HYPERTENSION

Summary

The appellant, surviving spouse of the Veteran, appeals the denial of service connection for hypertension, kidney disorder, bilateral shoulder disorder, bilateral hearing loss, diabetes mellitus type II, and gout. The Veteran served from August 1979 to July 1992 and passed away in June 2019. The claims involve both direct and secondary service connection arguments. The Board reviewed multiple VA medical opinions from November 2024, February 2025, and October 2025, finding them adequate to decide the claims. These opinions generally concluded that the Veteran's conditions were not related to service or service-connected disabilities, citing a lack of objective evidence during service, the natural progression of disease, or the absence of a medical nexus. For hypertension and kidney disorder, the Board noted the Veteran's contentions and the presence of elevated blood pressure readings during service but found no diagnosis until many years post-service, negating presumptive service connection. For bilateral shoulder disorder, service treatment records were negative, and post-service diagnoses of arthritis and tendinitis were not linked to service. For bilateral hearing loss, service records were negative, and post-service diagnoses occurred decades after separation, with VA opinions finding no nexus due to lack of in-service damage and potential ototoxic medication use. For diabetes mellitus type II and gout, VA opinions found no direct service connection and no pathophysiological link to the Veteran's service-connected orthopedic conditions, attributing them instead to family history, age, obesity, or kidney disease. All claims were denied.

Rationale

Service treatment records showed elevated blood pressure during service.; No diagnosis of hypertension until years after service.; VA opinions found no nexus to service or adjustment disorder.

Full Decision Text

Citation Nr: 26003007
Decision Date: 03/05/26	Archive Date: 03/05/26

DOCKET NO. 16-48 721
DATE: March 5, 2026

ORDER

Entitlement to service connection for hypertension, to include as secondary to service connected adjustment disorder with anxiety and depressed mood and/or nonservice-connected kidney disorder, is denied.  

Entitlement to service connection for a kidney disorder as secondary to nonservice-connected diabetes mellitus type II and/or hypertension is denied.

Entitlement to service connection for a bilateral shoulder disorder is denied.

Entitlement to service connection for bilateral hearing loss is denied.

Entitlement to service connection for diabetes mellitus type II, to include as secondary to service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, cervical strain, degenerative arthritis, right ankle, degenerative arthritis, left ankle, nonservice-connected hypertension and/or kidney disorder, is denied.

Entitlement to service connection for gout, to include as secondary to service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, cervical strain, degenerative arthritis, right ankle, degenerative arthritis, left ankle and nonservice-connected kidney disorder, is denied.

FINDINGS OF FACT

1. The Veteran's hypertension was not etiologically related to his active service, did not have its onset in service and was not caused or aggravated by his service connected adjustment disorder with anxiety and depressed mood and/or nonservice-connected kidney disorder.

2. The Veteran's kidney disorder was not caused or aggravated by his nonservice-connected diabetes mellitus type II and/or hypertension.

3. The Veteran's bilateral shoulder disorder was not etiologically related to his active service and did not have its onset in service. 

4. The Veteran's bilateral hearing loss was not etiologically related to his active service, did not have its onset in service and did not manifest to a compensable degree within one year of service discharge.

5. The Veteran's diabetes mellitus type II was not etiologically related to his active service, did not have its onset in service and was not caused or aggravated by his service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, cervical strain, degenerative arthritis, right ankle, degenerative arthritis, left ankle, nonservice-connected hypertension and/or kidney disorder.

6. The Veteran's gout was not etiologically related to his active service, did not have its onset in service and was not caused or aggravated by his service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, cervical strain, degenerative arthritis, right ankle, degenerative arthritis, left ankle, nonservice-connected hypertension and/or kidney disorder.

CONCLUSIONS OF LAW

1. The criteria for service connection for hypertension, to include as secondary to service connected adjustment disorder with anxiety and depressed mood and/or nonservice-connected kidney disorder, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for service connection for a kidney disorder as secondary to nonservice-connected diabetes mellitus type II and/or hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. The criteria for service connection for a bilateral shoulder disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

4. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.

5. The criteria for service connection for diabetes mellitus type II, to include as secondary to service connected bilateral flat feet, right knee
.303, 3.310.

3. The criteria for service connection for a bilateral shoulder disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

4. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.

5. The criteria for service connection for diabetes mellitus type II, to include as secondary to service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, cervical strain, degenerative arthritis, right ankle, degenerative arthritis, left ankle, nonservice-connected hypertension and/or kidney disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

6. The criteria for service connection for gout, to include as secondary to service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, cervical strain, degenerative arthritis, right ankle, degenerative arthritis, left ankle, nonservice-connected hypertension and/or kidney disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from August 1979 until July 1992. The Veteran died in June 2019. See June 2019 Death Certificate. The appellant is his surviving spouse and has been substituted into the claims on appeal. See January 2020 Correspondence; 38 U.S.C. § 5121A; 38 C.F.R. § 3.1010. 

These matters come before the Board of Veterans' Appeals (Board) on appeal from November 2013 (kidney disorder and hypertension), November 2016 (gout and bilateral hearing loss), June 2017 (bilateral shoulder disorder) and August 2017 (diabetes mellitus type II) rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). 

The Board notes that the Veteran requested a hearing in the Appeal to Board of Veterans' Appeals (VA Form 9) submitted in October 2016. In a signed statement submitted in May 2018, the Veteran withdrew his hearing request. Thus, the Board finds that this hearing request has been withdrawn.

The Board previously remanded the instant matters in July 2019, October 2021, September 2022, May 2023, February 2024 and January 2025. 

In January 2023, the Board denied entitlement to service connection for hypertension and a kidney disorder. The Board remanded the claims of entitlement to service connection for bilateral hearing loss, diabetes mellitus type II, a bilateral shoulder disorder, gout, entitlement to a higher initial rating for a cervical disability, a right knee disability, a left knee disability, a right ankle disability, a left ankle disability, tinnitus, an earlier effective date of service connection for a cervical disability, right knee disability, left knee disability, right ankle disability, left ankle disability, tinnitus, and entitlement to special monthly compensation based on aid and attendance/housebound. 

The appellant appealed the January 2023 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a September 2023 Order, as to entitlement to service connection for hypertension and entitlement to service connection for a kidney disorder, the Court granted a Joint Motion for Partial Remand of the parties and remanded the case to the Board for action consistent with the Joint Motion for Partial Remand. The Court did not disturb the Board's remand as to the claims of entitlement to service connection for bilateral hearing loss, diabetes mellitus type II, a bilateral shoulder disorder, gout, entitlement to a higher initial rating for a cervical disability, a right knee disability, a left knee disability, a right ankle disability, a left ankle disability, tinnitus, an earlier effective date of service connection for a cervical disability, right knee disability, left knee disability, right ankle disability, left ankle disability, tinnitus, and
 connection for hypertension and entitlement to service connection for a kidney disorder, the Court granted a Joint Motion for Partial Remand of the parties and remanded the case to the Board for action consistent with the Joint Motion for Partial Remand. The Court did not disturb the Board's remand as to the claims of entitlement to service connection for bilateral hearing loss, diabetes mellitus type II, a bilateral shoulder disorder, gout, entitlement to a higher initial rating for a cervical disability, a right knee disability, a left knee disability, a right ankle disability, a left ankle disability, tinnitus, an earlier effective date of service connection for a cervical disability, right knee disability, left knee disability, right ankle disability, left ankle disability, tinnitus, and entitlement to special monthly compensation based on aid and attendance/housebound.

In a May 2023 decision, the Board denied earlier effective dates for the grant of service connection for a cervical strain, right knee osteoarthritis, left knee osteoarthritis, right ankle degenerative joint disease, left ankle degenerative joint disease, tinnitus and an increased rating for tinnitus. The appellant did not appeal this decision to the Court and it is therefore final.  

In a September 2025 decision, the Board denied entitlement to increased ratings for cervical strain; right knee osteoarthritis with limitation of extension; left knee osteoarthritis with limitation of extension; degenerative arthritis, left ankle; degenerative arthritis, right ankle; special monthly compensation based on the need for aid and attendance of another; and special monthly compensation based on being housebound pursuant to 38 U.S.C. § 1114(s). The appellant did not appeal this decision to the Court and it is therefore final.  

The Board most recently remanded the service connection claims for bilateral hearing loss, diabetes mellitus type II, a bilateral shoulder disorder, gout, hypertension and a kidney disorder in September 2025 to the Agency of Original Jurisdiction (AOJ) for further development, to include obtaining etiology opinions for the Veteran's bilateral shoulder disorder, bilateral hearing loss, diabetes mellitus type II and gout. VA medical opinions for the Veteran's bilateral hearing loss, bilateral shoulder disorder, diabetes mellitus type II and gout were associated with the claims file in October 2025 and November 2025. The Board finds that the medical opinions for the Veteran's bilateral shoulder disorder, bilateral hearing loss, diabetes mellitus type II and gout are adequate and therefore finds that there has been substantial compliance with its previous remand. 

The Board acknowledges that in May 2018, August 2020 and August 2022 VA received from the Veteran's representative correspondence and Informal Hearing Presentations which contained hyperlinks to content that is not otherwise part of the record on appeal; however, that content was not accessed nor considered as part of the record before the Board. See Bowey v. West, 11 Vet. App. 106, 108-09 (1998) (holding that the mere reference to non VA documents is insufficient to incorporate them into the record).

In May 2025, the Board received an Appeals Satisfaction Notice from the appellant that was dated in August 2024. The notice indicated that the appellant wished to withdraw all remaining issues associated with her appeals. However, the issues of service connection for hypertension and a kidney disorder were adjudicated by the AOJ in an April 2025 supplemental statement of the case (SSOC) and the remaining issues were adjudicated in a July 2024 SSOC. Notably, hypertension and a kidney disorder were previously in a separate appeal stream as those issues were appealed to the Court and remanded to the Board. Therefore, ambiguity existed regarding which issues the appellant intended to withdraw.

A withdrawal of a claim must be "explicit, unambiguous, and done with full understanding of the consequences of such action on the part of the claimant." DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011). As the appellant's intent in this instance was unclear, the Board sought clarification. In June 2025 correspondence to the appellant, the Board indicated that the appellant's withdraw must be in writing and signed, requested she clarify if it was her intent to withdraw her appeals, and that failure to respond within 30 days would result in the Board proceeding to review the matters on appeal. The appellant did not respond to the letter. Therefore, the Board proceeds to adjudicate the appellant's claims based on the evidence of record.

SERVICE CONNECTION CRITERIA

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all evidence, including that
 Board indicated that the appellant's withdraw must be in writing and signed, requested she clarify if it was her intent to withdraw her appeals, and that failure to respond within 30 days would result in the Board proceeding to review the matters on appeal. The appellant did not respond to the letter. Therefore, the Board proceeds to adjudicate the appellant's claims based on the evidence of record.

SERVICE CONNECTION CRITERIA

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may be granted based on evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 38 C.F.R. § 3.304. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases such as diabetes mellitus, an organic disease of the nervous system and cardiovascular renal disease become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 C.F.R. §§ 3.307, 3.309(a).  

Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 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) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). VA has amended 38 C.F.R. § 3.310 to explicitly incorporate the holding in Allen, except that it will not concede aggravation unless a baseline for the claimed disability can be established with evidence created prior to any aggravation. 38 C.F.R. § 3.310(b).

The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991).

The veteran can provide competent reports of factual matters of which he has first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Similarly, laypersons are competent to diagnose and provide nexus opinions to some extent, notably where the diagnosis or opinion is not of a complex nature. Id.; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).

The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (
 diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Similarly, laypersons are competent to diagnose and provide nexus opinions to some extent, notably where the diagnosis or opinion is not of a complex nature. Id.; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).

The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999).

When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

1. Entitlement to service connection for hypertension, to include as secondary to service connected adjustment disorder with anxiety and depressed mood and/or nonservice-connected kidney disorder, is denied. 

Prior to his passing, the Veteran asserted that he had hypertension with onset during his military service. See June 2014 Notice of Disagreement (VA Form 21-0958). Specifically, during his lifetime, the Veteran contended that he had elevated blood pressure readings while on active duty. Id. The appellant also submitted a statement in October 2015 in which she noted that when she met the Veteran in 1990 he was having problems with his blood pressure at that time. The appellant also asserts that the Veteran's hypertension was due to exposure to Agent Orange or secondary to his service connected adjustment disorder with anxiety and depressed mood. 

The appellant contends that the Board erred by finding the duty to assist satisfied because it failed to ensure reasonable efforts were made to obtain relevant private treatment records. See September 2023 Appellate Brief. In the alternative, she contends that the Board failed to address the reasonably raised issue of whether the duty to assist required notifying the appellant that she must obtain a copy of her Certificate of Appointment from the probate court to obtain the records or send a request that appellant obtain the records and provide them to VA. Id. In January 2025, the Board found that the AOJ made attempts to obtain a Certificate of Appointment from the appellant. Three attempts were made in July 2024, September 2024 and October 2024. In February 2024, VA asked the appellant to provide an authorization to obtain private treatment records. No response was received. Accordingly, VA satisfied its duty to assist with obtaining the relevant private treatment records.

The appellant then contends that the Board erred when it found that the October 2022 VA opinion substantially complied with its remand instructions to address whether the Veteran's elevated blood pressure readings during service may have been indicative of or early manifestations of hypertension that were not diagnosed until a later date. Id. The appellant further contends that the Board erred when it failed to provide a VA opinion that opined on the reasonably raised issue of whether the Veteran's hypertension was due to exposure to Agent Orange or secondary to his service connected adjustment disorder with anxiety and depressed mood. Id. The appellant indicates that the Board failed to address evidence that the Veteran may have been diagnosed with hypertension during service and that he suffered from blood pressure problems within one year of discharge. Id. The appellant notes that previous counsel argued that a February 1984 note diagnosing "ertension" was intended to read hypertension and indicated that the Veteran was diagnosed with the condition during service. Id. The appellant contends that the Board also failed to adequately address her lay statement that the Veteran had problems with his blood pressure and chest pains since 1990 when she met him. Id. The appellant also contends that the Board failed to explain its contradictory reliance on the Veteran's failure to report cardiovascular problems in service and the Board's statement that he is unable to opine on whether he incurred cardiovascular disease during service. Id. 

Turning to the evidence, service treatment records reveal that elevated blood pressure readings were present during service. As detailed in the September 2022 remand, elevated blood pressure readings are noted in the February 1979 enlistment report of medical examination and in multiple service treatment records dated in the 1980s and early 1990s. Post-service treatment records document that the Veteran was diagnosed with hypertension. See November 2015 VA treatment record.

The Board has first considered whether presumptive service connection for cardiovascular-renal disease is warranted. In this regard, the clinical evidence of record fails to show that the Veteran manifested such disease to a compensable
 statement that he is unable to opine on whether he incurred cardiovascular disease during service. Id. 

Turning to the evidence, service treatment records reveal that elevated blood pressure readings were present during service. As detailed in the September 2022 remand, elevated blood pressure readings are noted in the February 1979 enlistment report of medical examination and in multiple service treatment records dated in the 1980s and early 1990s. Post-service treatment records document that the Veteran was diagnosed with hypertension. See November 2015 VA treatment record.

The Board has first considered whether presumptive service connection for cardiovascular-renal disease is warranted. In this regard, the clinical evidence of record fails to show that the Veteran manifested such disease to a compensable degree within the year following his discharge from active duty service. Post-service treatment records did not reflect a diagnosis of hypertension until 2014, which is more than 20 years after separation from service. The Board notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability may be considered as evidence against a claim of entitlement to service connection. See Maxon v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Therefore, the Board finds that presumptive service connection for hypertension as a cardiovascular-renal disease, to include on the basis of continuity of symptomatology, is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309.

In June 2014, the Veteran submitted a May 2014 private disability benefits questionnaire. The provider opined that the Veteran's hypertension was due to renal dysfunction or caused by a kidney condition. The Board finds the opinion inadequate to decide the claim as the Veteran is not service connected for renal dysfunction or a kidney disorder.

In a November 2015 private opinion associated with the claims file in December 2015, a private physician indicated that the Veteran's hypertension "occurred" on active duty. The Board notes that it previously found the private opinion to be inadequate in January 2023. 

The VA reports each contain an opinion opposing the service-connection claims. The February and April 2022 reports note elevated blood pressure readings during service but nevertheless find an absence of evidence in service treatment records indicating chronic disease during service. The Board notes that it had previously found both VA etiology opinions to be inadequate in September 2022. 

An October 2022 VA opinion was obtained. The Board notes that it previously found the VA etiology opinion to be inadequate in February 2024. 

In a November 2024 VA opinion, the examiner opined that the Veteran's hypertension was less likely than not due to or the result of the Veteran's service connected adjustment disorder with anxiety and depressed mood. The examiner noted that the Veteran reported in an August 2014 Social Security Administration Function report that stress caused his blood pressure to increase, and that December 2016 VA provider Dr. R.M. stated that the Veteran's psychological disorder affected his situational stress tolerance. However, the examiner determined that the development of hypertension from mental health conditions had not been sufficiently demonstrated or substantiated in the peer-reviewed medical literature, as there were not sufficient scientific data/studies to support this causative connection currently. The examiner indicated that the August 2014 report and December 2016 opinion contained no objective evidence supporting such a relationship. The examiner noted that there were no primary source medical records that would support any causative connection. 

The November 2024 VA examiner also opined that the Veteran's hypertension was less likely than not aggravated beyond its natural progression by his service connected adjustment disorder with anxiety and depressed mood. The rationale provided was that there was insufficient objective evidence to support that the Veteran's hypertension had deviated outside of its natural trajectory or that it had been otherwise aggravated beyond its natural progression. 

The Board notes that in January 2025 it found the November 2024 VA opinion incomplete to decide the claim. Specifically, the examiner did not provide a direct service connection opinion as directed in the Board's February 2024 Remand.

A VA medical opinion was provided in February 2025 and associated with the claims file in March 2025. The examiner opined that it was less likely than not that the Veteran's hypertension was due to service. The rationale provided was that the Veteran's service treatment records showed only one episode of elevated blood pressure at which time he was under stress getting attended for a nosebleed. The examiner noted that nearly all of the Veteran's blood pressure readings were less than 120/80 which did not justify a diagnosis of hypertension during service. The examiner indicated that the Veteran clearly and unmistakably had hypertension as of 2014 as documented in multiple health records. The examiner noted that it is very possible that the Veteran had hypertension earlier than that
.

A VA medical opinion was provided in February 2025 and associated with the claims file in March 2025. The examiner opined that it was less likely than not that the Veteran's hypertension was due to service. The rationale provided was that the Veteran's service treatment records showed only one episode of elevated blood pressure at which time he was under stress getting attended for a nosebleed. The examiner noted that nearly all of the Veteran's blood pressure readings were less than 120/80 which did not justify a diagnosis of hypertension during service. The examiner indicated that the Veteran clearly and unmistakably had hypertension as of 2014 as documented in multiple health records. The examiner noted that it is very possible that the Veteran had hypertension earlier than that due to his chronic renal failure, having been on peritoneal dialysis and ultimately having a renal transplant. The examiner indicated that although there is mention of the Veteran having hypertension since 1985 on the most recent renal transplant intake form, there is no objective documentation available that confirms him having hypertension in 1985. The examiner stated that the Veteran's April 1990 Report of Medical Examination showed no objective evidence of hypertension or medication taken to control hypertension. Therefore, the examiner concluded that it is very unlikely that the Veteran's hypertension had its onset and/or is otherwise etiologically related to service. 

The February 2025 VA examiner also opined that it was less likely than not that the Veteran's hypertension was caused by the indicated toxic exposure risk activity, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The rationale provided was that the Veteran developed hypertension as a result of developing chronic kidney disease in 2001. The examiner indicated that the Veteran did not have hypertension during service when he was exposed to lead. 

The Board in September 2025 found that the February 2025 VA opinion raised a new theory of entitlement, namely, that the hypertension was secondary to the Veteran's kidney disorder. See Bailey v. Wilkie, 33 Vet. App. 188 (2021).

In an October 2025 VA medical opinion, the examiner opined that the Veteran's hypertension was less likely than not due to service. The examiner noted that she reviewed the entirety of the claims file, including lay statements, literature, treatment notes and prior remands. The examiner stated that on active duty there were no records to support a chronically elevated blood pressure consistent with a diagnosis of hypertension. The examiner indicated that on active duty there were no records to support a chronically elevated blood pressure consistent with a diagnosis of hypertension. The examiner noted that intermittent elevations of blood pressure are not a diagnosis of hypertension. The examiner stated that the Veteran's statement that his hypertension began in 1985 was not supported by available records. The examiner noted that no evidence showed that hypertension was objectively diagnosed on or within one year of release from active duty. The examiner noted the lay statements but that they were not supported by available evidence. The examiner noted the Veteran's family history of hypertension and concluded that there was no relationship to service. The examiner then opined that the Veteran's hypertension was less likely than not proximately caused by his service connected adjustment disorder with anxiety and depressed mood. The rationale provided was that the conditions are not medically related and separate entities entirely. The examiner noted that a thorough review of medical literature failed to demonstrate a causal relationship. The examiner stated that the Veteran was competent to report his suspicions but was not qualified to establish a nexus. Therefore, the examiner concluded that a nexus was not established. 

Taken together, the Board finds the November 2024, February 2025 and October 2025 VA medical opinions adequate to decide the claim. In this regard, the VA examiners reviewed the claims file, discussed relevant medical literature and provided a supporting rationale for the conclusions reached. The VA examiners noted the Veteran's contentions that his hypertension was related to service and/or his service connected adjustment disorder with anxiety and depressed mood. In addition, the VA examiners adequately considered the statements and contentions of the Veteran, to include the circumstances of his service, and the onset and continuity of his symptoms. The opinions also have clear conclusions and supporting data, as well as reasoned medical explanations. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21?Vet. App.?120, 124 (2007).  

Upon reviewing the aforementioned opinions, the Board finds that the only probative opinions of record determined that the Veteran's hypertension was not related to service and/or service connected adjustment disorder with anxiety and depressed mood. 

The Board notes that lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge
 onset and continuity of his symptoms. The opinions also have clear conclusions and supporting data, as well as reasoned medical explanations. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21?Vet. App.?120, 124 (2007).  

Upon reviewing the aforementioned opinions, the Board finds that the only probative opinions of record determined that the Veteran's hypertension was not related to service and/or service connected adjustment disorder with anxiety and depressed mood. 

The Board notes that lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465 (1994). 

In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's hypertension and any instance of his service to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Specifically, while the Veteran was competent to describe his symptoms, the Board accords his statements regarding the etiology of such claimed disorder little probative value as he was not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of diagnostic testing. In the instant case, there is no suggestion that the Veteran has had any medical training. Hence, the Board finds that he was not competent to provide a medical opinion to support the claim on the basis of his assertions alone. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinions of the Veteran are nonprobative evidence.

As to appellant's contentions that the Board erred when it found that the October 2022 VA opinion substantially complied with its remand instructions to address whether the Veteran's elevated blood pressure readings during service may have been indicative of or early manifestations of hypertension that were not diagnosed until a later date, that the Board failed to address evidence that the Veteran may have been diagnosed with hypertension during service and that he suffered from blood pressure problems within one year of discharge, that the Board failed to explain its contradictory reliance on the Veteran's failure to report cardiovascular problems in service and the Board's statement that he is unable to opine on whether he incurred cardiovascular disease during service and that the Veteran had problems with his blood pressure and chest pains since 1990 when she met him, the Board notes that it previously found the October 2022 VA etiology opinion to be inadequate in February 2024. The February 2025 examiner noted that the Veteran's service treatment records showed only one episode of elevated blood pressure at which time he was under stress getting attended for a nosebleed. The examiner noted that nearly all of the Veteran's blood pressure readings were less than 120/80 which did not justify a diagnosis of hypertension during service. The October 2025 examiner stated that on active duty there were no records to support a chronically elevated blood pressure consistent with a diagnosis of hypertension. The examiner indicated that on active duty there were no records to support a chronically elevated blood pressure consistent with a diagnosis of hypertension. The examiner noted that intermittent elevations of blood pressure are not a diagnosis of hypertension. The examiner stated that the Veteran's statement that his hypertension began in 1985 was not supported by available records. The examiner noted that no evidence showed that hypertension was objectively diagnosed on or within one year of release from active duty. The examiner noted the lay statements but that they were not supported by available evidence. The examiner noted the Veteran's family history of hypertension and concluded that there was no relationship to service. These contentions are therefore without merit. 

The appellant further contends that the Board erred when it failed to provide a VA opinion that opined on the reasonably raised issue of whether the Veteran's hypertension was due to exposure to Agent Orange or secondary to his service connected adjustment disorder with anxiety and depressed mood. The Board notes that an October 2024 VA memorandum found that the Veteran was not exposed to Agent Orange. A November 2024 registry search found no individual longitudinal exposure record. November 2024 and October 2025 VA medical opinions provided adequate secondary service connection opinions. These contentions are therefore without merit. 

Accordingly, the Board finds that entitlement to service connection for hypertension, to include as
 that there was no relationship to service. These contentions are therefore without merit. 

The appellant further contends that the Board erred when it failed to provide a VA opinion that opined on the reasonably raised issue of whether the Veteran's hypertension was due to exposure to Agent Orange or secondary to his service connected adjustment disorder with anxiety and depressed mood. The Board notes that an October 2024 VA memorandum found that the Veteran was not exposed to Agent Orange. A November 2024 registry search found no individual longitudinal exposure record. November 2024 and October 2025 VA medical opinions provided adequate secondary service connection opinions. These contentions are therefore without merit. 

Accordingly, the Board finds that entitlement to service connection for hypertension, to include as secondary to service connected adjustment disorder with anxiety and depressed mood and/or nonservice-connected kidney disorder, is not warranted. The appeal is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, supra.

2. Entitlement to service connection for a kidney disorder as secondary to nonservice-connected diabetes mellitus type II and/or hypertension is denied.

Prior to his passing, the Veteran asserted that he had a kidney disorder that was secondary to his nonservice-connected hypertension and/or diabetes mellitus type II. See June 2014 VA Form 21-0958. 

The appellant also contends that the Board failed to explain its contradictory reliance on the Veteran's failure to report renal problems in service and the Board's statement that he is unable to opine on whether he incurred renal disease during service. See September 2023 Appellate Brief.  

Turning to the evidence, service treatment records are negative for any complaints, treatments, and/or diagnoses relating to a kidney disorder. Post-service treatment records document that the Veteran was diagnosed with a kidney disorder. See March 2019 VA treatment record.

The Board has first considered whether presumptive service connection for cardiovascular-renal disease is warranted. In this regard, the clinical evidence of record fails to show that the Veteran manifested such disease to a compensable degree within the year following his discharge from active duty service. Post-service treatment records did not reflect a diagnosis of a kidney disorder until 2001. Therefore, the Board finds that presumptive service connection for a kidney disorder as a cardiovascular-renal disease, to include on the basis of continuity of symptomatology, is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309.

A May 2014 private disability benefits questionnaire was associated with the claims file in June 2014. Therein, the physician attributed kidney disease to diabetes. The Board in its January 2023 decision found the medical opinion inadequate as diabetes is not service connected.  

A November 2015 private medical opinion associated with the claims file in December 2015 states that the Veteran's chronic kidney disease was due to his hypertension. The Board in its January 2023 decision found the medical opinion inadequate as hypertension is not a service-connected disability so the statement cannot support the secondary service connection claim.  

A February 2022 VA opinion was obtained. The examiner opined that the Veteran's kidney disorder was less likely than not proximately caused by his nonservice-connected hypertension. The rationale provided was that a review of the medical record and service treatment records showed no evidence of the diagnosis, treatment or symptoms suggestive of renal disease or hypertension while on active duty or within one year of separation from military service. The Board finds the medical opinion inadequate to decide the claim as hypertension is not a service connected disability.  

An October 2022 VA opinion was obtained. The Board notes that it previously found the VA etiology opinion to be inadequate in February 2024. 

A November 2024 VA opinion was obtained. The examiner opined that the Veteran's kidney failure with kidney transplant and dialysis was less likely than not proximately due to or the result of the Veteran's hypertension. The rationale provided was that primary source medical records beginning in 2005 do not support that hypertension was the underlying reason or cause for the kidney transplant and for his kidney failure in 2005, in spite of a December 2015 private opinion from Dr. A.U. that the Veteran's kidney disease was due to hypertension. The Board notes that it previously found the VA etiology opinion incomplete to decide the claim in January 2025 as the examiner failed to provide an opinion as to whether kidney failure with kidney transplant and dialysis was aggravated by the Veteran's hypertension. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013).

A February 2025 VA medical opinion was associated with the claims file in March 2025. The examiner opined that it was less likely than not that the Veteran's kidney disorder was due to service
 transplant and for his kidney failure in 2005, in spite of a December 2015 private opinion from Dr. A.U. that the Veteran's kidney disease was due to hypertension. The Board notes that it previously found the VA etiology opinion incomplete to decide the claim in January 2025 as the examiner failed to provide an opinion as to whether kidney failure with kidney transplant and dialysis was aggravated by the Veteran's hypertension. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013).

A February 2025 VA medical opinion was associated with the claims file in March 2025. The examiner opined that it was less likely than not that the Veteran's kidney disorder was due to service. The rationale provided was that the Veteran was diagnosed in 2001, nine years after separation. The examiner also noted that the Veteran's service treatment records did not reflect any diagnosis of any kidney or renal disease during service or within one year following service. The examiner also opined that it was less likely than not that the kidney disorder was aggravated by his hypertension. The rationale was that the Veteran's blood pressure was under control with medication, which made it unlikely that hypertension aggravated the kidney disorder.

An October 2025 VA medical opinion was obtained. The examiner opined that the Veteran's kidney disorder was less likely than not due to service. The examiner noted that she reviewed the entire claims file including prior remands, lay statements and prior medical opinions. She stated that on active duty there was no objective evidence to support a diagnosis of the onset of kidney disease or chronic kidney disease. The examiner noted that kidney disease is diagnosed initially with laboratory testing and abnormalities in creatine, blood urea nitrogen or proteinuria and that on active duty there was no evidence of laboratory testing showing early or chronic kidney disease. The examiner stated that kidney disease was not diagnosed until years after active duty. The examiner noted lay statements of chronicity but they were not supported by objective evidence and laboratory findings. The examiner further opined that the kidney disorder was less likely than not proximately caused by his service connected adjustment disorder with anxiety and depressed mood. The rationale provided was that the conditions are not medically related. The examiner noted that kidney disease is a separate entity entirely from the mental health condition and unrelated. The examiner noted that a thorough review of medical literature failed to demonstrate a causal relationship. The examiner stated that the file clearly showed that the Veteran's initial kidney failure was due to hypertension. The examiner also noted a family history of kidney failure. Therefore, the examiner found that a nexus was not established. 

Taken together, the Board finds the November 2024, February 2025 and October 2025 VA medical opinions adequate to decide the claim. In this regard, the VA examiners reviewed the claims file, discussed relevant medical literature and provided a supporting rationale for the conclusions reached. The VA examiners noted the Veteran's contentions that his kidney disorder was secondary to his nonservice-connected hypertension. In addition, the VA examiners adequately considered the statements and contentions of the Veteran, to include the circumstances of his service, and the onset and continuity of his symptoms. The opinions also have clear conclusions and supporting data, as well as reasoned medical explanations. Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. While the October 2025 VA medical opinion did not address whether the Veteran's kidney disorder was aggravated by his service connected adjustment disorder with anxiety and depressed mood, the Board notes that neither the Veteran nor the appellant have claimed, and the claims file does not reasonably raise, a service connection claim as secondary to service connected adjustment disorder with anxiety and depressed mood. Therefore, the Board is able to proceed with adjudication.

Upon reviewing the aforementioned opinions, the Board finds that the only probative opinions of record determined that the Veteran's kidney disorder was not related to service and/or nonservice-connected hypertension. 

The Board notes that lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, supra. 

In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's kidney disorder and any instance of his service to be complex in nature. Woehlaert v. Nicholson, supra. Specifically, while the Veteran was competent to describe his symptoms, the Board accords his statements regarding the etiology of such claimed disorder little probative value as he was not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, supra. In this regard, the
, such as medical expertise. Layno v. Brown, supra. 

In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's kidney disorder and any instance of his service to be complex in nature. Woehlaert v. Nicholson, supra. Specifically, while the Veteran was competent to describe his symptoms, the Board accords his statements regarding the etiology of such claimed disorder little probative value as he was not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, supra. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of diagnostic testing. In the instant case, there is no suggestion that the Veteran has had any medical training. Hence, the Board finds that he was not competent to provide a medical opinion to support the claim on the basis of his assertions alone. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinions of the Veteran are nonprobative evidence.

As to the appellant's contention that the Board failed to explain its contradictory reliance on the Veteran's failure to report renal problems in service and the Board's statement that he is unable to opine on whether he incurred renal disease during service, the October 2025 examiner noted that kidney disease is diagnosed initially with laboratory testing and abnormalities in creatine, blood urea nitrogen or proteinuria and that on active duty there was no evidence of laboratory testing showing early or chronic kidney disease. This contention is therefore without merit. 

The Veteran argued that he suffers from a kidney disorder that is secondary to hypertension and/or diabetes mellitus type II. As service connection for hypertension is being denied herein, there simply is no legal basis to award service connection for a kidney disorder on a secondary basis. In addition, service connection for diabetes mellitus type II is not in effect and there simply is no legal basis to award service connection on a secondary basis. 38 C.F.R. § 3.310. See also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994).

Accordingly, the Board finds that entitlement to service connection for a kidney disorder as secondary to nonservice-connected diabetes mellitus type II and/or hypertension is not warranted. The appeal is denied. 38 U.S.C. § 5107; 38 C.F.R.           § 3.102; Lynch v. McDonough, supra.

3. Entitlement to service connection for a bilateral shoulder disorder is denied.

Prior to his passing, the Veteran contended that his bilateral shoulder disorder was due to carrying a 70 pound ruck sack on road marches during service. See June 2017 VA Form 21-0958. 

Turning to the evidence, service treatment records are negative for any complaints, treatments, and/or diagnoses relating to a shoulder disorder. Post-service treatment records document that the Veteran was diagnosed with degenerative joint disease and tendinosis of the left shoulder and rotator cuff tendinitis of the right shoulder. See March 2017 and May 2017 VA treatment records.

An October 2023 VA medical opinion was associated with the claims file in November 2023. The Board in September 2025 found the VA opinion inadequate to decide the claim.

The Board has first considered whether service connection for arthritis is warranted on a presumptive basis, to include on the basis of continuity of symptomatology. In this regard, the clinical evidence of record fails to show that the Veteran manifested such disease to a compensable degree within the year following his discharge from active duty service. The Veteran's post-service treatment record did not reflect any complaints for his shoulders until March 2017. The Board notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability may be considered as evidence against a claim of entitlement to service connection. See Maxon v. Gober, supra. Therefore, the Board finds that presumptive service connection for arthritis, to include on the basis of continuity of symptomatology, is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309.

A VA medical opinion was obtained in October 2025. The examiner opined that the Veteran's bilateral shoulder disorder was less likely than not related to service. The examiner noted that the entire claims file including lay statements, prior remands and the entirety of the treatment records were reviewed. The examiner stated that on active duty there was no evidence of chronicity of care, continuity symptoms or pathology for chronic orthopedic shoulder conditions. The examiner
 supra. Therefore, the Board finds that presumptive service connection for arthritis, to include on the basis of continuity of symptomatology, is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309.

A VA medical opinion was obtained in October 2025. The examiner opined that the Veteran's bilateral shoulder disorder was less likely than not related to service. The examiner noted that the entire claims file including lay statements, prior remands and the entirety of the treatment records were reviewed. The examiner stated that on active duty there was no evidence of chronicity of care, continuity symptoms or pathology for chronic orthopedic shoulder conditions. The examiner noted that no evidence from active duty showed disruption of the articular surface of the joint which could later lead to arthritis. The examiner stated that no treatment note showed even an acute shoulder injury from being a drill instructor and going on ruck marches with heavy backpacks. The examiner indicated that the separation examination was silent for chronicity of an orthopedic shoulder condition. The examiner noted that it was not until decades after service when the Veteran complained of left and right shoulder issues and imaging obtained in 2017 showed a mix of arthritis and tendinitis. The examiner stated that it is well established in the medical literature that degenerative arthritis is a result of normal aging and wear and tear. The examiner indicated that per literature, causes of tendinitis include overuse, age, sudden increase in activity and certain medications such as corticosteroids. The examiner noted that the Veteran was on corticosteroids for his kidney transplants in addition to other established causes. Given the literature and the Veteran's specific evidence, the examiner concluded that there was no nexus for the current diagnoses to active duty or injuries on active duty as a drill instructor carrying heavy rucksacks. 

In November 2025, a VA addendum medical opinion was obtained. The examiner noted that the most probative evidence of record is the service treatment records and post-service treatment records which were negative for complaints, diagnosis or treatment for the claimed disorder until after the last period of service and well after one year from release of active duty. Therefore, the examiner found these records more probative than the appellant's lay statements to the contrary. 

Taken together, the Board finds the October 2025 and November 2025 VA medical opinions adequate to decide the claim. In this regard, the VA examiner reviewed the claims file, discussed relevant medical literature and provided a supporting rationale for the conclusions reached. The VA examiner noted the Veteran's contentions that his bilateral shoulder disorder was due to service. In addition, the VA examiner adequately considered the statements and contentions of the Veteran, to include the circumstances of his service, and the onset and continuity of his symptoms. The opinions also have clear conclusions and supporting data, as well as reasoned medical explanations. Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. 

Upon reviewing the aforementioned opinions, the Board finds that the only probative opinions of record determined that the Veteran's bilateral shoulder disorder was not related to service. 

The Board notes that lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, supra. 

In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's bilateral shoulder disorder and any instance of his service to be complex in nature. Woehlaert v. Nicholson, supra. Specifically, while the Veteran was competent to describe his symptoms, the Board accords his statements regarding the etiology of such claimed disorder little probative value as he was not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, supra. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of diagnostic testing such as X-rays. In the instant case, there is no suggestion that the Veteran has had any medical training. Hence, the Board finds that he was not competent to provide a medical opinion to support the claim on the basis of his assertions alone. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinions of the Veteran are nonprobative evidence.

Accordingly, the Board finds that entitlement to service connection for a bilateral shoulder disorder is not warranted. The appeal is denied. 38 U.S.C. § 5107; 
 of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of diagnostic testing such as X-rays. In the instant case, there is no suggestion that the Veteran has had any medical training. Hence, the Board finds that he was not competent to provide a medical opinion to support the claim on the basis of his assertions alone. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinions of the Veteran are nonprobative evidence.

Accordingly, the Board finds that entitlement to service connection for a bilateral shoulder disorder is not warranted. The appeal is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, supra.

4. Entitlement to service connection for bilateral hearing loss is denied.

The appellant asserts that the Veteran's bilateral hearing loss was due to acoustic trauma during service related to training exercises with weapons fire. See August 2020 Informal Hearing Presentation.

Turning to the evidence, service treatment records are negative for any complaints, treatments, and/or diagnoses relating to bilateral hearing loss. Post-service treatment records document that the Veteran was diagnosed with bilateral hearing loss. See September 2016 VA examination.

The Board has first considered whether presumptive service connection for bilateral hearing loss as an organic disease of the nervous system is warranted. In this regard, the clinical evidence of record fails to show that the Veteran manifested such disease to a compensable degree within the year following his discharge from active duty service. Post-service treatment records did not reflect a diagnosis of bilateral hearing loss until 2016, which is more than 20 years after separation from service. The Board notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability may be considered as evidence against a claim of entitlement to service connection. See Maxon v. Gober, supra. Therefore, the Board finds that presumptive service connection for bilateral hearing loss as an organic disease of the nervous system, to include on the basis of continuity of symptomatology, is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309.

A September 2016 VA medical opinion was obtained. The Board in May 2023 found the VA opinion inadequate to decide the claim.

The Veteran was afforded a VA examination in May 2019. The Board finds the examination incomplete to decide the claim as an etiology opinion for bilateral hearing loss was not provided. 

An October 2023 VA medical opinion was obtained. The Board in September 2025 found the VA opinion inadequate to decide the claim.

A March 2024 VA medical opinion was obtained. The Board in September 2025 found the VA opinion inadequate to decide the claim. 

A VA medical opinion was obtained in October 2025. The examiner opined that the Veteran's bilateral hearing loss was less likely than not related to service. The examiner noted that the entrance examination revealed normal hearing bilaterally with the exception of a loss at 500 and 1000 Hertz in the left ear that appeared to be in error as it resolved upon every subsequent test during military service. Although the examiner conceded noise exposure during service, she noted that multiple hearing examinations conducted decades after separation were within normal limits, with the exception of the Maryland CNC scores in 2016, which subsequently resolved upon further testing. The examiner further noted that records indicated that the Veteran was treated with Furosemide, with refills dating from March 2016 through March 2017. As there was no evidence of permanent auditory damage during military service and the Veteran was being treated with a known ototoxic medication at the time of the initial VA examination, the examiner concluded that there was no nexus.

In November 2025, a VA addendum medical opinion was obtained. The examiner reiterated that as the Veteran was treated with a known ototoxic medication (Furosemide) at the time of the September 2016 VA examination and multiple tests conducted decades after military service revealed normal hearing, and in the absence of recorded auditory damage during military service, the available evidence did not support a direct, causal relationship between hearing loss and military service. 

Taken together, the Board finds the October 2025 and November 2025 VA medical opinions adequate to decide the claim. In this regard, the VA examiner reviewed the claims file, discussed relevant medical literature and provided a supporting rationale for the conclusions reached. The VA examiner noted the Veteran's contentions that his bilateral hearing loss was due to service. In addition, the VA examiner adequately considered the statements and contentions of the Veteran, to include the circumstances of his service, and the onset and continuity of his symptoms. The opinions also have clear conclusions and supporting data, as well as
 hearing, and in the absence of recorded auditory damage during military service, the available evidence did not support a direct, causal relationship between hearing loss and military service. 

Taken together, the Board finds the October 2025 and November 2025 VA medical opinions adequate to decide the claim. In this regard, the VA examiner reviewed the claims file, discussed relevant medical literature and provided a supporting rationale for the conclusions reached. The VA examiner noted the Veteran's contentions that his bilateral hearing loss was due to service. In addition, the VA examiner adequately considered the statements and contentions of the Veteran, to include the circumstances of his service, and the onset and continuity of his symptoms. The opinions also have clear conclusions and supporting data, as well as reasoned medical explanations. Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. 

Upon reviewing the aforementioned opinions, the Board finds that the only probative opinions of record determined that the Veteran's bilateral hearing loss was not related to service. 

The Board notes that lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, supra. 

In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's bilateral hearing loss and any instance of his service to be complex in nature. Woehlaert v. Nicholson, supra. Specifically, while the Veteran was competent to describe his symptoms, the Board accords his statements regarding the etiology of such claimed disorder little probative value as he was not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, supra. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of diagnostic testing such as audiological testing. In the instant case, there is no suggestion that the Veteran has had any medical training. Hence, the Board finds that he was not competent to provide a medical opinion to support the claim on the basis of his assertions alone. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinions of the Veteran are nonprobative evidence.

The appellant's representative asserted in an August 2020 Informal Hearing Presentation that the September 2016 VA medical opinion was inadequate as it relied on a 2006 Institute of Medicine study that was opposed to delayed onset hearing loss. As previously mentioned, the Board in May 2023 found the September 2016 VA medical opinion inadequate to decide the claim. The October 2025 and November 2025 VA opinions did not rely on the 2006 Institute of Medicine study. As previously mentioned, the Board is unable to access hyperlinks provided by the Veteran's representative with the August 2020 Informal Hearing Presentation. This contention is therefore without merit. 

The appellant's representative also contends in the August 2020 Informal Hearing Presentation that the service treatment records appear to be incomplete, to include a separation physical with the final audiogram and a number of Reports of Medical History. The October 2025 and November 2025 VA opinions conceded noise exposure during service but noted that multiple hearing examinations conducted decades after separation were within normal limits, with the exception of the Maryland CNC scores in 2016, which subsequently resolved upon further testing. The examiner further noted that records indicated that the Veteran was treated with Furosemide, with refills dating from March 2016 through March 2017. As there was no evidence of permanent auditory damage during military service and the Veteran was being treated with a known ototoxic medication at the time of the initial VA examination, the examiner concluded that there was no nexus. This argument is therefore without merit. 

Accordingly, the Board finds that entitlement to service connection for bilateral hearing loss is not warranted. The appeal is denied. 38 U.S.C. § 5107; 38 C.F.R.                  § 3.102; Lynch v. McDonough, supra. 

5. Entitlement to service connection for diabetes mellitus type II, to include as secondary to service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, cervical strain, degenerative arthritis, right ankle, degenerative arthritis, left ankle, nonservice-connected hypertension and/or kidney disorder, is denied.

Prior to his passing
 for bilateral hearing loss is not warranted. The appeal is denied. 38 U.S.C. § 5107; 38 C.F.R.                  § 3.102; Lynch v. McDonough, supra. 

5. Entitlement to service connection for diabetes mellitus type II, to include as secondary to service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, cervical strain, degenerative arthritis, right ankle, degenerative arthritis, left ankle, nonservice-connected hypertension and/or kidney disorder, is denied.

Prior to his passing, the Veteran asserted that his diabetes mellitus type II was due to Agent Orange exposure. See January 2019 Hearing Transcript. In the alternative, the Veteran contended that his diabetes mellitus type II was secondary to his service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, cervical strain, degenerative arthritis, right ankle, degenerative arthritis, left ankle, nonservice-connected hypertension and/or kidney disorder. Id.; see also June 2014 VA Form 21-0958. 

Turning to the evidence, service treatment records are negative for any complaints, treatments, and/or diagnoses relating to diabetes mellitus type II. Post-service treatment records document that the Veteran was diagnosed with diabetes mellitus type II. See March 2019 VA treatment record.

The Board has first considered whether presumptive service connection for diabetes mellitus type II is warranted. In this regard, the clinical evidence of record fails to show that the Veteran manifested such disease to a compensable degree within the year following his discharge from active duty service. Post-service treatment records did not reflect a diagnosis of diabetes mellitus type II until 2004. Therefore, the Board finds that presumptive service connection for diabetes mellitus type II, to include on the basis of continuity of symptomatology, is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309.

An October 2023 VA medical opinion was associated with the claims file in November 2023. The examiner opined that it was less likely than not that the Veteran's diabetes mellitus type II was due to service. The rationale provided was that the service treatment records were silent for diabetes mellitus type II. The examiner also opined that it was less likely than not that the Veteran's diabetes mellitus type II was secondary to his service connected bilateral flat feet, cervical strain, right knee osteoarthritis, left knee osteoarthritis, degenerative arthritis, left ankle and degenerative arthritis, right ankle. The rationale provided was that there was no pathophysiologic connection between diabetes mellitus type II and any of the above listed orthopedic disorders. The examiner noted that diabetes mellitus type II is caused by genetic propensity, age and obesity. The examiner stated that obesity is not caused or influenced by any specific orthopedic disorder. Rather, the examiner found that the decision to eat more calories than one burns is a conscious decision over which we have specific control. The examiner also indicated that there was no evidence of aggravation by any of the above orthopedic disorders and that there was no aggravating event or circumstance which would provide a pre-and post baseline. In September 2025, the Board found the VA medical opinion as to direct service connection inadequate to decide the claim.

A February 2024 VA medical opinion was provided. In September 2025, the Board found the VA medical opinion inadequate to decide the claim.

A VA medical opinion was provided in October 2025. The examiner opined that the Veteran's diabetes mellitus type II was less likely than not due to service. The examiner noted that the entire claims file was reviewed, including the lay statements, literature, treatment notes and prior Board remands. The examiner stated that on active duty there was no objective evidence or suspicion of concerns for diagnosis of diabetes mellitus type II. The examiner noted that review of the active duty treatment notes showed no chronically elevated glucose or persistent urine problem while on active duty. The examiner referenced a post-service treatment record referencing a diagnosis of diabetes in 2004, which would be well after active duty. The examiner concluded that the diabetes mellitus type II was most likely due to a strong family history of diabetes and elevated body mass index at the time of diagnosis. Given the available evidence and considering the Veteran's statements, the examiner opined that no nexus existed. 

The October 2025 VA examiner then opined that the diabetes mellitus type II was less likely than not proximately due to service connected bilateral flat feet, right knee osteoarthritis with limitation of extension
 type II. The examiner noted that review of the active duty treatment notes showed no chronically elevated glucose or persistent urine problem while on active duty. The examiner referenced a post-service treatment record referencing a diagnosis of diabetes in 2004, which would be well after active duty. The examiner concluded that the diabetes mellitus type II was most likely due to a strong family history of diabetes and elevated body mass index at the time of diagnosis. Given the available evidence and considering the Veteran's statements, the examiner opined that no nexus existed. 

The October 2025 VA examiner then opined that the diabetes mellitus type II was less likely than not proximately due to service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, degenerative arthritis, right ankle, degenerative arthritis, left ankle, cervical strain and nonservice-connected kidney disorder and hypertension. The rationale provided was that the diabetes mellitus type II and service connected disabilities are not medically related. The examiner noted that diabetes is a separate entity entirely from the service connected disabilities and unrelated. The examiner referenced that a thorough review of medical literature failed to demonstrate a causal relationship. The examiner also opined that it was less likely than not that the Veteran's service connected disabilities contributed to, caused or aggravated his obesity and led to diabetes mellitus type II. The rationale provided was that the conditions of weight gain and the Veteran's service connected disabilities were not medically related. The examiner noted that weight gain is a separate entity entirely from the service connected disabilities and unrelated. The examiner indicated that an orthopedic or mental health condition does not preclude all forms of exercise as there are paraplegics who are not obese. The examiner noted that the service connected disabilities have not caused a barrier to negative calorie count as the treatment notes reflect that the Veteran was clearly able to lose weight despite his service connected disabilities. The examiner indicated that obesity would have occurred regardless of service connected disabilities/medications as the obesity was due to consuming more calories than the body needs. The examiner noted that the Veteran's lay statements and prior medical opinions were not supported by his specific evidence.

Taken together, the Board finds the October 2023 and October 2025 VA medical opinions adequate to decide the claim. In this regard, the VA examiners reviewed the claims file, discussed relevant medical literature and provided a supporting rationale for the conclusions reached. The VA examiner noted the Veteran's contentions that his diabetes mellitus type II was due to service and/or service connected disabilities. In addition, the VA examiners adequately considered the statements and contentions of the Veteran, to include the circumstances of his service, and the onset and continuity of his symptoms. The opinions also have clear conclusions and supporting data, as well as reasoned medical explanations. Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. 

Upon reviewing the aforementioned opinions, the Board finds that the only probative opinions of record determined that the Veteran's diabetes mellitus type II was not related to service and/or service connected disabilities. 

The Board notes that lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, supra. 

In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's diabetes mellitus type II and any instance of his service and/or service connected disabilities to be complex in nature. Woehlaert v. Nicholson, supra. Specifically, while the Veteran was competent to describe his symptoms, the Board accords his statements regarding the etiology of such claimed disorder little probative value as he was not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, supra. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of diagnostic testing. In the instant case, there is no suggestion that the Veteran has had any medical training. Hence, the Board finds that he was not competent to provide a medical opinion to support the claim on the basis of his assertions alone. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinions of the Veteran are nonprobative evidence.

Accordingly, the Board finds that entitlement to service connection for diabetes mellitus type II, to include as secondary to service connected bilateral flat
 See Jones v. Brown, supra. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of diagnostic testing. In the instant case, there is no suggestion that the Veteran has had any medical training. Hence, the Board finds that he was not competent to provide a medical opinion to support the claim on the basis of his assertions alone. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinions of the Veteran are nonprobative evidence.

Accordingly, the Board finds that entitlement to service connection for diabetes mellitus type II, to include as secondary to service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, cervical strain, degenerative arthritis, right ankle, degenerative arthritis, left ankle, nonservice-connected hypertension and/or kidney disorder is not warranted. The appeal is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, supra.

6. Entitlement to service connection for gout, to include as secondary to service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, cervical strain, degenerative arthritis, right ankle, degenerative arthritis, left ankle and nonservice-connected kidney disorder, is denied.

Prior to his passing, the Veteran asserted that his gout was due to service. See October 2015 Application for Disability Compensation and Related Compensation Benefits (VA Form 21-526EZ). In the alternative, the appellant contends that the Veteran's gout was secondary to his service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, cervical strain, degenerative arthritis, right ankle and/or degenerative arthritis, left ankle. See May 2025 Informal Hearing Presentation. 

Turning to the evidence, service treatment records are negative for any complaints, treatments, and/or diagnoses relating to gout. Post-service treatment records document that the Veteran was diagnosed with gout. See May 2016 VA treatment record.

An October 2023 VA medical opinion was associated with the claims file in November 2023. The examiner opined that the Veteran's gout was less likely than not due to service. The rationale provided was that the service treatment records were silent for gout. The examiner also opined that the gout was less likely than not secondary to service connected orthopedic disabilities. The rationale provided was that gout is caused by age, genetic propensity and renal disease, with no indication of any pathophysiological pathway for causation of gout by any of the above unrelated orthopedic disorders. The examiner also stated that there was no evidence of aggravation by any of the above orthopedic disorders and there was an absence of an aggravating event or circumstance which would provide a pre-and post baseline. In September 2025 the Board found the VA medical opinion inadequate to decide the claim as to direct service connection.

A February 2024 VA medical opinion was provided. In September 2025 the Board found the VA medical opinion inadequate to decide the claim. 

An October 2025 VA medical opinion was obtained. The examiner opined that the Veteran's gout was less likely than not due to service. The examiner noted that she reviewed the entire claims file including prior Board remands, lay statements and the Veteran's submitted evidence. The examiner noted that on active duty there was no evidence of a chronic condition of gout. The examiner indicated that no evidence supported that the joint conditions noted on active duty were an early symptom of the later diagnosed gout. Given the known physiology of gout, the examiner opined that the systemic condition of gout was most likely due to the Veteran's kidney disease preventing proper regulation of uric acid. The examiner reiterated that there was no objective evidence of early level of chronic kidney disease on active duty. The examiner concluded that no nexus existed.

The October 2025 examiner then opined that the Veteran's gout was less likely than not proximately caused by service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, degenerative
 of the later diagnosed gout. Given the known physiology of gout, the examiner opined that the systemic condition of gout was most likely due to the Veteran's kidney disease preventing proper regulation of uric acid. The examiner reiterated that there was no objective evidence of early level of chronic kidney disease on active duty. The examiner concluded that no nexus existed.

The October 2025 examiner then opined that the Veteran's gout was less likely than not proximately caused by service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, degenerative arthritis, right ankle, degenerative arthritis, left ankle and cervical strain. The rationale provided was that gout and service connected disabilities are not medically related. The examiner noted that gout is a separate entity entirely from the service connected disabilities and unrelated. The examiner referenced that a thorough review of medical literature failed to demonstrate a causal relationship. The examiner noted that gout is a systemic condition and not caused by a specific joint. The examiner also opined that the Veteran's gout was at least as likely as not proximately due to his nonservice-connected kidney disorder. The rationale provided was that the medical literature supports that causes of gout include overproduction or underproduction of excretion of uric acid and that kidney disease is a major risk factor for gout.

Taken together, the Board finds the October 2023 and October 2025 VA medical opinions adequate to decide the claim. In this regard, the VA examiners reviewed the claims file, discussed relevant medical literature and provided a supporting rationale for the conclusions reached. The VA examiner noted the Veteran's contentions that his gout was due to service and/or service connected disabilities. In addition, the VA examiners adequately considered the statements and contentions of the Veteran, to include the circumstances of his service, and the onset and continuity of his symptoms. The opinions also have clear conclusions and supporting data, as well as reasoned medical explanations. Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. 

Upon reviewing the aforementioned opinions, the Board finds that the only probative opinions of record determined that the Veteran's gout was not related to service and/or service connected disabilities. While a positive secondary opinion was provided as to kidney disorder, the Veteran is not service connected for a kidney disorder.

The Board notes that lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, supra. 

In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's gout and any instance of his service and/or service connected disabilities to be complex in nature. Woehlaert v. Nicholson, supra. Specifically, while the Veteran was competent to describe his symptoms, the Board accords his statements regarding the etiology of such claimed disorder little probative value as he was not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, supra. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of diagnostic testing. In the instant case, there is no suggestion that the Veteran has had any medical training. Hence, the Board finds that he was not competent to provide a medical opinion to support the claim on the basis of his assertions alone. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinions of the Veteran are nonprobative evidence.

Accordingly, the Board finds that entitlement to service connection for gout, to include as secondary to service connected bilateral flat feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, cervical strain, degenerative arthritis, right ankle, degenerative arthritis, left ankle and nonservice-connected kidney disorder is not warranted. The appeal is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, supra.

 

 

KRISTY L. ZADORA

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	A. Kuhn, Associate Counsel

The Board's decision in
 feet, right knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of extension, left knee osteoarthritis with limitation of flexion, right knee osteoarthritis with limitation of flexion, cervical strain, degenerative arthritis, right ankle, degenerative arthritis, left ankle and nonservice-connected kidney disorder is not warranted. The appeal is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, supra.

 

 

KRISTY L. ZADORA

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	A. Kuhn, 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.