Citation Nr: 21030203 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 15-38 969 DATE: May 18, 2021 ORDER Service connection for type II diabetes mellitus (with associated diabetic peripheral neuropathy of the lower extremities and erectile dysfunction), as secondary to service-connected major depressive disorder (MDD) with an adjustment disorder, is granted. Service connection for tension headaches as secondary to service-connected MDD with an adjustment disorder is granted. FINDINGS OF FACT 1. The Veteran had active service at the Camp Lejeune Marine Corps Base in North Carolina from March 1985 to June 1987. He was exposed to contaminated water while serving at this facility. 2. The Veteran's current type II diabetes mellitus and tension headaches are not related to his exposure to contaminated water at Camp Lejeune during active service. 3. The Veteran has type II diabetes mellitus (with associated diabetic peripheral neuropathy of the lower extremities and erectile dysfunction) proximately due to or the result of his service-connected MDD with an adjustment disorder, with obesity serving as an intermediate step between the two disabilities. 4. The Veteran has tension headaches proximately due to or the result of his service-connected MDD with an adjustment disorder. CONCLUSIONS OF LAW 1. The criteria have been met for secondary service connection for type II diabetes mellitus. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310(a), 17.400 (2020). 2. The criteria have been met for secondary service connection for tension headaches. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310(a) (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from July 1984 to June 1988 in the U.S. Marine Corps. He served at the Camp Lejeune Marine Corps Base in North Carolina from March 1985 to June 1987. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2013 rating decision issued by an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). This appeal has been advanced on the Board's docket. 38 U.S.C. § 7107(b) (effective February 19, 2019); 38 C.F.R. § 20.800(c) (2020). In a July 2018 Board decision, the Board denied service connection and secondary service connection for a headache disorder and type II diabetes mellitus. However, the Veteran appealed the Board's July 2018 decision (that denied the above issues) to the United States Court of Appeals for Veterans Claims (Court). In an April 2019 Order, the Court partially vacated and remanded the Board's decision to deny service connection for a headache disorder and type II diabetes mellitus, for proceedings consistent with a Joint Motion for Partial Remand (Joint Motion). The reasons for the Court's Order and the specific instructions of the Joint Motion will be discussed in further detail below. Upon return to the Board, in October 2019, the Board remanded the entire appeal for further development. This case has since been returned to the Board for appellate review, after the AOJ substantially complied with the Board's remand order. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes that the Veteran has requested that the Board wait the full 90 days prior to issuing a decision. However, given that the Board is granting all benefits sought on appeal, there is no prejudice to the Veteran in adjudicating the claim at this time. I. VA's Duty to Notify and Assist VA's duty to notify under the Veterans Claims Assistance Act of 2000 (VCAA) was satisfied by VA notice letters sent to Veteran dated in April 2012 and December 2012. See 38 U.S.C. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159 (2020). These letters advised the Veteran of the information and evidence necessary to substantiate his service connection and secondary service connection claims. Moreover, the Veteran is represented by an attorney in the present matter. In any event, in the decision below, the Board has granted both secondary service connection claims on appeal. Therefore, the benefits sought on appeal have been granted in full for these particular claims. Accordingly, regardless of whether the notice and assistance requirements have been met, no harm or prejudice to the Veteran has resulted. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92. II. Service Connection and Secondary Service Connection (SSC) for Type II Diabetes Mellitus The Veteran contends that his current type II diabetes mellitus was caused by exposure to contaminated water at Camp Lejeune, North Carolina during active duty service in the 1980s. He points out that during active duty, service personnel records (SPRs) confirm he was assigned to Camp Lejeune from March 1985 to June 1987. He says that medical science has discovered how sensitive the insulin receptor sites for type II diabetes mellitus are to chemical poisoning, in particular benzene in contaminated water. He did not experience any symptoms of type II diabetes mellitus during active duty from 1984 to 1988. Rather, post-service, he maintains that his initial symptoms of type II diabetes mellitus began in January 2005, which is 17 years after separation from service. See March 2012 Application for Compensation (VA Form 21-526); April 2012 Veteran statement; May 2013 informal notice of disagreement (NOD). In the alternative, the Veteran asserts that his current type II diabetes mellitus is caused or aggravated by his service-connected MDD with an adjustment disorder. In other words, he contends that his type II diabetes mellitus is secondary to his service-connected MDD with adjustment disorder. He has submitted a private medical opinion concluding that his service-connected psychiatric problems are a "major contributing metabolic factor" that impacts his eating habits, leading to "significant" weight gain and obesity. In turn, the Veteran's obesity has "seriously contributed" to the development of his type II diabetes mellitus. See August 2016 attorney letter and August 2016 private medical opinion from Dr. P.L.L., MD., a brain surgeon and psychiatrist. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service the "nexus" requirement. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Initially, the Board will briefly address the theories of direct service connection and presumptive service connection. In this regard, the Board finds that service connection for type II diabetes mellitus, on either a direct or presumptive basis, is denied. With regard to presumptive service connection, under recently amended law, effective March 14, 2017, a veteran or former reservist or member of the National Guard who had no less than 30 days (consecutive or nonconsecutive) of service at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987, shall be presumed to have been exposed during such service to contaminants in the water supply, even though there is no record of such disease during service, unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(a)(7)(iii). See also Diseases Associated with Exposure to Contaminants in the Water Supply at Camp Lejeune, 82 Fed. Reg. 4173, 4184-85 (Jan. 13, 2017). For purposes of the Camp Lejeune presumption, "contaminants in the water supply" means the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride, that were in the on-base water-supply systems located at United States Marine Corps Base Camp Lejeune, during the period beginning on August 1, 1953, and ending on December 31, 1987. 38 C.F.R. § 3.307(a)(7)(i). On this issue, the Veteran's SPRs confirm that he served at the Camp Lejeune Marine Corps Base from March 1985 to June 1987. This is approximately 780 days at Camp Lejeune during the required time period. Therefore, he is presumed to have been exposed to contaminants in the water supply during his active duty at Camp Lejeune. 38 C.F.R. § 3.307 (a)(7)(iii). However, the Veteran's type II diabetes mellitus is not on the list of diseases associated with contaminants in the water supply at Camp Lejeune for purposes of awarding presumptive service connection. 38 C.F.R. § 3.309(f). In other words, his type II diabetes mellitus is not one of the presumptive Camp Lejeune disabilities. Thus, although he was exposed to contaminated water at Camp Lejeune during his service in the Marine Corps, the Veteran is not entitled to service connection for his type II diabetes mellitus on a presumptive basis under 38 C.F.R. § 3.309(e). With regard to direct service connection, under the Camp Lejeune Act of 2012, VA has also recognized 15 "covered illnesses" or "conditions" that it will assume are attributable to a veteran's active duty service at Camp Lejeune, but for treatment purposes only. See 38 U.S.C. § 1710(e); 38 C.F.R. § 17.400(b). A "covered illness or condition" means any of the following illnesses and conditions: (i) Esophageal cancer; (ii) Lung cancer; (iii) Breast cancer; (iv) Bladder cancer; (v) Kidney cancer; (vi) Leukemia; (vii) Multiple myeloma; (viii) Myelodysplastic syndromes; (ix) Renal toxicity; (x) Hepatic steatosis; (xi) Female infertility; (xii) Miscarriage; (xiii) Scleroderma; (xiv) Neurobehavioral effects; and(xv) Non-Hodgkin's lymphoma. Id. For a Camp Lejeune veteran, VA will assume that a "covered illness or condition" listed above is attributable to the veteran's active duty service at Camp Lejeune unless it is clinically determined, under VA clinical practice guidelines, that such an illness or condition resulted from a cause other than such service. 38 C.F.R. § 17.400(c). VA has determined that manifestation of any of the above diseases in a veteran with verified Camp Lejeune service between 1957 and 1987 is sufficient to request a VA medical examination and an opinion regarding its relationship to Camp Lejeune service. However, in the present case, the Veteran's type II diabetes mellitus is not on this list of "covered illnesses or conditions" assumed attributable to service for treatment purposes only under 38 C.F.R. § 17.400(b). As such, this provision does not assist the Veteran in the present case. Finally, with regard to direct service connection, service treatment records (STRs) dated from 1984 to 1988 are negative for any complaint, treatment, or diagnosis of type II diabetes mellitus. In fact, the first medical evidence or lay allegation regarding the onset of symptoms of type II diabetes mellitus is in 2005, which is 17 years after separation from active duty. Finally, with regard to a nexus, there is no probative medical evidence of record establishing a relationship between the Veteran's current type II diabetes mellitus and his presumed exposure to contaminated water at Camp Lejeune during service in the 1980s. Holton, 557 F.3d at 1366. See also 38 C.F.R. § 3.303(a), (d). Absent such evidence of a nexus, direct service connection is not in order for the Veteran's type II diabetes mellitus. Regardless, when determining service connection, all theories of entitlement, direct and secondary, must be considered if raised by the evidence of record, applying all relevant laws and regulations. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). A disability can be service connected on a secondary basis if it is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(a). To be service connected on a secondary basis under a causation theory, the primary disability need not be service connected, or even diagnosed, at the time the secondary condition is incurred. Frost v. Shulkin, 29 Vet. App. 131, 138 (2017) (holding that there was not a temporal requirement inherent in 38 C.F.R. § 3.310(a) for claims for service connection on a secondary basis). Moreover, secondary service connection may also be established, by any increase in severity (i.e., aggravation) of a nonservice-connected condition that is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(b). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. A VA medical opinion regarding both the causation and aggravation facets of a secondary service connection claim must be provided in a secondary service connection claim. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under § 3.310(b)). Moreover, when addressing secondary service connection, a VA medical opinion should not combine the concepts of causation and aggravation. Rather, separate, and independent findings and rationale should be provided for each theory. Atencio v. O'Rourke, 30 Vet. App. 74, 90-91 (2018). In short, in order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) probative evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). In determining whether secondary service connection or secondary service connection is warranted, the Board shall consider the benefit-of-the-doubt doctrine. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1991). Pursuant to the April 2019 CAVC Order and Joint Motion, the parties agreed that the previous July 2018 Board decision must be vacated and remanded. Specifically, the parties agreed that the issue of service connection for type II diabetes mellitus was inextricably intertwined with another pending service-connection issue for an acquired psychiatric condition. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991), overruled on other grounds, Tyrues v. Shinseki, 23 Vet. App. 166, 178 (2009) (en banc). The Joint Motion pointed out that an August 2016 letter from a private physician opined that the Veteran's type II diabetes mellitus was secondary to his psychiatric condition. As such, the two issues were determined to be inextricably intertwined. Since the Joint Motion was already remanding the issue of service connection for an acquired psychiatric disorder, the intertwined issue of service connection for type II diabetes mellitus should likewise be remanded. The Board complied by remanding the type II diabetes mellitus issue for further development in an October 2019 Board remand. Upon review of the evidence of record, the Board grants the appeal for service connection for type II diabetes mellitus (with associated diabetic peripheral neuropathy of the lower extremities and erectile dysfunction) as secondary to the Veteran's service-connected MDD with an adjustment disorder. In an August 2020 rating decision, the AOJ service-connected the Veteran for the underlying MDD with an adjustment disorder at 30 percent disabling under Diagnostic Codes 9434-9440 (major depressive disorder and an adjustment disorder). See 38 C.F.R. § 4.130. This 30 percent rating has been in effect since March 16, 2012. There is probative clinical evidence of record demonstrating that the Veteran's current type II diabetes mellitus is proximately due to or the result of his service-connected MDD with an adjustment disorder. See 38 C.F.R. § 3.310(a); Atencio, 30 Vet. App. at 90-91. Specifically, the Veteran's service connected MDD with an adjustment disorder caused the development of his obesity, which in turn caused his type II diabetes mellitus. On this issue of obesity, obesity is not a "disease" or "disability" for VA purposes and, therefore, is not eligible for service connection on a direct or secondary basis. Obesity also cannot qualify as an in-service "event" to warrant service connection for another disability because obesity occurs over an extended period of time. However, obesity can be an "intermediate step" between a current disability and a service-connected disability for purposes of secondary service connection if it is found that "(1) the service-connected disability caused the veteran to become obese; (2) the obesity was a substantial factor in causing the claimed secondary disability; and (3) the claimed secondary disability would not have occurred but for obesity caused by the service-connected disability." Marcelino v. Shulkin, 29 Vet. App. 155 (2018); VAOPGCPREC 1-2017 (Jan. 6, 2017). It is noted that Precedent opinions issued by VA's chief legal officer are binding on the Board. See 38 U.S.C. § 7104(c). In a more recent decision, the Court determined that the proper interpretation of VAOPGCPREC 1-2017 required consideration of both proximate causation and aggravation in its analytical framework: (1) whether the service-connected disability caused or aggravated the veteran to become obese; (2) if so, whether the obesity as a result of the service-connected disability was a substantial factor in causing the current disability; and (3) whether the current disability would not have occurred but for the obesity caused or aggravated by the service-connected disability. Walsh v. Wilkie, 32 Vet. App. 300, 305-07 (2020). If these questions are answered in the affirmative, then the current disability may be service connected on a secondary basis. Id. Stated another way, obesity can constitute an "intermediate step" in showing secondary service connection, i.e., that service connection is warranted when a service-connected disability causes or aggravates obesity, which in turn causes another disability. Id. The Court most recently held that to reasonably raise the theory of secondary service connection via obesity as an intermediate step, there must be some evidence in the record that draws an association or suggests a relationship between a veteran's obesity, or weight gain resulting in obesity, and a service-connected disability. Conversely, incidental references in the record to obesity, or weight gain resulting in obesity, are insufficient to reasonably raise this theory of entitlement. The Court provided a list of six non-exhaustive considerations that could give rise to a reasonably raised theory of secondary service connection with obesity as an intermediate step. See Garner v. Tran, __ Vet. App. __, No. 18-5865 (Jan. 26, 2021). Here, it is undisputed that secondary service connection via obesity as an intermediate step was reasonably raised by the record. More importantly, the clinical evidence of record establishes that the Veteran's documented obesity was an intermediate step between his service-connected psychiatric problems and the development of his type II diabetes mellitus. See 38 C.F.R. § 3.310(a); Walsh, 32 Vet. App. at 305-07; VAOPGCPREC 1-2017. A November 2011 VA mental health treatment record documented that as a result of his service-connected depression, hopelessness, and insomnia, the Veteran was overeating and gaining weight. His job as a police officer was quite stressful. His weight had increased to 240 pounds. The VA clinician assessed that "secondarily" to this obesity and weight gain the Veteran had developed a metabolic syndrome with type II diabetes mellitus. Of even greater significance is the favorable August 2016 private medical opinion from Dr. P.L.L., MD., a brain surgeon and psychiatrist. Dr. P.L.L. is a veteran himself and has worked as a physician at multiple VA Medical Centers. After a detailed discussion of the evidence of record, Dr. P.L.L. opined that the Veteran's type II diabetes mellitus was related to his service-connected recurrent major depression. Dr. P.L.L. advised it is "well known" that there are significant vegetative components of major depression, which include metabolic functions. Depression is known to cause appetite changes, increase or decrease, and with the changes in energy and sleep. Increased appetite with weight gain is common, contributing to metabolic factors and causing type 2 diabetes mellitus. Dr. P.L.L. advised that the Veteran has these problems of significant weight gain and type II diabetes mellitus, along with other components of the metabolic syndrome: hyperlipidemia and hypertension. Considering the long standing pattern of his recurring major depression, which is clearly service-connected, Dr. P.L.L. concluded it was also clear from the record that his major depression was a "significant contributor" to his current type II diabetes mellitus and metabolic syndrome. Dr. P.L.L. in his August 2016 private medical opinion added that the earlier VA examiners had failed to consider the impact of his "labile mood" on his metabolic status, such as metabolic syndrome, appetite dysfunction, and serious weight gain, which has "seriously contributed" to the development of the Veteran's type II diabetes mellitus. Any clinician must consider the impact of the MDD upon the life of the Veteran, taking a holistic view of the general health of the Veteran. In the present case, Dr. P.L.L. surmised that the Veteran's major depression "no doubt" affected his eating habits, energy, sleep, appetite, and metabolism. It was common for depression to affect eating habits ... causing significant weight gain. The so called vegetative effects of depression "certainly contributed significantly" to this Veteran's metabolic syndrome defined by weight gain. The Board concludes that this favorable August 2016 private medical opinion of Dr. P.L.L. was fully adequate as it correctly discussed the specific facts and circumstances of the present Veteran's case. Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018). All of the above provides strong evidence in support of secondary service connection for type II diabetes mellitus via obesity as an intermediate step. See 38 C.F.R. § 3.310(a). In addition, other clinical evidence of record confirmed that diabetic peripheral neuropathy of the lower extremities and erectile dysfunction are both "complications" of the Veteran's now service-connected type II diabetes mellitus disability. See November 2020 VA diabetes mellitus examination; November 2020 VA male reproductive organ examination; and November 2020 VA peripheral neuropathy examination. As such, these disabilities will be service-connected on a secondary basis as well in the present decision. In making this favorable determination regarding secondary service connection for type II diabetes mellitus, the Board acknowledges the negative November 2020 VA examination and medical opinion for diabetes mellitus by a VA physician and a December 2020 VA addendum opinion from the same VA physician. This VA physician opined that it was "less likely than not" the Veteran's type II diabetes and the associated conditions of erectile dysfunction and bilateral diabetic peripheral neuropathy were proximately due to or aggravated by the Veteran's MDD and adjustment disorder. This VA examiner assessed that the records in the claims file and "common medical knowledge" did not support a connection between type II diabetes mellitus and the Veteran's service-connected psychiatric disorder, as both conditions are "unrelated." However, the VA examiner did postulate that the Veteran's body mass index (BMI) of 33.7 was in "the obese range." He added that the Veteran's obesity is "a more likely cause" of his type II diabetes mellitus and the conditions secondary thereto. Therefore, in retrospect, without intending to, the VA examiner actually provided evidence in support of the favorable August 2016 private medical opinion from Dr. P.L.L., regarding the impact of the Veteran's obesity. Unlike Dr. P.L.L, the VA examiner failed to address whether the Veteran's service-connected depression caused the development of his obesity. As such, his rationale is incomplete. If a VA examination or opinion is incomplete, this impacts its probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, secondary service connection for type II diabetes mellitus (with associated diabetic peripheral neuropathy of the lower extremities and erectile dysfunction) is granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). (The Board emphasizes that it is granting secondary service connection for type II diabetes mellitus on the basis that it is the direct result of the Veteran's service-connected MDD with an adjustment disorder, as opposed to aggravation.) III. Service Connection and Secondary Service Connection (SSC) for Tension Headaches The Veteran contends that his current tension headaches disorder was caused by exposure to contaminated water at Camp Lejeune, North Carolina during active duty service in the 1980s. SPRs confirm he was assigned to Camp Lejeune from March 1985 to June 1987. He says that he first experienced headaches during active duty in 1987 or 1988. See March 2012 Application for Compensation (VA Form 21-526); May 2013 informal NOD. In the alternative, the Veteran asserts that his current tension headaches disorder is caused or aggravated by his service-connected MDD with an adjustment disorder. In other words, he contends that his tension headaches disorder is secondary to his service-connected MDD with adjustment disorder. In particular, as a result of his service-connected "neurobehavioral effects" from his exposure to contaminated water at Camp Lejeune in the 1980s, he developed tension headaches. See May 2013 informal NOD. Pursuant to the April 2019 CAVC Order and Joint Motion, the parties agreed that the previous July 2018 Board decision must be vacated and remanded. Specifically, the parties agreed that the Board provided an inadequate statement of reasons or bases for its denial of service connection for headaches. See Allday v. Brown, 7 Vet. App. 517, 527 (1995). The Joint Motion pointed out that the Board incorrectly considered whether there was a current diagnosis for headaches based only on the clinical evidence of record. The Joint Motion instructed the Board that headaches are a condition that lay persons are also competent to identify. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). On remand, the Joint Motion instructed the Board to address the lay statements from the Veteran and his buddies regarding his headaches. Although not cited by the Joint Motion of the parties, the Board is also cognizant of the Court's holding in another case that lay evidence may can be probative of the frequency, prolongation, and severity of headaches. Pierce v. Principi, 18 Vet. App. 440 (2004). The first and perhaps most fundamental requirement for either a direct or secondary service connection claim is proof the Veteran has a current disability. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a); Degmetich v. Brown, 104 F.3d 1328, 1332 (1997). In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). In the present case, clinical evidence of record has established a current diagnosis of tension headaches for the Veteran, which are "episodic" in nature. See November 2020 VA headaches examination by VA physician; October 2020 VA medical opinion from occupational medicine physician. The above evidence is sufficient to establish a current diagnosis of tension headaches. The Veteran therefore meets this threshold criterion for service connection of a current tension headaches disability. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Initially, the Board will briefly address the theories of direct service connection and presumptive service connection for tension headaches. In this regard, the Board finds that service connection for tension headaches, on either a direct or presumptive basis, is denied here. With regard to presumptive service connection, the Veteran's current tension headaches disability is not on the list of diseases associated with contaminants in the water supply at Camp Lejeune for purposes of awarding presumptive service connection. 38 C.F.R. § 3.309(f). In other words, his tension headaches disability is not one of the presumptive Camp Lejeune disabilities. Thus, although he was exposed to contaminated water at Camp Lejeune during his service in the Marine Corps, the Veteran is not entitled to service connection for his tension headaches disability on a presumptive basis under 38 C.F.R. § 3.309(e). With regard to direct service connection, the Veteran's tension headaches disability is not on this list of "covered illnesses or conditions" assumed attributable to service for treatment purposes only under 38 U.S.C. § 1710(e) and 38 C.F.R. § 17.400(b). As such, these provisions do not assist the Veteran in the present case. Also, with regard to direct service connection, STRs dated from 1984 to 1988 are negative for any complaint, treatment, or diagnosis of headaches. The Veteran's subsequent lay report of the existence of headaches during active duty is unsupported by the clinical STRs of record. Contemporaneous evidence can have greater probative value than inconsistent testimony provided by the claimant at a later date. Curry v. Brown, 7 Vet. App. 59, 68 (1994). In fact, the first clinical documentation in the claims file for "occasional" headaches is from a July 2012 VA telehealth note. This is 24 years after separation from active duty. Earlier VA treatment records and VA examinations dated in 1988, 1989, 1998, and 2004 did not mention any history of headaches for the Veteran. Finally, with regard to a nexus, there is no probative medical evidence of record establishing a relationship between the Veteran's current tension headaches and his presumed exposure to contaminated water at Camp Lejeune during service in the 1980s, or to his service in general. Holton, 557 F.3d at 1366. See also 38 C.F.R. § 3.303(a), (d). In fact, an October 2020 VA medical opinion from an occupational medicine physician opined there was no nexus between the Veteran's current tension headaches and his exposure to contaminated water at Camp Lejeune in the 1980s. Absent such evidence of a nexus, direct service connection is not in order for the Veteran's tension headaches. The Board now turns to the theory of secondary service connection for tension headaches. Upon review of the evidence of record, the Board grants the appeal for service connection for tension headaches as secondary to the Veteran's service-connected MDD with an adjustment disorder. As noted above, in an August 2020 rating decision, the AOJ service-connected the Veteran for the underlying MDD with an adjustment disorder at 30 percent disabling under Diagnostic Codes 9434-9440 (major depressive disorder and an adjustment disorder). See 38 C.F.R. § 4.130. This 30 percent rating has been in effect since March 16, 2012. There is probative clinical and lay evidence of record demonstrating that the Veteran's current tension headaches disability is proximately due to or the result of his service-connected MDD with an adjustment disorder. See 38 C.F.R. § 3.310(a); Atencio, 30 Vet. App. at 90-91. Specifically, with regard to favorable lay evidence, in an April 2012 lay buddy statement, J.C.G., a coworker of the Veteran, observed the Veteran would complain of headaches when he "appeared to be under strain or stress." During these episodes, the Veteran confided to him that he was suffering from headaches. The Veteran's co-worker is indeed competent and credible in his lay observation of the Veteran experiencing headaches during times of mental health stress. See 38 C.F.R. § 3.159(a)(2); Pierce v. Principi, 18 Vet. App. 440 (2004). Specifically, with regard to favorable clinical evidence, in an October 2013 private opinion, Dr. L.M.T., an Assistant Professor of Neurology at Indiana University, recorded the Veteran's reported history that he began to experience headaches at the same time he experienced mood disturbance, anxiety, and memory loss. At the time, he was diagnosed with depression. The same reported history of headaches accompanying the onset of his mental health problems was mentioned in an October 2013 VA outpatient toxicology clinic note. In addition, a July 2015 VA social work note documented a 50-minute counseling session for the Veteran for depression and anxiety disorders. At this mental health appointment, the Veteran commented that he was using acupressure and reflexology treatment for his depression and anxiety to relieve his accompanying headaches. At an October 2016 VA social work note, the Veteran was particularly interested in reducing anxiety and "stress-headaches." But most importantly, an October 2020 VA medical opinion from an occupational medicine physician diagnosed "episodic tension headaches" associated with the Veteran's lifestyle factors including his stress, anxiety, and insomnia. This VA opinion and the other evidence listed above provide strong evidence in support of secondary service connection for tension headaches. In making this favorable determination regarding secondary service connection for tension headaches, the Board acknowledges the negative November 2020 VA headaches examination and medical opinion for headaches by a VA physician and December 2020 VA addendum opinion from same. This VA physician opined that it was "less likely than not" the Veteran's tension headaches were proximately due to or aggravated by his MDD and adjustment disorder. The rationale was that the diagnostic criteria for MDD, or signs and symptoms used to diagnose this condition as being unique to MDD, did not include headaches according to cited medical treatise evidence. The same applies to an adjustment disorder. Despite holding some probative value against the secondary service connection claim, the Board concludes this negative VA opinion is unsupported and outweighed by the other clinical and lay evidence of record discussed above. The Board is not required to accept a medical opinion that is unsupported by other clinical findings. Godfrey v. Brown, 8 Vet. App. 113, 121 (1995). See also Evans v. West, 12 Vet. App. 22 (1998) (when adequately explained, the Board is free to favor one medical opinion over another). Accordingly, secondary service connection for a tension headaches disorder is granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). (The Board emphasizes that it is granting secondary service connection for a tension headaches disorder on the basis that it is the direct result of the Veteran's service-connected MDD with an adjustment disorder, as opposed to aggravation.) Romina A. Casadei Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P.S. Rubin, 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.