, to include coronary artery disease, is not caused by an event, injury. or illness during active service, it is not proximately due to, a result of or made worse beyond its natural progression by service-connected diabetes mellitus, type I, nor did it manifest to a compensable degree within one year of separation from active service. CONCLUSIONS OF LAW 1. With all reasonable doubt resolved in the Appellant’s favor, the criteria for service connection for retinopathy, to include as secondary to and/or aggravated by diabetes mellitus, type I, have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2019). 2. The criteria for service connection for insulin reaction (previously claimed as adrenal cortical hypofunction and Addison’s Disease), to include as secondary to and/or aggravated by diabetes mellitus, type I, have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2019). 3. The criteria for service connection for hypertension, to include as secondary to and/or aggravated by diabetes mellitus, type I, have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2019). 4. The criteria for service connection for hyperthyroidism, to include as secondary to and/or aggravated by diabetes mellitus, type I, have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2019). 5. The criteria for service connection for arteriosclerotic heart disease, to include as secondary to and/or aggravated by diabetes mellitus, type I, have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from February 1958 to May 1966. The Veteran died in May 2017. His spouse has been substituted for the purposes of pursuing this appeal. In January 2020, the Appellant, with her son as an observer, testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. These matters were Remanded by the Board In April 2020, and have now been returned to the Board. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in active service or that a preexisting injury or disease was aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2019). Establishing service connection generally requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Additionally, service connection may be granted on a secondary basis for a disability which is proximately due to, the result of or made worse beyond its natural progression by a service-connected disease or injury. 38 C.F.R. § 3.310. Moreover, service connection of a nonservice–connected disease or injury will be established if an increase in severity of the nonservice–connected disability is shown to be proximately due to or the result of a service-connected disease or injury and not due to the natural progress of the nonservice–connected disease or injury. 38 C.F.R. § 3.310 (b). The evidence must show (1) a current disability exists and (2) the current disability was the (a) proximately caused by or (b) proximately aggravated (worsened in severity beyond its natural progress) by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). Certain chronic diseases may be service connected on a presumptive basis if manifested to a compensable degree in a specified period after service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. That period is usually one year. 38 C.F.R. § 3.307 (a)(3). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303 (b). Under 38 C.F.R. § 3.303 (b), an alternative method of establishing and in-service disease or injury and a nexus for chronic diseases is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was “noted” during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303 (b). 1. Entitlement to service connection for retinopathy, to include as secondary to and/or aggravated by diabetes mellitus, type I. 2. Entitlement to service connection insulin reaction (previously claimed as adrenal cortical hypofunction and Addison’s Disease), to include as secondary to and/or aggravated by diabetes mellitus, type I. 3. Entitlement to service connection for hypertension, to include as secondary to and/or aggravated by diabetes mellitus, type I. 4. Entitlement to service connection for hyperthyroidism, to include as secondary to and/or aggravated by diabetes mellitus, type I. 5. Entitlement to service connection for arteriosclerotic heart disease, to include coronary artery disease, to include as secondary to and/or aggravated by diabetes mellitus, type I. The service treatment records (STRs) show in all in-service examinations the categories of eyes, ophthalmoscopic, endocrine system, heart, and vascular system were checked off as normal. In all in-service examinations, the Veteran denied past or current frequent or severe headache, dizziness or fainting spells, eye trouble, shortness of breath, pain or pressure in the chest, palpitation or pounding heart, high or low blood pressure, recent gain or loss of weight, or periods of unconsciousness. A January 1962 in-service ophthalmologic consultation shows slight right-eye exotropia (convergent strabismus). The Veteran was diagnosed with right-eye amblyopia and left-eye emmetropia (normal). A January 1962 profile states “uncorrectable vision with no apparent cause; tendency of eye to turn.” The December 1965 separation examination states a diagnosis of “amblyopia bilateral, uncorrected with perm. E-3 profile.” The March 1966 separation examination shows right-eyesight at 20/100 and the same when corrected. Left eye was at 20/20. May 1964, December 1965 and April 1966 separation results for chest x-rays showed normal findings. A July 1961 x-ray result stated heart and lungs within normal limits. The February 1958 enlistment examination shows a blood pressure reading of 128/74. An August 1961 special forces examination and the December 1965 separation examination both show blood pressure at 110/72. The May 1966 separation examination shows blood pressure at 124/82. The post-service treatment record shows a July 1986 private treatment electrocardiogram (EKG) produced abnormal results, with changes to the inferior wall and occasional ventricular contractions. August 1986 private hospital notes show a physical examination revealed no heart murmur, a regular sinus rhythm and cardiac borders were within normal limits. Dr. S.G.M.’s January 1987 examination showed a normal EKG. An August 1986 blood pressure reading by a private treatment provider was 146/90. An October 1986 private treatment note states, based on the Veteran’s report, his mother had hypertension. Dr. S.G.M.’s January 1988 examination noted blood pressure readings between November 1987 and January 1988 as 160/94, 150/82 and 156/86. In March 1988, the Veteran reported to his private treatment provider left-eye vision fluctuation during a period of 18 months when his diabetes was uncontrolled. He further reported that he had had a “lazy” left-eye disorder since birth. Ocular examination showed visual acuity in each eye at less than normal and fundoscopic examination revealed some scattered hemorrhages and microaneurysms, but no evidence of vitreous hemorrhage in either eye. Imaging supported the impression of bilateral proliferative retinopathy, greater in the left eye than the right eye. The treatment provider informed the Veteran that there were definite diabetic changes in both eyes. He diagnosed bilateral proliferative diabetic retinopathy. March 1989 imaging showed hemorrhaging leaking into the vitreous, supporting the impression of pre-retinal hemorrhage secondary to proliferative diabetic retinopathy, right eye, and bilateral post panretinal photocoagulation treatment for proliferative diabetic retinopathy. A July 1989 treatment note of Dr. S.G.M. states the Veteran at this time was symptomatic for diabetes, retinopathy, nephropathy and neuropathy. Additionally, the treatment provider noted prior hypertension, but treatment had begun only as recent as October 1987. A September 1989 private treatment medical statement of Dr. D. H. O. states the Veteran has advanced proliferative diabetic retinopathy in both eyes and, although having had laser treatment, he experiences repeated hemorrhages in both eyes; accordingly, his prognosis is guarded and he cannot undertake strenuous activities which would induce more hemorrhages. Additionally, at this time records indicate the Veteran underwent photocoagulation treatment for proliferative diabetic retinopathy, with a small indication of neovascularization in each eye which leaks fluorescein into the vitreous. The treatment provider’s impression was bilateral proliferative diabetic retinopathy, post-panretinal photocoagulation treatment. However, overall clearing of hemorrhages was noted in the left eye, but sustained hemorrhaging remained in the right. Appropriate “fill-in panretinal treatment” was recommended accordingly. Dr. S.G.M.’s December 1990 medical statement states the Veteran is being treated for diabetes mellitus with insulin and he has diabetic retinopathy, nephropathy and neuropathy. By the end of August 1991, the Veteran reported almost complete right-eye blindness due to hemorrhaging. A June 1991 Social Security document shows the Veteran reported complications related to his diabetes of retinopathy, noted him to be on a blood pressure medication since 1987 and he was “losing protein due to the Diabetes.” An August 1991 summary in a Social Security document noted, “The claimant’s diabetes is out of control. Since 6/13/1991, he has taken 100 units of insulin... has neuropathy... burning in his feet. He has hemorrhages in his eyes.... On February 4, 1988, the claimant underwent an implantation of a hydrofl[e]x penile prosthesis because of impotency due to diabetes... March 4 1988... ophthalmologist... the claimant had bilateral proliferative retinopathy... On September 28, 1989, Dr. []... reported that the claimant had advanced proliferative diabetic retinopathy in both eyes. Despite extensive laser surgery...repeated vitreous hemorrhages in both eyes...” Partly based on this record, the Social Security Administration determined the Veteran became disabled on May 1, 1988. Private treatment notes in or near 1995 show comments that the Veteran underwent laser eye surgeries between 1988 and 1995. July 2002 private treatment notes shows blood pressure readings of 121/51, 100/48 and 100/50. In or near January 2002, Dr. M.H.R.’s problems list for the Veteran states diabetes mellitus, as well as diabetic nephropathy and hypertension, stating each was first noted in September 1995. A private treatment note in July 2002 noted the Veteran starting peritoneal dialysis that month and included a diagnosis of “[e]nd stage renal disease.” A March 2003 stress test of heart, conducted as a pre-kidney transplant evaluation, was negative for chest pain or EKG changes suggestive of ischemia. In October 2003, the Veteran filed his claim service connection for diabetes mellitus, type I, asserting its onset in April 1967. In August 2004, a private treatment provider detected hypercalcemia, thought to be probably related to hyperparathyroidism. Medication was to be considered if it did not resolve. In the period of May 2007 through October 2010, the Veteran presented once or twice a year to a private treatment eye clinic with various eye complaints, ranging from itchiness, to tearing, to conjunctivitis, to blurred vision in one eye, and for a checkup for his amblyopia. In July 2007, the Veteran was assessed with hyperparathyroidism, probably on the basis of renal osteodystrophy. The November 2007 assessment stated hyperparathyroidism, “etiology of which is not clear.” As the Veteran’s renal function was normal, the nephrologist considered the possibly of parathyroid hyperplasia. Although presenting to private a treatment provider in November 2007 with chest pain, the Veteran was assessed as stable. The echocardiogram which followed showed concentric left-ventricular hypertrophy, with normal contractility and ejection fraction, stage 1 diastolic dysfunction and bilateral enlargement, left greater than right. However, a November 2007 myocardial perfusion study showed no evidence in nuclear images suggesting any ischemia or infarction, and further showed normal left-ventricular function. In January 2008, renal tests results included secondary hyperparathyroidism, usually associated with renal failure, as a result of constant stimulation of the parathyroid gland by low calcium levels. In December 2008, the Veteran was prescribed medication. In March 2009, the Veteran’s hyperparathyroidism was referred to as “tertiary.” In January 2010, the Veteran’s assessment stated hyperparathyroidism, with “actual[] improvement with control of vitamin D level.” In the April 2010 treatment notes of the Veteran’s private treatment provider, the Veteran was referred to as having “some issues with hyperthyroidism and taking medication in the past couple of years with improvement.” In a July 2010 nephrology visit, hyperparathyroidism was noted as a complication of the Veteran’s chronic kidney disease. In July 2011, the Veteran’s diagnosis was secondary hyperparathyroidism (of renal origin). Overall, the medical evidence shows the Veteran’s thyroid gland showed no nodules, masses, tenderness, enlargement, and was without adenopathy. With the grant of service connection for diabetes mellitus, type I in the Board’s April 2020 decision, the Board also remanded those issues remaining in this appeal so that it could be medically determined which might reasonably be associated on secondary bases with diabetes and which might not be. As directed, an August 2020 VA examiner rendered a series of opinions, the first of which addressed direct service connection. She opined that retinopathy, insulin reaction and hypertension were less likely as not (less than 50 percent probability) incurred in service, are the result of injury or disease in service, or were present within one year of separation from service or are otherwise related to any in-service event or occurrence. She explained in her rationale for retinopathy that the March 1988 private treatment provider noting 18 months of left-eye changes at the same time the Veteran’s diabetes “has been out of control” and diagnosing bilateral proliferative diabetic retinopathy “supports this condition as starting many years after separation from service, and many years after his [diagnosis] of Type I Diabetes, which is a fairly common time-course for its onset with that type of Diabetes.” For insulin reactions, which August 2020 VA examiner characterized as such because the medical record does not support the Veteran having a diagnosis for adrenal cortical hypofunction (Addison’s Disease), her rationale explains that, although the Veteran reported a history of occasional low-blood sugars, which arguably would indicate “insulin reactions,” that report was many years after separation from service. Moreover, the August 2010 VA examiner found specific treatment notes in the medical evidence documenting those findings. Additionally, as the Veteran reported starting insulin for diabetes mellitus, type I, in April 1967, “this does not support this condition as starting in service.” Regarding hypertension, the August 2020 VA examiner explains, as the June 1991 Social Security document indicates the Veteran had been on hypertension medication in 1987 and his in-service May 1966 separation examination noted a blood pressure reading of 124/ 82, “[t]he records do not support his HTN [hypertension] as starting in service or being [diagnosed] within a year of separation or directly related to service.” The August 2020 VA examiner did not render an opinion for arteriosclerotic heart disease, stating the Veteran’s medical records do not support him as having received such a diagnosis and his several stress tests of record did not show findings consistent with ischemia. Moreover, a December 2016 nursing home notes shows the Veteran was admitted for a duodenal ulcer with bleed and “bright red blood loss per rectum” at the time when he was noted to have elevated troponin blood tests and a diagnosis with a non-Q wave myocardial infarction (NQWMI). “However, in the absence of definitive evidence of IHD [ischemic heart disease], the N[QW]MI is attributed to his blood loss and not to IHD, by this Examiner.” The August 2020 VA examiner also did not include an opinion for hyperthyroidism, because she did not find that diagnosis in the medical evidence of record. She added that, although the Veteran reported a “thyroid problem,” he was diagnosed with hyperparathyroidism by his nephrologist in July 2007, believing it might be due to the Veteran’s renal disease. However, the nephrologist concluded in November 2007 the cause to be uncertain, as the Veteran’s renal function was normal. He considered the possibly of parathyroid hyperplasia. Additionally, the nephrologist found the Veteran’s vitamin D level had been low, but noted his hyperparathyroidism to improve with vitamin D supplementation, as shown in the January 2010 treatment note. The August 2020 VA examiner concluded, “Vitamin D deficiency is a known cause of Hyperparathyroidism. Therefore, in the absence of additional information, this Examiner is not attributing his Hyperparathyroidism to his Type I Diabetes condition to an as least as likely as not level, at this time [sic].” The August 2020 VA examiner in addressing a secondary basis for service connection, next opined that retinopathy, as well as two other disorders not before the Board in this appeal, were at least as likely as not (50 percent probability or higher) proximately due to or the result of the Veteran service-connected diabetes mellitus, type I. She explained in her rationale that diabetic retinopathy and the two other disorders “are all common complications of Diabetes - both Type I and Type II. These conditions were all noted to be dx [diagnosed] after his Type I Diabetes was dx. Please see other evidence as above.” However, she did not include insulin reaction for an opinion, as it was noted by her not to be a chronic condition. She explained, “As noted above, intermittent low blood sugars are common complications of insulin treatment for Type I Diabetes, but is less likely a chronic health condition. This Examiner did note in this Veteran’s 8/27/11 claims, ‘Insulin reaction from Dr. (name withheld here) related to falls and broken bones,’ but this Examiner was unable to confirm definitive falls and/or broken bones, directly related to low blood sugar events/insulin reactions, based on the available records.” She next opined hypertension was less likely as not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected diabetes mellitus, type I. She explained in her rationale that the medical records show the onset of hypertension in 1987. “While at times Diabetes Type I can cause and/or aggravate HTN, usually this is in the setting of established Diabetic nephropathy with renal dysfunction. This Veteran was not noted to have signs of his Diabetic nephropathy until 1988, based on the available records, which is after his dx of HTN.” Once again, the August 2020 VA examiner did not include arteriosclerotic heart disease in her opinions for the same reasons stated above for a direct service connection opinion. Nor did she include hyperthyroidism and stated the same reasons as above for that disorder. However, she added, “Stated more specifically, his Hyperparathyroidism is less likely as not (less than 50 [percent] probability) proximately due to/the result of, his now [service-connected] Type I Diabetes. Rationale: The Veteran was noted to have been [diagnosed] with the Hyperparathyroidism condition, after his kidney transplant, at a time when his renal function was noted to be normal and his nephrologist was not noted to attribute that condition to his Diabetes.” In regard to opinions for aggravation, the August 2020 VA examiner stated she would not “re-address” those disorders above which had received positive secondary opinions. However, once again, she excluded insulin reaction from consideration for the same reason stated above for exclusion from a secondary opinion. She again excluded arteriosclerotic heart disease for the same reasons stated above regarding a secondary opinion. She opined that hypertension was not at least as likely as not aggravated beyond its natural progression by service-connected diabetes mellitus, type I. She explained in her rationale that, although at times diabetes mellitus, type I, can cause and/or aggravate, this usually occurs with established diabetic nephropathy with renal dysfunction. She added, “The evidence supports this Veteran as being started on one medication for his blood pressure starting around 1987. At his 7/16/02 Nephrology visit prior to his dialysis, he was noted to be on 2 anti-hypertensive type medications. At his nephrology f/u [follow-up] after his kidney transplant 8/5/04, he was noted to be on one anti-hypertensive medication and that his renal function was “excellent” at this point. At a specific/descriptive record notes seen close to his time of death, in a 2/14/17 note, he was noted to be on 4 anti-hypertensive medications, but the most recent kidney function tests noted, also in this note, show a normal Creatinine level of 0.92 on 12/19/16. Therefore, this does not support his HTN as being permanently aggravated by his Diabetes Type I, to an at least as likely as not level.” The August 2020 VA examiner lastly opined that hyperparathyroidism was not at least as likely as not aggravated beyond its natural progression by service-connected diabetes mellitus, type I. She explained in her rationale that, as already stated above, the Veteran’s nephrologist in November 2007 found normal renal function and concluded the cause of hyperparathyroidism was uncertain and further noted that hyperparathyroidism improved with higher vitamin D levels. She added, “This Examiner also did not see records clearly supporting worsening of his renal function again after his kidney transplant with accompanying worsening of his Hyperparathyroidism condition.” It appears from the record that the AOJ requested a re-statement of a secondary opinion for retinopathy to be entered more properly on a template for an ophthalmology Disability Benefits Questionnaire (DBQ). In any case, a second VA examiner in October 2020 opined that retinopathy and other disorders not now in the appeal before the Board are at least as likely as not (50 percent or greater probability) proximately due to or the result of the Veteran’s service connected condition. The October 2020 VA examiner explained: “Rationale: These are all well known complications of diabetes mellitus, either type 1 or type 2.” This in turn was followed by a December 2020 VA examination for eye conditions, which after review of the Veteran’s record of treatment, stated diagnoses of proliferative diabetic retinopathy (1988), post-operative cataracts, both eyes (pre-2008) and amblyopia right eye (from birth). The accompanying opinions addressed conflicting evidence. To the request to outline the Veteran’s symptomatology of diabetic retinopathy for the period June 1,2011 until the Veteran’s death on May 30, 2017, to include a discussion of available information regarding bilateral vision and field of vision, medications taken for symptoms, incapacitating episodes, and whether retinopathy entailed one or both eyes, the December 2020 the Veteran opined as follows: “All of the records I found were dated BEFORE 06/01/2011 except one dated 11/09/2011 where it was noted that he had a new lacunar infarct in the left basal ganglia. There was no evidence of effects from that on vision. The retinopathy clearly affected both eyes from 1988 until his death, with best corrected vision in 2010 of 20/60-2 in the amblyopic right eye and 20/30 in the left eye at that time. I have no information on any medications taken for symptoms or incapacitating episodes in the requested time period.” He explained in his rationale: “Given the severity of the diabetic retinopathy, it is very unlikely that his vision improved after the above-noted visual acuities. In fact, in likely got worse, but I have no direct information in that regard. His peripheral vision was severely constricted from 2008 onward for the rest of his life, caused by the panretinal photocoagulation done for the diabetic retinopathy, as this ALWAYS damages peripheral vision.” The December 2020 next responded to the request if there was a documented change in severity of the Veteran’s vision/symptomatology during the applicable time period please discuss the nature and severity of the Veteran’s retinopathy at each stage. “I have no information for that period.” He explained: “All of the records were dated BEFORE 06/01/2011 except one dated 11/09/2011.” The comprehensive series of August 2020 opinions, as set forth in the above summary of the record, are self-explanatory, but they are numerous and they are varied in their rationales. For the purpose of clarity, the Board notes the following. Although not directed by the Board in its April 2020 Remand, the August 2020 VA examiner first proceeded with a medical determination of service connection based on direct causation, consistent with VA’s policy to afford veterans the broadest opportunity to maximize benefits. For retinopathy, insulin reaction and hypertension, each opinion is negative. For heart disease, the August 2020 VA examiner found no diagnosis in the medical evidence and therefore rendered no opinion. For hyperthyroidism, she determined from her review of the record that the record did not reflect a true diagnosis, as hypertension was not conclusively related to diabetes and she therefore rendered no opinion on direct causation. For secondary causation, as being caused by diabetes mellitus, type I, the August 2020 VA examiner opined that retinopathy was in fact more likely caused by diabetes. However, her opinions on secondary causation for hypertension and hyperthyroidism were negative. Once again, as she noted no diagnosis in the medical evidence for arteriosclerotic heart disease, to include coronary artery disease, she formulated no opinion. Regarding secondary causation of insulin reaction, the Board first notes that the Appellant in her January 2020 Board hearing testimony stated the Veteran “didn’t know what he was doing. And he just kept on going for more insulin, that’s what the doctors, you know, told him that would help,” and ultimately, he could no longer work, because of the risk of falling from ladders, presumably due to reactions to insulin. The Board is well aware that lay persons are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Appellant is competent to provide statements of symptoms which are observable to her senses and there is no reason to doubt her credibility. However, the lay evidence of the Veteran must in turn be weighed against other evidence, as all relevant evidence of varying kinds must be considered. The August 2020 VA examiner concluded from her review of the record and based on her medical expertise that insulin reaction was an occasional occurrence, but not an identifiable chronic disorder which in and of itself could be “caused” by diabetes. She therefore rendered no opinion. The Board ascribes greater probative value to August 2020 VA examiner’s findings and conclusion, as she rendered them in her capacity as a medical professional and after objective review of the medical evidence of record. Her conclusion displays a thorough knowledge of the Veteran’s medical history and exhibits consistency and sound clinical judgment. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). For opinions on the aggravation of a disorder by diabetes mellitus, type I, she stated no opinion for retinopathy, as she had already opined positively for secondary service connection. She gave no opinion for aggravation of insulin reaction, stating the same reasons as just stated for secondary causation. Her opinions for aggravation of hypertension and hyperthyroidism were negative. She gave no opinion for arteriosclerotic heart disease and gave no explanation and the Board presumes the reasons are the same as for secondary and direct causation, that the record does not contain a diagnosis for this disorder. Overall, where no opinion was given, the Board understands that to signify there is no basis on which to establish of service connection, whether direct or on any secondary basis, to include aggravation. Lastly, chronic diseases eligible for presumptive service connection include the following claims on appeal. The record shows the Veteran was treated for possible heart disease and he asserted the disorder as coronary artery disease. That disorder would fall within the chronic-disease category of endocarditis (covering all forms of valvular heart disease). Hypertension is accorded the same eligibility for presumptive service connection, as it is often an early symptom long preceding the manifestation of other chronic diseases listed under the regulation. 38 C.F.R. § 3.309 (a). The record consistently shows assessments of the Veteran’s hypertension or its appearance on problems lists. It also shows numerous diagnoses of hyperthyroidism, which falls under the category of endocrinopathies, appearing among chronic diseases in the regulation. However, the record offers no evidence of the manifestation of the above disorders to a compensable degree within one year of separation from active service. Additionally, because they were never identified in service or directly after, and putting aside the lack of medical evidence of treatment for those disorders at that time, it would be otherwise impossible to establish continuity of symptomatology based on the identification of symptoms during, directly after or continuing for a longer period after active service. Consequently, the presumption of service connection for these disorders as chronic diseases is not available to the Veteran. For the foregoing reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence supports the claim for service connection for retinopathy, as secondary to diabetes mellitus, type I. However, based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claims for service connection on any basis for insulin reaction (previously claimed as adrenal cortical hypofunction and Addison’s Disease), hypertension, hyperthyroidism, and arteriosclerotic heart disease, to include coronary artery disease. Where the Board has not ruled favorably for the Appellant, it has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. The preponderance of the evidence is against the claims not granted service connection, the doctrine is therefore not applicable and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Franke, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.