Citation Nr: 21022175 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 16-24 573A DATE: April 15, 2021 ORDER Entitlement to a compensable rating for hypertension is denied. Entitlement to a compensable rating for epistaxis associated with hypertension is denied. Entitlement to service connection for diabetes mellitus, to include as secondary to service-connected hypertension, is denied. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran’s hypertension required continuous medication for control, with no evidence of diastolic pressure of predominantly 100 or more, a history of diastolic pressure of predominantly 100 or more or by systolic pressure of predominantly 160 or more. 2. Throughout the appeal period, the Veteran’s epistaxis did not manifest in nose, loss of part of, or scars resulting in loss of part of one ala, or other obvious disfigurement. 3. The Veteran’s diabetes mellitus is not shown to be causally or etiologically related to any disease, injury, or incident in service and did not manifest within one year of the Veteran’s discharge from service; and was not caused by, proximately due to, nor permanently aggravated beyond its natural progression by his service connected hypertension. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.104, Diagnostic Code 7101. 2. The criteria for a compensable rating for epistaxis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.97, Diagnostic Code 6504. 3. The criteria for service connection for diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from October 1999 to November 1999, the Army National Guard from July 2006 to October 2006, and in the United States Army from October 2012 to August 2013. These matters come to the Board of Veterans’ Appeals (Board) on appeal from February 2015 and June 2017 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction of this appeal is currently with the RO in Philadelphia, Pennsylvania. This case was most recently before the Board in June 2020, at which time the appeal was remanded to the Agency of Original Jurisdiction (AOJ) for further development. The case has now been returned to the Board for appellate action. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant’s current symptoms. See Read v. Shinseki, 651 F. 3d 1296, 1302 (Fed. Cir. 2011). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable DC, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran’s claims. Hypertension The Veteran asserts that he is entitled to a higher rating for his hypertension as his symptoms are more severe than currently contemplated by the assigned rating. Specific argument in support of this appeal has not been provided. However, at a January 2016 Decision Review Officer (DRO) hearing, the Veteran’s attorney asserted the Veteran had several blood pressure readings from 2013 that warrant a 10 percent rating. See Hearing Testimony Transcript, January 26, 2016. The Veteran’s hypertension is currently rated as noncompensable (zero percent) under Diagnostic Code 7101. 38 C.F.R. § 4.104. Under Diagnostic Code 7101, a 10 percent rating is assigned for hypertension with diastolic pressure (bottom number) predominantly 100 or more, or systolic pressure (top number) predominantly 160 or more. A 10 percent rating also is the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is assigned for hypertension with diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. A 40 percent rating is assigned for hypertension with diastolic pressure predominantly 120 or more. The maximum 60 percent rating is assigned for hypertension with diastolic pressure predominantly 130 or more. 38 C.F.R. § 4.104. There are three notes to 38 C.F.R. § 4.104, Diagnostic Code 7101. Note (1) provides that hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic blood pressure (i.e., bottom number) is predominantly 90 mm or greater, and isolated systolic hypertension means the systolic blood pressure (i.e., top number) is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. Note (2) requires the evaluation of hypertension due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, as part of the condition causing it rather than by a separate evaluation. Note (3) states that hypertension should be evaluated separately from hypertensive heart disease and other types of heart disease. The Board notes that the use of medications is explicitly contemplated in Diagnostic Code 7101 and that the Court of Appeals for Veterans Claims has held that the Board did not err in failing to discount the ameliorative effects of blood pressure medication as the plain language of Diagnostic Code 7101 contemplates the effects of medications. McCarroll v. McDonald, 28 Vet. App. 267, 272-73 (2016). Turning to the evidence, the Veteran was afforded a VA examination in October 2013. At that time, the Veteran reported that his hypertension currently caused no symptoms; and he had not had epistaxis since June 2013. The Veteran’s treatment plan included continuous medication for hypertension or isolated systolic hypertension. The examiner found the Veteran did not have a history of a diastolic blood pressure elevation to predominantly 100 or more. Current blood pressure readings at his October 20013 VA examination were as follows: 121/65 on October 29, 2013; 130/71 on August 9, 2013; and 136/88 on September 21, 2012. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner noted the Veteran’s hypertension impacted his ability to work because the Veteran must stop all activity during epistaxis episodes; and the Veteran may require emergency medical care during these episodes. The Veteran was afforded a VA examination in February 2015. At that time, the Veteran reported his blood pressure readings were above 160 systolic in the past, specifically in 2012 when he deployed to Kuwait. The examiner noted that there were no records of this in his service treatment records and noted that the readings above 160 were as follows: 162/62 on May 13, 2014; 160/90 on June 7, 2013; and 200/120 on February 21, 2013. The Veteran’s treatment plan included continuous medication for hypertension or isolated systolic hypertension. The examiner found the Veteran did not have a history of a diastolic blood pressure elevation to predominantly 100 or more. Current blood pressure readings at his February 2015 VA examination were as follows: 142/86 on March 7, 2014; 126/70 on November 10, 2014; and 126/82 on February 4, 2015. The average blood pressure reading was 131/79. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner found the Veteran’s hypertension did not impact his ability to work. The examiner noted the Veteran’s reports of a history of nose bleeds with his uncontrolled hypertension, but there were no clinical notes in the record found. A September 2015 private treatment record indicates the Veteran’s blood pressure reading at that time was 145/83. A November 2015 private treatment record indicates the Veteran was evaluated regarding his rehabilitative needs by Dr. R.M. At that time, Dr. R.M. noted the Veteran had a blood pressure of 145/83. A February 2016 VA treatment record indicates the Veteran’s blood pressure reading at that time was 81/63. The Veteran was afforded a VA examination in March 2016. At that time, the examiner noted the Veteran was diagnosed with hypertension in 2013 and treatment began; the Veteran had now been stabilized. The examiner further noted that, at first, he had a diastolic blood pressure that would range over 100 at times, but this was not predominant, and it was now under adequate control. The Veteran’s treatment plan included continuous medication for hypertension or isolated systolic hypertension. The examiner found the Veteran did not have a history of a diastolic blood pressure elevation to predominantly 100 or more. Current blood pressure readings at his March 2016 VA examination were as follows: 146/85; 140/82; and 141/82. The average blood pressure reading was 142.83. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner noted the Veteran’s hypertension did not impact his ability to work. A May 2016 VA treatment record indicates the Veteran’s blood pressure reading at that time was 130/85. His blood pressure was controlled. A September 2016 VA treatment record indicates the Veteran’s blood pressure reading at that time was 130/85. The Veteran was afforded a VA examination in December 2020. At that time, the Veteran reported he had recurrent nose bleeds with elevated blood pressure; and that his current blood pressure was in the 130s/90s while on medication, and 150s/90s when not taking medication. He reported that his hypertension improved since its onset. His current symptoms included epistaxis with elevated blood pressure. The Veteran’s treatment plan included continuous medication for hypertension or isolated systolic hypertension. The examiner found the Veteran did not have a history of a diastolic blood pressure elevation to predominantly 100 or more. Current blood pressure readings at his December 2020 VA examination were as follows: 136/85; 141/84; 134/8. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner noted the Veteran’s hypertension did not impact his ability to work. The examiner remarked the Veteran’s blood pressure readings were taken five minutes apart. The Board notes that the Veteran has received treatment at the VA Medical Center for various disabilities, to include his hypertension. However, a review of those records does not show that the Veteran has symptoms of his hypertension, to include blood pressure readings, that are worse than those described at his VA examinations. Based on the foregoing, the Board finds that a compensable rating for his hypertension is not warranted. In this regard, the Board notes that diastolic pressure has never been shown to be 100 or more, or systolic pressure that was predominantly 160 or more. See October 2013, February 2015, March 2016, and December 2020 VA examination reports. Also, while the Veteran’s hypertension requires continuous medication, there is no indication that his hypertension is, or has historically been, predominantly manifested by diastolic pressure that is 100 or more. Instead, the evidence shows diastolic pressures to be consistently less than 100 and systolic pressures to be consistently less than 160. These readings are not supportive of a higher 10 percent rating under Diagnostic Code 7101. Therefore, a higher 10 percent is not warranted at any time. Notably, the Veteran himself asserts that his blood pressure readings were 130s/90s, and at worst 150s/90s. See December 2020 VA examination report. The Board acknowledges the Veteran’s lay testimony and statements regarding the severity of his symptoms. Laypersons are competent to attest to physical symptoms that are experienced or observed. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) . However, the Board finds that the lay evidence describing the symptoms in this case does not establish a greater degree of functional impairment. The evidence of record does not support a rating higher than those assigned. The Veteran’s belief that he is entitled to higher ratings for his hypertension is outweighed by the objective medical findings of record. That is, the Board assigns greater probative value to the pertinent objective findings on the VA examination reports and treatment records that were recorded following physical examinations of the Veteran, than to the Veteran’s general belief that he is entitled to a higher rating. The Board observes that the Veteran, while competent to report his observable symptoms, he is not competent to report that his hypertension is of sufficient severity to warrant a higher rating under VA’s tables for rating such disabilities because such an opinion requires medical expertise which he has not been shown to have. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (2007). Even after considering any contentions as to the effects of the disability on his daily life, the Board finds that the criteria for a higher rating are not met. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The Rating Schedule contemplates such impairment under the ordinary conditions of daily life. 38 C.F.R. § 4.10; see also Martinak v. Nicholson, 21 Vet. App. 447, 455-456 (2007). Consideration has been given to assigning staged ratings. However, at no time during the period in question has the disability warranted a higher schedular rating than that assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Additionally, the Board has considered whether an inferred claim for a TDIU has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran’s current employment status is unknown. The Veteran has also not alleged, and the record does not suggest, that he is unable to obtain and maintain employment due solely to his service-connected hypertension. As such, a Rice claim is not raised. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a compensable rating for hypertension. Consequently, the benefit of the doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Epistaxis The Veteran asserts that he is entitled to a higher rating for his epistaxis as his symptoms are more severe than currently contemplated by the assigned rating. Specifically, he testified that he experienced uncontrolled nose bleeding if his hypertension medication did not work. See Hearing Testimony Transcript, January 26, 2016. The Veteran’s epistaxis is currently rated as noncompensable under Diagnostic Code 6504. 38 C.F.R. § 4.97. Under Diagnostic Code 6504, a 10 percent rating is assigned for nose, loss of part of, or scars resulting in loss of part of one ala, or other obvious disfigurement. A schedular maximum 30 percent rating is assigned for exposing both nasal passages. 38 C.F.R. § 4.97. Turning to the evidence, the Veteran was afforded a VA examination in October 2013. At that time, the Veteran reported he had recurrent nosebleeds that were determined to be due to inadequately treated hypertension. His epistaxis improved with adjustment of anti-hypertensive medication, and he had not experienced epistaxis since June 2013. The Veteran did not have any scars related to any conditions or to the treatment of his epistaxis. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. A December 2012 endoscopy showed that epistaxis occurred due to blown out capillaries on nasal septum bilateral nostrils. The examiner noted the Veteran’s epistaxis impacted his ability to work because he must stop all activity during episodes, and may require emergency medical care during episodes. The Veteran was afforded a VA examination in February 2017. At that time, the Veteran reported he had not had epistaxis since 2014. In pertinent part, the Veteran was not shown to have any scars related to his epistaxis. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. He did not have any loss of part of the nose or other scars of the nose exposing both nasal passages. The Veteran did not have loss of part of the nose or other scars causing loss of part of one ala. The Veteran did not have loss of part of the nose or other scars causing other obvious disfigurement. The examiner noted the Veteran’s epistaxis impacted his ability to work because episodes stopped all activity immediately, and the Veteran must see physician for control of epistaxis; and sinus related symptoms are distracting. The Veteran was afforded a VA examination in February 2020. At this time, the Veteran reported he had been treated with cauterization four times, and most recently in December 2012. He reported intermittent nasal bleeding without any specific trigger, and denied any current treatment. He reported that his epistaxis had remained the same. Pertinent physical findings showed the Veteran had nasal bleeds. He did not have any scars related to his epistaxis. The Veteran did not have loss of part of the nose or other scars of the nose exposing both nasal passages. The Veteran did not have loss of part of the nose or other scars causing loss of part of one ala. The Veteran did not have loss of part of the nose or other scars causing other obvious disfigurement. The examiner noted the Veteran’s epistaxis did not impact his ability to work. The Board notes that the Veteran has received treatment at the VA Medical Center for various disabilities, to include his epistaxis. However, a review of those records does not show that the Veteran has symptoms of his epistaxis that are worse than those described at his VA examinations. Based on the foregoing, the Board finds that a compensable rating for his epistaxis is not warranted. In this regard, the Board notes that the Veteran has never been shown to have loss of part of, or scars resulting in loss of part of one ala, or other obvious disfigurement at any time. See October 2013, February 2017, and February 2020 VA examination reports. Rather, the Veteran himself reports that his epistaxis symptoms are limited to intermittent and uncontrolled nosebleeds, without loss of part of the nose, scars, nor obvious disfigurement. The Board has also considered whether any other diagnostic code under the criteria for diseases of the nose and throat (Diagnostic Codes 6502-6524); however, a rating under 38 C.F.R. § 4.97, Diagnostic Code 6504 is not warranted as the Veteran has not lost part of the nose, nor has there been nasal scarring. Further, as the Veteran has not been diagnosed with tuberculous laryngitis (Diagnostic Code 6515), complete organic aphonia (Diagnostic Code 6519), and/or stenosis of the larynx (Diagnostic Code 6520), a compensable disability rating under any of these diagnostic codes is not warranted. The Veteran has not had a laryngectomy, and as such, a disability rating is not warranted under Diagnostic Code 6518. Further, none of the present symptoms more nearly approximates those symptoms listed for a rating under Diagnostic Code 6521 for an injury to the pharynx. 38 C.F.R. § 4.97. The Board acknowledges the Veteran’s lay testimony and statements regarding the severity of his symptoms. Laypersons are competent to attest to physical symptoms that are experienced or observed. Washington v. Nicholson, supra. However, the Board finds that the lay evidence describing the symptoms in this case does not establish a greater degree of functional impairment. The evidence of record does not support a rating higher than those assigned. The Veteran’s belief that he is entitled to higher ratings for his epistaxis is outweighed by the objective medical findings of record. That is, the Board assigns greater probative value to the pertinent objective findings on the VA examination reports and treatment records that were recorded following physical examinations of the Veteran, than to the Veteran’s general belief that he is entitled to a higher rating. The Board observes that the Veteran, while competent to report his observable symptoms, he is not competent to report that his epistaxis is of sufficient severity to warrant a higher rating under VA’s tables for rating such disabilities because such an opinion requires medical expertise which he has not been shown to have. See Davidson v. Shinseki, supra; Jandreau v. Nicholson, supra. Even after considering any contentions as to the effects of the disability on his daily life, the Board finds that the criteria for a higher rating are not met. See Lendenmann, supra. The Rating Schedule contemplates such impairment under the ordinary conditions of daily life. 38 C.F.R. § 4.10; see also Martinak v. Nicholson, supra. Consideration has been given to assigning staged ratings. However, at no time during the period in question has the disability warranted a higher schedular rating than that assigned. Hart v. Mansfield, supra. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, supra. Additionally, the Board has considered whether an inferred claim for a TDIU has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran’s current employment status is unknown. The Veteran has also not alleged, and the record does not suggest, that he is unable to obtain and maintain employment due solely to his service connected epistaxis. As such, a Rice claim is not raised. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a compensable rating for epistaxis. Consequently, the benefit of the doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Service Connection Diabetes The Veteran asserts that his diabetes mellitus is related to his active service. Specifically, the Veteran asserts that his hypertension caused his diabetes mellitus, or at the very least increased his chances of developing diabetes. See VA Form 9, April 10, 2018. Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called “nexus” requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). VA has established certain rules and presumptions for chronic diseases, such as diabetes mellitus and arthritis. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that §§ 1110 and 1131’s requirement of the existence of a present disability for VA compensation purposes cannot be considered arbitrary); see also McClain v. Nicholson, 21 Vet. App. 319, 323 (2007) (holding that the requirement of a current disability is met when a claimant has a disability at the time a claim for VA compensation is filed or during the pendency of that claim). Consequently, the evidence of record must show that the Veteran currently has the disability for which benefits are being claimed. Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). As an initial matter, the Board notes that the Veteran is currently diagnosed with diabetes mellitus. See e.g., December 2020 VA examination report. Additionally, the Board notes that service connection is currently in effect for hypertension. Turning to the evidence, the Veteran’s service treatment records are unremarkable for any complaints of, treatment for, or diagnosis of a diabetes during active service. The Veteran was afforded a VA examination in December 2020. At that time, the examiner diagnosed diabetes mellitus, type II. The examiner opined that his diabetes mellitus was less likely than not incurred in or caused by his claimed in-service injury, event, or illness. In this regard, the examiner noted that all of the Veteran’s electronic medical records were reviewed, and a complete physical examination was completed. The examiner noted that the available medical records lacked any documented evidence of hypertension during active service or one year afterwards. Additionally, the examiner noted a December 2014 private treatment record indicated that the Veteran had high blood sugars due to chewing tobacco. Therefore, the examiner opined there was insufficient factual evidence that his diabetes was incurred during military service or diagnosed within the presumptive period, and a nexus was not established. Next, the December 2020 VA examiner opined that his diabetes mellitus was less likely than not proximately due to or the result of his hypertension. In this regard, the examiner noted that diabetes mellitus type II is an endocrine disease characterized by hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion. The examiner noted that the pathogenesis of essential hypertension is multifactorial, and factors that play a role in the development of hypertension included genetics, activation of neurohormonal systems such as obesity and increased dietary salt intake. Therefore, the examiner noted that diabetes mellitus and hypertension are two separate and unrelated medical conditions, and there is no medical literature that the examiner was personally aware of which directly linked hypertension as a direct cause of diabetes mellitus type II. Therefore, the nexus was not established. Finally, the December 2020 VA examiner opined that diabetes mellitus was not proximately due to or the result of his hypertension, and was not at least as likely as not aggravated beyond its natural progression by his hypertension. In this regard, the examiner noted that all urine analysis were within normal limits from March 2019 through October 2020. The examiner noted the Veteran was currently taking oral medication without insulin therapy, and there was no documented evidence of complication from his diabetes, such as heart or blood vessel disease, renal disease, or neuropathy. Additionally, the examiner noted that an April 2019 medical evaluation noted improvement of his diabetes mellitus type II, and therefore it was less likely than not aggravated beyond its natural progression by his service connected hypertension. The Board affords great probative weight to the December 2020 VA examiner’s opinions as such considered all of the pertinent evidence of record, to include the statements of the Veteran and relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. There is no contrary opinion of record. The Board also considered the Veteran’s lay statements in support of his claim, to include his contentions that his diabetes is secondary to his service connected hypertension. However, he has not reported being diagnosed with diabetes mellitus, type II, during active service or within one year following service discharge. Rather, as noted above, his service treatment records are silent for all complaints of, treatment for, or diagnoses of diabetes mellitus during his active service, and post-service records do not show treatment or a diagnosis within one year of service discharge. Moreover, lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, “VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to” and a mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran’s diabetes mellitus type II and any instance of his service to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Specifically, while the Veteran is competent to describe his current symptoms, the Board accords their statements regarding the etiology of such a disorder little probative value as they are not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. In the instant case, there is no suggestion that the Veteran has had any medical training. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinions of the Veteran are nonprobative evidence. As discussed, to the extent that the Veteran contends that the diabetes mellitus existed in service, the Board finds that contemporaneous medical evidence showing no such disorder at separation to be of greater probative value. Based on the foregoing, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran’s claimed diabetes mellitus, type II, was not incurred in service, was not caused or proximately due or aggravated by his service connected hypertension, and is not otherwise causally or etiologically related to service. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for service connection for diabetes mellitus, type II. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. CHRISTOPHER J. O’DONNELL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mariah N. Sim, 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.