Citation Nr: 1321520 Decision Date: 07/03/13 Archive Date: 07/12/13 DOCKET NO. 06-07 332A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1968 to July 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In July 2009, the Veteran and his wife testified before the undersigned Veterans Law Judge (VLJ) at a hearing held at the RO. A transcript of that hearing is associated with the claims file. In August 2010, February 2012, June 2012, and January 2013, the Board remanded the Veteran's claim to the RO via the Appeals Management Center (AMC) for additional development. The claim has been returned to the Board for further appellate consideration. FINDINGS OF FACT 1. The Veteran has a current diagnosis of hypertension. 2. The evidence of record does not establish that the Veteran experienced symptoms of chronic hypertension during service or continuous symptoms of hypertension since separation from service. 3. The Veteran's hypertension did not manifest within one year of separation from service. 4. The probative, competent evidence of record does not demonstrate that the Veteran's hypertension is causally or etiologically related to service. 5. The probative, competent evidence of record does not demonstrate that the Veteran's hypertension is causally or etiologically related to his service-connected PTSD, nor was it aggravated by the service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for hypertension, to include as secondary to service-connected PTSD, have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The record shows that a March 2005 letter informed the Veteran of the information and evidence necessary to substantiate the claim for service connection. The Veteran was also advised of the types of evidence VA would assist in obtaining, as well as the Veteran's own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The United States Court of Appeals for Veterans Claims (Court) decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that VCAA notice as required by 38 U.S.C. § 5103(a) must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits. Further, the 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 v. Nicholson, 19 Vet. App. 473 (2006). Here, notice of the requirements under Dingess was provided in a March 2006 letter to the Veteran after the initial unfavorable decision in June 2005. However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In any event, where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by re-adjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Following the issuance of the March 2006 letter, the Veteran's claim was re-adjudicated in Supplemental Statements of the Case dated in August 2006 and October 2011. For these reasons, the Board finds that the duty to notify the Veteran has been satisfied in this case. See Pelegrini, 18 Vet. App. at 120 (2004). The Board also finds that the duty to assist the Veteran has been satisfied in this case. The record includes service treatment records, VA examination reports, VA treatment records, private treatment records, and lay evidence. The Board first remanded the Veteran's claim in August 2010 to provide the Veteran with a VA examination. Accordingly, the Veteran was afforded a VA examination in January 2011. The record demonstrates that the January 2011 VA examiner reviewed the Veteran's relevant medical history and his lay testimony, completed a physical examination and other appropriate testing, and provided an opinion with respect to whether the Veteran's hypertension was related to active duty. The VA examiner also commented as to whether the Veteran's hypertension was caused by his service-connected PTSD. However, because the January 2011 VA examiner did not address whether the Veteran's hypertension was aggravated by his PTSD, the Board remanded the Veteran's claim in February 2012 for an addendum opinion. As a result, the Veteran underwent additional VA examination in March 2012. The record shows the VA examiner reviewed the Veteran's claims file, to include his service treatment records, VA treatment records, and private treatment records, completed a physical examination, and provided complete opinions with respect to the theories of entitlement based on direct and secondary service connection. 38 C.F.R. § 3.159(c)(4); Barr v Nicholson, 21 Vet. App. 303 (2007). Therefore, the Board finds the examinations and opinions of record to be sufficient and adequate for purposes of determining service connection. Subsequently, in June 2012, the Board remanded the Veteran's claim for additional development. Specifically, the Board instructed that the RO obtain and associate with the claims file any records on file with the Social Security Administration (SSA) in connection with his claim for disability benefits. In addition, after obtaining authorization from the Veteran, the RO was to obtain and associate with the record all of the Veteran's treatment records from Dr. Joseph Davidson. The record includes the Veteran's SSA records and demonstrates that the AMC requested that the Veteran provided the required authorization. The evidence does not demonstrate that the Veteran responded to the request with a completed VA Form 21-4142, and the Veteran's representative has not indicated that additional records are available. In January 2013, the Board again remanded the Veteran's claim to obtain and associate with the claims file all records reviewed in conjunction with the adjudication of the Veteran's claim and the Veteran's post-June 2012 treatment records from the Dallas VA Medical Center, which was completed. As such, the Board finds the AMC substantially complied with the August 2010, February 2012, June 2012, and January 2013 remand directives with respect to the issue on appeal. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ asked the Veteran specific questions regarding his symptoms of and treatment for his hypertension during active duty and following separation from service. The hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. In addition, the Veteran was assisted at the hearing by an accredited representative from the Texas Veterans Commission. No pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran or his representative. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) . There is no indication in the record that any additional evidence relevant to the issue decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. All of the evidence in the Veteran's claims file has been thoroughly reviewed. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matter decided. The Veteran should not assume that pieces of evidence, not explicitly discussed, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). The Veteran asserts that his current hypertension had its onset during active duty, and he contends that he has had hypertension since his separation from active duty. Alternatively, the Veteran asserts that his hypertension is causally related to his service-connected PTSD or is aggravated by his service-connected PTSD. Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). 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). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as hypertension, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309. Additionally, service connection may be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). Under the pertinent regulations, hypertension means that the diastolic blood pressure is predominantly 90 millimeters (mm.) or greater, and isolated systolic hypertension means that the systolic blood 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). The Board is to consider all lay and medical evidence as it pertains to the issues. 38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). On an April 1968 report of medical history, the Veteran reported a history of high blood pressure dating back to 1966. On his enlistment examination, the Veteran's blood pressure was 130/88. A July 1970 separation examination reflects that the Veteran's blood pressure was 114/72. The Veteran reported that he was in good health. A December 1970 VA examination shows the Veteran's blood pressure was 120/84. A December 1998 private treatment record reflects blood pressure readings of 129/93, 132/86, and 135/92. The private physician diagnosed hypertension. In May 2002, the Veteran's blood pressure was 118/74, and the private treatment record appears to indicate that the Veteran had a history of hypertension since 1992, which was currently well-controlled by prescription medication. A September 2002 private physical examination indicates the Veteran had a history of hypertension. A March 2003 private medical record shows the Veteran's blood pressure was 138/82, and the impression was hypertension. The private physician noted the Veteran's blood pressure was usually controlled by medication. In June 2009, the Veteran and his wife testified before the Board. The Veteran reported that he had some hypertension in service that was not recorded. He explained that the in-service medics told him that he had high blood pressure but did not report it because it was not constant. The Veteran also reported that he was currently treated with daily medication for his hypertension at the Dallas VA Medical Center. He also stated that in the mid-1970s, a private physician, Dr. Joseph Davidson at the Parkland Health & Hospital System in Dallas, Texas, had informed him that his hypertension could be related to his time in Vietnam or it could be related to his PTSD. The Veteran stated that he did not know whether the records documenting his treatment from Dr. Davidson would be available. The Veteran's wife reported that the Veteran had had hypertension for quite a while. In January 2011, the Veteran underwent VA examination in connection with his claim. The VA examiner reviewed the Veteran's claims file and noted the diagnosis of hypertension in the 1990s by Dr. Davidson. On examination, the Veteran's blood pressure readings were 132/90, 128/90, and 122/77. The assessment was hypertension. The VA examiner noted the Veteran had separated from service in July 1970 and that his high blood pressure was not diagnosed until he was in his 40s. Because the diagnosis came approximately 20 years after the Veteran's separation from service, the VA examiner found the Veteran's hypertension was not at least as likely as not caused or aggravated by active service. The VA examiner also commented that hypertension was a common condition and that to date, there had been only a few studies that had shown an increase in hypertension due to PTSD. The VA examiner stated that those studies had had significant issues regarding methodology. In contrast, a VA study did not show an increase in blood pressure in patients with higher scores for PTSD in the sample population. Archives in General Psychiatry, January 2007, Volume 64. As a result, the VA examiner opined that the Veteran's hypertension was not due to the effects of his PTSD. Pursuant to the Board's February 2012 remand, the Veteran underwent additional VA examination in March 2012. The Veteran's blood pressure readings appear to have been 220/120, 210/118, and 222/120, and the VA examiner diagnosed hypertension. The VA examiner opined that the Veteran's hypertension was less likely as not related to his military service, nor did it manifest to a compensable degree within one year of separation from service. The VA examiner also found it was less likely as not that the Veteran's hypertension was related to or aggravated by his service-connected PTSD. The VA examiner reported that there was no medical literature that confirmed hypertension as being directly caused by PTSD. In addition, hypertension had not been related to anxiety or neurosis. While it was known that stress could transiently elevate blood pressure in all individuals, the VA examiner opined that this was a normal response to catecholamine release and that such temporary elevation did not aggravate or cause an underlying condition of hypertension. The VA examiner also opined that per the massive literature available, hypertension could be caused by smoking. The law provides that every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002). This presumption attaches only where there has been an induction examination in which the later-complained-of disability was not noted. The term "noted" denotes only such conditions as are recorded in examination reports. Here, the Veteran's entrance examination shows the Veteran's blood pressure was 130/88, and there are no notations concerning hypertension. The Board acknowledges that the Veteran reported a history of high blood pressure on the April 1968 report of medical history. However, history provided by a veteran of the pre-service existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. §§ 3.304(b)(1); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). Therefore, the Board finds the Veteran is presumed sound upon entrance into active duty. In addition, the service treatment records do not demonstrate that the Veteran experienced chronic symptoms of hypertension during service. Here, the April 1968 enlistment examination shows the Veteran's blood pressure was 130/88, and the July 1970 separation examination reflects that the Veteran's blood pressure was 114/72. Further, the Veteran testified that because his high blood pressure was not constant, in-service medics did not record their findings. Further, the Board acknowledges that in some circumstances, 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). In this respect, the Veteran and his wife testified at the Board hearing that he has had hypertension since service. The Board acknowledges that the Veteran is competent to testify to matters within the realm of his personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that a lay witness is competent to testify to that which the witness has actually observed and is within the realm of his personal knowledge). However, while the Veteran's statements are competent evidence of events and symptomatology, the Board must also determine whether such evidence is credible. Id. In this respect, the evidence of record does not support the Veteran's statements regarding his symptoms during and since active duty. See Caluza, 7 Vet. App. at 511. Here, the Veteran's blood pressure reading at the time of separation from service is of more probative value than the lay assertions made many years after service separation. Also, the December 1970 VA examination shows the Veteran's blood pressure was 120/84. In addition, although the Veteran asserts Dr. Davidson initially diagnosed hypertension in the 1970s, the May 2002 private treatment record shows a notation that the Veteran's hypertension dated back to 1992. Therefore, the Board finds that the Veteran's statements as to the onset of hypertension are not supported by the evidence of record. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007) (holding that as a finder of fact, the Board, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing.) In addition, the evidence indicates that hypertension was not clinically diagnosed until over 20 years following the Veteran's separation from service. As a result, the Board finds the Veteran has not established a continuity of symptomatology for the purpose of service connection. Furthermore, regardless of whether hypertension was first diagnosed in 1992 or 1998, the clinical evidence of record does not demonstrate that hypertension manifested to a compensable degree within the year following active duty. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As such, the Board finds the Veteran is not entitled to service connection for hypertension on a presumptive basis. With respect to service connection on a direct basis, the record reflects a current diagnosis of hypertension, and therefore, the Board finds the Veteran has established a current disability. Concerning the second element of a claim for direct service connection, the Veteran's service treatment records are negative for any complaints of, treatment for, or diagnosis of hypertension. As stated above, the evidence also does not demonstrate that the Veteran experienced chronic symptoms during service or continuous symptoms since separation from service. In addition, the only competent medical opinions of record do not support a relationship between the Veteran's current hypertension and active duty. Here, the Board finds the opinions provided by the January 2011 and March 2012 VA examiners more probative than the Veteran and his wife's assertions. The VA examiners reviewed the Veteran's relevant medical history and his lay testimony concerning his in-service and post-service symptoms. The VA examiners also provided opinions as to the clinical findings and adequate rationale for the opinions stated, relying on and citing to the records reviewed. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). First, the January 2011 VA examiner found it significant that high blood pressure was not diagnosed until approximately 20 years after the Veteran's separation from service and commented that hypertension was a common condition. As a result, the VA examiner found the Veteran's hypertension was not at least as likely as not caused or aggravated by active service. Likewise, the March 2012 VA examiner opined that the Veteran's hypertension was less likely as not related to his military service, nor did it manifest to a compensable degree within one year of separation from service. The VA examiner also stated that per the massive literature available, hypertension could be caused by smoking. The Veteran is competent to testify as to symptoms that are non-medical in nature; however, a layperson without medical training is not qualified to render a medical diagnosis or medical opinion concerning the etiology of hypertension. See 38 C.F.R. § 3.159(a)(1). In certain unique instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Here, the Board finds that the relationship between the Veteran's current hypertension and active duty is not something for which a layman is competent to provide an opinion. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions). The evidence does not show that the Veteran or his wife possesses the requisite training or credentials needed to render a competent opinion as to the medical causation of hypertension. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). As such, the lay opinions provided by the Veteran and his wife do not constitute competent medical evidence and lack probative value. With respect to service connection on a secondary basis, the evidence must show that the current disability was either caused or aggravated by a service-connected disability. Harder v. Brown, 5 Vet. App. 183, 187-89 (1993). Here, the Veteran asserts that his hypertension is caused or aggravated by his service-connected PTSD. However, the competent clinical evidence of record is against a finding that the Veteran's hypertension is caused or aggravated by his PTSD. First, the January 2011 VA examiner opined that the Veteran's hypertension was not due to the effects of PTSD. The VA examiner found it significant that there had been only a few studies that had shown an increase in hypertension due to PTSD, and the VA examiner stated that those studies had had significant issues regarding methodology. In contrast, the VA examiner found probative a VA study that did not show an increase in blood pressure in patients with higher scores for PTSD. Similarly, the March 2012 VA examiner found it was less likely as not that the Veteran's hypertension was related to or aggravated by his service-connected PTSD. The VA examiner reported that there was no medical literature that confirmed hypertension as being directly caused by PTSD. In addition, hypertension had not been related to anxiety or neurosis. While it was known that stress could transiently elevate blood pressure in all individuals, the VA examiner opined that this was a normal response to catecholamine release and that such temporary elevation did not aggravate or cause an underlying condition of hypertension. Here, the Board finds that the opinions provided by the VA examiners are more than adequate and highly probative as to whether the Veteran's hypertension is caused or aggravated by his service-connected PTSD. The VA examiners reviewed the Veteran's claims file, performed physical examinations of the Veteran, considered the Veteran's statements regarding his past medical history and current symptoms, and provided sufficient rationale for the opinions stated. Again, the Board acknowledges the Veteran is competent to describe his symptoms. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, a veteran's own conclusion stated in support of his claim that his present disability is secondary to his service-connected disability is not competent evidence as to the issue of medical causation of hypertension. See 38 C.F.R. § 3.159; see also Grivois v. Brown, 6 Vet. App. 136 (1994). Thus, a medical opinion is needed to connect one medical condition to another medical condition. In this case, the probative medical evidence of record provides negative opinions concerning a nexus between the Veteran's hypertension and his service-connected PTSD. Based on the foregoing, the Board finds that the preponderance of the evidence is against a grant of service connection for hypertension, to include as secondary to service-connected PTSD. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55-56. ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs