Citation Nr: 21041643 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 11-04 336 DATE: July 9, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus, is denied. FINDINGS OF FACT 1. A preponderance of the evidence of record is against a finding that the Veteran's diastolic blood pressure manifested to a degree predominantly 90mm or greater, or; systolic pressure predominantly 160 or more, or; diastolic pressure predominantly 100 or more requiring continuous medication for control while in service. 2. A preponderance of the evidence of record is against a finding that the Veteran's hypertension manifested to a compensable degree within one year of separation from active duty service and is otherwise etiologically related to service. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension, to include as secondary to diabetes mellitus, have not been met. 38 U.S.C. §§ 1110, 1112, 1155, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 4.3, 4.104, Diagnostic Code (DC) 7101. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the U.S. Army from November 1965 to November 1967, to include service in the Republic of Vietnam. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. In June 2012, the Veteran testified before the undersigned Veteran's Law Judge (VLJ) at a videoconference hearing. A copy of the hearing transcript is part of the record. The Board remanded the matter in April 2014 and September 2016 for additional development, to include VA examinations regarding service connection. See April 2014 and September 2016 BVA Decisions. The matter was returned to the Board in July 2018, at which time the Board issued a denial of service connection. See July 2018 BVA Decision. The Veteran filed a timely notice of appeal (NOA) from the July 2018 Board decision with the United States Court of Appeals for Veterans Claims (CAVC). In a December 2019 Memorandum Decision, the CAVC vacated the July 2018 Board decision and remanded the case for additional development. See December 2019 CAVC Decision. The matter was remanded again in September 2020 for a new VA examination consistent with the instructions contained in the December 2019 CAVC Decision. See September 2020 BVA Decision. Finally, the matter was remanded in April 2021 for the issuance of a Supplemental Statement of the Case (SSOC). See April 2021 BVA Decision. The matter is now returned to the Board to address the Veteran's October 2010 appeal. This case has been advanced on the docket pursuant to 38 U.S.C. § 7107(b) and 38 C.F.R. § 20.902(c). 1. Service connection for hypertension The Veteran contends that his hypertension is the result of his service-connected diabetes mellitus. See June 2012 Board videoconference hearing transcript ("I just think that they came on at the same time...I heard people talk about it...I heard several people with diabetes say that their blood pressure was high too. And they seem to think the same thing."). Duty to Assist VA must notify the claimant of any information, including any medical or lay evidence, not previously provided to VA, that is necessary to substantiate the claim. See 38 U.S.C. § 5103 (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VA has satisfied its duties to inform the Veteran in this case. See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 21.1032(a). The duty to notify was satisfied by June and August 2010 VA VCAA / DTA Letters. See also September 2010 VA Rating Decision Narrative, December 2010 Statement of the Case, February 2012, December 2014, and November 2016 SSOC, May 2018 VA Correspondence, April 2020 VA Appeal Notification Letter, December 2020 SSOC, February 2021 BVA General Letter, and April 2021 SSOC. VA's duty to assist functions to aid a claimant in obtaining evidence necessary to substantiate a claim, but VA is not required to provide assistance to a claimant when there is no reasonable possibility that assistance would aid in substantiating the claim. See 38 U.S.C. § 5103A (2012). As for VA's assistance to the Veteran, service treatment records (See June and July 2010 VA Forms 21-3101, Request for Information), VA treatment records (See June 2010 Medical Treatment Record Government Facility, May and December 2014, October 2015, January and March 2017, September 2020, and January and April 2021 CAPRI records), and private treatment records (See July 2010 Medical Treatment Record Non-Government Facility) were obtained and associated with the claims file and evidence of record. The Veteran has not identified any additional, outstanding records relevant to the claim decided herein. See July 2010 VCAA Notice Response ("I have enclosed all the remaining information or evidence that will support my claim, or I have no other information or evidence to give VA to support my claim."). Further, the entire record was available to the August 2010, October 2014, October 2016, November 2017, and November 2020 medical examiners, Diabetes Mellitus and Hypertension examinations were performed, and the testing was sufficient to adequately address all potential rating criteria. See 38 U.S.C. § 7104(d)(1); 38 C.F.R. §§ 3.385, 4.87. Any defects identified in the August 2010, October 2014, and November 2017 VA medical examinations were cured by the November 2020 medical examination. See April 2014, September 2016, and September 2020 BVA Decisions and December 2019 CAVC Decision. The Board finds that VA has done everything reasonably possible under 38 C.F.R. § 21.1032(a) and in keeping with principles of basic fairness, in the spirit of the non-adversarial nature of VA benefits adjudication, to assist the Veteran. See Gambill v. Shinseki, 576 F.3d 1307 (Fed. Cir. 2009) (quoting Prickett v. Nicholson, 20 Vet. App. 370, 382 (2006) ("[C]reating a procedural right in the name of fair process principles [for applicants for VA disability benefits] is primarily based on the underlying concept of the VA adjudicatory scheme, not the U.S. Constitution."). All pertinent due process requirements have been met. See 38 C.F.R. § 3.103 (2017). Further development and further assistance by VA are not warranted. The RO's efforts have substantially complied with the instructions contained in the April 2014, September 2016, September 2020, and April 2021 Board and December 2019 CAVC remands. See Stegall v. West, 11 Vet. App. 268 (1998). An additional remand for further development of this claim would serve no useful purpose. Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of his claim in this Board decision. Service Connection In general, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish entitlement to service connection, there must be: (1) competent and credible evidence confirming the Veteran has the claimed disability or at least has since filing the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. § 1113(b) (2014); 38 C.F.R. § 3.303(d) (2016). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. See generally 38 C.F.R. § § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Presumptive service connection can satisfy both the elements of an in-service event and a nexus to military service. Chronic diseases listed under 38 C.F.R. § 3.309(a)-(f) that manifest either during active service or subject to the requirements of 38 C.F.R. § 3.307 after discharge or release from military service are sufficient to establish in-service incurrence or aggravation. If a chronic disease enumerated in 38 C.F.R. § 3.309 does not manifest in-service or within the applicable time limits, service connection may be granted based on continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The United States Court of Appeals for the Federal Circuit (Fed Circuit) clarified that the law providing for awards of service connection on the basis of continuity of symptomatology is limited to those "chronic" diseases listed under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). Although the Veteran is competent to provide a diagnosis of an observable condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of mental health or musculoskeletal diseases. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Although the credibility of lay evidence may not be refuted solely by the absence of corroborating medical evidence, it is a factor. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (lay evidence concerning continuity of symptoms after service, if credible, may be competent, regardless of the lack of contemporaneous medical evidence). Other factors are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence thereof, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a) (2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2017). Factual Background Service treatment records for the Veteran indicate a blood pressure (BP) of "120/70" on his September 1965 entry examination. The Veteran recorded a "Normal" clinical evaluation, including "Heart, Vascular System." In addition, the Veteran reported his present health as "Good" and indicated "No high or low blood pressure." See September 1965 Reports of Medical Examination and Medical History. When the Veteran separated from service, a September 1967 medical evaluation was "Normal," including "Heart, Vascular System." Because the best version of the medical evaluation is a photocopy, the recorded BP at separation is not clear. It appears to be "124/71." The Veteran was determined to be "qualified for [s]eparation." On his self-evaluation, the Veteran reported, "Health is good...No high or low blood pressure." See September 1967 Reports of Medical Examination and Medical History. The first recorded indication of high blood pressure is found in private treatment notes from August 1999. See August 1999 Dr. W.T.W., MD notes ("BP 136/88. (Systolic) mid 90's consistently...severe (headaches). No (chest pain), (shortness of breath). Smoker...(Assessment): (hypertension)."); see also March 2010, October 2011, and April 2012 VA Primary Care Notes ("Social History: tobacco, (alcohol) use."). A private treatment record from September 1999 documented, "BP 108/74." See September 1999 Dr. W.T.W, MD notes. In a July 2010 lay statement from the Veteran, he stated, "High blood pressure was first noticed in 2004." See July 2010 VA Form 21-4138, Statement in Support of Claim. Blood pressure readings from 2004 are reflected in private treatment records for the Veteran: "March 2004 = 152/86. April 2004 = 134/74. May 2004 = 118/63. June 2004 = 148/80." See March to June 2004 Dr. W.T.W., MD notes. At the Veteran's first VA treatment appointment, records indicated, "This is a first visit for this (Veteran). He is currently under the care of Dr. W.... Past Medical History: 1. (Hypertension)." According to the record, symptoms of diabetes mellitus were not reported by the Veteran or observed by the treating physician. See August 2008 VA Primary Care Initial Evaluation Note. A February 2009 VA treatment record documented: "Chief Complaint: 'I'm still having weak spells'...Diet controlled diabetes - at first visit (Aug 22, 2008), HGA1C 6.4, Glucose 102...Reports no known diabetes...(Past Medical History): (Hypertension), Agent Orange exposure, history of pneumonia, Arthritis, Malaria, Hyperlipidemia, hemorrhoids, Actinic Keratosis, Hay fever...Diagnoses: Hypertension. Diabetes. Subjective tinnitus." See February 2009 VA Primary Care Note. Pursuant to a duty to assist, the Veteran was provided with a VA medical examination in August 2010. The examiner reviewed the claims file and evidence of record in preparation for the examination. Diabetes was noted as diagnosed in 2009. The Veteran was examined, and his statements were considered by the examiner, including a diagnosis of hypertension in 2002, controlled by medication. No functional loss or effect on daily activities was reported by the Veteran. The examiner concluded that the Veteran's hypertension was not a complication of diabetes. His rationale in arriving at the conclusion was that the hypertension was diagnosed in 2002, seven years before the Veteran's diabetes. The examiner also concluded that the Veteran's hypertension was not aggravated by diabetes. See August 2010 VA Diabetes Mellitus examination report. An October 2011 VA treatment note recorded: "diabetes - diet-controlled - has not taken any medication in the past and does not check (blood sugar) at home...Does complain of periodic lightheadedness when he hasn't eaten. No syncope, no falls. (Hypertension) - BP elevated today 151/96, using amlodipine 1/2 tablet. Brings BP log with him which shows BP up and down at home [sic] with highest BP being 148/90 and lowest being 118/60. I have discussed with him importance of consistent BP below 140/90. Recommend increasing medication - patient declines at this time." See October 2011 VA Primary Care Note. A June 2013 VA treatment record dictated: "(hypertension) - (blood pressure) today is 130/98. States he is taking amlodipine 5mg daily. Has not been recently checking (blood pressure) at home." See June 2013 VA Regular Visit. Pursuant to the April 2014 Board remand, the Veteran was provided with a VA Hypertension examination in October 2014 to address direct service connection and aggravation. The examining physician reviewed the claims file and the evidence of record in preparation for the examination. The Veteran was examined in person, and his statements were considered, including a reported onset of hypertension in 2002, controlled by amlodipine medication. The record did not indicate whether the Veteran's reported diagnosis of hypertension was substantiated by blood pressure readings taken two or more times on at least three different days. See October 2014 VA Hypertension examination report. The October 2014 examining physician determined that the Veteran's hypertension was less likely than not incurred in or caused by military service. In formulating his opinion, the examining physician stated: "There is no evidence military service caused or worsened this condition in (service treatment records). Veteran's hypertension was diagnosed in 2002. In my opinion, based on review of medical records and today's examination, [V]eteran's hypertension is less likely than not due to military service." Regarding aggravation, the examining physician concluded, "Veteran's hypertension is less likely than not due to or aggravated by diabetes mellitus. There is no evidence diabetes mellitus caused or worsened this condition in (service treatment records). In my opinion, based on review of medical records and today's examination, [V]eteran's hypertension is less likely than not due to or aggravated by diabetes mellitus." See October 2014 VA Hypertension examination report. May and June 2015 VA treatment notes indicated: "BP 128/74...Assessment / Plan...Hypertension: Well-controlled with current meds and low salt diet." See May and June 2015 VA Primary Care Notes. Pursuant to the September 2016 Board remand, an additional VA medical opinion was completed to address the issues of direct service connection and aggravation. The examining physician reviewed the claims file and the evidence of record in preparation for his report. The conclusion reached by the examining physician was that the Veteran's hypertension was less likely than not proximately due to or aggravated by his diabetes mellitus. In arriving at his conclusion, the examining physician stated, "There is no evidence his diabetes mellitus caused or worsened this condition. Veteran's hypertension is more likely than not due to independent factors including hereditary and renovascular genetics. In my opinion, based on review of medical records and today's examination, [V]eteran's hypertension is less likely than not proximately due to or aggravated by his diabetes mellitus." See October 2016 VA Hypertension examination report. In November 2017, the RO requested a "medical expert opinion" to address the issue of service connection for the Veteran's hypertension. The examining physician answered the question regarding direct service connection by stating, "It's less likely as not (less than 50% probability) that Veteran's currently diagnosed hypertension had its onset during his active military service or is in any other way causally related to his active military service." In formulating his expert opinion, the examining physician wrote: "The (service treatment records) do not show any evidence that hypertension was ever diagnosed during service. In addition, there's no evidence of persistently elevated blood pressure readings: There are two blood pressures in the (service treatment records); only one is legible. That reading is 120/70 (which is within normal range). The second BP reading shows a systolic of 124 (diastolic is not legible; however, a second blood pressure reading was not taken; [sic] which implies that most likely is was within normal range)." See November 2017 VA Medical Advisory Opinion report. Regarding presumptive service connection due to herbicide agent exposure, the November 2017 examining physician concluded, "It is less likely as not (less than 50% probability) that the Veteran's currently diagnosed hypertension is causally related to his in-service presumed herbicide agent exposure." His rationale for the expert opinion included, "There are inconclusive studies at this time that support an association between Agent Orange exposure and hypertension." Regarding proximate causation due to diabetes mellitus, the examining physician opined, "It's less likely as not (less than 50% probability) that the Veteran's currently diagnosed hypertension is proximately due to or the result of his service-connected diabetes mellitus, type II. In formulating his expert opinion, the examining physician stated, "Records (progress notes from VA) show that the Veteran was diagnosed with hypertension prior to his diagnosis of diabetes. Diabetes was diagnosed in 8/2009. Several progress notes dated prior to that note a history of hypertension." See November 2017 VA Medical Advisory Opinion report. Pertaining to aggravation, the November 2017 examining physician determined, "It is less likely as not that the Veteran's currently diagnosed hypertension is permanently aggravated by his service-connected diabetes mellitus, type II." In arriving at his expert opinion, the examining physician reported, "Diabetes can lead to hypertension [if] there's renal involvement (diabetic nephropathy). This is manifested by microalbuminuria. This Veteran does not have any evidence of diabetic nephropathy. All of his microalbumins (searched from time of diabetic onset until most recent labs) have been normal (3/3/2010, 11/18/2014, 8/11/2017)." See November 2017 VA Medical Advisory Opinion report. Unfortunately, the RO provided the incorrect standard of review in the instructions to the Medical Director who arranged for the opinion by stating, "If hypertension is permanently (emphasis added) aggravated by service-connected diabetes mellitus, type II, then quantify (if possible) the increase in severity." See November 2017 VA Correspondence. The resulting report, and the opinion predicated upon "permanent" aggravation, was the focus of the December 2019 remand by the CAVC. See December 2019 CAVC Decision. Pursuant to the December 2019 CAVC and September 2020 Board remands, a new VA medical opinion was obtained in November 2020 to address the 2012 National Academy of Sciences (NAS) report on herbicide agent exposure and hypertension and aggravation of hypertension due to diabetes. The examining physician reviewed the claims file and the evidence of record in preparation for his opinion, "The claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness." In formulating his medical opinion, the examining physician stated: "There is no evidence of chronic hypertension while in-service. The blood pressure on the separation examination dated 9/21/67 is not completely legible. The systolic number appears to be in the 120s, but the diastolic is not discernible. The separation questionnaire is marked negative for high or low blood pressure...Hypertension is not due to Agent Orange exposure. The [V]eteran cites the 2012 NAS review. This has been superseded by at least three later editions. The 2018 NAS study suggests an association between Agent Orange and hypertension but does not establish cause and effect. Review of the current, widely accepted, peer-reviewed literature has not established Agent Orange as a cause of hypertension. This includes a review of Up-to-Date, a widely respected source." See November 2020 VA Hypertension examination report. Regarding secondary service connection, the November 2020 examining physician opined, "The claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition." In formulating his medical opinion, the examiner stated: "On the (hypertension) (Disability Benefits Questionnaire) and the diabetes (Disability Benefits Questionnaire), hypertension onset is noted as 2002. Furthermore, diabetes is noted with an onset in 2009. Therefore, it is less likely than not that the [V]eteran's hypertension is due to diabetes. It clearly predated diabetes. Additionally, and this applies to aggravation as well, hypertension cannot be attributed as due to or aggravated by diabetes in the absence of diabetic nephropathy. There clearly was no diabetic nephropathy at the time of diabetes onset, and therefore, none at the onset of hypertension." See November 2020 VA Hypertension examination report. Relating to aggravation, the November 2020 examining physician determined that the Veteran's hypertension condition was not aggravated beyond its natural progression by his service-connected condition. Rationale in formulating his medical opinion included: "The [V]eteran has normal renal labs as late as 2020, with a creatinine of 1.1 and a (Glomerular Filtration Rate) of 65.3 on 9/8/2020. An additional 2020 reference gives a (Glomerular Filtration Rate) of 71.4. Furthermore, there is no evidence of aggravation of the [V]eteran's hypertension beyond its natural course due to any cause, including the [V]eteran's diabetes. Blood pressure records from 2004 and 2008 show blood pressures 120 to 130/80, with occasional diastolic near 90. This is essentially the same as current blood pressure levels. Addition or substitution of medications or changing doses are common in the natural history of hypertension and do not connote aggravation. There is no end organ damage attributable to hypertension." See November 2020 VA Hypertension examination report. February 2021 VA treatment notes indicated that the Veteran was taking "Norvasc 10mg, HCTZ 25mg daily" for hypertension. See February 2021 VA Primary Care Clinic Note. Analysis The Veteran has a diagnosis of hypertension, and according to the Veteran, he was prescribed medication for the condition between 2002 and 2004. See July 2010 VA Form 21-4138, Statement in Support of Claim ("High blood pressure was first noticed in 2004.") and August 2010 VA Diabetes Mellitus ("Date of Diagnosis of Hypertension: 2002") and October 2014 VA Hypertension examination reports ("Reports long (history of) (hypertension) since (approximately) 2002"). Regardless of when the diagnosis was first provided, the first element of service connection is satisfied. However, service treatment records and medical examinations are against a finding of relevant symptoms of an in-service hypertension disorder, the second element of service connection. The only references to heart health during active duty service came in the form of entry and separation physical examinations. Both the September 1965 and September 1967 medical and self-evaluations exclude the possibility of a high blood pressure or hypertension condition during service. See September 1965 and 1967 Reports of Medical Examination and Medical History. Further, according to private treatment records and the Veteran's lay statements, hypertension was diagnosed between August 1999 and 2004. See August 1999 Dr. W.T.M., MD notes ("(Assessment): (hypertension)"), July 2010 VA Form 21-4138, Statement in Support of Claim ("High blood pressure was first noticed in 2004.") and August 2010 VA Diabetes Mellitus ("Date of Diagnosis of Hypertension: 2002") and October 2014 VA Hypertension examination reports ("Reports long (history of) (hypertension) since (approximately) 2002"). In any event, hypertension was diagnosed more than 30 years after service. Regarding the third element of service connection, a nexus or link between the Veteran's hypertension and service, the record does not support a finding of service connection. The Veteran's diagnosis of hypertension is not included on the list of chronic diseases enumerated in 38 C.F.R. § 3.309(a), nor is it included on the list of presumptive conditions enumerated under 38 C.F.R. § 3.309(e), diseases associated with exposure to certain herbicide agents. While diabetes mellitus and type 2 diabetes are included on the list of presumptive conditions under 38 C.F.R. § 3.309(a) and (e) respectively, the Veteran was clearly diagnosed with diabetes years after he was diagnosed with hypertension. See August 1999 Dr. W.T.W., MD notes ("(Assessment): (hypertension).") and February 2009 VA Primary Care Note ("(Past Medical History): (Hypertension), Agent Orange exposure, history of pneumonia, Arthritis, Malaria, Hyperlipidemia, hemorrhoids, Actinic Keratosis, Hay fever...Diagnoses: Hypertension...Diabetes...Subjective tinnitus."). Numerous medical examinations have relied on the same medical history in concluding that the Veteran's hypertension was neither proximately caused nor aggravated by diabetes. See August 2010 VA Diabetes Mellitus examination report, October 2014 VA Hypertension examination report, October 2016 VA Hypertension examination report, November 2017 VA Medical Advisory Opinion report, and November 2020 VA Hypertension examination report. The Veteran's sworn testimony, "I just think (hypertension and diabetes) came on at the same time (See June 2021 Board videoconference hearing transcript)" is not supported by the contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). While the Board cannot make an adverse determination regarding credibility, the lay statement is not considered competent or sufficient to establish a simultaneous onset of hypertension and diabetes. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Further, the Veteran explicitly denied a history of diabetes when he was first diagnosed in February 2009. See February 2009 VA Primary Care Note ("Reports no known diabetes."). Based on the evidence of record, the Veteran does not meet the requirements for presumptive service connection, either by diagnosis in-service, within the prescribed time limits after service, or through continuity of symptomatology, and he is not entitled to the presumption of an in-service incurrence, aggravation in-service, or nexus to service. Conclusion In summary, a clear preponderance of the evidence of record indicates the Veteran does not meet the relevant diagnostic criteria under 38 C.F.R. § 4.104, DC 7101, for service connection of hypertension. The Board has considered the statements of the Veteran. However, the Board assigns more probative weight to the contemporaneous medical evidence, including service treatment records, private and VA treatment records, and VA medical examinations. In addition to the lack of in-service complaints, medical examinations and self-reports were negative for vascular conditions while in-service. Treatment records document the onset of hypertension between 1999 and 2004, more than 30 years after service and at least five years before diabetes was diagnosed. The Veteran denied a history of diabetes before the February 2009 diagnosis. There is not a positive medical opinion of record indicating that the Veteran's hypertension is related in any way to service or to a subsequent diagnosis of diabetes. Moreover, there is no evidence of nephropathy, end organ damage, or significant change in blood pressure readings to indicate that the Veteran's hypertension was aggravated in any way by diabetes. The Board acknowledges the Veteran's lay assertions that he believes his current hypertension condition is the result of active duty service. The Veteran is not shown to have medical education or experience. He is not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition, as these are medically complex issues. A conclusory, generalized lay statement that military service caused his current hypertension condition is insufficient to prove service connection. Thus, his lay assertions, including his June 2012 Board testimony referencing what "several people with diabetes say," do not constitute evidence upon which service connection can be granted in his case. The August 2010, October 2014, October 2016, November 2017, and November 2020 reports from the VA examiners are the most probative evidence of record on the question of entitlement to service connection. The opinions were based on an extensive review of all the evidence, including lay statements from the Veteran, were supported by a detailed rationale, provided data to support any conclusions, and they provided a clear and reasoned analysis, the source of the most probative value in a medical opinion. See Nieves-Rodrigues v. Peake, 22 Vet. App. 295 (2008). The August 2010, October 2014, October 2016, November 2017, and November 2020 VA examiner opinions are consistent with one another and the evidence of record. The VA examiner opinions provide compelling evidence against the Veteran's claim for service connection. There is no competent, credible evidence to refute the August 2010, October 2014, October 2016, November 2017, and November 2020 VA examiner opinions. The weight of the probative evidence of record is against a finding that the Veteran is entitled to service connection for hypertension. Finally, the Veteran does not meet the requirements for presumptive service connection. Consequently, service connection for hypertension, to include as secondary to diabetes mellitus, is not warranted, and the claim for service connection must be denied. In reaching the conclusions stated above, the Board has considered the applicability of the benefit of the doubt doctrine. The rule does not apply when the Board finds that a preponderance of the evidence is against the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (2018); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Small, Attorney Advisor 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.