Citation Nr: 21021468 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 16-60 136 DATE: April 13, 2021 ORDER Entitlement to service connection for major depressive disorder is granted. Entitlement to service connection for right upper extremity neuropathy, diagnosed as right-hand peripheral neuropathy, is granted. Entitlement to service connection for left upper extremity neuropathy, diagnosed as left-hand peripheral neuropathy, is granted. Entitlement to service connection for a bilateral foot disability, claimed as pes planus, foot callouses, and hallux valgus, is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for diabetes mellitus is denied. Entitlement to service connection for right lower extremity neuropathy, to include as secondary to diabetes mellitus, is denied. Entitlement to service connection for left lower extremity neuropathy, to include as secondary to diabetes mellitus, is denied. REMANDED Entitlement to service connection for hypertension, to include as secondary to the now service-connected major depressive disorder, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to the now service-connected major depressive disorder or hypertension, is remanded. FINDINGS OF FACT 1. The Veteran’s major depressive disorder is related to an in-service event. 2. The Veteran’s diagnosed right-hand peripheral neuropathy and left-hand peripheral neuropathy had their onset in service or are otherwise related to his active service. 3. Pes planus of the bilateral feet was noted on entry and was not aggravated by service. 4. Bilateral foot callouses and hallux valgus did not have onset in service and are not otherwise related to service. 5. The Veteran’s right knee disability, left knee disability, diabetes mellitus, right lower extremity neuropathy, and left lower extremity neuropathy were not shown during active duty, were not diagnosed for several years post-service, and the evidence fails to establish an etiological relationship between the Veteran’s claimed disabilities and his active service. CONCLUSIONS OF LAW 1. The criteria for service connection for major depressive disorder have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 2. The criteria for service connection for a right upper extremity neuropathy, diagnosed as right-hand peripheral neuropathy, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 3. The criteria for service connection for a left upper extremity neuropathy, diagnosed as left-hand peripheral neuropathy, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 4. The criteria for entitlement to service connection for a bilateral foot disability, claimed as bilateral pes planus, foot callouses, and hallux valgus, have not been met. 38 U.S.C. §§ 1131, 1153, 5107; 38 C.F.R. § 3.303, 3.304, 3.306. 5. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 6. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 7. The criteria for entitlement to service connection for diabetes mellitus have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 8. The criteria for entitlement to service connection for right lower extremity neuropathy, to include as secondary to diabetes mellitus, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 9. The criteria for entitlement to service connection for left lower extremity neuropathy, to include as secondary to diabetes mellitus, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1980 to July 1984, with additional service in the Army National Guard. This case comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in January 2019, when new and material evidence claims for entitlement to service connection for a left knee disability, bilateral foot disability, left lower extremity neuropathy, and right lower extremity neuropathy were granted. Service connection claims for a bilateral foot disability, left knee disability, right knee disability, hypertension, erectile dysfunction, diabetes mellitus, neuropathy of the left lower extremity, neuropathy of the right lower extremity, neuropathy of the right upper extremity, neuropathy of the left upper extremity, and an acquired psychiatric disability were remanded for additional development. A June 2020 supplemental statement of the case was most recently issued, and the claims are once again before the Board. With respect to the Veteran’s claim for a psychiatric disability, the Board notes that it was characterized by the RO as one for entitlement to service connection for a nervous disorder. Additionally, following certification of his psychiatric claim to the Board, the RO for unknown reasons issued an April 2018 rating decision separately adjudicating and denying service connection claims for anxiety, depression, and posttraumatic stress disorder (PTSD). The Veteran subsequently perfected an appeal on these specific diagnoses and requested a hearing in a March 2020 substantive appeal. The Board notes, however, that when the Veteran made a claim for a nervous disorder, he was seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, the Board has recharacterized the issue into a claim for any acquired psychiatric disability, and his acquired psychiatric disability claim stems from the October 2015 rating decision already on appeal. Although it appears that the Veteran has now requested a hearing on this issue, as the Board is granting this issue in full, the Board finds no prejudice in adjudicating this claim without a hearing on the matter. The Board additionally notes that a November 2019 hand and finger examination that considered the Veteran’s bilateral upper extremity peripheral neuropathy was provided to the Veteran following the latest June 2020 supplemental statement of the case. As the Board is granting service connection for peripheral neuropathy of both the right and left upper extremities, there is no prejudice in considering this examination with respect to these two issues. SERVICE CONNECTION Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131. Generally, the evidence must show: (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 or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Finally, 38 U.S.C. § 1154(a) requires that VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Specifically, “[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). 1. Entitlement to service connection for an acquired psychiatric disability. The Veteran contends that his acquired psychiatric disability is the result of service. In-service treatment records do not note treatment for a psychiatric disability. The Veteran asserts that he has suffered from an acquired psychiatric disability since service. See October 2017 Statement. His story has remained consistent throughout the years. The Veteran has consistently reported incidents which occurred during his service in Germany as leading to his acquired psychiatric disability. See January 2018 Stressor Statement. His personnel records confirm service in Germany between November 1980 and November 1983. VA has not confirmed these stressful events. However, the Board finds the Veteran credible, especially considering that he has been consistent and specific in his report of the traumatic events throughout the entirety of the appeal. Accordingly, the Board will turn to the question of whether his acquired psychiatric disability is related to military service. The Veteran underwent a November 2019 VA examination. He was diagnosed with a major depressive disorder, recurrent, severe with psychotic symptoms. It was also noted that the Veteran uses substance to self-medicate and as a result had a moderate cannabis use disorder. The VA examiner noted that it was at least as likely as not that the Veteran’s symptoms of major depressive disorder are related to his military service. The examiner noted that the Veteran had reported several traumatic events that occurred while he was stationed in Germany. It was noted that the Veteran had mental health treatment through the VA medical center for several years and used THC as a means to self-medicate for his symptoms. The VA examiner noted that the Veteran did not meet the criteria for PTSD. Rather, the examiner attributed the Veteran’s psychiatric symptomatology to his major depressive disorder with cannabis use disorder. After consideration of the evidence, and resolving all doubt in favor of the Veteran, the Board finds service connection for an acquired psychiatric disorder, currently diagnosed as a major depressive disorder, is warranted. Significantly, the November 2019 VA examiner has provided an opinion that the Veteran’s major depressive disorder is at least as likely as not related to an event in service. Thus, the claim is granted. The nature and extent of the disorder is not before the Board at this time. 2. Service connection for right upper extremity neuropathy, diagnosed as right-hand peripheral neuropathy. 3. Service connection for left upper extremity neuropathy, diagnosed as left-hand peripheral neuropathy. In-service treatment records do not note treatment for peripheral neuropathy. The Veteran contends that during service he was assigned duties in supply/armor and had to lift heavy objects. He reported that he would get sharp pains in his hands but did not go to sick call because it was frowned upon. See September 2020 VA examination report. Service personnel records confirm his assignment as a general supplyman and armorer. The Veteran underwent a September 2020 VA examination. He was diagnosed with peripheral neuropathy of the bilateral hands. The VA examiner opined that the Veteran’s claimed condition is at least as likely as not incurred in or caused by the claimed in-service injury, event or illness. The examiner considered the Veteran’s contentions that when he was in service, he had to lift heavy objects as part of his duties. The examiner considered the Veteran’s reports of sharp pain in both of his hands and that he did not go to sick call because it was frowned upon. The examiner noted various studies regarding peripheral neuropathy. She noted that per the Veteran’s history, he performed repetitive grasping and lifting throughout his military career in supply and armor. She noted that according to the literature, occupation should be considered when determining the cause of peripheral neuropathy, and grasping and lifting heavy objects overtime can result in hand pain and nerve conditions. The examiner stated that based on the Veteran’s history of hand injuries and complaints of ongoing, chronic bilateral hand pain, numbness and tingling, there is evidence of chronicity and a nexus has been established. This September 2020 opinion, coupled with the reports from the Veteran of continuous neurological issues in his upper extremities since service, result in the Board finding that the point of relative equipoise has been reached regarding a nexus between the Veteran’s service and his current right and left neuropathy of the upper extremities. Therefore, with resolution of all reasonable doubt in favor of the claim, the Board finds that service connection for right upper extremity neuropathy, diagnosed as right-hand peripheral neuropathy, and service connection for left upper extremity neuropathy, diagnosed as left-hand peripheral neuropathy, is warranted. The nature and extent of the disabilities is not before the Board at this time. Although the Veteran has additionally been diagnosed with diabetic peripheral neuropathy of the bilateral upper extremities, as the Veteran is not service-connected for diabetes mellitus, service connection for this specific diagnosis is not warranted. 4. Entitlement to service connection for a bilateral foot disability, claimed as pes planus, foot callouses, and hallux valgus. Under ordinary circumstances for veterans of active military wartime service or peacetime service on or after January 1, 1947, for purposes of 38 U.S.C. §§ 1110, 1131, and 1137, every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1132. The presumption of soundness may only be rebutted by clear and unmistakable evidence that the Veteran’s disability was both preexisting and not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); 38 C.F.R. § 3.304(b). This statutory provision is referred to as the ‘presumption of soundness.’ Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). In VAOGCPREC 3-2003, VA’s General Counsel reinforced that the presumption of soundness is rebutted only where clear and unmistakable evidence shows both that the condition existed prior to service and that it was not aggravated by service. The General Counsel concluded that 38 U.S.C. § 1111 requires VA to bear the burden of showing the absence of aggravation in order to rebut the presumption of sound condition. See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Therefore, where there is evidence showing that a disorder manifested or was incurred in service, and this disorder is not noted on the Veteran’s entrance examination report, this presumption of soundness operates to shield the Veteran from any finding that the unnoted disease or injury preexisted service. See Gilbert v. Shinseki, 26 Vet. App. 48, 52-53 (2012); see also 38 C.F.R. § 3.304(b) (‘Only such conditions as are recorded in examination reports are considered as noted.’). This presumption is only rebutted where the evidence clearly and unmistakably shows that the Veteran’s disability (1) existed before acceptance and enrollment into service and (2) was not aggravated by service. See Wagner, 370 F.3d at 1096; Bagby v. Derwinski, 1 Vet. App. 225 (1991). The two parts of this rebuttal standard are referred to as the ‘preexistence prong’ and the ‘aggravation prong.’ Horn, 25 Vet. App. at 234. The aggravation prong may be met by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. Wagner, 370 F.3d at 1096; see also 38 U.S.C. § 1153. If this burden is met, then the Veteran is not entitled to service-connected benefits, and, conversely, where the presumption is not rebutted, the Veteran’s claim is one for service connection, and not aggravation. Wagner, 370 F.3d at 1096. On the Veteran’s June 1980 entrance examination, pes planus was noted. With an explicit finding of pes planus on enlistment, the presumption of soundness does not attach, as the disability was noted at entrance to service. Therefore, the only benefit that can be awarded for bilateral pes planus is service connection on the basis of aggravation of preexisting bilateral pes planus disability. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). With regard to the ‘aggravation prong’, the Board finds that there is clear and unmistakable evidence that the Veteran’s preexisting pes planus was not aggravated during military service beyond its natural progression. A December 2019 VA examiner noted that there are no records of complaints of or treatment for pes planus noted during any active period or Guard duty, indicating that this condition most likely remained asymptomatic during the Veteran’s military service and therefore was not aggravated or exacerbated beyond it natural course during service. Given the foregoing, the Board finds that the most probative evidence of record clearly and unmistakably shows that the Veteran’s bilateral pes planus was not aggravated by his active duty service. Wagner, 370 F.3d at 1096; Horn, 25 Vet. App. at 234. There is no basis to allow the Veteran’s claim for service connection for his preexisting bilateral pes planus disability. Both the facts and the medical evidence, overall, provide highly significant evidence against the claim that meets this high standard. Consideration has been given to the Veteran’s assertion that his bilateral pes planus was either aggravated by his active service or had its onset therein. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, aggravation of a bilateral pes planus disability, this falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). A bilateral pes planus disability is not the type of condition that is readily amenable to mere lay diagnosis or probative comment regarding its etiology, as the evidence shows that multiple VA medical opinions were needed to address the root cause of this disorder. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that the Veteran is competent to report his foot pain, there is no indication that he is competent to provide an opinion that the reported bilateral foot problems represented an aggravation of his pre-existing bilateral pes planus (as opposed to the natural waxing and waning of the conditions). The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation for the above-cited bilateral pes planus. Nothing in the record demonstrates that the Veteran has received any special training or acquired any medical expertise in evaluating otitis media. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. As there is no competent medical evidence of record to support the claim for service connection for a bilateral pes planus disability, the preponderance of the evidence is against the claim, and the doctrine of reasonable doubt is not for application. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). With respect to his diagnosed hallux valgus and foot callouses, the Board notes that service treatment records do not note treatment for either diagnosis. The Board has also considered the statements of the Veteran regarding continuity of symptoms since service. However, the Federal Circuit has held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). As the Veteran’s current hallux valgus and foot callouses are not listed under 3.309(a), continuity of symptomatology is simply not applicable in the present case. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board nevertheless notes that treatment records do not note hallux valgus until around 2014 and foot calluses in 1988, years following separation from service. The Board next considers that service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. Here, however, the service and post-service evidence provides negative evidence against service connection for hallux valgus or foot callouses. A December 2019 VA examiner opined that the Veteran’s claimed conditions were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner noted that a June 1988 entrance exam for the National Guard in 1988 noted a callous on the Veteran’s left foot and that a September 1989 medical evaluation reflected bilateral foot callouses. The examiner noted that an August 2014 medical record reflects bilateral hallux valgus but does not discuss onset of timing. The examiner stated that while foot calluses are noted during guard duty there are no records found during his active duty period to support that the condition existed during active duty. Additionally, it was noted that there are no records found of hallux valgus during his active duty period. Hence, although there are records of bilateral foot disorders, there is no evidence found of the onset of these disorders occurring during active service, and therefore it is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Additionally, consistent with the examiner’s opinion, post-service treatment records continue to reflect complaints of hallux valgus and callouses issues, but the reports make no reference to a causal relationship to service or any event of service. The Board has closely reviewed the medical and lay evidence in the Veteran’s claims file and finds no evidence that may serve as a medical nexus between the Veteran’s service and his current hallux valgus or foot callouses. Although the Board recognizes that the Veteran is competent to report foot trouble, the evidence in this case clearly demonstrates that his current hallux valgus and callouses developed following separation from service. The weight of the evidence of record simply does not support a finding that they are in any way related to service. In any event, the probative value of the statements of the Veteran are outweighed by the December 2019 VA opinion. In sum, the competent evidence does not establish that the Veteran’s currently diagnosed bilateral foot disability is related to his period of active duty in any way. Therefore, the evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The preponderance of the evidence is against the Veteran’s claim, and as such it must be denied. 5. Entitlement to service connection for a right knee disability. 6. Entitlement to service connection for a left knee disability. 7. Entitlement to service connection for diabetes mellitus. 8. Entitlement to service connection for right lower extremity neuropathy, to include as secondary to diabetes mellitus. 9. Entitlement to service connection for left lower extremity neuropathy, to include as secondary to diabetes mellitus. Where a veteran served continuously for ninety days or more during a period of war, or during peacetime service after December 31, 1946, and certain disabilities become manifest to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1131, 1133; 38 C.F.R. §§ 3.307, 3.309. However, the Veteran’s treatment records do not reflect a diagnosis of or treatment for right knee, left knee, diabetes mellitus, right lower extremity neuropathy or left lower extremity neuropathy listed under 38 C.F.R. § 3.309(a) for many years following separation from service. Thus, this presumption is not available to the Veteran. Id. The Board also considers the theory of entitlement to service connection for right knee, left knee, diabetes mellitus, right lower extremity neuropathy or left lower extremity neuropathy on a direct basis. Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). However, the evidence does not show a causal relationship between the claimed disabilities and any other incident of active service, as will be discussed below. Review of the record reflects that the Veteran’s service treatment records do not show treatment for right knee, left knee, diabetes mellitus, right lower extremity neuropathy or left lower extremity neuropathy. In fact, in a June 1988 National Guard examination, four years following separation from active duty service, the clinical evaluation of his lower extremities and neurologic system were normal. A sugar test at that time was negative. Next, and more importantly, post-service evidence does not reflect complaints of right knee, left knee, diabetes mellitus, right lower extremity neuropathy or left lower extremity neuropathy for several years after service discharge. Such tends to negate a finding for service connection based on direct service incurrence. The Veteran’s reported history of continued symptomatology since active service has also been considered but is not found to be accurate. In making this determination, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant’s uncorroborated account of his active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). Notably, records do not reflect problems related to the Veteran’s right knee, left knee, diabetes mellitus, right lower extremity neuropathy or left lower extremity neuropathy for several years following separation from service. The mere absence of medical records does not contradict a Veteran’s statements about his symptom history. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, if it is determined based upon reliable evidence that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). This long period without problems weighs against the claims. Accordingly, the Board finds the statements made by the Veteran asserting continuity of symptomatology of right knee, left knee, diabetes mellitus, right lower extremity neuropathy or left lower extremity neuropathy since service lack credibility and are without probative value. See, e.g. Madden v. Gober, 125 F.3d 1477, 1481 (1997) (the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration a veteran’s statements, it may consider whether self-interest may be a factor in making such statements). Continuity of symptomatology has not here been established, either through the competent evidence or through the statements submitted by the Veteran. Having determined that the Veteran’s alleged clinical history regarding onset and continuity of right knee, left knee, diabetes mellitus, right lower extremity neuropathy or left lower extremity neuropathy is not consistent with the evidence, the Board next considers that service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. The service and post-service evidence provide particularly negative evidence against these claims. With respect to the Veteran’s right and left knees, a December 2019 VA examination and opinion were provided. The examiner opined that the claimed condition was less likely as not incurred in or caused by the claimed in-service injury, event or illness. The examiner noted that a June 1988 examination from the Veteran’s National Guard was negative for knee complaints and there were no complaints for the right knee or left knee found in the service treatment records. The examiner stated that the first complaints of left knee issues were in 2015 and for his right knee in 2016. The examiner concluded that there was no evidence of the onset of these disorders occurring during active service and therefore it was less likely than not that the claimed conditions were incurred in or caused by service. With respect to the Veteran’s diabetes mellitus, the December 2019 VA examiner opined that it was less likely than not incurred in or caused by in-service illness, event or injury. The examiner noted that a June 1988 entrance examination for the National Guard made no mention of diabetes or prediabetes. The examiner considered that a 2013 medical record reflected a new diagnosis of diabetes with no previous diabetes noted. Hence, although records of diabetes are found, there is no evidence found of onset of this disorder occurring during active service and therefore it is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The Board has closely reviewed the medical and lay evidence in the Veteran’s claims file and finds no evidence that may serve as a medical nexus between the Veteran’s service and his right knee, left knee, or diabetes mellitus. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issues in this case, the etiology of his right knee, left knee, and diabetes mellitus fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In any event, the probative value of the contentions of the Veteran is outweighed by the medical opinions of record. With respect to the remaining bilateral lower extremity peripheral neuropathy claims, the Veteran was diagnosed with diabetic neuropathy of the bilateral lower extremities. See December 2019 VA Diabetic Sensory-Motor Peripheral Neuropathy examination. However, as the Veteran is not service-connected for diabetes mellitus, and service connection for diabetes mellitus is being denied in this decision, a secondary service connection claim for neuropathy as secondary to diabetes must be denied as a matter of law. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.310; see also Sabonis v. Brown, 6 Vet. App. 426 (1994). The Board acknowledges that a VA medical opinion regarding direct service connection for the Veteran’s claimed bilateral lower extremity peripheral neuropathy has not been obtained but finds a Remand to obtain a direct service connection opinion is not warranted in this case. A mere conclusory generalized lay statement that service caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). To the extent that the Veteran contends his bilateral lower extremity peripheral neuropathy is generally due to service, there is simply no competent evidence supporting his contention. The evidence of record fails to show symptoms related to bilateral lower extremity peripheral neuropathy during active service; a credible assertion of continuity of related symptoms since service; or competent and credible evidence of record suggesting that the Veteran’s currently diagnosed bilateral lower extremity peripheral neuropathy is related to service. Thus, the low standard of McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006) has not been met and a VA medical opinion regarding direct service connection is not warranted. In sum, the competent evidence does not establish that the Veteran’s right knee, left knee, diabetes mellitus, right lower extremity neuropathy, and left lower extremity neuropathy are related to his active duty in any way. Therefore, the evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The preponderance is against the claims, and as such they must be denied. REASONS FOR REMAND 1. Entitlement to service connection for hypertension, to include as secondary to the now service-connected major depressive disorder, is remanded. 2. Entitlement to service connection for erectile dysfunction, to include as secondary to the now service-connected major depressive disorder or hypertension, is remanded. As noted above, the Board is granting service connection for an acquired psychiatric disability, namely major depressive disorder. The Veteran has asserted service connection for hypertension and erectile dysfunction on a direct basis, and alternatively, as secondary to an acquired psychiatric disability. There has not been an opinion provided regarding any relationship between the Veteran’s now service-connected major depressive disorder and his hypertension. Additionally, a medical opinion regarding any relationship between his erectile dysfunction and his now service-connected major depressive disorder has not been provided. Thus, on remand, addendum VA medical opinions with supporting rationale should be obtained. The matters are REMANDED for the following actions: 1. Forward the Veteran’s claims folder to an examiner for an addendum opinion. The examiner is requested to review the claims folder, to include this remand. Following review of the claims file the examiner should provide an opinion on the following: a) Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s hypertension is caused by his now service-connected acquired psychiatric disability. b) Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s hypertension is aggravated by his now service-connected acquired psychiatric disability. c) Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s erectile dysfunction is caused by his now service-connected acquired psychiatric disability, or by his hypertension. d) Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s erectile dysfunction is aggravated by his now service-connected acquired psychiatric disability, or by his hypertension. The term “aggravated” in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 2. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraph, the Veteran’s claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Caroline B. Fleming Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. M. Clark, 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.