Citation Nr: 21023360 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 16-59 315 DATE: April 20, 2021 ORDER Entitlement to service connection for chronic kidney disease, to include as due to exposure to contaminants in the water at Camp Lejeune, is denied. Entitlement to service connection for a gastrointestinal disability, to include as due to exposure to contaminants in the water at Camp Lejeune, is denied. Entitlement to service connection for type II diabetes mellitus, to include as due to exposure to contaminants in the water at Camp Lejeune, is denied. Entitlement to service connection for vertigo, to include as due to exposure to contaminants in the water at Camp Lejeune, is denied. Entitlement to service connection for hypothyroidism, to include as due to exposure to contaminants in the water at Camp Lejeune, is denied. Entitlement to service connection for hypertension, to include as due to exposure to contaminants in the water at Camp Lejeune, is denied. Entitlement to service connection for hyperlipidemia, to include as due to exposure to contaminants in the water at Camp Lejeune, is denied. Entitlement to service connection for a left knee disability, to include as due to exposure to contaminants in the water at Camp Lejeune, is denied. Entitlement to service connection for a right knee disability, to include as due to exposure to contaminants in the water at Camp Lejeune, is denied. REMANDED Entitlement to service connection for pes planus is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Chronic kidney disease is not shown to be causally related to an in-service injury or disease, to include exposure to contaminants in the water at Camp Lejeune. 2. A gastrointestinal disability manifested more than one year after separation and is not shown to be causally related to an in-service injury or disease, to include exposure to contaminants in the water at Camp Lejeune. 3. Type II diabetes mellitus manifested more than one year after separation and is not shown to be causally related to an in-service injury or disease, to include exposure to contaminants in the water at Camp Lejeune. 4. Vertigo disease is not shown to be causally related to an in-service injury or disease, to include exposure to contaminants in the water at Camp Lejeune. 5. Hypothyroidism is not shown to be causally related to an in-service injury or disease, to include exposure to contaminants in the water at Camp Lejeune. 6. Hypertension manifested more than one year after separation and is not shown to be causally related to an in-service injury or disease, to include exposure to contaminants in the water at Camp Lejeune. 7. Hyperlipidemia, or high cholesterol, is a laboratory finding and not a disability for VA purposes. 8. A left knee disability has not been shown during the period on appeal or proximate thereto. 9. A right knee disability has not been shown during the period on appeal or proximate thereto. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic kidney disease have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a gastrointestinal disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for type II diabetes mellitus have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for vertigo have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for hypothyroidism have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for service connection for hyperlipidemia have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1961 to May 1965. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in July 2013 by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the issues on appeal for additional development in October 2017. In November 2017 the RO requested that the Veteran identify all VA medical facilities where he receives treatment, and obtained all private treatment records authorized for release. The Veteran’s National Guard records were obtained in February 2018. The Veteran was scheduled for examinations in June 2018. However, in October 2018 the Veteran contacted the RO and inquired as to whether an in-person examination was necessary or if all that was needed was a medical opinion. The RO informed the Veteran that if an opinion was all that was needed, the RO would forgo scheduling an in-person examination. The in-person examinations were subsequently cancelled and in January 2019 the RO obtained medical opinions addressing the questions asked in the Board’s remand directives. As such, the directives have been substantially complied with and the matter is again properly before the Board. D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). In October 2017 the Board also reopened the claims for service connection for type II diabetes mellitus, pes planus, left and right knee disabilities, hypertension, hypothyroidism, vertigo, and hyperlipidemia. As this constitutes a full grant as to the question of reopening, the Board need not address the question of new and material evidence herein. Ab v. Brown, 6 Vet. App. 35 (1993). The Veteran, as a layperson, is not competent to distinguish between competing diagnoses, and so a claim of service connection for one is considered a claim for all. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In this case, the Veteran filed a claim for service connection for gastric cancer. However, the record also reflects that the Veteran has been diagnosed with gastritis. As such, the Board has recharacterized the claim as one for service connection for a gastrointestinal disability generally. Id. Veterans Claims Assistance Act of 2000 (VCAA) The duty to assist includes assisting the claimant in the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). In November 2017 correspondence the RO requested that the Veteran identify any VA treatment that he had received for his claimed disabilities. However, to date the Veteran has not identified any VA Medical Centers where he receives treatment The duty to assist in the development and the adjudication of a claim is not a one-way street. Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996); Zarycki v. Brown, 6 Vet. App. 91, 100 (1993); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). As the Veteran has not responded to VA requests for information concerning any potential VA treatment, the Board finds that the duty to assist with respect to obtaining VA records has been satisfied. 38 C.F.R. § 3.159(c)(2). All private records authorized for release have been obtained. 38 C.F.R. § 3.159(c)(1). The duty to assist includes providing a medical examination or obtaining a medical opinion when necessary. 38 C.F.R. § 3.159(c)(4). In determining whether the duty to assist requires that a VA provide a medical examination or obtain a medical opinion with respect to a veteran’s claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran’s service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The threshold for determining a possibility of a nexus to service is a low one. McLendon v. Nicholson, 20 Vet. App. 79 (2006). While medical or competent evidence is not necessarily required for there to be an indication that a disability is causally related to a period of service, a generalized statement that a disability or disabilities are related to service is not sufficient to provide such an indication. Waters v. Shinseki, 601 F.3d 1274, 1278–79 (Fed. Cir. 2010). To allow a generalized statement to serve as sufficient indication that a disability is related to service would require VA to provide examinations in almost all cases, thus rendering meaningless the statutory and regulatory sections governing when an examination must be provided. Id. at 1279. In this case, the Veteran has been diagnosed with type II diabetes mellitus, hypothyroidism and vertigo, and has reported that he experiences bilateral knee pain and high cholesterol. The Veteran’s service treatment records do not reflect treatment for any of these disabilities during his period of service, but personnel records reflect that the Veteran served at Camp Lejeune and therefore he is presumed to have been exposed to contaminants in the water there. However, there is no evidence indicating that the claimed disabilities are related to the Veteran’s service generally or contaminant exposure specifically. None of the private treatment records associated with the file indicate the disabilities are related to the Veteran’s service, nor are there any positive VA opinions, private opinions, or articles or treatises linking any of the claimed disabilities to contaminant exposure. Thus, the only evidence of record indicating that the disabilities are causally related to exposure to contaminants in the water at Camp Lejeune are the Veteran’s own statements to that effect, which are insufficient. As there is no evidence indicating that there is a nexus between the claimed disabilities and the Veteran’s service, VA did not have a duty to obtain a medical examination or opinion with respect to the above disabilities. Id.; 38 C.F.R. § 3.159(c)(4). Neither the Veteran, the representative nor the record has raised any other issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). As such, the Board will proceed to adjudicate the issues on appeal. Service Connection Generally, to establish service connection a Veteran 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.” Davidson v. Shinseki, 581 F.3d 1313, 1315–16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). Generally, the disease must have manifested to a degree of 10 percent or more within one year of service. 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, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” 38 C.F.R. § 3.303(b). When the disease identity is established, there is no requirement of evidentiary showing of continuity. Id. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. Continuity of symptomatology is only applicable to those diseases recognized as chronic for VA purposes. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. Service connection may be established based on exposure to contaminants in the water supply at Camp Lejeune. 38 C.F.R. § 3.309(f). A veteran who had no less than 30 days, consecutive or nonconsecutive, of service at Camp Lejeune during the period from August 1, 1952 to December 31, 1987 will be presumed to have been exposed to contaminants in the water supply at Camp Lejeune. 38 C.F.R. § 3.307(a)(7)(iii). If exposure is presumed or established on a facts-found basis, certain disabilities will be presumed to be causally related to such exposure. 38 C.F.R. § 3.309(f). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay 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). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336–37 (Fed. Cir. 2006). 1. Entitlement to service connection for chronic kidney disease. Private treatment records reflect that the Veteran was diagnosed with chronic kidney disease, stage III, in November 2010. Further, while the Veteran’s service treatment records do not reflect treatment for or a diagnosis of a kidney disability during service, the Veteran’s personnel records reflect that he was stationed at Camp Lejeune between August 1, 1953 and December 31, 1987 for at least 30 days, and therefore is presumed to have been exposed to contaminants in the water supply at Camp Lejeune. 38 C.F.R. § 3.307(a)(7)(iii). As a current disability and an in-service injury have been shown, the remaining question is whether the kidney disease is causally related to contaminant exposure in service. The Veteran has asserted that his chronic kidney disease is casually related to his contaminant exposure in service. While the Veteran is competent to report the onset and continuance of lay observable symptoms, he is not competent to opine as to the etiology of his kidney disability as to do so requires medical knowledge and training beyond that which may be expected of a lay person. Jandreau, 492 F.3d 1372; Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). As such, the Veteran’s statements concerning a causal relationship between his kidney disease and his service are entitled to no probative weight. VA obtained opinions concerning the etiology of the Veteran’s chronic kidney disease in June 2013 and January 2019. The July 2013 examiner stated that it was less likely than not that the Veteran’s kidney disease was causally related to his period of service, including his contaminant exposure. In support of this opinion, the examiner first noted that in November 2010 the Veteran was first seen for renal insufficiency by a private provider. The examiner noted that at the time the private provider did a complete work up and stated that the kidney disease was likely from hypertensive nephrosclerosis and diabetic nephropathy, with an additional contributing factor of chronic interstitial nephritis from intermittent use of Septra therapy. The examiner continued on to explain the definitions for each stage of chronic kidney disease, from Stage 1 to Stage 5, highlighting that each stage is based on steadily decreasing GFR values. The examiner then noted that medical studies have shown that GFR values also decrease with age, and therefore a large percentage of elderly individuals may be classified as having kidney disease despite the fact that they have stable kidney function, which has been established by several studies. The examiner then noted that at the time of the examination the Veteran was 72 years old, and his GFR value was in fact normal for his age. Thus, the examiner indicated that the chronic kidney disease is also likely related to the natural aging process rather than contaminant exposure. The January 2019 examiner also stated that the kidney disease was less likely than not related to the Veteran’s service, including contaminant exposure. In support of this opinion the January 2019 examiner also cited to the November 2010 private treatment record noting that the kidney disease was likely due to hypertensive nephrosclerosis and diabetic nephropathy. The examiner then noted that the Veteran was not treated for renal failure until 44 to 49 years following exposure, which is not consistent with medical literature concerning the onset of renal failure due to such exposures. Instead, the examiner noted that the kidney disease is more likely due to longstanding hypertension, diabetes mellitus and high cholesterol, as confirmed by the Veteran’s private treatment records. Finally, the examiner noted that while the Institute of Medicine report concerning Camp Lejeune contaminated water exposure reflected that there was evidence of an association between exposure to solvents and hypertensive end-stage renal disease, the association between trichloroethylene (TCE) and perchloroethylene (PCE) and chronic kidney disease was not clear. There is no evidence that the above examiners were not competent or credible. Further, both examiners supported their opinions with well-reasoned rationales that discussed the nature of chronic kidney disease, provided a review of relevant studies, and included direct citations to the medical evidence of record. As such, the Board finds that each respective examination report is entitled to significant probative weight as to the presence of a nexus. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Treatment records reflect that in June 2004 the Veteran denied any issues with his kidneys. The Veteran was then treated in November 2010 for renal insufficiency, at which point the private physician stated that the Veteran had chronic kidney disease, stage III, likely due to hypertensive nephrosclerosis and diabetic nephropathy, with an additional contributing factor of chronic interstitial nephritis from intermittent use of Septra therapy. Records since that point reflect on-going treatment for chronic kidney disease, but no opinions linking the Veteran’s kidney disease to his service generally or Camp Lejeune water contaminants specifically. Based on the foregoing, the preponderance of the evidence is against a finding that the Veteran’s kidney disease is casually related to his period of service. The Veteran’s assertions that his chronic kidney disease is causally related to his service are not competent, and therefore entitled to no probative weight. Conversely, both VA examiners stated that the kidney disease was less likely than not related to his service, including contaminant exposure, and supported their opinions with citations to the medical evidence of record and discussions of treatise evidence and the nature of kidney disease itself. Further, the opinions are corroborated by the Veteran’s own private treatment records, which attribute the kidney disease to hypertensive nephrosclerosis, diabetic nephropathy, and chronic interstitial nephritis. As the preponderance of the evidence is against a nexus, service connection for chronic kidney disease is not warranted in this case. 38 C.F.R. § 3.102, 3.303. The Board notes that certain disabilities are presumed to be causally related to exposure to contaminants in the water at Camp Lejeune. 38 C.F.R. § 3.309(f). However, chronic kidney disease is not one of the diseases that is presumed to be related to such exposure. While kidney cancer is a listed disability, there is no evidence that the Veteran has at any point been diagnosed with kidney cancer. Therefore service-connection on a presumptive basis for chronic kidney disease as related to contaminant exposure is not warranted in this case. Id. The preponderance of the evidence weighs against a finding that the Veteran’s chronic kidney disease is causally related to his service. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55–57 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. 2. Entitlement to service connection for a gastrointestinal disability. Private treatment records reflect that the Veteran was diagnosed with gastritis in June 2011 and gastric cancer in April 2011. Further, the Veteran is presumed to have been exposed to contaminants in the water supply at Camp Lejeune based on the nature of his service. 38 C.F.R. § 3.307(a)(7). As a current disability and an in-service injury have been shown, the dispositive issue in this case is whether the current disability is casually related to the Veteran’s in-service exposure. The Veteran has asserted that his gastrointestinal disability is casually related to his in-service contaminant exposure. While the Veteran is competent to report the onset and continuance of lay observable gastrointestinal symptoms, he is not competent to opine as to the etiology of his disability as to do so requires medical knowledge and training beyond that which may be expected of a lay person. Jandreau, 492 F.3d 1372; Kahana, 24 Vet. App. at 435. As such, the Veteran’s statements concerning a causal relationship between his gastrointestinal disability and his service are entitled to no probative weight. VA obtained opinions concerning the etiology of the Veteran’s gastrointestinal disabilities in June 2013 and January 2019. The June 2013 examiner stated that it was less likely than not that the Veteran’s gastrointestinal disabilities were causally related to his period of service, to include exposure to water contaminants. The examiner first noted that gastritis is caused by chronic H. pylori infections, pernicious anemia or high salt diets, and not exposure to contaminants such as TCE and PCE. The examiner continued on to state that a review of available medical literature indicates no association between gastric cancer and low level exposure to TCE, PCE or other solvents. The January 2019 examiner also stated that it was less likely than not that the gastrointestinal disabilities were causally related to the Veteran’s service. The examiner first noted that while their precise cause is unknown, risk factors for carcinoid tumors such as the Veteran’s gastric cancer include older age, gender, and family history. The examiner then noted that a review of applicable literature did not reflect that there was an associated between gastric cancer and exposure to low levels of TCE, PCE, or other solvents. The examiner acknowledged that both TCE and PCE are considered to be carcinogens by the Environmental Protection Agency (EPA), but further noted that EPA studies did not reflect that there was an associated between either solvent and gastric cancer specifically. The examiner then noted that a subsequent study found that TCE exposure was associated with kidney cancer, non-Hodgkin’s lymphoma and liver cancer and that PCE was associated with bladder cancer, with inconsistent evidence of an association with non-Hodgkin’s lymphoma, and esophageal, kidney and cervical cancers. The examiner concluded that studies did not reflect an association between solvent exposures and the development of gastric cancer. There is no evidence that the above examiners were not competent or credible. Further, the examiners supported their opinions with well-reasoned rationales which discussed the nature and progression of the diagnosed conditions, common causes, and relevant medical literature. As such, the Board finds that each respective examination report is entitled to significant probative weight as to the presence of a nexus. Nieves-Rodriguez, 22 Vet. App. 295. Treatment records reflect that the Veteran was treated for gastric cancer in April 2011 and was noted to have gastritis in June 2011. A June 2004 treatment record notes that the Veteran denied any bowel issues, including nausea or vomiting. None of the private treatment records in any way link the Veteran’s gastrointestinal diagnoses either to his period of service generally or his in-service exposure specifically. Based on the foregoing, the preponderance of the evidence is against a finding that the Veteran’s gastrointestinal disability is casually related to his period of service. The Veteran’s statements that his gastrointestinal disabilities are causally related to his active service are not competent, and therefore entitled to no probative weight. Conversely, the VA examiners both stated that it was less likely than not that the gastrointestinal disabilities were causally related to the Veteran’s contaminant exposure, and supported the opinions with citations to numerous medical studies as well as discussions of the nature of gastric cancer and gastritis. As such, the preponderance of the evidence is against a finding of a nexus, and therefore service connection for a gastrointestinal disability is not warranted on a direct basis. 38 C.F.R. §§ 3.102, 3.303. Malignant tumors are considered to be a chronic disease for VA purposes. 38 C.F.R. § 3.309(a). However, gastric cancer was not diagnosed in service nor is there evidence that the cancer manifested to a compensable degree within one year of the Veteran’s separation. 38 C.F.R. §§ 3.303(b), 3.307(a)(3). The first evidence of a diagnosis of gastric cancer is in an April 2011 private treatment record, which is well after the Veteran’s separation from service and the National Guard. As such, gastric cancer cannot be presumed to be related to the Veteran’s period of active service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Finally, the Board notes that certain disabilities are presumed to be causally related to exposure to contaminants in the water at Camp Lejeune. 38 C.F.R. § 3.309(f). However, while several cancers are listed, gastric cancer is not one of the types of cancer considered to be presumptively related to contaminant exposure. Therefore service-connection on a presumptive basis for gastric cancer as related to contaminant exposure is not warranted in this case. Id. The preponderance of the evidence weighs against a finding that the Veteran’s gastrointestinal disability is causally related to his service. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55–57; 38 C.F.R. § 3.102. For these reasons, the claim is denied. 3. Entitlement to service connection for type II diabetes mellitus, vertigo, and hypothyroidism. The evidence reflects that the Veteran has current diagnoses of type II diabetes mellitus and hypothyroidism, and further that he has been treated for episodes of dizziness or vertigo. While there is no evidence of treatment for or a diagnosis of any of the three disabilities in service, as discussed above the Veteran is presumed to have been exposed to contaminants in the water at Camp Lejeune. 38 C.F.R. § 3.307(a)(7). Therefore, the dispositive issue is whether the current disabilities are related to such exposure. While the Veteran has asserted that his diabetes, vertigo and hypothyroidism are causally related to his in-service exposure, these statements are not competent as the Veteran does not have the medical knowledge or training to provide such an opinion. Jandreau, 492 F.3d 1372; Kahana, 24 Vet. App. at 435. As the statements are not competent, they are entitled to no probative weight. Private treatment records reflect that in November 2010 the Veteran reported a four year history of diabetes, establishing an onset date of approximately 2006. The Veteran was treated for instances of dizziness and diagnosed with vertigo in January 2007 and July 2009. Records also reflect a diagnosis of hypothyroidism, with a prescription for Synthroid dating from approximately 2009. However, none of the private treatment records contain any opinions linking the claimed disabilities to the Veteran’s period of service generally or his in-service exposure specifically. Indeed, in June 2004 the Veteran generally reported that he was healthy other than a reported problem with an inguinal hernia. Based on the above, the preponderance of the evidence is against a finding of a nexus between the claimed disabilities and service. Private treatment records show that the Veteran generally reported being in good health in June 2004, and was not diagnosed with or treated for diabetes, vertigo or hypothyroidism until approximately 2006, 2007 and 2009, respectively. None of the treatment records in any way link the Veteran’s disabilities to his period of service, nor does the record reflect that the Veteran endorsed a longstanding history of any of the three disabilities dating back to service. As the preponderance of the evidence is against a nexus, service connection on a direct basis is not warranted for diabetes mellitus, vertigo or hypothyroidism. 38 C.F.R. §§ 3.102, 3.303. Diabetes mellitus is considered to be a chronic disease for VA purposes. 38 C.F.R. § 3.309(a). However, diabetes was not diagnosed in service and did not manifest to a compensable degree within one year of the Veteran’s separation. 38 C.F.R. §§ 3.303(b), 3.307(a)(3). In November 2010 the Veteran reported an onset of diabetes mellitus in 2006, which is well after his separation from service and from the National Guard. As such, presumptive service connection for diabetes mellitus is not warranted in this case. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Finally, the Board notes that certain disabilities are presumed to be causally related to exposure to contaminants in the water at Camp Lejeune. 38 C.F.R. § 3.309(f). However, diabetes mellitus, vertigo and hypothyroidism are not included among the disabilities which may be presumed to be causally related to such exposure. Therefore service-connection on a presumptive basis for the claimed disabilities as related to contaminant exposure is not warranted. Id. The preponderance of the evidence weighs against a finding that the Veteran’s type II diabetes mellitus, vertigo, or hypothyroidism are causally related to his service. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55–57; 38 C.F.R. § 3.102. For these reasons, the claim is denied. 4. Entitlement to service connection for hypertension. Private treatment records reflect that the Veteran was diagnosed with hypertension in approximately June 2004. Further, the Veteran has stated that his hypertension is causally related to elevated blood pressure in service, in particular a July 1965 examination report where the Veteran’s blood pressure was noted to be 140/90. As a current disability and an in-service injury have been shown, the dispositive issue is whether the Veteran’s hypertension is causally related to his active service. While the Veteran has asserted that his disabilities are causally related to his in-service contaminant exposure, these statements are not competent as the Veteran lacks the medical training and knowledge necessary to provide such an etiological opinion. Jandreau, 492 F.3d 1372; Kahana, 24 Vet. App. at 435. As such, the statements are entitled to no probative weight. During his March 2010 hypertension examination, the Veteran reported that he had elevated blood pressure on a July 1965 in-service medical examination, and that his blood pressure had remained elevated since his separation. In determining the weight to be assigned to evidence, credibility can be affected by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor. Caluza v. Brown, 7 Vet. App. 498, 511–12 (1995), aff’d per curiam, 78 F.3d. 604 (Fed. Cir. 1996). In this case, the Veteran denied any current or history of high or low blood pressure on his corresponding July 1965 report of medical history. Following separation in June 2004 the Veteran was diagnosed with hypertension, at which point he reported that his blood pressure had been elevated that day. At that time the Veteran did not indicate that he had any prior history of hypertension or elevated blood pressure. Finally, in November 2010 the Veteran reported that he had an eight year history of hypertension, which would establish an onset of the disability in approximately 2002. In light of the inconsistent nature of the Veteran’s statements concerning the onset and persistence of his hypertension, the Board findings that his statements are not credible and therefore entitled to no probative weight. Id. VA obtained an opinion concerning the etiology of the Veteran’s hypertension in March 2010. The examiner stated that it was less likely than not that the hypertension was due to the Veteran’s service. The examiner stated that the Veteran’s blood pressure readings in service, including the July 1965 readings, did not meet JNC-7 guidelines for hypertension and therefore were likely not the cause of the Veteran’s hypertension. The examiner then noted that the Veteran was not subsequently diagnosed with hypertension until 2004, well after service. There is no evidence that the above examiner was not competent or credible. Further, the examiner provided a well-reasoned rationale for the opinion which cited to the medical evidence of record and governing medical norms concerning diagnosing hypertension. As such, the Board finds that the opinion is entitled to significant probative weight as to the presence of a nexus. Nieves-Rodriguez, 22 Vet. App. 295. Hypertension is considered to be a chronic disease for VA purposes. 38 C.F.R. § 3.309(a). However, the Veteran was not diagnosed with hypertension in service, nor is there evidence that hypertension manifested to a compensable degree within one year of the Veteran’s separation from service. 38 C.F.R. §§ 3.303(b), 3.307(a)(3); see 38 C.F.R. § 4.104, Diagnostic Code 7101. The first evidence of a diagnosis of hypertension is a June 2004 private treatment record, which did not note a history of high blood pressure. Further, in a separate November 2010 private treatment record the Veteran reported an eight year history of hypertension, placing its onset well after his separation from service. As such, the hypertension cannot be presumed to be related to the Veteran’s period of active service, nor has it been shown to have been continuous since service. 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a). The Board notes that the Veteran had additional service in the Alabama State National Guard following his separation from active service, which included numerous periods of ADT and IDT. However, the presumption in favor of chronic diseases only applies to periods of service lasting 90 days or more. 38 C.F.R. § 3.307(a)(1). As such, even if the documented periods of ADT and IDT constituted active service, none of the periods lasted the requisite 90 days and thus the presumption does not apply to these periods. Id. The preponderance of the evidence weighs against a finding that the Veteran’s hypertension is causally related to his service. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55–57; 38 C.F.R. § 3.102. For these reasons, the claim is denied. 5. Entitlement to service connection for hyperlipidemia. Treatment records reflect that the Veteran has been treated for high cholesterol, or hyperlipidemia. However, elevated cholesterol is a laboratory finding and not a disability in and of itself for which VA compensation benefits are payable. 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (stating that diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities and are therefore not appropriate for the rating schedule). Further, the term “disability,” as used for VA purposes, refers to impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1367–68 (Fed. Cir. 2018). There is no evidence of record suggesting the appellant’s elevated cholesterol causes any functional impairment of earning capacity. Wait v. Wilkie, No. 18-4349, 2020 U.S. App. Vet. Claims LEXIS 1609, *16–*19 (Vet. App. Aug. 26, 2020). Here, although there is evidence of elevated cholesterol readings, there is no competent evidence of a resulting disability. In the absence of proof of a current disability stemming from high cholesterol, service connection for high cholesterol is not warranted. Brammer, 3 Vet. App. at 225; Rabideau v. Derwinski, 2 Vet. App. 141, 143–44 (1992). Service connection can only be granted for a disability resulting from an in-service disease or injury. 38 U.S.C. §§ 1110, 1131. High cholesterol is a laboratory finding that manifests itself only in laboratory test results and is not a disability for which service connection can be granted. The preponderance of the evidence weighs against a finding that the Veteran has a disability for which VA compensation may be awarded. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55–57; 38 C.F.R. § 3.102. For these reasons, the claim is denied. 6. Entitlement to service connection for a left and right knee disability. In this case, the Veteran has stated that he has bilateral knee pain that is causally related to his service, including exposure to contaminants in the water at Camp Lejeune. However, the Veteran has not provided any information asserting that he has been given a specific diagnosis by a competent medical professional. Jandreau, 492 F.3d 1372. As such, the Veteran’s statements are of minimal probative weight as to the presence of a current disability. Turning to the medical evidence, records reflect that the Veteran has sporadically reported bilateral knee pain at various points but contain no diagnoses of a left or right knee disability of any kind. Based on the foregoing, the Board finds that there is no evidence of a left or right knee disability either during the appellate period or proximate thereto. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). None of the medical evidence contains diagnoses of a left or right knee disability, nor did the Veteran identify any diagnoses in his statements. While pain alone may constitute a disability for the purposes of service connection, there must be a showing that the pain reaches the level that results in a functional impairment of earning capacity. Saunders, 886 F.3d at 1367–68; Wait, No. 18-4349, at *16–*19. In this case, there is no evidence that the reported pain has in any way resulted in a functional impairment of earning capacity. There is no evidence that the Veteran experiences limitation of motion of either knee joint that would be compensable, or any other symptomatology rising to a compensable level. As such, the report of pain is not sufficient to establish the presence of a current disability. Id. Based on the foregoing, the preponderance of the evidence is against a finding that the Veteran has a current left or right knee disability, and therefore there can be no valid claim for benefits. Brammer, 3 Vet. App. at 225 (1992). Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55–57; 38 C.F.R. § 3.102. For these reasons, the claims are denied. REASONS FOR REMAND 1. Entitlement to service connection for pes planus. The Veteran’s June 1961 enlistment examination does not reflect a diagnosis of pes planus at the time the Veteran was accepted into service. An August 1961 service treatment record subsequently notes that on re-examination the Veteran had third degree bilateral pes planus which was asymptomatic. While made close in time to the Veteran’s enlistment, the notation of pes planus made two months after the Veteran’s enlistment does not result in the pes planus being “noted at entry” for the purposes of the presumption of soundness. As such, the Veteran is presumed to have been sound upon entry. 38 U.S.C. §§ 1111, 1132, 1137. VA obtained an opinion concerning the Veteran’s pes planus in March 2010. The examiner stated that it was at least as likely as not that the Veteran’s current pes planus was causally related to the noted pes planus in service. However, the examiner further stated that the Veteran’s pes planus pe-existed his period of service and that there was no evidence of treatment for the disability in service. However, the examiner did not apply the correct legal standard. When rebutting the presumption of soundness there must clear and unmistakable evidence that a disability pre-existed service and clear and unmistakable evidence that the disability was not aggravated by service. 38 U.S.C. §§ 1111, 1132, 1137; Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). As such, the Board finds that a remand is warranted so that a new opinion may be obtained addressing whether the Veteran’s pes planus clearly and unmistakably both pre-existed and was not aggravated by his service. 2. Entitlement to a TDIU. Concerning entitlement to a TDIU, the Board finds the claim would be materially affected by any determinations with respect to the other remanded claim. As such, it is inextricably intertwined with the service connection claim being remanded and must be remanded as well. Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s pes planus. The examiner should answer the following: a) Did the Veteran’s pes planus clearly and unmistakably (obviously, manifestly or undebatably) pre-exist his period of service? Attention is invited to the Veteran’s June 1961 enlistment examination which noted no foot abnormalities and an August 1961 treatment record noting that on re-examination the Veteran had bilateral third degree pes planus that was asymptomatic (labelled “STR - Medical” – pgs. 30, 16 – uploaded 9/29/2009). b) If yes, was the Veteran’s pes planus clearly an unmistakably NOT aggravated (i.e., permanently increased in severity) by his service? Attention is invited to the Veteran’s statements that he purchased arch supports while in service for his feet, but otherwise did not received treatment and had no problems with his feet (labelled “VA Examination” – pg. 6 – uploaded 3/23/2010). Clear and unmistakable evidence means evidence that cannot be misinterpreted and misunderstood, i.e., it is undebatable. Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered aggravation in service. c) If the answer to (a) or (b) is no, is it at least as likely as not (a fifty percent probability or greater) that the Veteran’s bilateral pes planus is related to his active service? A detailed rationale for the opinion must be provided. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as against it. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Wendell, 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.