Citation Nr: 1315554 Decision Date: 05/10/13 Archive Date: 05/15/13 DOCKET NO. 05-33 974 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for hypertension claimed as secondary to service-connected residuals of C4/C5, C5/C6 anterior cervical discectomy and fusion for cervical spondylosis with residual scar, neck pain, and left arm radiculopathy, or under the provisions of 38 U.S.C.A. § 1151. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. Giannecchini, Counsel INTRODUCTION The Veteran had active service from May 1975 to November 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2004 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In connection with the appeal, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge sitting at the RO in November 2009; a transcript of that hearing is associated with the claims file. The Board remanded this case in November 2010 and in June 2012. The case has since been returned to the Board by the Appeals Management Center (AMC) for further appellate review. FINDINGS OF FACT 1. The Veteran does not have hypertension that is attributable to her active military service, to include during the presumptive one year period following service; nor is hypertension caused or made worse by service-connected disability. 2. On May 11, 2004, the Veteran underwent a cervical epidural steroid injection procedure at the VA Medical Center (VAMC) in Tampa, Florida. 3. The medical evidence does not reflect that the Veteran suffered any additional disability, to include hypertension, as a result of the May 11, 2004 cervical epidural steroid injection procedure. CONCLUSIONS OF LAW 1. The Veteran does not have hypertension that is the result of disease or injury incurred in or aggravated during active service nor may hypertension be presumed to have been so incurred; hypertension is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1101, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012); 38 C.F.R. § 3.310 (2006). 2. The criteria for compensation benefits under 38 U.S.C.A. § 1151 for additional disability due to VA treatment have not been met. 38 U.S.C.A. §§ 1151, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.361, 17.32 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), was signed into law in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate the claim, including apprising him of his and VA's respective responsibilities in obtaining this supporting evidence. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining this evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). (The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008. See 73 Fed. Reg. 23353-56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the veteran to provide any evidence in the veteran's possession that pertains to the claim. See 38 C.F.R. § 3.159(b)(1).) In the present case, July 2004, February 2008, and December 2010 notice letters satisfy the statutory and regulatory requirement that VA notify a claimant which evidence, if any, will be obtained by the claimant and which evidence, if any, will be obtained by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)). In those letters, the Veteran was notified that VA was responsible for obtaining relevant records from any Federal agency and that VA would make reasonable efforts to obtain relevant records not held by a Federal agency, such as from a state, private treatment provider, or an employer. Additionally, the notice letters asked the Veteran to submit medical evidence, opinions, statements, and/or treatment records regarding her claim. Furthermore, the February 2008 and December 2010 notice letters provided the Veteran notice concerning the assignment of disability ratings and effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). With respect to the above, the Board also notes that while complete notice was not provided until after the RO initially adjudicated the Veteran's claim on appeal in November 2004, following the above noted December 2010 notice letter, the claim was properly re-adjudicated in December 2011 and January 2013 supplemental statements of the case (SSOC). See Prickett v. Nicholson, 20 Vet. App. 370, 376-77 (2006). Additionally, VA has fulfilled its duty to assist the Veteran with her claim by obtaining all potentially relevant evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. To this end, the RO and the AMC have obtained the Veteran's service treatment records (STRs), VA treatment records, and Social Security Administration (SSA) records. Pertinent VA examinations/opinions have also been obtained. 38 C.F.R. § 3.159(c)(4). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In this case, medical opinions were obtained in March 2011 and July 2012. These opinions are deemed sufficient, as the VA examiner considered all of the pertinent evidence of record including the statements of the Veteran, and provided her explanation for the opinions stated. The Board is mindful that in its June 2012 remand, the AMC was requested to obtain the Veteran's signed consent form associated with the May 11, 2004 cervical epidural steroid injection procedure. In response to the Board's June 2012 remand request, the AMC (through the CAPRI records system) obtained and associated with the claims file a copy of a May 11, 2004 VAMC Tampa anesthesia procedure note. The AMC tabbed the document in the claims file and highlighted the word "CONSENT." This document had previously been associated with the record on appeal prior to the Board's June 2012 remand. It appears that the AMC misunderstood the Board's request, or was otherwise unaware, that the "consent form" sought by the Board was a VA OF 522 (Request for Administration of Anesthesia and for Performance of Operations and Other Procedures). The OF 522 (also referred to at times in VA treatment records as an SF 522) documents the signed informed consent of the Veteran for the May 11, 2004 cervical epidural steroid injection procedure. See e.g., 38 C.F.R. § 17.32. Here, notwithstanding the lack of any OF 522/SF 522 associated with the record on appeal, the Board notes that the evidence, as discussed in further detail below, does not reflect any additional disability resulting from the May 11, 2004 cervical epidural steroid injection procedure. Furthermore, in light of the purpose of the OF 522/SF 522, there is nothing to indicate that the document would otherwise provide pertinent medical findings. As such, in light of the above, a remand to have the AMC obtain any available OF 522/SF 522 is not warranted. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran should be avoided); Soyini v. Derwinski, 1 Vet. App. 540 (1991). Also, the Board has interpreted the Veteran's July 2004 claim as including the issue of entitlement to compensation benefits under 38 U.S.C.A. § 1151. As such, 38 C.F.R. § 3.361 is for application, which applies to claims for benefits under 38 U.S.C.A. § 1151 received by VA on or after October 1, 1997. However, in considering the claim for benefits under 38 U.S.C.A. § 1151, the AMC, in December 2011 and January 2013 SSOCs, provided the Veteran with the text of 38 C.F.R. § 3.358, a regulation that implemented a version of 38 U.S.C.A. § 1151 which was no longer in effect at the time the Veteran filed her claim in July 2004. (The Board notes that 38 C.F.R. § 3.358 applies to claims received by VA prior to October 1, 1997.). Otherwise, the Veteran, in the above December 2010 VCAA notice letter, was provided with proper notice on what she needed to substantiate her claim for compensation benefits under 38 U.S.C.A. § 1151-i.e., the occurrence of additional disability or aggravation of an existing injury or disease, and evidence that the disability or aggravation thereof was the result of VA fault (carelessness, negligence, lack of proper skill, etc.) during, in particular, VA hospitalization, medical or surgical treatment, or examination. Here, notwithstanding the lack of citation to 38 C.F.R. § 3.361 in the December 2011 and January 2013 SSOCs, the evidence discussed below does not reflect, as noted previously, that the Veteran suffered any additional disability due to the May 11, 2004 cervical epidural steroid injection procedure. As such, a remand to provide the Veteran with the correct regulation (38 C.F.R. § 3.361) would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran. See Sabonis, Soyini, supra. As such, in light of the above, a remand to provide the regulatory provisions of 38 C.F.R. § 3.361 is not deemed warranted. Therefore, the Board finds that VA has met its duty to notify and assist the Veteran, to include obtaining a VA medical opinion. 38 C.F.R. § 3.159(c)(4). II. Analysis The Board has reviewed the Veteran's physical claims file and the large number of records maintained in the Virtual VA paperless claims processing system. Service Connection Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. § 1131. Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be granted for certain chronic diseases, such as hypertension, when such disease is manifested to a compensable degree within one year of separation from service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1137; 38 C.F.R. §§ 3.307, 3.309(a). In the present case, the Veteran's STRs do not reflect any diagnosis or treatment for hypertension. Additionally, the evidence does not reflect that hypertension manifested within the first year following the Veteran's separation from service in November 1975. As such, the Board does not find the evidence supports service connection for hypertension on either a direct basis to service or within the one year presumptive period following service. Otherwise, under 38 C.F.R. § 3.310, service connection may also be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board notes that there has been an amendment to the provisions of 38 C.F.R. § 3.310. See 71 Fed. Reg. 52744- 47 (Sept. 7, 2006) (codified at 38 C.F.R. § 3.310 (2007)). The amendment sets a standard by which a claim based on aggravation of a nonservice-connected disability by a service-connected one is judged. Although VA has indicated that the purpose of the regulation was merely to apply the Court's 1995 ruling in Allen, it was made clear in the comments to the regulation that the 2006 changes were intended to place a burden on the claimant to establish a pre-aggravation baseline level of disability for the nonservice-connected disability before an award of service connection based on aggravation may be made. This had not been VA's practice, which strongly suggests that the revision amounts to a substantive change in the regulation. In the present case, given what appear to be substantive changes in 38 C.F.R. § 3.310, and because the Veteran's claim for service connection for hypertension was pending before the regulatory change was made, the Board will consider the version of 38 C.F.R. § 3.310 in effect before the revision, the version which favors the Veteran. See 38 C.F.R. § 3.310 (2006). With regard to secondary service connection, the Veteran has alleged that she developed hypertension following the May 2004 VA cervical epidural steroid injection procedure (hereinafter "cervical procedure"). The Veteran is service connected for residuals of C4/C5, C5/C6 anterior cervical discectomy and fusion for cervical spondylosis with residual scar, neck pain, and left arm radiculopathy (hereinafter "cervical spine disability"). As such, she claims service connection for hypertension, as secondary to service-connected cervical spine disability, is warranted. A review of the Veteran's VA outpatient treatment records reflects elevated blood pressure readings prior to the noted May 2004 VA cervical procedure. These records also reflect that the Veteran was apparently first prescribed blood pressure medication, identified as atenolol, in July 2004, some two months following the May 2004 VA cervical procedure. Otherwise, the evidence of record reflects that in a report of October 2004 VA examination, the examiner noted the Veteran's report of receiving a cervical epidural steroid injection in May 2004 and within one week feeling sick and experiencing an increase in her blood pressure. The Veteran indicated that she was subsequently started on blood pressure medication. In review of the Veteran's VA records, the examiner commented that the Veteran's blood pressure was elevated in the hypertensive range during periods in 2000, 2001, 2002, 2003, and 2004. The examiner also noted that at other times the Veteran's blood pressure was normal. Following examination and review of the claims file, the examiner diagnosed the Veteran with hypertension. The examiner opined that the Veteran's hypertension was not due to any treatment secondary to her cervical spine disability. No explanation was provided for the examiner's opinion. Thereafter, in a report of March 2011 VA examination, the Veteran was noted as having failed to report to a scheduled VA examination. The examiner was requested to review the claims file and provide a medical opinion. In particular, the examiner discussed medical literature pertaining to hypertension and precipitating factors for the disorder. Furthermore, the examiner, in reviewing the Veteran's records, cited to instances where the Veteran's blood pressure readings were elevated as far back as the year 2000. Following her review of the evidence and consideration of the Veteran's clinical history, the examiner opined that the Veteran's hypertension was less likely as not the result of her service-connected cervical spine disability, to include the May 2004 cervical procedure. The examiner commented that the Veteran's hypertension was documented as occurring a number of years prior to the May 2004 cervical procedure and a later September 2004 cervical spine discectomy and fusion (hereinafter "cervical spine surgery"). Furthermore, the examiner commented that there had been no aggravation of the Veteran's hypertension, and the disorder was likely related to the Veteran's elevated body mass index (BMI). In a subsequent July 2012 addendum medical opinion, the examiner commented that the Veteran's records failed to document any aggravation of her hypertension. In this regard, the examiner noted that there could be transient increases in blood pressure following clinical procedures/surgery, and that VA vital signs following the Veteran's cervical procedure and the cervical spine surgery supported such a finding. The examiner commented that there was no significant change in the Veteran's blood pressure following either the cervical procedure or the cervical spine surgery. When assessing the probative value of a medical opinion, the Board must consider whether the medical opinion contains "such sufficient information that it does not require the Board to exercise independent medical judgment." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board must also be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion. Id. Furthermore, a medical examination report is adequate where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one. See Ardison v. Brown, 6 Vet. App. 405, 407 (1994). In the present case, the VA examiner has identified hypertensive blood pressure readings being present prior to the Veteran's cervical procedure and cervical spine surgery. As such, and as opined by the VA examiner, there is a basis in the record that hypertension, while not necessarily diagnosed at that time, was present prior to the Veteran's cervical procedure and cervical spine surgery. Thus, the medical evidence supports that the Veteran's hypertension was not proximately due to her service-connected cervical spine disability. Additionally, the VA examiner discussed the high blood pressure readings following the Veteran's cervical procedure and noted that an escalation of blood pressure could occur following medical procedures or surgery. The examiner explained that in the case of the Veteran, any such escalation in blood pressure was transient in nature and not otherwise reflective of an aggravation (permanent worsening) of any existing hypertensive condition. The VA examiner, in providing support for her opinion, noted her review of the Veteran's VA vital signs following the Veteran's cervical procedure and cervical spine surgery. Here, the Board finds the opinions of the VA examiner to probative of the matter at issue. The examiner has provided the rationale for her opinions, and the opinions are supported by a VA examiner's findings and opinion in October 2004. Otherwise, neither the Veteran nor her representative has alluded to or submitted any medical opinion evidence that refutes or contradicts the opinions provided by the VA examiners. Therefore, the Board finds that the Veteran does not have hypertension that is proximately due to or aggravated by her cervical spine disability, to include the May 2004 cervical procedure or subsequent September 2004 cervical spine surgery. Here, without sufficient evidence linking the Veteran's hypertension to her cervical spine disability, service connection is not warranted for hypertension on a secondary basis. See 38 C.F.R. § 3.303; 38 C.F.R. § 3.310 (2006). In so finding, the Board notes that although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case-whether the Veteran's hypertension is related to service or service-connected disability falls outside the realm of common knowledge or expertise of the Veteran. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). Thus, while sympathetic to the Veteran's claim, the Board finds that the claim of service connection for hypertension, to include as secondary to service-connected disability, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b). However, as the preponderance of the evidence is against the Veteran's claim of service connection, to include on a secondary basis, that doctrine is not applicable. Benefits under 38 U.S.C.A. § 1151 The Veteran contends that she suffered additional disability, manifested as hypertension, as a result of the May 2004 cervical procedure at the VAMC Tampa. The Veteran's claim for compensation benefits under 38 U.S.C.A. § 1151 was received by the RO in July 2004. With respect to claims filed on or after October 1, 1997 (see VAOPGCPREC 40-97 (Dec. 31, 1997)), 38 U.S.C.A. § 1151 provides in pertinent part that compensation shall be awarded for a qualifying additional disability in the same manner as if such additional disability was service connected. For purposes of this section, a disability is a qualifying additional disability if the disability was not the result of the veteran's willful misconduct and the disability was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by the Secretary, and the proximate cause of the disability was (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not reasonably foreseeable. 38 U.S.C.A. § 1151(a); 38 C.F.R. § 3.361. To determine whether additional disability exists within the meaning of § 1151, the veteran's condition immediately before the beginning of the hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy program upon which the claim is based is compared to his condition after such care, treatment, examination, services, or program has been completed. Each body part or system involved is considered separately. 38 C.F.R. § 3.361(b). To establish causation, evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the veteran's additional disability. Merely showing that a veteran received care, treatment, or examination and that the veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361(c)(1). Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). Additional disability caused by a veteran's failure to follow properly given medical instructions is not caused by hospital care, medical or surgical treatment, or examination. 38 C.F.R. § 3.361(c)(3). The proximate cause of disability is the action or event that directly caused the disability, as distinguished from a remote contributing cause. 38 C.F.R. § 3.361(d). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability, it must be shown that the hospital care, medical or surgical treatment, or examination caused the veteran's additional disability and (i) that VA failed to exercise the degree of care that would be expected of a reasonable health care provider or (ii) that VA furnished the hospital care, medical or surgical treatment, or examination without the veteran's or, in appropriate cases, the veteran's representative's informed consent. 38 C.F.R. § 3.361(d)(1). Finally, the determination of whether the proximate cause of a veteran's additional disability was an event not reasonably foreseeable is to be based on what a reasonable health care provider would have foreseen. The event does not have to be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. 38 C.F.R. § 3.361(d)(2). The regulation further provides that, in determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). The provisions of 38 C.F.R. § 17.32, Informed Consent, a section under the heading of Protection of Patient Rights, are extensive. In particular, under 38 C.F.R. § 17.32(b), all patient care furnished under title 38 U.S.C. shall be carried out only with the full and informed consent of the patient or, in appropriate cases, a representative thereof. The record reflects that in May 2004, the Veteran underwent a cervical procedure at the VAMC Tampa. The purpose of the procedure was to alleviate chronic neck pain and radiculopathy. A May 2004 VAMC Tampa anesthesia procedure note reported that informed and written verbal consent had been obtained from the Veteran. It also described the actions undertaken by the clinical staff during the cervical procedure, and documented that the Veteran had tolerated the procedure well and that her vital signs had remained stable. She was discharged to home following the procedure. After the May 2004 cervical procedure, the evidence does not reflect treatment or a diagnosis for any additional injury or disability associated with the May 2004 cervical procedure. Later, in September 2004, the Veteran underwent cervical spine surgery. Post-surgical VA treatment notes in November 2004 and December 2004 note the Veteran as doing well and wearing a soft neck collar. In the above noted report of March 2011 VA examination, the examiner was noted to have reviewed the Veteran's VA medical records as well as the Veteran's August 2004 statement alleging the onset of hypertension following the May 2004 cervical procedure. The examiner commented that the Veteran had not had post cervical procedure complications, and that she had been seen later by the neurosurgery department and no complications from the cervical procedure were identified. Otherwise, the examiner commented that the Veteran's hypertension had existed prior to her May 2004 cervical procedure and was most likely related, as noted previously, to her BMI. In consideration of the evidence of record, the Board finds that the Veteran did not incur additional disability, to include hypertension, as a result of the May 2004 cervical procedure. Here, the Veteran's only contention is that her diagnosed hypertension resulted from the May 2004 cervical procedure. The only medical evidence addressing the issue of additional disability is the opinion of the March 2011 VA examiner. The Board finds the examiner's opinion to be probative of the issue under consideration. Stefl, 21 Vet. App. at 124. As noted above, with regard to claim for secondary service connection, the VA examiner opined that the Veteran's hypertension existed prior to the May 2004 cervical procedure. In support of her opinion, the VA examiner cited to various VA treatment records created prior to May 2004 reflecting hypertensive blood pressure readings. As such, the evidence supports that the May 2004 cervical procedure is not the proximate cause of the Veteran's hypertension. Likewise, the VA examiner also discussed, as noted above, that the increase in blood pressure readings soon after the May 2004 cervical procedure were transient in nature, and that a review of VA vital signs (blood pressure readings) thereafter support this finding. Thus, the VA examiner's opinion, along with her explanation, supports that the Veteran's existing hypertension condition prior to the May 2004 cervical procedure was not aggravated by the cervical procedure. Otherwise, neither the Veteran nor her representative has alluded to or submitted any medical opinion evidence that refutes or contradicts the opinion provided by the VA examiner. As such, the Board does not find evidence of any additional disability or aggravation of a pre-existing disability, to include hypertension, to have resulted from the May 2004 cervical procedure performed at the VAMC Tampa. The Board has considered the Veteran's contentions with respect to her claim. Although lay persons are competent to provide opinions on some medical issues, as to the specific issue in this case-whether the Veteran incurred additional disability as a result of her May 2004 cervical procedure, falls outside the realm of common knowledge or expertise of the Veteran. See Jandreau, supra. Therefore, the Board finds that without evidence of the occurrence of additional disability or aggravation of an existing injury or disease, and evidence that the disability or aggravation thereof was the result of VA fault (carelessness, negligence, lack of proper skill, etc.) during, in particular, VA medical or surgical treatment, benefits under 38 U.S.C.A. § 1151 are not for application. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.361. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b). However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. ORDER Service connection for hypertension, to include as due to service-connected disability, is denied. Entitlement to compensation benefits under the provisions of 38 U.S.C.A. § 1151 for additional disability, to include hypertension, due to VA treatment is denied. ____________________________________________ JOAQUIN AGUAYO-PERELES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs