Citation Nr: 21025906 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 17-00 193 DATE: April 29, 2021 ORDER Entitlement to service connection for diabetes mellitus, to include as secondary to service-connected hypertension with heart disease and chronic renal insufficiency, is DENIED. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to hypertension with hypertensive heart disease and chronic renal insufficiency with tachycardia, is DENIED. Entitlement to service connection for a bladder condition, to include lower urinary tract symptoms (LUTS) and secondary to a service-connected hypertension disability, is DENIED. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran’s current diabetes mellitus was incurred during service in the United States Army. Additionally, the current diabetes mellitus is not proximately due to, or aggravated by, the service-connected hypertension or chronic renal disabilities. 2. The preponderance of the evidence is against a finding that the Veteran’s current OSA was incurred during service in the United States Army. Additionally, the current OSA is not proximately due to, or aggravated by, the service-connected hypertension or chronic renal disabilities. 3. The preponderance of the evidence is against a finding that the Veteran’s current bladder conditions were incurred during service in the United States Army. Additionally, the current bladder conditions are not proximately due to, or aggravated by, a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2020). 2. The criteria for service connection for OSA have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310. 3. The criteria for service connection for a bladder disability, to include LUTS, have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Army from September 1975 to September 1979. In November 2019, the Board addressed the claims on the title page. At that time, the Board concluded that the requirements for service connection for diabetes mellitus, Type II and OSA had not been satisfied. The Board remanded the Veteran’s claim for service connection for LUTS to the agency of original jurisdiction (AOJ) for additional development. In October 2020, the Court of Appeals for Veterans’ Claims (Court) issued a Joint Motion for Partial Remand (JMPR). Therein, the Court vacated the Board’s November 2019 decisions on diabetes mellitus and OSA. The Court remanded the diabetes claim for the Board to reconsider a May 2017 VA examination report. The Court remanded the OSA claim for the Board to address internet articles, which were submitted by the Veteran on April 14, 2014. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted while in the active military, naval, or air service. 38 U.S.C. § 1110. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). In order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In each case where service connection for any disability is sought, due consideration shall be given to the places, types, and circumstances of the Veteran’s service as shown by the Veteran’s service record, the official history of each organization in which the Veteran served, the Veteran’s medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154 (a). In making these determinations, the Board must consider and assess the credibility and weight of all evidence in the claim file, including the medical and lay evidence, to determine its probative value. In doing so, the Board must provide its reasoning for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Barr v. Nicholson, 21 Vet. App. 303 (2007). Service connection may also be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury, will be service-connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). (This standard of assessing aggravation of disability under 38 C.F.R. § 3.310 was established in 2006. See 71 Fed. Reg. 52744-47 (Sept. 7, 2006) (codified at 38 C.F.R. § 3.310)). Although VA indicated that the purpose of the regulation was merely to apply the Court’s 1995 ruling in Allen, it was made clear in the comments to the regulation that the 2006 changes were intended to place the burden on the claimant to establish a pre-aggravation baseline level of disability for the nonservice-connected disability before an award of service connection based on aggravation may be made. This had not been VA’s practice, which strongly suggests that the revision amounted to a substantive change in the regulation. Because the Veteran’s claim was received after the regulatory change, his claim will be adjudicated under the current version of the regulation. The VA is responsible for determining whether the evidence supports the claim or is in relative equipoise (with the Veteran prevailing in either event) or whether a preponderance of the evidence is against the claim (in which case the claim is denied). Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (b). 1. Entitlement to service connection for diabetes mellitus, to include as secondary to service-connected hypertension with heart disease and chronic renal insufficiency, is denied. In April 2014, the Veteran submitted a VA Form 21-4138. Thereby, the Veteran initiated a claim to reopen a finial denial of service connection for diabetes mellitus. The Veteran relayed that diabetes had impacted a service-connected renal disability. Again, in order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson, 12 Vet. App. at 253. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. In January 2006, an Emergency Department Clinician Note was generated at the Dall VA Medical Clinic (VAMC). Therein, a VA provider reported a “new onset of diabetes.” In May 2006, the Veteran’s service treatment records (STRs) were associated with the claims file. In October 1967, the Veteran underwent an annual clinical evaluation. At that time, the military examiner noted that all of the Veteran’s physical systems were normal. In July 1979, the Veteran underwent a clinical evaluation for separation from the U.S. Army. At that time, the military examiner noted that all of the Veteran’s physical systems were normal. After deliberate review, the Board finds that the STRs do not indicate that the Veteran was treated for, and/or diagnosed with, diabetes mellitus during service in the U.S. Army. In April 2014, the Veteran submitted an article that addressed diabetes and kidney failure. After review, the Board notes that the article indicates that people with diabetes are at risk of developing kidney problems. However, the article does not support an inverse relationship. Meaning, the article does not support a finding that the Veteran’s service-connected kidney disability caused or aggravated any current diabetes. In August 2014, a Nephrology Attending Note was generated at the North Texas Health Care System (HCS). Therein, a VA provider relayed that, “(g)iven his risk factors of hypertension (on echo with left ventricular hypertrophy) and type 2 diabetes, the most likely etiology of his kidney disease is a combination of the two.” The Board notes that the provider did not relay that diabetes mellitus was caused or aggravated by the service-connected hypertension and/or kidney disabilities. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. See 38 C.F.R. § 3.159 (a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. See 38 C.F.R. § 3.159 (a)(2). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). In August 2014, correspondence from Wheatland Medical Associates was associated with the claims file. Therein, the Veteran’s primary care physician relayed that the Veteran had been treated at that facility for diabetes mellitus since 2011. In August 2014, the Veteran submitted a VA 21-4138. Therein, the Veteran posited that he had tingling in his feet and hands while in service. In January 2015, the Veteran submitted a VA Form 21-4138. Therein, the Veteran posited that he developed diabetes mellitus while on active duty, but it was never diagnosed. The Board notes that while the Veteran is competent to identify the symptoms he has observed during the course of his claimed disability, he is not competent to diagnosis diabetes mellitus. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (citing Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992)). A diagnosis for diabetes mellitus requires equipment, education, training, and experience that the Veteran does not possess. In October 2016, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured diabetes mellitus. The VA examiner noted a 2006 diagnosis for diabetes mellitus. The examiner opined that it is less likely than not that the Veteran’s hypertension caused his diabetes. The examiner relayed that the Veteran was diagnosed with diabetes mellitus in 2006, and his diabetic neuropathy was diagnosed in 2012, six years later. The examiner explained that, generally, diabetic neuropathy develops about ten years after the onset of diabetes, but this is highly variable, and depends on a person’s glycemic control and other factors. Consequently, the examiner could not determine if the Veteran’s disease is progressing at a baseline or not. The examiner relayed that hypertension could aggravate some of the sequelae of diabetes (such as heart disease, erectile dysfunction, and renal disease), but it does not worsen a person’s glucose levels. Thus, the examiner opined that it is less likely than not that the Veteran’s diabetes mellitus was aggravated beyond its natural progression by the Veteran’s hypertension with hypertensive heart disease and chronic renal insufficiency. In May 2017, a VA examination report was associated with the claims file. Therein, the examiner was addressing a possible etiological relationship between the Veteran’s in-service eyelid surgery and current diabetes mellitus. The VA examiner opined that, “the Veteran’s diabetes mellitus is at least as likely as not (50 percent or greater probability) caused by post-service insulin resistance and underproduction due to his obesity.” In September 2017, a VA examination report was associated with the claims file. The VA examiner explained that a chalazion is caused by a blockage in one of the tiny meibomian glands of the upper and lower eyelids. The examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran’s diabetes began during service or was etiologically related to the in-service eyelid surgery (removal of chalazion). The examiner opined that the it is at least as likely as not that the Veteran’s diabetes began post-service. The examiner relayed that, “(t)here is no nexus between chalazia and diabetes. No objective medical record or medical literature evidence to indicate otherwise was found. The risk factors for chalazia which do not include diabetes are below. Therefore, the presence of chalazia is not used to diagnose diabetes but rather lab values as outlined the Diabetes Mellitus DBQ. No laboratory evidence to indicate that the Veteran had diabetes during service was found.” In August 2019, the Veteran supplied sworn testimony to the undersigned Veterans’ Law Judge (VLJ). At that time, the Veteran relayed that he did not have diabetes mellitus during service in the United States Army. When questioned by the undersigned, the Veteran relayed a diagnosis for diabetic neuropathy in or around 2000. The Veteran also relayed that blood tests were not necessary to monitor his sugars before 2000. In November 2019, the Board addressed the Veteran’s claim for service connection for diabetes mellitus, Type II. At that time, the Board found that sufficient evidence had been submitted to reopen the AOJ’s denial of the claim in November 2006. However, the Board found that the evidence of record did not show that the Veteran’s diabetes mellitus, Type II had its onset during active service, within one year after separation, or was etiologically related to a service-connected disability. In January 2020, an Addendum notation was generated at the Dallas VAMC. Therein, the VA provider reported that, “(p)atient called today inquiring to what degrees / percent his prostate is contributing to his voiding symptoms. Advised I'm unable to quantify to a specific degree. He does have BPH as noted cystoscopically which certainly can contribute to his LUTS.” In October 2020, the Court issued a JMPR. Therein, the Court vacated the Board’s November 2019 decision on diabetes mellitus. The Court remanded the diabetes claim for the Board to reconsider a May 2017 VA examination report. As noted above, the May 2017 VA examination report addressed a claimed etiological relationship between the Veteran’s current diabetes mellitus and an in-service eyelid surgery. The VA examiner did not consider the Veteran’s service-connected hypertension when rendering the negative opinion on etiology. The Board notes that the Veteran maintains a diagnosis for diabetes mellitus, Type II. Consequently, the first requisite element for direct and secondary service connection have been substantiated. See Hickson, 12 Vet. App. at 253; Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. Again, the Board notes that the STRs do not indicate that diabetes mellitus was considered and/or addressed during the Veteran’s service in the U.S. Army. Moreover, there is no evidence that the Veteran’s diabetes mellitus was a chronic condition that manifested within one year of separation. In fact, the Veteran’s diabetes mellitus was not diagnosed until at least two decades after he separated from the U.S. Army. In September 2017, the VA examiner opined that it was less likely than not that the Veteran’s diabetes began during service or was etiologically related to the in-service eyelid surgery (removal of chalazion). Consequently, the Board finds that the second requisite element for direct service connection has not been substantiated. See Hickson, 12 Vet. App. at 253. The Board observes that the Veteran is service connected for chronic renal insufficiency and hypertensive heart disease. Consequently, the Board finds that the second requisite element for secondary service connection has been substantiated. See Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. On numerous occasions during the claim period, the Veteran’s government and non-government treatment records were associated with the claims file, to include those generated at the North Texas HCS, Dallas VAMC, and Olin E. Teague Veteran Center. After deliberate review, the Board finds that the records do not identify an etiological relationship between the Veteran’s service-connected hypertension or chronic renal insufficiency and the current diabetes mellitus. In October 2016, the VA examiner opined that it is less likely than not that the Veteran’s hypertension caused his diabetes. The examiner also opined that it is less likely than not that the Veteran’s diabetes mellitus was aggravated beyond its natural progression by the service-connected hypertension with hypertensive heart disease or chronic renal insufficiency. Upon review of the appellate record, the Board finds that the medical evidence does not include an indication that the Veteran’s hypertension or chronic renal disease caused or aggravated the diabetes mellitus. However, it is noted in the medical records do indicate that the diabetes mellitus complicates that Veteran’s hypertension, and that the diabetes mellitus was a partial cause of his service-connected renal disease. Consequently, the Board finds that the final requisite element for secondary service connection has not been substantiated. See id. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s claim for service connection for a diabetes mellitus disability. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claim for service connection for diabetes mellitus disability must be denied, because the preponderance of the evidence weighs against his claim. 2. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to hypertension with hypertensive heart disease and chronic renal insufficiency with tachycardia, is denied. In August 2013, the Veteran submitted a VA Form 21-4138. Therein, the Veteran initiated an entitlement claim for service connection for a sleep apnea, secondary to hypertension with hypertensive heart disease and chronic renal insufficiency with tachycardia. Again, in order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson, 12 Vet. App. at 253. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. In July 1999, the Veteran underwent a sleep study at Texas Medical Diagnostics, Inc. Important to this Board analysis, the examiner acknowledged the Veteran’s history of teeth grinding, snoring, and hypertension. The examiner relayed that the Veteran demonstrated evidence of sleep disordered breathing. The examiner relayed that the Veteran’s overall apnea / hypopnea index was less than 1 event per hour. The examiner determined that the Veteran was not a candidate for a CPAP assistive device. In May 2006, the Veteran’s STRs were associated with the claims file. In October 1967, the Veteran underwent an annual clinical evaluation. At that time, the military examiner noted that all of the Veteran’s physical systems were normal. Within a July 1979 Report of Medical History, the Veteran denied frequent trouble sleeping. In July 1979, the Veteran underwent a clinical evaluation for separation from the United States Army. At that time, the military examiner noted that all of the Veteran’s physical systems were normal. After deliberate review, the Board finds that the STRs do not indicate that the Veteran was treated for and/or diagnosed with OSA during service in the U.S. Army. In February 2014, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured sleep apnea. The VA examiner noted a 2013 diagnosis for obstructive sleep apnea. The VA examiner opined that, based on the available record, it would require speculation to casually / proximately link the Veteran’s current obstructive sleep apnea to his service-connected hypertension and chronic renal insufficiency. In April 2014, the Veteran submitted a VA Form 21-4138. Therein, the Veteran posited that sleep apnea was secondary to service-connected hypertensive heart disease. The Board notes that while the Veteran is competent to identify the symptoms he has observed during the course of his claimed disability, he is not competent to identify the etiology of his current OSA. See Clemons, 23 Vet. App. at 4-5 (citing Espiritu, 2 Vet. App. at 494-95). In April 2014, the Veteran submitted a number of articles that addressed OSA. After review, the Board notes that the articles address the symptoms and complications that accompany OSA. An article indicated that OSA can be associated with long-term complications if not diagnosed and treated properly, to include hypertension. An article indicated that OSA impacted the blood vessels in the lung(s) and increased the risk of several forms of heart and vascular disease. An article indicated that OSA could lead to serious health problems over time, to include diabetes, high blood pressure, heart disease, stroke, and weight gain. In February 2016, the Veteran submitted a VA Form 9. Therein, the Veteran relayed that symptoms of sleep apnea could be found in his military dental records. Specifically, the Veteran relayed that in-service teeth grinding / bruxism was an indicator for sleep apnea. In May 2017, a VA examination report was associated with the claims file. At that time, the VA examiner opined the Veteran’s OSA was less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner noted that the Veteran was diagnosed with OSA in July 2013. The examiner also opined that the Veteran’s OSA is less likely than not (less than 50 percent probability) incurred in or caused by teeth grinding and snoring during service; proximately due to or the result of hypertension, heart disease, chronic renal insufficiency; or, permanently aggravated beyond its natural progression by the service connected hypertension, heart disease, chronic renal insufficiency. The VA examiner relayed that the Veteran’s OSA is at least as likely as not (50 percent or greater probability) caused by his post-service weight gain/obesity. In August 2017, the Veteran submitted a VA Form 21-4138. Therein, the Veteran relayed that bruxism was clearly a condition of sleep apnea. In August 2019, the Veteran supplied sworn testimony to the undersigned VLJ. At that time, the Veteran indicated that an unidentified doctor told him his OSA was secondary to his service-connected hypertension. The Veteran testified that, “when I started the program at the VA, doing the classes, and I went back once and those people weren’t there anymore, it was, like, the ladies over there . . .. So it was some doctor prior to that. I can’t recall his name.” The undersigned asked if the Veteran had problems with snoring and waking up during his period of active duty. In response, the Veteran relayed that, “well, you know, when I went (Inaudible) due to the way I was sleeping the other guys in my rank they kind of said that I kept them up at night because I was grinding my teeth all night.” In October 2020, the Court issued a JMPR. Therein, the Court vacated the Board’s November 2019 decisions on OSA. The Court remanded the OSA claim for the Board to address internet articles, which were submitted by the Veteran on April 14, 2014. After further review, the Board observes that the April 2014 articles address a correlation between OSA and hypertension. The articles do indicate that OSA may result in and/or aggravate hypertension and heart disease. However, the articles do not support the inversion conclusion. Meaning, they do not indicate that hypertension, heart disease, and/or chronic renal insufficiency cause or aggravate OSA. Again, the Veteran contends that his current OSA is etiologically related to in-service teeth grinding and snoring. The Veteran also contends his OSA is secondary to his service-connected hypertension, heart disease, and chronic renal insufficiency. The Board notes that the Veteran maintains a current diagnosis for OSA. Consequently, the first requisite element for direct and secondary service connection have been substantiated. See Hickson, 12 Vet. App. at 253; Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. Again, the Board notes that the STRs do not indicate that OSA was considered and/or addressed during the Veteran’s service in the U.S. Army. Moreover, there is no evidence that the Veteran’s OSA was a chronic condition that manifested within one year of separation. In fact, the Veteran’s OSA was not diagnosed until at least three decades after he separated from the U.S. Army. The May 2017 VA examiner opined that the Veteran’s current OSA was less likely than not incurred during service or caused by in-service teeth grinding and snoring. Consequently, the Board finds that the second requisite element for direct service connection has not been substantiated. See Hickson, 12 Vet. App. at 253. The Board observes that the Veteran is service connected for chronic renal insufficiency and hypertensive heart disease. Consequently, the Board finds that the second requisite element for secondary service connection has been substantiated. See Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. On numerous occasions during the claim period, the Veteran’s government and non-government treatment records were associated with the claims file, to include those generated at the North Texas HCS, Dallas VAMC, and Olin E. Teague Veteran Center. After deliberate review, the Board finds that the treatment records do not support a conclusion that the Veteran’s service-connected hypertension and/or chronic renal insufficiency caused the current OSA or aggravated it beyond its natural course. Additionally, the May 2017 VA examiner opined that the Veteran’s OSA is less likely than not proximately due to or the result of hypertension, heart disease, or chronic renal insufficiency. The examiner also opined that the Veteran’s OSA is less likely than not aggravated beyond normal progression by his service-connected conditions. Upon review of the appellate record, the Board finds that the medical evidence does not include an indication that the Veteran’s service-connected hypertension or chronic renal insufficiency caused or aggravated the current OSA. Consequently, the Board finds that the final requisite element for secondary service connection has not been substantiated. See id. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s claim for service connection for an OSA disability. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claim for service connection for obstructive sleep apnea must be denied, because the preponderance of the evidence weighs against his claim. 3. Entitlement to service connection for a bladder disability, to include lower urinary tract symptoms (LUTS) and secondary to a service-connected hypertension disability, is denied. In August 2013, the Veteran submitted a VA Form 21-4138. Therein, the Veteran initiated an entitlement claim for service connection for a bladder condition, secondary to hypertension with hypertensive heart disease and chronic renal insufficiency with tachycardia. Again, in order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson, 12 Vet. App. at 253. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. Before the claim period, in January 2006, a treatment notation was generated at the North Texas HCS. At that time, the VA provider noted that the Veteran reported “urgency” for a symptom of bladder function. In May 2006, the Veteran’s STRs were associated with the claims file. In October 1967, the Veteran underwent an annual clinical evaluation. At that time, the military examiner noted that all of the Veteran’s physical systems were normal. In July 1979, the Veteran underwent a clinical evaluation for separation from the U.S. Army. At that time, the military examiner noted that all of the Veteran’s physical systems were normal. After deliberate review, the Board finds that the STRs do not indicate that the Veteran was treated for, and/or diagnosed with, a bladder condition, to include LUTS, during active duty service. In April 2014, the Veteran submitted a VA Form 21-4138. Therein, the Veteran posited that a current bladder condition was the result of a service-connected erectile dysfunction disability. The Board notes that, while the Veteran is competent to testify about the symptoms he has observed during the course of his claimed disability, he is not competent to identify the etiology for his current bladder disorder(s). See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (citing Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992)). In August 2015, the Veteran submitted an article that addressed the causes of nocturia. After review, the Board notes that the article indicates that nocturia may be a sign of a developing chronic kidney disease. The article also relayed that cardiovascular disease and erectile dysfunction had been linked to nocturia. In February 2016, correspondence from the Dallas Veterans Administration Medical Center was associated with the claims file. Therein, a provider opined that, “I feel the prostate has ~75% chance of being responsible for his LUTS.” In May 2017, a VA examination report was associated with the claims file. Therein, the VA examiner opined that the Veteran’s LUTS was less likely than not (less than 50 percent probability) proximately due to, or the result, of erectile dysfunction. The examiner also opined that the Veteran’s LUTS condition was less likely than not permanently aggravated beyond its natural progression by the service-connected erectile dysfunction. In August 2019, the Veteran supplied sworn testimony to the undersigned Veterans Law Judge (VLJ). The Veteran testified that, “the bladder condition is secondary to the hypertension because the effects of it causes the renal, the kidney problems, along with the bladder. It makes the bladder work hard, because, like I said, I’m constantly going through the day.” The Veteran testified that he frequently had to urinate during military service, but he did not receive treatment for a bladder condition. In November 2019, a VA addendum medical report was generated that addressed the nature and etiology of the Veteran’s bladder condition. The VA examiner relayed that, “(t)he Veteran's overactive bladder (OAB) and LUTS are less likely than not (less than 50% probability) proximately due to or the result of hypertension, heart disease, and/or renal insufficiency. The Veteran's OAB and LUTS are less likely than not permanently aggravated beyond their natural progression by his service-connected hypertension, heart disease, and/or renal insufficiency. The Veteran's OAB and LUTS are at least as likely as not (50% or greater probability) proximately due to or the result of diabetes mellitus and BPH respectively. No objective medical record or reputable medical literature evidence to indicate otherwise was found. There is no mechanism of action for cause or permanent aggravation beyond natural progression of the OAB and LUTS by hypertension, heart disease, and/or renal insufficiency. The Veteran's greatest risk factor for his OAB is his diabetes mellitus per the current reputable medical literature. The Veteran's greatest risk factor for his LUTS is BPH.” In November 2019, the Board considered the Veteran’s entitlement claim for service connection for a bladder condition, to include LUTS. The Board noted that, “(t)he Veteran further argues that his bladder condition, to include LUTS, is secondary to his erectile dysfunction, hypertension, heart disease, or chronic renal insufficiency.” The Board remanded the Veteran’s claim to the AOJ, noting that, “(p)ursuant to the now vacated October 2019 Board decision, the AOJ obtained additional treatment records and the Veteran underwent a VA compensation and pension examination addressing his claimed bladder condition in November 2019. On remand, the AOJ should consider this evidence and readjudicate the case.” In February 2020, the Veteran underwent a VA examination that considered the current severity of his service-connected hypertension. Important to this Board analysis, the VA examiner noted that the Veteran was prescribed Amlodipine, furosemide, Metoprolol, Hydralazine, HCTZ and Lisinopril for treatment of hypertension. In March and November 2020, the Veteran’s representative submitted Appellant’s Briefs. Therein, the Veteran’s representative relayed that, “(a)ccording to the Simon Foundation for Continence, taking medication for high blood pressure may relax the muscles of the bladder neck, which may cause stress urinary incontinence and leakage.” In April 2020, the Board addressed the Veteran’s claim for service connection for a bladder condition. At that time, the Board concluded that the October VA examination was not adequate. The Board remanded the claim to the AOJ to obtain an addendum opinion that considered whether the Veteran’s medications for the service-connected hypertension is the cause of, and/or an aggravation to, the current bladder condition, to include LUTS. The Board also directed the AOJ to contact the Veteran and ask him to submit a copy of any supporting medical literature he wished VA to consider, to include information from the Simon Foundation for Continence. In May 2020, the AOJ contacted the Veteran and requested that, “(he) submit a copy of any supporting medical literature to us to consider with respect to the issue on appeal to include any information from The Simon Foundation for Continence referenced the February 2020 Appellant's Brief.” In June 2020, an addendum VA opinion was associated with the claims file. Therein, after review of the claims file and the Veteran’s medical records, the VA examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran’s overactive bladder (OAB) and LUTS were proximately due to, or the result of, hypertension heart disease, renal insufficiency, or the medications used to treat the service-connected disabilities. The VA examiner also opined that it was less likely than not that the OAB and LUTS were permanently aggravated beyond their natural progression by the service-connected disabilities. The VA examiner opined that the OAB and LUTS were at least as likely as not proximately due to the non-service-connected diabetes mellitus and benign prostate hyperplasia. The VA examiner relayed that, “(n)o objective medical record or reputable medical literature evidence to indicate otherwise was found. There is no mechanism of action for cause or permanent aggravation beyond natural progression of the Veteran's OAB and LUTS by his hypertension, heart disease, renal insufficiency, or the medications used to treat such. The Veteran's greatest risk factor for his OAB is his diabetes mellitus per the current reputable medical literature and not his hypertension, heart disease, renal insufficiency, or the medications used to treat such. The Veteran's greatest risk factor for his LUTS is BPH and not his hypertension, heart disease, renal insufficiency, or the medications used to treat such.” In December 2020 and January 2021, correspondence from the Veteran was associated with the claims file. Therein, the Veteran relayed that he had no additional evidence to submit for his pending claim(s). The Board notes that the duty to assist is a two-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Consequently, without the Veteran’s submission of any medical literature from the Simon Foundation for Continence, VA did not have an opportunity to review the evidence while addressing his claim for service connection for a bladder disability. During the claim period, the Board notes that the Veteran has been diagnosed with bladder conditions, to include OAB and LUTS. Consequently, the first requisite element for direct and secondary service connection have been substantiated. See Hickson, 12 Vet. App. at 253; Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. The Board notes that the Veteran testified that he had to urinate frequently during service in the U.S. Army. However, the STRs reveal that the Veteran was not seen for, or diagnosed with, a bladder condition during active duty service. Moreover, the Veteran’s post-service treatment records reveal that he reported “frequency” as a bladder symptom more than two decades after separation from U.S. Army. Consequently, the Board finds that the second requisite element for direct service connection has not been substantiated. See Hickson, 12 Vet. App. at 253. The Board observes that the Veteran is service connected for multiple disabilities. The Veteran’s service-connected disabilities include hypertension, erectile dysfunction, chronic renal insufficiency, hypertensive heart disease, and gout. The Board notes that the Veteran is not service connected for diabetes mellitus and/or prostate disabilities. Based on the Veteran’s currently service-connected disabilities, the Board finds that the second requisite element for secondary service connection has been substantiated. See Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. On numerous occasions during the claim period, the Veteran’s government and non-government treatment records were associated with the claims file, to include those generated at the North Texas HCS, Dallas VAMC, and Olin E. Teague Veteran Center. After deliberate review, the Board finds that the records do not identify an etiological relationship between one of the Veteran’s service-connected disabilities and the current bladder condition. The Board notes that the August 2015 article relayed that erectile dysfunction had been linked to nocturia. However, the May 2017 VA examiner opined that the Veteran’s current LUTS was less likely than not aggravated beyond its natural progression by the service-connected erectile dysfunction. Additionally, the June 2020 addendum VA opinion relayed that the Veteran’s OAB and LUTS were less likely than not proximately due to, or the result of, hypertension heart disease, renal insufficiency, or the medications used to treat the service-connected disabilities. During the claim period, the Veteran has undergone multiple VA examinations. In the resultant examination reports, the examiners opined that the Veteran’s current bladder condition was less likely than not etiologically related to a service-connected disability. In November 2019 and June 2020, the VA examiners opined that it was at least as likely as not that the Veteran’s current bladder conditions were etiologically related to the non-service-connected diabetes mellitus and benign prostate hyperplasia. Consequently, the Board finds that the final requisite element for secondary service connection has not been substantiated. See id. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s claim for service connection for a bladder disability. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claim for service connection for a bladder disability must be denied, because the preponderance of the evidence weighs against his claim. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board RLBJ, 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.