Citation Nr: 21032484 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 09-29 129 DATE: May 27, 2021 ORDER Entitlement to service connection for hypertension, to include as due to herbicide or environmental exposures, is denied. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to posttraumatic stress disorder (PTSD), is denied. FINDINGS OF FACT 1. The Veteran's hypertension did not manifest during active service or within one year of his separation from service; nor is it shown to be casually or etiologically related to his active service, to include environmental and herbicide exposures. 2. The Veteran's GERD did not manifest during active service, not is it shown to be causally or etiologically related to his active service, to include environmental exposures; or to be caused or aggravated by his service-connected PTSD or medications taken to treat the same. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension, to include as due to herbicide or environmental exposures, have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. 2. The criteria for entitlement to service connection for GERD, to include as due to herbicide or environmental exposures as well as secondary to PTSD, have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from November 1966 to August 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a September 2008 rating decision issued by a regional office (hereinafter agency of original jurisdiction or AOJ) of the Department of Veterans Affairs (VA). The Veteran testified before the undersigned Veterans Law Judge at a February 2011 hearing, a transcript of which has been attached to the record. The Board initially remanded these claims to the AOJ for further development in August 2012. The Board denied the Veteran's claim of entitlement to service connection for GERD and hypertension in an April 2016 decision. The Veteran appealed this denial to the United States Court of Appeals for Veterans Claims (Court), which vacated the Board's decision and granted a Joint Motion for Remand (JMR) in a December 2016 order. The Board denied these claims in a November 2017 decision, which the Veteran appealed. The Court vacated the Board's decision and granted a JMR in a February 2019 order. The Board then remanded these claims to the AOJ for further development in July 2019, October 2020 and January 2021. Service Connection Service connection will be granted if the Veteran has a disability resulting from personal injury or disease incurred in the line of duty, or for aggravation of a preexisting injury or disease incurred in the line of duty during active service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. To establish service connection, the evidence must show competent evidence of (1) a present disability, (2) an in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Whenever there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the veteran. 38 U.S.C. § 5107(b). A valid service connection claim requires competent evidence of a current disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). However, the presence of a disability at any time during the claim process or relatively close thereto can justify a grant of service connection, even where such disability has become asymptomatic. McClain v. Nicholson, 21 Vet. App. 319 (2007). Certain chronic diseases, such as hypertension, may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Moreover, if a disease listed in 38 C.F.R. § 3.309(a) is shown to be chronic in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). 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. Id. However, if evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not "shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned," i.e., "when the fact of chronicity in service is not adequately supported," then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013) (quoting 38 C.F.R. § 3.303(b)). A claimant "can benefit from continuity of symptomatology to establish service connection in the ultimate sense, but only if [the] chronic disease is one listed in § 3.309(a)." Id. at 1337. In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for hypertension, to include as secondary to herbicide or environmental exposures The Veteran asserts entitlement to service connection for hypertension, to include as a result of inservice exposure to herbicides and other environmental factors. If a Veteran was exposed to an herbicide agent during active military, naval, or air service, and has one of the diseases enumerated under 38 C.F.R. § 3.309(e), to include certain cancers, that disease shall be service-connected (provided the requirements of 38 C.F.R. § 3.307 (a)(6) have been met) even though there is no record of such disease during service. 38 U.S.C. §§1113, 1116; 38 C.F.R. §§ 3.307, 3.309. As the Veteran served in the Republic of Vietnam, his exposure to herbicides is conceded. Hypertension is not one of the enumerated diseases under 38 C.F.R. § 3.309(e), but the Board observes that the NAS Institute of Medicine's Veterans and Agent Orange: Update 11 (2018) upgraded hypertension from "limited or suggestive evidence" to "sufficient" evidence of an association between Agent Orange exposure and hypertension. VA has defined hypertension as diastolic blood pressure predominantly 90 mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater. 38 C.F.R. § 4.104, DC 7101, NOTE 1. Additionally, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. A 10 percent rating is warranted for diastolic pressure predominantly 100 or more; or, systolic pressure predominantly 160 or more; or, a history of diastolic pressure predominantly 100 or more requiring medication for control. Id. VA treatment records indicate the Veteran was diagnosed with hypertension in September 2012. The Veteran's service treatment records are silent for complaints of or treatment for hypertension, and his blood pressure at service entrance and separation was recorded as 130/80 and 130/70, respectively. Service treatment records indicate that the Veteran denied a history of high blood pressure during his August 1968 separation examination. Post-service, the Veteran submitted 1969 to 1981 medical records from his employer, the Tennessee Valley Authority (TVA), which include several high blood pressure readings. A February 1969 reading indicated blood pressure of 140/76, and an undated examination diagnosed the Veteran with hypertension. However, the Board notes this examination was conducted no earlier than 1973, as a later entry notes a valid 1973 tetanus shot. An additional undated examination records a blood pressure reading of 140/100 as well as a diagnosis of hypertension. However, a date bleeding through the paper from the front of the page reads May 15, 1978 (written 78/05/15, a style appearing in other TVA records in the Veteran's claims file). In an October 2012 and August 2009 statements by the Veteran and his spouse, respectively, both indicated that the Veteran was treated for high blood pressure in 1977 but stated that these medical records were destroyed. A March 2004 private treatment record documented high blood pressure and a "strong family history of hypertension." June 2007 VA treatment records note the Veteran reported receiving a hypertension diagnosis "five to six years" previously. He also described isolated episodes of hypertension associated with anxiety in the 1970s, as well as brief treatment with anti-hypertensives until he developed orthostatic hypotensive symptoms. An October 2006 private medical record noted a history of mild anxiety which increased his blood pressure. At the June 2011 Board hearing, the Veteran was observed to be emotional due to his PTSD and anxiety symptoms were evident. He recalled that he may have had hypertension in service as he had been under a lot of pressure and "had some fights." He also recalled that, in the summer of 1968, his employer told him his blood pressure was "a little high." He stated he was referred to a doctor who prescribed potassium, which he declined. He described treating high blood pressure moments by calming himself down and taking asprin, and stated he was never told by a physician that his PTSD had caused or aggravated his hypertension. In an October 2012 statement, the Veteran acknowledged his mother was diagnosed with hypertension, but denied a family history of the disorder, stating she only manifested the disorder after undergoing kidney surgery in her 50's. The Veteran was afforded a VA examination in September 2012. The examiner opined that the Veteran's hypertension was less likely as not related to or caused by his active service. The examiner reasoned that the Veteran's service treatment records did not reveal a diagnosis of hypertension, which appeared to have its onset in the mid-1970s, and while his exposure to Agent Orange was conceded, hypertension is not a presumptive condition listed for herbicide exposure. The examiner concluded that the most likely causes of the Veteran's hypertension were the risk factors of family history, diet, and obesity (body mass index over 30), all of which were well documented in the claims file. The Veteran was afforded an additional VA examination in April 2015. After review of the file, to include the lay statements of the Veteran and his wife, the examiner opined that the Veteran's hypertension was less likely than not incurred in or otherwise caused by his active service. The examiner concurred with the findings of the September 2012 VA examiner regarding the risk factors and etiology of the Veteran's hypertension, and also noted that hypertension was not presumptively related to herbicide exposure. The examiner also observed that the Veteran's hypertension was not recorded during service, his blood pressure at discharge was 130/78, and he was not diagnosed until the mid-1970s, several years after his separation from service. The Veteran's contentions and claims file were reviewed by a Veterans Health Administration (VHA) expert in July 2017. The examiner found that the Veteran's service treatment records were silent for a diagnosis of hypertension, hypertensive blood pressure readings, and prescriptions for anti-hypertensive medications. The examiner acknowledged elevated blood pressure readings immediately after separation with formal treatment for hypertension years after service and reviewed the latest medical literature regarding hypertension and environmental exposure, to include herbicides, as well as a medical article discussing the physiology of stress. Based on the entirety of the record, the examiner concluded that the Veteran's hypertension did not develop until years after his service and was not casually related to the stresses of combat or exposure to environmental toxins such as herbicides, diesel fuel fumes, or the burning of human waste. With regard to PTSD, the examiner noted that while a recent medical article suggested the severity of combat injury was associated with subsequent development of hypertension, the study upon which the article was based had several limitations and failed to establish a causal relationship. The examiner concluded that the Veteran's hypertension was less likely than not caused or worsened by his PTSD. At the Board's behest, the AOJ obtained VA addendum opinions in October 2020 and January 2021. The October 2020 examiner opined that the Veteran's hypertension was less likely than not due to herbicide exposure, reasoning that hypertension is a multi-factorial problem, rarely attributed to a single cause, and noting that obesity is a common comorbidity and weight loss reduces the severity of hypertension. The January 2021 examiner reviewed the primary risk factors of hypertension, including family history, which makes one twice as likely to develop hypertension; as well as the NAS Institute of Medicine's Veterans and Agent Orange: Update 11 (2018) which upgraded evidence of an association between herbicide exposure and hypertension to "sufficient." The examiner concluded that the sum of the Veteran's risk factors, to include age, obesity, family history, physical inactivity, diabetes, and personality traits was more likely than not the cause of his hypertension, making it less likely than not attributable to his conceded exposure to herbicides. On review of the entirety of the lay and medical evidence, the Board finds that a preponderance of the evidence is against finding hypertension as first manifesting in, being attributable to, or presumptively related to the Veteran's active service. The documentary evidence does not reflect blood pressure readings indicative of hypertension during service, and based on a review of his medical records, it does not appear that hypertension was diagnosed until several years after service in the mid-1970s. The VA examiners, to include a VHA expert, have all opined that the Veteran's hypertension is less likely than not due to his active service, and there are no competent medical opinions to the contrary. Additionally, several VA examiners put forth a more likely alternative theory to address the Veteran's hypertension, namely his family history, diet, obesity, and personality traits. For these reasons, service connection on a direct basis, to include as due to environmental factors, must be denied. While hypertension is considered a chronic disease for VA purposes, the Veteran's claim cannot be granted based on a continuity of symptomatology. Although the record documents high blood pressure shortly after separation from service, there is no record of a diagnosis of hypertension until at least 1973 and no evidence of a manifestation of blood pressure readings with diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more (manifestation of the minimum compensable rating) within one year of separation. 38 C.F.R. § 4.104, DC 7101. As there is no inservice documentation noting diagnosis of or treatment for hypertension, the Board finds that the evidence does not establish that a "chronic disorder' first manifested inservice or within one year of separation. 38 C.F.R. § 3.303; Walker, 708 F.3d at 1331. While the Veteran's recollection that he may have been diagnosed with hypertension inservice holds some probative value as it could relate a contemporaneous diagnosis by a medical professional, its value is limited as the Veteran himself is unsure of its veracity and the Board finds it is greatly outweighed by objective medical evidence indicating normal blood pressure during service. The Board acknowledges the Veterans statements regarding the onset and etiology of his hypertension, including theories that combat-related stress or exposure to environmental factors such as diesel fumes caused his hypertension. The Veteran recalled high blood pressure readings shortly after service, but he denied a history of high blood pressure on his August 1968 separation and 1969 TVA employment examinations. To the extent that the recollections of the Veteran and his spouse speak to the onset of hypertension during or shortly after separation from service, the Board places greater probative weight on the contemporaneous statements and medical records than more recent lay statements made in support of the claim. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant); see also Lilly's An Introduction to the Law of Evidence, 2nd Ed. (1987), pp. 245- 46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rational that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). The Veteran's separation and employment induction examination statements denying high blood pressure are consistent with his normal blood pressure readings at the time. With regard to etiology, while the Veteran is competent to describe the nature and circumstances of his service, he is not competent to provide a diagnosis or in this case to determine the etiology of a chronic disability such as hypertension. This issue is medically complex, as it requires medical training and knowledges of the internal workings of the human body. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, the Board places greater probative value on the concurring opinions of the VA examiners. Similarly, while the Board has considered the Veteran's submitted medical articles regarding the etiology of hypertension, these studies and conclusions are not based on the specific facts of this case, do not establish a causal relationship, and are outweighed by the expert opinions which are based on a review of the lay and medical evidence of record. The Board also finds that a preponderance of the evidence is against granting service connection on a secondary basis, which requires a medical nexus between the service-connected disability and current disorder. The Veteran has provided recollections of physician comments that his anxiety increased his blood pressure levels and reported that he was treated for anxiety or hypotension in the 1970s. An October 2006 private treatment record noted a history of anxiety which increased the Veteran's blood pressure. However, the September 2012 VA examiner stated that there was no medically accepted cause and effect link between PTSD and hypertension and opined that the Veteran's hypertension was caused by his family history, diet, and obesity. Similarly, the April 2015 VA examiner, after review of the articles submitted by the Veteran, determined that his hypertension was less likely than not caused or aggravated by his service-connected PTSD, as hypertension is not etiologically related to PTSD. The April 2015 examiner also concurred with the September 2012 examiner's opinion regarding the most likely etiology of the Veteran's hypertension. Finally, a June 2011 VA clinician denied awareness of any evidence of a PTSD etiology for the Veteran's hypertensive vascular disease. While the medical treatise article discussing the physiology of stress and the Veteran's recollection of a physician linking hypertension with anxiety holds some probative value as it indicates that physiologic stress could cause or aggravate hypertension, their value is outweighed by the VA clinician and examiner opinions denying a specific link between his PTSD and hypertension. These opinions are based upon an application of general medical principles to the specific facts of the Veteran's case and, more importantly, include supporting rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("most of the probative value of a medical opinion comes from its reasoning"). Similarly, the October 2006 treatment record which reflects a history of anxiety which increased the Veteran's blood pressure is simply recorded information and does not reflect an actual diagnosis or opinion. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995) ("evidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by that examiner, does not constitute 'competent medical evidence'"). Finally, as noted above, the Veteran does not possess the medical training or credentials to opine as to the etiology of his hypertension or to establish a diagnosis inservice or within one year of separation based on observable symptoms such as high blood pressure or anxiety. Jandreau, 49 F.3d at 1377. As such, the Board finds that the credible and probative evidence of record is against finding that the Veteran's hypertension first manifested in or is otherwise due to his service, to include environmental exposures; or that it was caused or aggravated by his service-connected PTSD. As a preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable, and the claim must be denied. See Gilbert, 1 Vet. App. at 49. 2. Entitlement to service connection for GERD, to include as secondary to PSTD The Veteran seeks entitlement to service connection for GERD, to include as secondary to PTSD, as well as secondary to inservice herbicide and environmental exposures. September 2012 VA treatment records indicate the Veteran was diagnosed with GERD. As noted above, the Veteran is presumed to have been exposed to herbicides during his service in the Republic of Vietnam, although GERD is not one of the conditions listed as presumptively due to herbicide exposure. 38 C.F.R. §§ 3.307, 3.309. The Veteran's service treatment records are silent for complaints of or treatment for GERD, and no symptoms associated with the disorder were noted at his August 1968 separation examination, during which he denied a history of pain or pressure in the chest, palpitation or pounding heart, frequent indigestion, and more generally stomach, liver or intestinal difficulties. In an October 2008 statement, the Veteran claimed he was exposed to environmental toxins from burning tress and vegetation, and in March 2010 he asserted exposure to diesel fumes, human waste and exhaust fumes. Although his service records are silent for exposure to environmental toxins, as his record indicate he was a power plant operator the Board will assume exposure to some environmental toxins during service. During a February 1969 medical examination for employment with the TVA, the Veteran denied having or ever having chest pain or pressure, pounding or palpitation of the heart, as well as frequent stomach or intestinal trouble. He provided similar denials during 1970, 1971, 1975, 1978 and 1981 medical examinations. A December 2007 VA treatment record notes a 1992 GERD diagnosis in the medical history section. The Veteran was afforded a VA examination for GERD in September 2012. Following a review of the claims file, the examiner opined that the Veteran's GERD was less likely than not due to his service, to include chemical exposure. The examiner observed that the Veteran's service treatment records did not reveal the onset GERD, that GERD was not a presumptive condition linked in any way to herbicide exposure, and that the Veteran's treatment records document the onset of the disorder in 1990. Finally, the examiner opined that the causes of the Veteran's GERD were his diet choices and obesity, both of which were well documented. The Veteran submitted a medical article discussing the physiology of stress, including acute, episodic and chronic stress. The article examined the flight-or-fight physiologic response of the body in preparation for an emergency and how the physiology of stress could possibly result in changes to the digestive system. The Veteran specifically alleged the onset of GERD symptoms inservice, which he reported self-treating with over-the-counter medications. His spouse, whom he married in 1969, also described a history of gastrointestinal symptoms since 1969. The Veteran was afforded an additional VA examination in April 2015. The VA examiner reviewed the claims file as well as the lay statements of the Veteran and his wife as well as submitted medical articles. The examiner opined that the Veteran's GERD was less likely than not related to his service, noting that GERD is not presumptively related to environmental toxins, to include herbicides. Observing that the Veteran did not develop GERD until long after his separation and that service treatment records were silent for symptoms of the disorder, the examiner stated there did not appear to be any connection between the two. The Veteran's contentions and claims were reviewed by a VHA expert in July 2017. Observing service treatment records silent for indications of GERD, as well as the Veteran's denial of "frequent stomach or intestinal problems" on his 1968 separation examination, the examiner opined that his disorder was less likely than not due to his service. The examiner also reviewed medical literature regarding occupational and environmental medicine, an article concerning functional dyspepsia and the article discussing the physiology of stress. Ultimately, the examiner concluded that the Veteran's GERD did not develop until years after service and was not casually related to the stresses of combat or exposure to environmental toxins, to include herbicides, diesel fumes, and the burning of waste. On review of the entirety of the lay and medical evidence, the Board finds that service connection for GERD on a direct basis must be denied as a preponderance of the evidence is against the claim. Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. While the Veteran is competent to report the onset and treatment of gastrointestinal symptoms in 1969, this report conflicts with statements made during his service separation and numerous post-service employment examinations. The Board places more probative weight on his contemporaneous statements than lay statements made in support of a claim many years later. See Seng v. Holder, 584 F.3d 13, 19 (1st Cir.2009) (notwithstanding the declarant's intent to speak the truth, statement may lack credibility because of faulty memory). Additionally, while the Veteran is competent to report readily observable symptoms, he does not have the medical training or knowledge to diagnose or speak to the etiology of a condition such as GERD. Jandreau, 492 F.3d at 1377. Finally, while the submitted medical article holds some probative value as it speaks to general medical principles that physiological stress could cause or aggravate gastrointestinal disorders, its probative value is greatly outweighed by the expert examiner opinion which applies general medical principles to the specific facts of this case. As such, the Board finds the medical articles and lay statements submitted by the Veteran and his wife less probative than opinions of the qualified VA examiners agreeing that the Veteran's GERD did not have its onset in or is otherwise related ot his active service. There is no competent medical opinion to the contrary, and the Board finds that the medical examiner opinions were made upon a solid factual foundation and are not contradicted by the factual record. Finally, the Veteran's statements alleging a continuity of symptomatology alone are insufficient to substantiate service connection as GERD is not deemed a chronic disease pursuant to 38 C.F.R. § 3.309(a); Walker, 708 F.3d at 1131 (explaining that the theory of continuity of symptomatology can be used only in cases involving those specifically recognized as "chronic"). With regard to secondary service connection, the Board finds that a preponderance of the evidence is against finding that the Veteran's service-connected PTSD caused or aggravated his diagnosed GERD. While a December 2019 VA examiner cited a medical article noting that antidepressants can "cause reflux by inducing LES hypotension," a January 2021 VA examiner noted that the article in question did not include the "SSRI category of antidepressants," which the Veteran is prescribed. The January 2021 examiner noted that there is no medical evidence to show that the Veteran's PTSD medication is causative for GERD, a separate and distinct diagnosis, and opined that it was less likely than not that the Veteran's PTSD or associated medication caused or aggravated his GERD. Both the September 2012 and April 2015 examiners stated that there was no physiological or anatomic link between the Veteran's PTSD and GERD, and the September 2012 examiner provided an alternative theory for his onset of GERD: diet and obesity. Additionally, the VHA expert examiner reviewed the Veteran's medical history, lay statements and submitted articles, and provided an opinion that is supported by and consistent with the objective medical evidence of record. The claims file does not contain a contrary medical opinion, and, as noted above, the Veteran and his spouse do not possess the education and training to opine as to the etiology of his GERD. As the Veteran has not alleged GERD symptoms during combat, the provisions of 38 U.S.C. § 1154(b) do not apply. Although the benefit of the doubt is to be resolved in the claimant's favor when there is an approximate balance of positive and negative evidence with regard to a material issue, in this case the Board finds that a preponderance of the evidence is against finding a relationship between the Veteran's diagnosed GERD and his active service or his service-connected PTSD. Therefore, there is no reasonable doubt to resolve in his favor, and the claim must be denied on direct, presumptive and secondary bases. Gilbert,1 Vet. App. at 49. T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. C. Schumacher, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.