BRAIN DISEASE DUE TO TRAUMA

THOMAS H. O'SHAY · 2026 · Case ID: A26033299

DENIED

Summary

The veteran, who served from July 1965 to December 1968, appeals the denial of service connection for cerebrovascular strokes, chronic lymphocytic leukemia (CLL), diabetes mellitus type II, hypertension, and heart disease. The veteran claims these conditions are due to exposure to jet fuel and chemicals as an aircraft mechanic, with alleged onsets or worsening between 2007 and 2016. The Board found that the veteran's service treatment records were silent for all claimed conditions, and post-service records indicated diagnoses many years after separation, precluding direct or presumptive service connection. The Board reviewed multiple VA medical opinions, finding the November 2023 opinion to be the most probative. This opinion concluded that it was less likely than not that the claimed conditions were related to service or the conceded toxic exposure risk activity (TERA), citing the lack of scientific evidence and the presence of non-service-related risk factors such as age, race, and lifestyle choices. The Board also found the veteran's lay assertions regarding causation to be without probative value, as the issues extended beyond observable cause-and-effect relationships. The Board acknowledged the veteran's competency to report symptoms but not to diagnose or determine etiology. The Board denied all claims, finding the evidence persuasively against service connection and noting the benefit-of-the-doubt doctrine was not applicable due to the weight of evidence against the claims. The Board also addressed a challenge to the VA examiner's competency, finding it was not a pre-decisional duty to assist error as it was raised after the rating decision.

Rationale

No in-service onset or continuity of symptoms; VA opinions found less likely than not related to service/TERA; No probative medical opinion to the contrary

Special Benefit

NO SPECIAL BENEFIT

Docket No.

251217-624072

Full Decision Text

Citation Nr: A26033299
Decision Date: 04/09/26 Archive Date: 04/09/26

DOCKET NO. 251217-624072
DATE: April 9, 2026

ORDER

Entitlement to service connection for cerebrovascular strokes is denied.

Entitlement to service connection for chronic lymphocytic leukemia (CLL) is denied.

Entitlement to service connection for diabetes mellitus type II is denied.

Entitlement to service connection for hypertension is denied.

Entitlement to service connection for heart disease, to include ischemic heart disease (IHD) and coronary artery disease (CAD), is denied.

FINDINGS OF FACT

1. The Veteran's cerebrovascular strokes did not have their onset in service or within one year of service; nor are the Veteran's cerebrovascular strokes etiologically related to service, or any exposure event therein, or a service-connected disability.

2. The Veteran's CLL did not have its onset in service or within one year of service; nor is the Veteran's CLL etiologically related to service, or any exposure event therein.

3. The Veteran's diabetes mellitus type II did not have its onset in service or within one year of service; nor is the Veteran's diabetes mellitus type II etiologically related to service, or any exposure event therein.

4. The Veteran's hypertension did not have its onset in service or within one year of service; nor is the Veteran's hypertension etiologically related to service, or any exposure event therein, or a service-connected disability.

5. The Veteran's heart disease did not have its onset in service or within one year of service; nor is the Veteran's heart disease etiologically related to service, or any exposure event therein, or a service-connected disability.

CONCLUSIONS OF LAW

1. The criteria for service connection for cerebrovascular strokes have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

2. The criteria for service connection for CLL have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.

3. The criteria for service connection for diabetes mellitus type II have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.

4. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

5. The criteria for service connection for heart disease have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from July 1965 to December 1968.

In August 2025, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of August 2024 (cerebrovascular strokes, diabetes mellitus type II, hypertension, and IHD) and October 2024 (CLL) decisions. In November 2025, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal, which considered the evidence of record at the time of the respective prior August 2024 and October 2024 decision.

In the December 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time of the respective August 2024 and October 2024 AOJ decision, which was subsequently subject to higher-level review, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision, which was subsequently subject to higher-level review and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA
), the Veteran elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time of the respective August 2024 and October 2024 AOJ decision, which was subsequently subject to higher-level review, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision, which was subsequently subject to higher-level review and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

After the November 2025 rating decision, the Veteran's representative requested a copy of the Curriculum Vitae (CV) of various VA examiners. Typically, a claimant must have the ability to secure from the VA the information necessary to raise the competency challenge. Once the request is made for information as to the competency of the examiner, a claimant normally has the right, absent unusual circumstances, to the curriculum vitae and other information about the qualifications of a medical examiner. This is mandated by the VA's duty to assist. Francway v. Wilkie, 940 F.3d 1304, 1308 (Fed. Cir. 2019).

However, pursuant to the provisions of the AMA, the Board reviews the record only to correct pre-decisional duty to assist errors. In this case, the AMA rating decision on appeal was issued in November 2025, and the challenge to the VA examiner's competency was received in December 2025. Because the challenge was received after the rating decision, the failure to provide the VA examiner's qualifications to the Veteran does not represent a pre-decisional duty to assist error.

This appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.900(c).

Service Connection

Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a).

For the showing of a chronic disease in service, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Service connection may also be established on a secondary basis. In this instance, the evidence must demonstrate an etiological relationship between a service-connected disability or disabilities on the one hand and the condition said to be proximately due to the service-connected disability or disabilities on the other. 38 C.F.R. § 3.310(a); Wallin v. West, 11 Vet. App. 509 (1998).

The Board also notes the recent enactment of the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive To
) and does not apply to other disabilities which might be considered chronic from a medical standpoint. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

The Board also notes the recent enactment of the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022, also known as the Honoring our PACT Act of 2022 (hereinafter referred to as the PACT Act), a new law that expands VA health care and benefits for veterans exposed to burn pits or other toxic substances during military service. Here, in January 2023, VA issued a toxic exposure risk activity (TERA) memorandum indicating the Veteran's participation in a TERA during service, due to his military occupational specialty (MOS) as an Aircraft Maintenance Specialist with exposure to jet fuel and chemicals. Therefore, the TERA examination requirements under 38 U.S.C. § 1168 are implicated. Specifically, the PACT Act directs that, in certain circumstances, when a veteran is found to have been involved in a TERA during service, VA must obtain an adequate opinion addressing whether such toxic exposure caused a currently diagnosed disability. The Board notes that TERA opinions have been obtained and are of record.

The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value.

1. Entitlement to service connection for cerebrovascular strokes is denied.

The Veteran contends that he has cerebrovascular strokes due to his exposure to jet fuel as an aircraft mechanic. He asserts that his disability began or worsened in 2016.

The AOJ found that participation in a TERA is conceded, noting that records show that the Veteran was exposed to jet fuel while in service. Additionally, the AOJ found that the Veteran had a diagnosis of cerebrovascular strokes.

Service treatment records (STRs) are silent for any complaints, treatment, or diagnosis for cerebrovascular strokes. Post-service treatment records reflect that the Veteran had a stroke in October 2016.

The Veteran was afforded a VA examination in November 2022, which notes a diagnosis of cerebrovascular accident due to right carotid artery stenosis. The examination notes that the Veteran reported the onset of his disability as October 2016, noting that he recalled having temporary loss of vision in the left eye, slurred speech, and numbness in left side of the upper and lower extremity; he went to the hospital and had several transient ischemic attacks (TIAs). He was found to have a blocked right carotid artery and underwent a right carotid endarterectomy. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the Veteran reported that he had a stroke in October 2016 which resulted in findings of carotid stenosis and surgical treatment of right carotid endarterectomy. The examiner, citing to medical literature, noted that carotid stenosis may go unnoticed until it is serious enough to deprive the brain of blood, causing a stroke or transient ischemic attacks; carotid artery disease causes about 10 to 20 percent of strokes. In addition, the examiner indicated that a thorough review of medical literature failed to demonstrate that cerebrovascular strokes are caused by exposure to JP4 jet fuel. Therefore, based on review of the available evidence, it is less likely than not that the claimed condition is due to service as there is scant data supporting a nexus between the current diagnosis of cerebrovascular accident due to right carotid artery stenosis and military service.

A November 2023 VA opinion indicates that the claimed condition was less likely than not caused by the
stenosis may go unnoticed until it is serious enough to deprive the brain of blood, causing a stroke or transient ischemic attacks; carotid artery disease causes about 10 to 20 percent of strokes. In addition, the examiner indicated that a thorough review of medical literature failed to demonstrate that cerebrovascular strokes are caused by exposure to JP4 jet fuel. Therefore, based on review of the available evidence, it is less likely than not that the claimed condition is due to service as there is scant data supporting a nexus between the current diagnosis of cerebrovascular accident due to right carotid artery stenosis and military service.

A November 2023 VA opinion indicates that the claimed condition was less likely than not caused by the indicated toxic exposure risk activity(ies), 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 examiner noted review of the exposure information and the Veteran's MOS as an Aircraft Maintenance Specialist, and the Veteran's claimed exposure to jet fuel and chemicals. The examiner indicated that records reviewed do not indicate any risk factors outside of military service. The examiner noted review of the Veteran's electronic folder along with published medical/VA literature and indicated that there is no medical or scientific evidence available that provides any indication of a relationship between the development of the condition at issue and the TERA. The examiner noted that many factors can increase the risk of stroke. Potentially treatable stroke risk factors include: lifestyle risk factors, being overweight or obese, physical inactivity, heavy or binge drinking, use of illegal drugs such as cocaine and methamphetamine, medical risk factors, high blood pressure, cigarette smoking or secondhand smoke exposure, high cholesterol, diabetes, obstructive sleep apnea, cardiovascular disease, including heart failure, heart defects, heart infection or irregular heart rhythm, such as atrial fibrillation, personal or family history of stroke, heart attack or transient ischemic attack, COVID-19 infection; other factors associated with a higher risk of stroke include: age, race or ethnicity, sex, and hormones. However, the Veteran's electronic folder and evidence of record do not document symptoms, diagnoses, complaints of, and/or encounters that would indicate a causal relationship between indicated toxic exposure risk activity(ies) and the claimed condition. The examiner noted that published medical literature and general medical knowledge fail to demonstrate a causal relationship between indicated toxic exposure risk activity(ies) and the claimed condition, and a nexus could not be established.

After a review of the evidence, the Board finds that the evidence is persuasively against the Veteran's claim for service connection for cerebrovascular strokes.

At the outset, the Board notes that there is no evidence in this case, nor does the Veteran contend, that his cerebrovascular strokes had their onset during his period of active service. Nor is there evidence to suggest the presence of cerebrovascular strokes until many years after the Veteran's active service, and thus, there is no indication of continuity of symptoms since service or that the Veteran's cerebrovascular strokes manifested to a compensable degree within one year of his separation from military service. Indeed, as noted above, the evidence, both lay and medical, reflects a diagnosis and treatment for cerebrovascular strokes more than 40 years after his separation from service. Accordingly, service connection for cerebrovascular strokes cannot be granted on a direct basis based on in-service incurrence or on a presumptive basis for chronic diseases. 38 C.F.R. §§ 3.307, 3.309.

Moreover, other than the Veteran's claim that cerebrovascular strokes should be service connected, the record lacks any probative evidence connecting cerebrovascular strokes to his active service, to include any exposure event therein. There is no documentation in any of his medical records supporting such a relationship, and the Veteran has not provided a medical opinion or any other evidence for this connection.

The Board acknowledges that the Veteran has asserted that the VA opinions of record are not adequate. However, neither the Veteran nor his representative have provided any explanation regarding this assertion. Nevertheless, the Board finds the VA opinions to be adequate and the most probative evidence regarding a nexus. In this regard, the VA examiners considered the Veteran's reported history, the medical records, and medical literature; and provided opinions with supporting rationale that are consistent with the evidence record. The examiners considered the Veteran's exposure to jet fuel and chemicals and found that it is less likely than not that the cerebrovascular strokes are due to service, to include his in-service TERA. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). There is no probative medical opinion to the contrary.

The Board acknowledges that the Veteran is competent to report on
evidence regarding a nexus. In this regard, the VA examiners considered the Veteran's reported history, the medical records, and medical literature; and provided opinions with supporting rationale that are consistent with the evidence record. The examiners considered the Veteran's exposure to jet fuel and chemicals and found that it is less likely than not that the cerebrovascular strokes are due to service, to include his in-service TERA. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). There is no probative medical opinion to the contrary.

The Board acknowledges that the Veteran is competent to report on his symptoms and the history of those symptoms. However, the questions of diagnosis and causation of cerebrovascular strokes extend beyond an immediately observable cause-and-effect relationship. As the Veteran is not shown to possess the medical training to render competent opinions about such specialized medical matters, the Veteran is not competent to address the diagnosis or etiology of his cerebrovascular strokes. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Thus, the Veteran's assertions that his cerebrovascular strokes are due to service are afforded no probative value.

Finally, to the extent that the November 2023 VA examiner suggested that cerebrovascular strokes could be related to hypertension, diabetes, or heart disease, as will be addressed below, the Board finds that service connection is not warranted for these disabilities. Thus, secondary service connection is not available, as cerebrovascular strokes cannot be service-connected secondary to a nonservice-connected disability. 38 C.F.R. § 3.310.

Based on the foregoing, the Board finds that the evidence is persuasively against a grant of service connection for cerebrovascular strokes on a direct and secondary basis. In reaching this conclusion, the Board has considered the benefit-of-the-doubt doctrine. However, as the evidence is persuasively against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102.

2. Entitlement to service connection for chronic lymphocytic leukemia (CLL) is denied.

The Veteran contends that he has CLL due to his exposure to jet fuel as an aircraft mechanic. He asserts that his disability began or worsened in 2020.

STRs are silent for any complaints, treatment, or diagnosis for chronic lymphocytic leukemia. Post-service treatment records reflect a diagnosis of leukemia in 2021.

The Veteran was afforded a VA examination in February 2023, which notes a diagnosis of chronic lymphocytic leukemia and macrocytic anemia. The examination notes that the onset of the Veteran's disability was 2021, noting that CLL was discovered on routine labs. The examination notes that the cause of his CLL was unknown. In a June 2023 opinion, the examiner indicated that the claimed condition was less likely than not caused by the indicated toxic exposure risk activity(ies), 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 examiner indicated that the Veteran has a diagnosis of CLL. While the exact etiology of CLL is not known, genetic, rather than environmental factors, are favored. Those environmental factors that are suggested have not been definitively linked to the development of CLL. There is insufficient evidence in the medical and scientific literature to support the claim.

A September 2024 VA examination notes a diagnosis of CLL. The examination notes that his disability began around March 2020, noting that the Veteran reported that he was anemic several times; he reported that he had IV infusions and blood tests, swollen nodes, and tiredness. The Veteran reported that he began chemotherapy in November 2023. The examiner opined that the claimed condition was less likely than not caused by the indicated toxic exposure risk activity(ies), 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 examiner indicted that factors that may increase the risk of CLL include: age, noting that this disease occurs most often in older adults; race, noting that white people are more likely to develop chronic lymphocytic leukemia than are people of other races; family history of blood and bone marrow cancers, noting that a family history of CLL or other blood and bone marrow cancers may increase your risk; exposure to chemicals, noting that certain herbicides and insecticides, including Agent Orange used during the Vietnam War, have been linked to an increased risk of chronic lymphocytic leukemia. The examiner furthered that Monoclonal B-cell lymphocytosis (MBL) causes an increased number of one type of lymphocyte (B cells) in the blood, and for a small number of people with MBL, the condition may develop into CLL. If you have MBL and also have a family history of CLL, you may have a higher risk of developing cancer.

The examiner noted review of the exposure information and the Veteran's MOS as an Aircraft Maintenance Specialist, and the Veteran's claimed exposure to jet fuel and chemicals. The examiner noted that the records reviewed indicate the following risk factors outside of military service: age, race. The examiner indicated that there is no medical or scientific evidence available that notes a relationship between the development of the condition at issue and the TERA, and there are risk factors outside of military service (age, race) that far outweigh any potential risk factors identified in the TERA. Therefore, it is less likely than not that this Veteran's CLL was caused by the indicated toxic exposure risk activities.

After a review of the evidence, the Board finds that the evidence is persuasively against the Veteran's claim for service connection for CLL.

At the outset, the Board notes that there is no evidence in this case, nor does the Veteran contend, that his CLL had its onset during his period of active service. Nor is there evidence to suggest the presence of CLL until many years after the Veteran's active service, and thus, there is no indication of continuity of symptoms since service or that the Veteran's CLL manifested to a compensable degree within one year of his separation from military service. Indeed, as noted above, the evidence, both lay and medical, reflects a diagnosis and treatment for CLL more than 50 years after his separation from service. Accordingly, service connection for CLL cannot be granted on a direct basis based on in-service incurrence or on a presumptive basis for chronic diseases. 38 C.F.R. §§ 3.307, 3.309.

Moreover, other than the Veteran's claim that CLL should be service connected, the record lacks any probative evidence connecting CLL to his active service, to include any exposure event therein. There is no documentation in any of his medical records supporting such a relationship, and the Veteran has not provided a medical opinion or any other evidence for this connection.

The Board acknowledges that the Veteran has asserted that the VA opinions of record are not adequate. However, neither the Veteran nor his representative have provided any explanation regarding this assertion. Nevertheless, the Board finds the VA opinions, particularly the September 2024 VA opinion, to be adequate and the most probative evidence regarding a nexus. In this regard, the VA examiner considered the Veteran's history, the medical records, and medical literature; and provided an opinion with supporting rationale that is consistent with the evidence record. The examiner considered the Veteran's exposure to jet fuel and chemicals and found that it is less likely than not that the claimed condition is due to service, to include the in-service TERA. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Indeed, the examiner found that it was more likely than the Veteran's CLL was due to his age and race than his in-service TERA. There is no probative medical opinion to the contrary.

The Board acknowledges that the Veteran is competent to report on his symptoms and the history of those symptoms. However, the questions of diagnosis and causation of CLL extend beyond an immediately observable cause-and-effect relationship. As the Veteran is not shown
not that the claimed condition is due to service, to include the in-service TERA. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Indeed, the examiner found that it was more likely than the Veteran's CLL was due to his age and race than his in-service TERA. There is no probative medical opinion to the contrary.

The Board acknowledges that the Veteran is competent to report on his symptoms and the history of those symptoms. However, the questions of diagnosis and causation of CLL extend beyond an immediately observable cause-and-effect relationship. As the Veteran is not shown to possess the medical training to render competent opinions about such specialized medical matters, the Veteran is not competent to address the diagnosis or etiology of his CLL. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Thus, the Veteran's assertions that his CLL are due to service are afforded no probative value.

Based on the foregoing, the Board finds that the evidence is persuasively against a grant of service connection for CLL. In reaching this conclusion, the Board has considered the benefit-of-the-doubt doctrine. However, as the evidence is persuasively against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102.

3. Entitlement to service connection for diabetes mellitus type II is denied.

The Veteran contends that he has diabetes mellitus type II due to his exposure to jet fuel as an aircraft mechanic. He asserts that his disability began or worsened in 2007.

The AOJ found that participation in a TERA is conceded, noting that a TERA memorandum dated in January 2023 conceded toxic exposure. Additionally, the AOJ found that the Veteran had a diagnosis of diabetes, which is a chronic condition under 38 CFR 3.309 and may be presumptively linked to military service, and the Veteran has sufficient service to meet the minimum requirements for presumptive service connection.

STRs are silent for any complaints, treatment, or diagnosis for diabetes mellitus type II. Post-service treatment records note that diabetes was considered as early as May 2007 when he was assessed for neuropathy. However, available records do not reflect a confirmed diagnosis of diabetes mellitus until 2021.

The Veteran was afforded a VA examination in November 2022, which notes a diagnosis of diabetes mellitus type II. The examination notes that the Veteran's diabetes mellitus type II was diagnosed in 2007. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that a thorough review of medical literature failed to demonstrate that diabetes mellitus type II is caused by exposure to JP4 jet fuel. The examiner explained that diabetes mellitus type II is multifactorial in etiology as there are numerous factors that can cause diabetes mellitus type II including being overweight, physical inactivity, insulin resistance, and family history. The examiner therefore indicated that based on review of the available evidence, it is less likely than not that the claimed condition is due to service as there is scant data supporting a nexus between the current diagnosis of diabetes mellitus type II and military service.

A November 2023 VA opinion indicates that the claimed condition was less likely than not caused by the indicated toxic exposure risk activity(ies), 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 examiner noted review of the exposure information and the Veteran's MOS as an Aircraft Maintenance Specialist, and the Veteran's claimed exposure to jet fuel and chemicals. The examiner indicated that records reviewed do not indicate any risk factors outside of military service. The examiner noted review of the Veteran's electronic folder along with published medical/VA literature and indicated that there is no medical or scientific evidence available that provides any indication of a relationship between the development of the condition at issue and the TERA. The examiner noted that risk factors that may increase the risk of type II diabetes include: weight, fat distribution, inactivity, family history, race and ethnicity, blood lipid levels, age, prediabetes, pregnancy-related risks, and polycystic ovary syndrome. However, the Veteran's
exposure information and the Veteran's MOS as an Aircraft Maintenance Specialist, and the Veteran's claimed exposure to jet fuel and chemicals. The examiner indicated that records reviewed do not indicate any risk factors outside of military service. The examiner noted review of the Veteran's electronic folder along with published medical/VA literature and indicated that there is no medical or scientific evidence available that provides any indication of a relationship between the development of the condition at issue and the TERA. The examiner noted that risk factors that may increase the risk of type II diabetes include: weight, fat distribution, inactivity, family history, race and ethnicity, blood lipid levels, age, prediabetes, pregnancy-related risks, and polycystic ovary syndrome. However, the Veteran's electronic folder and evidence of record do not document symptoms, diagnoses, complaints of, and/or encounters that would indicate a causal relationship between indicated toxic exposure risk activity(ies) and the claimed condition. Therefore, the examiner indicated that the published medical literature and general medical knowledge fail to demonstrate a causal relationship between indicated toxic exposure risk activity(ies) and the claimed condition, and a nexus could not be established.

After a review of the evidence, the Board finds that the evidence is persuasively against the Veteran's claim for service connection for diabetes mellitus type II.

At the outset, the Board notes that there is no evidence in this case, nor does the Veteran contend, that his diabetes mellitus type II had its onset during his period of active service. Nor is there evidence to suggest the presence of diabetes mellitus type II until many years after the Veteran's active service, and thus, there is no indication of continuity of symptoms since service or that the Veteran's diabetes mellitus type II manifested to a compensable degree within one year of his separation from military service. Indeed, even considering that the diabetes mellitus type II began in approximately 2007 as noted in the November 2022 VA examination and reported by the Veteran, this is still more than 30 years after his separation from service. Accordingly, service connection for diabetes mellitus type II cannot be granted on a direct basis based on in-service incurrence or on a presumptive basis for chronic diseases. 38 C.F.R. §§ 3.307, 3.309.

Moreover, other than the Veteran's claim that diabetes mellitus type II should be service connected, the record lacks any probative evidence connecting diabetes mellitus type II to his active service, to include any exposure event therein. There is no documentation in any of his medical records supporting such a relationship, and the Veteran has not provided a medical opinion or any other evidence for this connection.

The Board acknowledges that the Veteran has asserted that the VA opinions of record are not adequate. However, neither the Veteran nor his representative have provided any explanation regarding this assertion. Nevertheless, the Board finds the VA opinions, particularly the November 2023 VA opinion, to be adequate and the most probative evidence regarding a nexus. In this regard, the VA examiner considered the Veteran's history, the medical records, and medical literature; and provided an opinion with supporting rationale that is consistent with the evidence record. The examiner considered the Veteran's exposure to jet fuel and chemicals and found that it is less likely than not that the claimed condition is due to service, to include his in-service TERA. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). There is no probative medical opinion to the contrary.

The Board acknowledges that the Veteran is competent to report on his symptoms and the history of those symptoms. However, the questions of diagnosis and causation of diabetes mellitus type II extend beyond an immediately observable cause-and-effect relationship. As the Veteran is not shown to possess the medical training to render competent opinions about such specialized medical matters, the Veteran is not competent to address the diagnosis or etiology of his diabetes mellitus type II. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Thus, the Veteran's assertions that his diabetes mellitus type II are due to service are afforded no probative value.

Based on the foregoing, the Board finds that the evidence is persuasively against a grant of service connection for diabetes mellitus type II. In reaching this conclusion, the Board has considered the benefit-of-the-doubt doctrine. However, as the evidence is persuasively against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C
. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Thus, the Veteran's assertions that his diabetes mellitus type II are due to service are afforded no probative value.

Based on the foregoing, the Board finds that the evidence is persuasively against a grant of service connection for diabetes mellitus type II. In reaching this conclusion, the Board has considered the benefit-of-the-doubt doctrine. However, as the evidence is persuasively against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102.

4. Entitlement to service connection for hypertension is denied.

The Veteran contends that he has hypertension due to his exposure to jet fuel and chemicals as an aircraft mechanic. He asserts that his disability began or worsened in 2002.

The AOJ found participation in a toxic exposure risk activity is conceded, noting that the records show he was exposed to jet fuel while in service. He also had a diagnosis of hypertension, which is a chronic disease that may be presumptively linked to military service, and the Veteran had sufficient service to meet the minimum requirements for presumptive service connection.

STRs are silent for any complaints, treatment, or diagnosis for hypertension; his separation examination revealed a blood pressure reading of 120/78, and the Veteran denied having high blood pressure. Post-service treatment records reflect treatment for hypertension as early as 2007.

The Veteran was afforded a VA examination in November 2022, which notes a diagnosis of hypertension. The examination notes that the date of onset of the Veteran's hypertension was 1996, noting that the Veteran had high blood pressure during his annual physicals with his primary care provider (PCP); he was immediately put on medication to control his blood pressure, and he is still on medication to control his blood pressure. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that a thorough review of medical literature failed to demonstrate that high blood pressure is caused by exposure to JP4 jet fuel. The examiner explained that high blood pressure is multifactorial in etiology as there are numerous factors that can cause high blood pressure including being overweight, physical inactivity, certain conditions such as diabetes and atherosclerosis. The examiner therefore found that, based on review of the available evidence, it is less likely than not that the claimed condition is due to service as there is scant data supporting a nexus between the current diagnosis of high blood pressure and military service.

After a review of the evidence, the Board finds that the evidence is persuasively against the Veteran's claim for service connection for hypertension.

At the outset, the Board notes that there is no evidence in this case, nor does the Veteran contend, that his hypertension had its onset during his period of active service. Nor is there evidence to suggest the presence of hypertension until many years after the Veteran's active service, and thus, there is no indication of continuity of symptoms since service or that the Veteran's hypertension manifested to a compensable degree within one year of his separation from military service. Indeed, even considering the Veteran's reports that he was diagnosed with hypertension
risk activity(ies) and the claimed condition, and a nexus could not be established.

After a review of the evidence, the Board finds that the evidence is persuasively against the Veteran's claim for service connection for hypertension.

At the outset, the Board notes that there is no evidence in this case, nor does the Veteran contend, that his hypertension had its onset during his period of active service. Nor is there evidence to suggest the presence of hypertension until many years after the Veteran's active service, and thus, there is no indication of continuity of symptoms since service or that the Veteran's hypertension manifested to a compensable degree within one year of his separation from military service. Indeed, even considering the Veteran's reports that he was diagnosed with hypertension in 1996, this is still almost 30 years after his separation from service. Accordingly, service connection for hypertension cannot be granted on a direct basis based on in-service incurrence or on a presumptive basis for chronic diseases. 38 C.F.R. §§ 3.307, 3.309.

Moreover, other than the Veteran's claim that hypertension should be service connected, the record lacks any probative evidence connecting hypertension to his active service, to include any exposure event therein. There is no documentation in any of his medical records supporting such a relationship, and the Veteran has not provided a medical opinion or any other evidence for this connection.

The Board acknowledges that the Veteran has asserted that the VA opinions of record are not adequate. However, neither the Veteran nor his representative have provided any explanation regarding this assertion. Nevertheless, the Board finds the VA opinions, particularly the November 2023 VA opinion, to be adequate and the most probative evidence regarding a nexus. In this regard, the VA examiner considered the Veteran's reported history, the medical records, and medical literature; and provided an opinion with supporting rationale that is consistent with the evidence record. The examiner considered the Veteran's exposure to jet fuel and chemicals and found that the Veteran's it is less likely than not that hypertension is due to service to include his in-service TERA. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). There is no probative medical opinion to the contrary.

The Board acknowledges that the Veteran is competent to report on his symptoms and the history of those symptoms. However, the questions of diagnosis and causation of hypertension extend beyond an immediately observable cause-and-effect relationship. As the Veteran is not shown to possess the medical training to render competent opinions about such specialized medical matters, the Veteran is not competent to address the diagnosis or etiology of his hypertension. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Thus, the Veteran's assertions that his hypertension are due to service are afforded no probative value.

Finally, to the extent that the November 2022 VA examiner suggested that hypertension could be related to diabetes or heart disease, the Board finds that service connection is not warranted for diabetes mellitus type II or heart disease. Thus, secondary service connection is not available, as hypertension cannot be service-connected secondary to a nonservice-connected disability. 38 C.F.R. § 3.310.

Based on the foregoing, the Board finds that the evidence is persuasively against a grant of service connection for hypertension. In reaching this conclusion, the Board has considered the benefit-of-the-doubt doctrine. However, as the evidence is persuasively against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102.

5. Entitlement to service connection for heart disease, to include IHD and CAD, is denied.

The Veteran contends that he has heart disease due to his exposure to jet fuel and radiation as an aircraft mechanic. He asserts that his disability began or worsened in 2016.

The AOJ found that the Veteran had a diagnosis of IHD, which was a chronic disease that may be presumptively linked to military service, and the Veteran had sufficient service to meet the minimum requirements for presumptive service connection. The AOJ also found that participation in a toxic exposure risk activity is conceded, noting that records show exposure to jet fuel in service.

STRs are silent for any complaints, treatment, or diagnosis for heart disease; while the Veteran endorsed chest pain
to service connection for heart disease, to include IHD and CAD, is denied.

The Veteran contends that he has heart disease due to his exposure to jet fuel and radiation as an aircraft mechanic. He asserts that his disability began or worsened in 2016.

STRs are silent for any complaints, treatment, or diagnosis for heart disease; while the Veteran endorsed chest pain or pressure at service separation, a chest radiograph was negative and he had a normal heart evaluation, noting that he had not had any problems the last couple years and there were no complications or sequalae. Post-service treatment records reflect that the Veteran had coronary artery calcifications in 2013 and a diagnosis of coronary artery disease in 2017.

The Veteran was afforded a VA examination in September 2022, which notes diagnoses of acute, subacute, or old myocardial infarction; atherosclerotic cardiovascular disease; unstable angina; arteriosclerotic heart disease (coronary artery disease); coronary artery bypass graft (CABG); and hypertensive heart disease. The Veteran indicated that the onset of his disability was in 2016, noting that he was admitted to the hospital for TIA's and strokes in November 2016. In December 2016, the Veteran had a NSTEMI with quadruple cardiac bypass. The Veteran reported that he was followed by multiple specialists and continued doing well until he was found to have A flutter in June 2021 and had a right carotid surgery in June 2021. The examiner noted that the Veteran's heart disability qualified as IHD. The examiner indicated that the Veteran's CAD and atherosclerotic heart disease of native coronary artery with unstable angina pectoris were due to exposure to Agent Orange. The examiner opined that the claimed condition was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran had exposure to toxic chemicals in jet fuel in service, and the Veteran had no issues related to the claimed cardiovascular/heart condition prior to military service. Thus, the current diagnosis of ischemic cardiovascular disease is related to the exposure to toxic chemicals in jet fuel, noting that exposure that occurred during Veteran's service exposed him to a proven cause of ischemic cardiovascular disease; there is evidence of chronicity, and a nexus has been established.

The Veteran was afforded another VA examination in February 2023, which notes diagnoses of acute, subacute, or old myocardial infarction; atherosclerotic cardiovascular disease; arteriosclerotic heart disease (coronary artery disease); coronary artery bypass graft; hypertensive heart disease, and atrial fibrillation. The examination notes the onset of the Veteran's disability was 2016, noting that he experienced chest pain and blockages were noted; thereafter the MI occurred and the CABG quad was done. The examiner noted that the Veteran's heart disability qualified as IHD. The examiner indicated that CAD was due to hyperlipidemia, smoking history, and agent orange exposure; the etiology of atrial fibrillation was unknown; MI was due to CAD and atherosclerosis with hyperlipidemia; atherosclerotic heart disease was due to hyperlipidemia and smoking; hypertensive heart disease was due to uncontrolled hypertension; CABG was due to CAD and atherosclerosis with hyperlipidemia. The examiner opined that the claimed condition was less likely than not caused by the indicated toxic exposure risk activity(ies), 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 examiner explained that the Veteran has a history of hyperlipidemia and hypertension, leasing risk factors for ischemic heart disease. The examiner indicated that the brief period of exposure to aviation fuels and chemicals leading to myocardial infarction, atherosclerotic cardiovascular disease, unstable angina and coronary artery bypass graft is not supported in the literature.

A November 2023 VA opinion indicates that the claimed condition was less likely than not caused by the indicated toxic exposure risk activity(ies), 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 examiner noted review of the exposure information and the Veteran's MOS as an Aircraft Maintenance Specialist, and the Veteran's claimed exposure to jet fuel and chemicals. The examiner indicated that records reviewed do not indicate any risk factors outside of military service. The examiner noted that the Veteran was claiming service connection for IHD based upon claimed exposure to indicated toxic exposure risk activity(ies)/ jet fuel and chemicals. The examiner noted review of the Veteran's electronic folder along with published medical/VA literature and indicated that there is no medical or scientific evidence available that provides any indication of a relationship between the development of the condition at issue and the TERA. The examiner noted that comprehensive risk factors for CAD, MI, atherosclerotic heart disease, hypertensive heart disease, and CABG include: being older than 45 if you're assigned male at birth (AMAB) or over 55 if you're assigned female at birth (AFAB); having a biological family member with heart disease, especially a father or brother with a diagnosis before age 55 or mother or sister before age 65; eating a lot of saturated fat or refined carbohydrates; not exercising enough; not getting enough sleep; smoking, vaping or other tobacco use; having atherosclerosis; high blood pressure; high LDL ("bad") cholesterol; low HDL ("good") cholesterol; high triglycerides (hypertriglyceridemia); anemia; autoimmune diseases, including lupus and rheumatoid arthritis; chronic kidney disease; diabetes; HIV/AIDS; metabolic syndrome; a body mass index (BMI) higher than 25; sleep disorders like sleep apnea; early menopause (before age 40); endometriosis; history of gestational diabetes, eclampsia or preeclampsia; and use of hormonal birth control. However, the Veteran's electronic folder and evidence of record do not document symptoms, diagnoses, complaints of, and/or encounters that would indicate a causal relationship between indicated toxic exposure risk activity(ies) and the claimed condition. The examiner noted that published medical literature and general medical knowledge fail to demonstrate a causal relationship between indicated toxic exposure risk activity(ies) and the claimed condition, and a nexus could not be established.

After a review of the evidence, the Board finds that the evidence is persuasively against the Veteran's claim for service connection for heart disease.

At the outset, the Board notes that there is no evidence in this case, nor does the Veteran contend, that his heart disease had its onset during his period of active service. In this regard, although STRs reflect complaints of chest pain or pressure, no diagnosis was provided at that time. Nor is there evidence to suggest the presence of heart disease until many years after the Veteran's active service, and thus, there is no indication of continuity of symptoms since service or that the Veteran's heart disease manifested to a compensable degree within one year of his separation from military service. Indeed, as noted above, the evidence, both lay and medical, reflects a diagnosis and treatment for heart disease more than 40 years after his separation from service. Accordingly, service connection heart disease cannot be granted on a direct basis based on in-service incurrence or on a presumptive basis for chronic diseases. 38 C.F.R. §§ 3.307, 3.309.

Moreover, other than the Veteran's claim that heart disease should be service connected, the record lacks any probative evidence connecting heart disease to his active service, to include any exposure event therein. There is no documentation in any of his medical records supporting such a relationship, and the Veteran has not provided a medical opinion or any other evidence for this connection.

Initially, the Board has considered the September 2022 VA positive nexus opinion. However, the Board does not find that this opinion is sufficient to place the matter in equipoise at this time. Specifically, the examiner indicated that the indicated that the Veteran's CAD and atherosclerotic heart disease of native coronary artery with unstable angina pectoris were due to exposure to Agent Orange; however, there is no evidence in the record, nor does the Veteran claim, that he was exposed to Agent Orange. Additionally, the examiner also indicated that there was evidence of chronicity. However, this is not supported by the record or even claimed by the Veteran. Indeed, as noted above, the Veteran separated from service in 1968, and he claimed the onset of his disability was 2016 with medical treatment records that generally support his reported date of onset. Thus, this opinion appears to be based, in part, on an inaccurate factual premise. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely" (citations omitted)). Moreover, to the extent that the examiner indicated that ischemic cardiovascular disease is related to the exposure to toxic chemicals in jet fuel because the exposure occurred during Veteran's service which exposed him to a proven cause of ischemic cardiovascular disease, the Board notes that the examiner did not explain how toxic chemicals in jet fuel is "a proven cause" of heart disease. Thus, the Board notes that this opinion is also conclusory and not supported by sufficient rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two); see also Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (a mere conclusory opinion is insufficient to allow the Board to make an informed decision as to the weight to assign to a medical opinion). Therefore, for all of these reasons, the Board finds that this opinion is inadequate and affords this opinion no probative value.

However, the Board finds the November 2023 VA opinion to be adequate and the most probative evidence regarding a nexus. In this regard, the VA examiner considered the Veteran's reported history, the medical records, and medical literature; and provided an opinion with supporting rationale that is consistent with the evidence record. The examiner considered the Veteran's exposure to jet fuel and chemicals and found that it is less likely than not that the claimed condition is due to service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).

The Board acknowledges that the Veteran is competent to report on his symptoms and the history of those symptoms. However, the questions of diagnosis and causation of heart disease extend beyond an immediately observable cause-and-effect relationship. As the Veteran is not shown to possess the medical training to render competent opinions about such specialized medical matters, the Veteran is not competent to address the diagnosis or etiology of his heart disease. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Thus, the Veteran's assertions that his heart disease are due to service are afforded no probative value.

Finally, to the extent that VA examinations suggested that heart disease could be related to hypertension or diabetes, as discussed above, the Board finds that service connection is not warranted for these disabilities. Thus, secondary service connection is not available, as heart disease cannot be service-connected secondary to a nonservice-connected disability. 38 C.F.R. § 3.310.

Based on the foregoing, the Board finds that the evidence is persuasively against a grant of service connection for heart disease on a direct and secondary basis. In reaching this conclusion, the Board has considered the benefit-of-the-doubt doctrine. However, as the evidence is persuasively against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C. § 5107; Gilbert v. Derw
or diabetes, as discussed above, the Board finds that service connection is not warranted for these disabilities. Thus, secondary service connection is not available, as heart disease cannot be service-connected secondary to a nonservice-connected disability. 38 C.F.R. § 3.310.

Thomas H. O'Shay

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board D. Hite, 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.

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