Citation Nr: 1317014 Decision Date: 05/23/13 Archive Date: 05/31/13 DOCKET NO. 08-21 835 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for hypertension, claimed as secondary to service-connected posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD T. M. Gillett, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1959 to October 1982. Effective October 2005, the Veteran is in receipt of a 100 percent schedular disability evaluation. This matter comes before the Board on appeal from a June 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran did not request a hearing before the Board. This case was previously before the Board of Veterans' Appeals (Board) for these and other claims since resolved in May 2010, July 2012, and January 2013. Each time, it was remanded for further development of the record. Following the directed development, the VA Appeals Management Center (AMC) in Washington, D.C. confirmed and continued the denial of entitlement to service connection for hypertension. Thereafter, in each instance, the case was returned to the Board for further appellate action. FINDING OF FACT The Veteran's hypertension was neither caused nor permanently worsened by service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for hypertension are not met or approximated. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Introductory Matters In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R."), and the precedential rulings of the United States Court of Appeals for the Federal Circuit (Federal Circuit) (as noted by citations to "Fed. Cir.") and the United States Court of Appeals for Veterans Claims (Court) (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d) (West 2002 & Supp. 2012); see also 38 C.F.R. § 19.7 (2012) (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts). Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 ("VCAA") describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify a veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice must be provided to the veteran prior to the initial adjudication of his or her claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). VA satisfied its duty to notify the Veteran by issuing a notice letter in December 2008. In this notice letter, VA informed the Veteran about the information and evidence not of record that was necessary to substantiate the claim; the information and evidence that VA would seek to provide; the information and evidence the Veteran was expected to provide; the information regarding the assignment of ratings and effective dates required by Dingess; and additional information regarding the substantiating of a claim for service connection secondary to an already service-connected disorder. The duty to assist provisions of the VCAA have been met. The claims file contains service treatment records, reports of post-service medical treatment, and reports of respective VA examinations provided in February 2009, February 2011, August 2012, and March 2013. In the June 2009 notice of disagreement (NOD), the Veteran stated that, instead of granting his claim for service connection based on Dr. H.'s September 2008 private opinion, VA provided the February 2009 VA medical examination for the "sole purpose" of developing negative evidence against his claim, in violation of the decision of Mariano v. Principi, 17 Vet. App. 305, 312 (2003). The Veteran argued that Dr. H. had been the Veteran's treating psychiatrist for five years while the February 2009 VA examiner met with the Veteran for either "twenty minutes" or "less than 20 minutes." The Veteran also argued that the private examiner had submitted a study to support his September 2008 opinion. The Veteran also contended that the RO denied his claim because the February 2009 VA examiner had access to the claims file prior to writing the February 2009 VA medical examination report while Dr. H. did not, in violation of the Court's decision in Nieves-Rodriguez v. Peake, 22 Vet App. 295 (2008). The Veteran's contention has been considered but is without merit. The Court has declined to adopt a "treating physician rule" under which a treating physician's opinion would presumptively be given greater weight than that of a VA examiner or another doctor. Winsett v. West, 11 Vet. App. 420, 424-25 (1998); Guerrieri v. Brown, 4 Vet. App. 467, 471-73 (1993). See White v. Principi, 243 F.3d 1378 (Fed. Cir. 2001). Dr. H.'s September 2008 private opinion is of insufficient probative value to allow for a granting of service connection for hypertension. As will be reiterated later, while the conclusions of a physician are medical conclusions that the Board cannot ignore or disregard, see Willis v. Derwinski, 1 Vet. App. 66 (1991), the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. See Wilson v. Derwinski, 2 Vet. App. 614 (1992). The Court has found that a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). In reviewing the records from the offices of Dr. H., the Board notes that the private examiner reported taking blood pressure readings for the Veteran four times between October 2007 and July 2008. In the September 2008 opinion, Dr. H. did not refer to these blood pressure readings or any other clinical evidence, to include the study mentioned in the June 2009 NOD, in explaining the basis for his opinion. Instead, in two sentences, Dr. H. wrote that the Veteran's PTSD at least as likely as not "contributed" to his hypertension without further explanation. The probative value of any opinion must be ascertained on the basis of multiple factors, including the strength of its language and its supporting data. The term "contributed," itself, is vague, as it does not state that the Veteran's PTSD either specifically caused or permanently aggravated the claimed hypertension. Therefore, as it contains no indication of the evidentiary basis for the opinion, the Board finds that Dr. H.'s September 2008 opinion, by itself, is not a sufficient basis to allow for the granting of service connection for hypertension. See Black, 5 Vet. App. at 180. In the June 2009 NOD, the Veteran contended that the RO provided the February 2009 VA medical examination for the sole purpose of developing negative evidence against the Veteran's claim for service connection for hypertension. The Board finds that this contention is without merit because the RO, by VA laws and regulations, was obligated to provide the Veteran with a VA medical examination, partly because of the Veteran's submission of Dr. H.'s September 2008 opinion. The Court has found that, in cases involving claims for service connection for disorders secondary to an already service-connected disability, VA must provide a medical examination when there is competent evidence of a current disability or persistent recurrent symptoms of a disability, an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but insufficient competent medical evidence on file for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). When the RO requested the February 2009 VA medical examination, the Veteran had been diagnosed with hypertension and had received service connection for PTSD. As noted above, Dr. H.'s September 2008 opinion, by itself, was insufficient evidence to allow for the granting of the Veteran's claim for service connection; Dr. H.'s opinion was evidence suggesting that the Veteran's hypertension might be associated with his service-connected PTSD disability. Therefore, as the file did not contain sufficient competent medical evidence for VA to decide the Veteran's claim after the submission of Dr. H.'s September 2008 private medical opinion, the RO was obligated to provide the February 2009 VA medical examination and the subsequent VA medical examinations. See id. Therefore, the Veteran's contention that the RO's sole purpose in providing the February 2009 VA medical examination was to develop negative evidence against his claim for service connection for hypertension lacks merit. Regarding the Veteran's contentions that the VA examiner provided too brief an examination, in the February 2009 VA medical examination report, the February 2009 VA examiner noted interviewing the Veteran and providing a thorough physical examination. After a review of the claims folder, the VA examiner found that the Veteran's hypertension was less likely than not caused by the service-connected PTSD. In the June 2009 Remand, the Board found that the June 2009 VA medical examination report was inadequate, not due to the length of the examination, but because the February 2009 VA examiner did not provide an adequate basis for the opinion. Specifically, the VA examiner did not explain whether the Veteran's PTSD permanently aggravated his claimed hypertension. As neither the record did not contain an adequate opinion regarding the etiology of the Veteran's hypertension disorder, the Board remanded the claim for a VA medical examination with an adequate etiology opinion. The March 2013 VA examiner reviewed the claims file and performed a fully responsive and informed examination, diagnosed the Veteran, and offered a probative opinion supported by lay and medical evidence. See Prejean v. West, 13 Vet. App. 444, 448 (2000) (indicating that the Board may determine the probative value of medical opinions based on their detail, the persuasiveness of their opinions, and the physicians' access to a veteran's medical records). VA has fulfilled its duty to assist the Veteran by providing the Veteran with a factually informed and medically supported VA medical examination. In the first remand regarding this matter, dated May 2010, the Board noted that the claims file did not contain a copy of the study mentioned by the Veteran in the June 2009 NOD. The Board remanded the Veteran's claim, in part, to allow the AMC to procure a copy of the study. In May 2010 letter issued to the Veteran, the AMC enclosed a copy of an authorization and consent form. In the May 2010 letter, the AM specifically requested that the Veteran complete and return the authorization and consent form in order to allow the AMC to procure a copy of the study mentioned in the June 2009 NOD from the office of Dr. H. The AMC also advised the Veteran that he could provide a copy of the study if he had one. In the three-year interim since the AMC's issuance of the May 2010 letter, the Veteran has never submitted either a copy of the study or a completed authorization and release form allowing VA to procure the claimed study from Dr. H. In an October 2012 Report of Contact, a VA employee noted contacting the Veteran at the Board's request and asking him if he wished to submit any completed authorization and release forms to allow VA to procure any outstanding evidence. In response, the Veteran told the VA employee that he had nothing else to send and that VA had everything required to adjudicate the claim. As the Veteran did not return a completed authorization and release form, or a copy of the study mentioned in the June 2009 NOD, VA was unable to procure the purported study. A claimant has the responsibility to present and support a claim for benefits under laws administered by the VA, 38 U.S.C.A. § 5107(a). The AMC fulfilled the duty to assist in attempting to procure the study and a further remand for its procural is unnecessary. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991), aff'd on reconsideration, 1 Vet. App. 406 (1991) (noting that the duty to assist is not a one-way street, and a veteran cannot passively wait for help in those circumstances where he may or should have information that is essential in obtaining the putative evidence). See 38 C.F.R. § 3.159(e)(2) (where claimant does not provide release for records, VA's duty to assist is fulfilled where the claimant is asked to provide the records). As noted, this case was remanded in May 2010, July 2012, and January 2013. The Board initially remanded the Veteran's claim in May 2010, requesting that the AMC make reasonable attempts to procure both any outstanding medical records and a copy of the study mentioned in the June 2009 NOD, and provide a VA medical examination to determine the etiology of the Veteran's claimed hypertension disorder. In the July 2012 Remand, the Board noted that in attempted compliance with the Board's May 2010 Remand requests, the AMC had procured a February 2011 VA medical examination, which did not contain a medical opinion regarding the etiology of the Veteran's hypertension disorder, and an August 2011 addendum to the February 2011 VA medical examination report, containing an inadequate etiology opinion with no references to any specific clinical evidence. See Black, at 180. In the July 2012 Remand, the Board noted that the Veteran had not provided VA with additional evidence, to include the above-mentioned study, or any authorization and release forms that would allow VA to procure said evidence. The Board remanded the claim, requesting that the AMC both contact the Veteran and ask about any outstanding evidence that should be submitted regarding his claim, and provide another VA medical examination. In an October 2012 Report of Contact, a VA employee noted contacting the Veteran and asking him if he wished to submit completed authorization and release forms to allow VA to procure any outstanding evidence. In response, the Veteran told the VA employee that he had nothing else to send and that VA had everything required to adjudicate the Veteran's claim. See Wood, 1 Vet. App. at 193 (noting that the duty to assist is not a one-way street, and a veteran cannot passively wait for help in those circumstances where he may or should have information that is essential in obtaining the putative evidence). In attempted compliance with the Board's Remand requests, in August 2012, the AMC provided the Veteran with a VA medical examination; however, in the August 2012 VA medical examination report, the VA examiner again did not provide an adequate etiology opinion, containing references to any specific clinical evidence. See Black, at 180. In January 2013, the Board remanded the Veteran's claim to the AMC, again requesting that the AMC provide a VA medical examination report containing an adequate etiology opinion regarding the Veteran's claimed hypertension disorder. In March 2013, the AMC provided a VA medical examination, performed by a qualified VA examiner. After a review of all evidence and a physical examination, the VA examiner provided an opinion regarding the etiology of the Veteran's hypertension, based on the evidence of record, with references to the evidence reviewed. Therefore, the Board finds that the March 2013 VA medical examination report has probative value in this matter. See Prejean, 13 Vet. App. at 448. Therefore, the Board finds that the AMC complied with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has been given ample opportunity to present evidence and argument in support of his claim. The Veteran has not provided VA with information regarding any additional evidence or authorization and consent forms that would allow for the procurement of any additional evidence not already on file. See Wood, at 193. Therefore, pursuant to 38 C.F.R. § 3.655 (2012), all relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). The Merits of the Claim The Veteran argues his service-connected PTSD either caused or aggravated his diagnosed hypertension disorder. The record indicates that the Veteran has been service-connected for PTSD since his discharge from service. Having reviewed the evidence of record, the Board finds that the preponderance of the evidence is against the claim and the Veteran's currently diagnosed hypertension disorder was neither caused nor aggravated (permanently worsened) by his service-connected PTSD. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder, there must be (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, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303; see also Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a non service-connected disability which is aggravated by a service connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). A claim for secondary service connection requires medical evidence that connects the asserted secondary disorder to the service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998). In order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). For VA rating purposes, hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1) (2012). In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson 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 layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, a veteran, the Court holding that medical opinion not required to prove nexus between service-connected mental disorder and drowning which caused veteran's death). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert, 1 Vet. App. at 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board has considered all evidence of record as it bears on the question of service connection. See 38 U.S.C.A. § 7104(a) (West 2002 & Supp. 2012) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's appeal. The Veteran has not claimed that his diagnosed hypertension is directly related to service. In fact, in a December 2008 statement, the Veteran specifically wrote that he was claiming service connection for hypertension secondary to service-connected PTSD. The Veteran indicated that his hypertension had not existed since service. The service treatment records contain no notation indicating treatment or diagnosis for hypertension during service. The earliest treatment record for hypertension is dated March 1998, more than 15 years after the Veteran's discharge from service. In various statements submitted during pendency of the appeal, the Veteran reported that he was first diagnosed with hypertension in 1984 or 1985, more than at least a year after his October 1982 discharge from service. Although he was not asked to provide such an opinion, in a March 2013 VA medical examination report, a VA examiner indicated that the Veteran's claimed hypertension was less likely than not related to service or any incident of service. In explaining his finding, the VA examiner noted the service examiner noted only two elevated blood pressure readings during the Veteran's lengthy period of service. Specifically, the VA examiner noted that the service examiners had recorded blood pressure readings of 120/90 and 124/90 on August 10, 1982 and August 25, 1982, respectively. The VA examiner noted that the Veteran was not diagnosed with hypertension until 1984, based on the Veteran's report. The VA examiner indicated that the two elevated blood pressure readings, noted near the end of the Veteran's 23 years of service, were insufficient to render a diagnosis of hypertension. The VA examiner indicated that such readings would raise a suspicion that the Veteran would have been predisposed to develop the disorder in the near future, but the issue could not be resolved without resort to speculation due to the lack of other blood pressure readings. See Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992) (holding that evidence favorable to a veteran's claim that does little more than suggest a possibility that his illnesses might have been caused by an in-service incident is insufficient to establish service connection); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (medical evidence, which merely indicates that the alleged disorder "may or may not" exist or "may or may not" be related, is too speculative to establish the presence of the claimed disorder or any such relationship). In a March 1998 private treatment record, the examiner noted that the Veteran had a long history of benign hypertension. Upon examination, the private examiner noted that the Veteran's blood pressure was 115/80. The diagnosis was essential benign hypertension. Subsequent treatment records contain a multitude of blood pressure readings. These ratings varied, often from month to month, sometimes based on the amount of medication taken by the Veteran. For example, in a June 2008 private treatment record, a private examiner noted that the Veteran's hypertension was 163/93. In a September 2008 private treatment record, the same private examiner noted blood pressure readings of 124/78 and 120/84. The private examiner noted that the Veteran had increased his blood pressure medications several weeks previously and that the Veteran was responding well to the medication. At the time, the private examiner diagnosed benign hypertension. Also of note, the record contains 2008 private treatment records denoting treatment for angina and coronary artery disease. In a February 2009 VA medical examination report, the Veteran reported that his heart disorders were related to hypertensive cardiovascular disease. Yet, the treatment records on file contain no notation indicating that the Veteran's heart disorders were related to his hypertension. In August 2008 private treatment records, written the month prior to the filing of the Veteran's claim for service connection for hypertension, a private examiner diagnosed coronary artery disease and hypertension "that is controlled." In an October 2008 private treatment record, (written one month after the filing of the Veteran's claim for service connection), the private examiner diagnosed coronary artery disease and angina for which the Veteran was asymptomatic following a recent coronary artery bypass graft. The private examiner also diagnosed hypertension "that is controlled in the office today, but apparently labile by his report." Moreover, in a February 2011 VA medical examination report, the Veteran reported that he did not experience any heart disease related to his hypertension. The Veteran's February 2009 suggestion that heart disease was related to his hypertension, lack credibility as they are inconsistent with the other evidence of record, to include the Veteran's comments contained therein. See Caluza, 7 Vet. App. at 498 (holding that, in weighing credibility of lay evidence, even that recorded in a medical record, VA may consider such elements as interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness). The record contains several medical opinions regarding the etiology of the Veteran's hypertension, specifically regarding the potential relationship between the Veteran's hypertension and his service-connected PTSD. As noted above, in a September 2008 letter, Dr. H. reported treating the Veteran for PTSD since May 2005. Dr. H. indicated that, in his opinion, it was at least as likely as not that the Veteran's PTSD "contributed" to his hypertension. The private examiner did not report any basis for this opinion. In a February 2009 VA medical examination report, a VA examiner noted that the Veteran reported experiencing hypertension since 1985. The Veteran stated that the disorder had worsened since its onset and that he was treating it with medication. In describing his medical history, the Veteran denied undergoing any hospitalization or surgery related to his hypertension. The Veteran denied experiencing a traumatic injury to the heart, or a history of cardiac neoplasm, hypertensive renal disease, epistaxis related to hypertension, or stroke or transient ischemic attack (TIA) related to hypertension. The Veteran reported experiencing a history of hypertensive cardiovascular disease. When asked when he was diagnosed as having hypertensive cardiovascular disease, the Veteran stated that he was diagnosed with angina and a coronary artery bypass graft in 2008. The Veteran noted that he used continuous medication to control his hypertension. Upon examination, the February 2009 VA examiner noted that the Veteran was obese, being 74 inches tall and weighing 230 pounds. The VA examiner noted blood pressure readings of 143/94, 150/82, and 132/90. A hypertensive cardiovascular examination indicated normal heart rhythm, and absent JVD, click, and pericardial rub symptomatology. The VA examiner indicated that heart sounds were normal and a hypertensive pulmonary examination was normal. After examination, the VA examiner diagnosed essential hypertension that would not affect the Veteran's daily or occupational activities. The February 2009 VA examiner opined that the Veteran's hypertension was less likely than not caused by or a result of his PTSD. In support of this finding, the VA examiner noted that studies based upon the Vietnam Era Twins Study (VETS) database did not support the assertion that PTSD had any significant role in causing or aggravating hypertension. In a February 2011 VA medical examination report, the Veteran reported being diagnosed with hypertension in either 1984 or 1985. The Veteran stated that the disorder had worsened since diagnosis, and that he had treated his hypertension symptomatology with medication and a low sodium diet. The Veteran reported that he did not have any history of hypertensive renal disease, or stroke/TIA, nosebleeds, or headaches related to hypertension. The Veteran also denied having a history of hypertensive-related disease, to include any heart disease. When asked if he had any possible complications resulting from his hypertension, the Veteran reported fatigue, memory impairment, intermittent claudication, weight gain, palpitations, and nocturia, occurring three to four times per night if he did not take his PTSD medication. Upon examination, the February 2011 VA examiner noted that the Veteran was obese, being 74 inches tall and weighing 245.9 pounds. Upon examination, the VA examiner noted no evidence of congestive heart failure or pulmonary hypertension. The VA examiner indicated that heart sounds were present and normal, and that heart rhythm was regular. The VA examiner indicated that blood pressure readings were 143/76, 143/75, and 144/74. The February 2011 VA examiner did not include a medical opinion regarding the etiology of the Veteran's claimed hypertension. In an August 2011 addendum to the February 2011 VA medical examination report, a different VA examiner, having reviewed the evidence, opined that the Veteran's hypertension was less likely than not caused or aggravated by his service-connected PTSD. In explaining the rationale for this opinion, the August 2011 VA examiner wrote that the predominance of the medical literature did not support PTSD being a cause of or an aggravating factor for hypertension. In an August 2012 VA medical examination report, the same VA examiner who wrote the August 2011 addendum to the February 2011 VA medical examination report noted reviewing the claims file prior to writing the report. During an interview, the Veteran stated that he had been diagnosed with hypertension in 1984. The Veteran stated that his treating physician told him that his hypertension was "doin good." The Veteran noted that he had taken medication for the disorder that morning. The August 2011 VA examiner opined that the Veteran's hypertension was less likely than not proximately due to or the result of the Veteran's service-connected PTSD. In explaining the rationale for this opinion, the August 2011 VA examiner wrote that the predominance of the medical literature did not support PTSD being a cause of or an aggravating factor for hypertension. In a March 2013 VA medical examination report, the August 2011 VA examiner noted reviewing the claims file prior to writing the report. During an interview, the Veteran reported that he had been diagnosed with hypertension in 1984 and that the disorder had worsened over the years. The Veteran indicated that he had undergone bypass surgery for arteriosclerotic cardiovascular disease. The Veteran also reported that his hypertension required the constant use of medication for treatment. Upon examination, the August 2011 VA examiner noted that the Veteran's heart and lungs were clear. Upon testing, the VA examiner noted that the Veteran's blood pressure readings were 141/78, 140/78, and 131/76, respectively. On the form provided for his March 2013 VA medical examination report, the August 2011 VA examiner checked a box indicating that the Veteran's claimed hypertension was less likely than not related to service or any incident of service. The August 2011 VA examiner did not check any box regarding a medical opinion regarding secondary service connection. Specifically, the VA examiner did not check a box indicating whether the Veteran's hypertension was at least as likely as not or less likely than not proximately due to or the result of the Veteran's service-connected PTSD. Yet, at the end of the report, the VA examiner wrote that he had reviewed the entirety of the claims file, including Dr. H.'s September 2008 private medical opinion and the VETS study regarding the relationship between hypertension and PTSD. Having noted reviewing the evidence, the VA examiner wrote that the predominance of peer-reviewed studies did not support the contention that PTSD caused hypertension. Regarding the possibility that the Veteran's PTSD might have permanently aggravated the Veteran's hypertension, the VA examiner wrote that emotional upset could cause episodic elevation of blood pressure; however, the VA examiner noted that episodically elevated blood pressure due to emotional upset was not the same thing as hypertension. In delineating an alternative cause for the Veteran's hypertension, other than PTSD, the VA examiner noted that the alternative cause was essential hypertension. The VA examiner noted that essential hypertension was a multietiology disorder influenced by an individual's heredity, weight, diet, and activity level among other factors. As noted above, the Board must determine the probative value of all evidence submitted, including lay and medical evidence. Buchanan, 451 F.3d at 1331. While the conclusions of a physician are medical conclusions that the Board cannot ignore or disregard, see Willis, 1 Vet. App. at 66, the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. See Wilson, 2 Vet. App. at 614. The Court has found that a medical opinion is inadequate when it is unsupported by clinical evidence. Black, 5 Vet. App. at 180. As explained above, in a September 2008 letter, Dr. H. reported treating the Veteran for PTSD since May 2005. In reviewing the records from the offices of Dr. H., the Board notes that Dr. H. reported taking blood pressure readings for the Veteran four times between October 2007 and July 2008. Specifically, Dr. H. noted blood pressure readings of 158/89 in October 2007, 150/80 in January 2008, 149/92 in April 2008, and 162/95 in July 2008. Dr. H. indicated that, in his opinion, it was at least as likely as not that the Veteran's PTSD "contributed" to his hypertension. Yet, in the September 2008 opinion, Dr. H. did not note any clinical basis for this opinion, to include the blood pressure readings taken at his office. Moreover, Dr. H. wrote that the Veteran's PTSD at least as likely as not "contributed" to his hypertension. The Board notes that the term "contributed," itself, is vague, as it does not state that the Veteran's PTSD either specifically caused or permanently aggravated the claimed hypertension. As explained above, in a June 2009 NOD, the Veteran stated that Dr. H. had submitted a study to support his September 2008 opinion. Yet, Dr. H.'s two-sentence opinion contains no notation indicating that the opinion was based on such a medical study or any other evidence. In the July 2009 SOC, the RO mentioned that the Veteran had submitted a study that suggested a link between PTSD and hypertension, but did not provide any indication that the Veteran's hypertension was caused or aggravated by his service-connected PTSD. See Mattern v. West, 12 Vet. App. 222 (1999) (citing Sacks v. West, 11 Vet. App. 314, 317(1998)) (holding that the generic information in a medical journal or treatise, in itself, too "general and inconclusive" to establish a medical nexus to a specific disease or injury). The record does not contain any copy of the study mentioned by the Veteran in the June 2009 NOD and all attempts to procure a copy of said study failed due to a lack of cooperation from the Veteran. See Wood, at 193, 38 C.F.R. § 3.159(e)(2). As the only opinion of record from Dr. H., by itself, contains no notation indicating a basis for the opinion, it does not have probative value in this matter. See Black, at 180. By contrast, in the February 2009 VA medical examination report, the February 2009 VA examiner noted reviewing the claims file, interviewing the Veteran, and performing an examination immediately prior to writing their opinion. In the opinion, the February 2009 VA examiner opined that the Veteran's hypertension was less likely than not caused by or a result of his PTSD. In support of this finding, the VA examiner noted that studies based upon the Vietnam Era Twins Study (VETS) database did not support the assertion that PTSD had any significant role in causing or aggravating hypertension. Yet, the Board notes that, in writing this opinion, the VA examiner did not note reviewing the opinion of Dr. H. Therefore, the February 2009 VA medical examination report is of weakened probative value in this matter. See Prejean, at 448 (2000) (indicating that the Board may determine the probative value of medical opinions based on their detail). As noted above, in February 2011, a VA examiner provided the Veteran with a VA medical examination, but did not offer any opinion regarding the etiology of the Veteran's hypertension disorder; however, in August 2011, a VA examiner, specifically a medical doctor, noted reviewing the claims file and the record of evidence. Having done so, the August 2011 VA examiner opined that the Veteran's hypertension was less likely than not caused or aggravated by his service-connected PTSD. In explaining the rationale for this opinion, the August 2011 VA examiner wrote that the predominance of the medical literature did not support PTSD being a cause of or an aggravating factor for hypertension. Subsequently, in an August 2012 VA medical examination report, the August 2011 VA examiner noted reviewing the claims file and interviewing the Veteran. Having done so, the August 2011 VA examiner opined that the Veteran's hypertension was less likely than not proximately due to or the result of the Veteran's service-connected PTSD. In explaining the rationale for this opinion, the August 2011 VA examiner again wrote that the predominance of the medical literature did not support PTSD being a cause of or an aggravating factor for hypertension. The Board notes that the August 2011 VA examiner, in writing both the August 2011 addendum and the August 2012 VA medical examination report, did not specifically note the opinion of Dr. H or any other specific evidence in the aforementioned opinions. Therefore, the August 2011 addendum and the August 2012 VA medical examination report are, by themselves, of weakened probative value in this matter. See id. Finally, in the March 2013 VA medical examination report, the August 2011 VA examiner noted reviewing the claims file prior to writing the report, interviewing the Veteran, and performing an examination. Prior to writing the opinion, the VA examiner specifically noted reviewing both Dr. H's September 2008 private medical opinion and the VETS study regarding the relationship between hypertension and PTSD. Having noted reviewing the evidence, the VA examiner wrote that the predominance of peer-reviewed studies did not support the contention that PTSD caused hypertension. R Regarding the possibility that the Veteran's PTSD might have aggravated (permanently worsened) the Veteran's hypertension, the VA examiner wrote that emotional upset could cause episodic elevation of blood pressure; however, the VA examiner noted that episodically elevated blood pressure due to emotional upset was not the same thing as hypertension. In looking for an alternative cause for the Veteran's hypertension, other than PTSD, the VA examiner noted that the alternate cause was essential hypertension. The VA examiner noted that essential hypertension was a multietiology disorder influenced by an individual's heredity, weight, diet, and activity level among other factors. The Board has considered the Veteran's reports that his hypertension was caused by his PTSD. As a layperson, the Veteran is competent to report what those medically untrained may observe, such as symptoms, blood pressure readings and those readily perceivable manifestations which may be remembered by a layperson. See Davidson, 581 F.3d at 1313; Jandreau, 492 F.3d at 1372. However, the Veteran's lay opinion as to the etiology of his hypertension has less probative value than the opinion of the August 2011 VA examiner, who, in the March 2013 VA medical examination report, noted basing his opinion on a medical examination, a review of the medical literature, and the his own medical knowledge. See Madden, 125 F.3d at 1481. Therefore, the Board finds that the preponderance of the evidence is against the finding that the Veteran's hypertension was either caused or permanently aggravated by his service-connected PTSD. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for hypertension is denied. ____________________________________________ VITO A. CLEMENTI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs