Citation Nr: 1754579 Decision Date: 11/29/17 Archive Date: 12/07/17 DOCKET NO. 13-26 169 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for hypertension. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD JR Cummings, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1969 to January 1972, including service in Vietnam. This matter comes before the Board on appeal from a May 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) that denied service connection for hypertension. In May 2013, a hearing was held before a decision review officer (DRO). A transcript of the hearing is associated with the record. In June 2015, the Board remanded the claim to the RO for a VA examination and nexus opinion, which took place in October 2015. For the reasons indicated in the discussion below, the opinion obtained pursuant to the June 2015 remand is adequate to decide the claim, and the RO thus complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. The Veteran is in receipt of service connection for diabetes mellitus (diabetes). 2. The Veteran's hypertension did not manifest in service, within the one year presumptive period, or for many years thereafter, and is unrelated to service. 3. The Veteran's hypertension was neither caused nor aggravated by his service-connected diabetes. CONCLUSION OF LAW Hypertension was not incurred in or aggravated by active service and is not proximately due to, the result of, or aggravated by service-connected disease or injury. 38 U.S.C. §§ 1101, 1110, 1112 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159; Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93. The requirements of the statutes and regulation have been met in this case. VA notified the Veteran in September 2009 of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence he was to provide, what part VA would attempt to obtain, and how disability ratings and effective dates are determined. The case was most recently readjudicated in December 2015. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, pursuant to the June 2015 remand, afforded the Veteran a VA examination. There is no evidence that additional records have yet to be requested, or that additional examinations are in order. The Board will therefore proceed to the merits of the appeal. II. Analysis The Veteran contends that his hypertension should be secondarily service connected to his service-connected diabetes. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In general, service connection requires evidence of (1) current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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). Certain chronic diseases, including hypertension, may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time post-service (one year for hypertension). 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. 38 C.F.R. § 3.310(a) provides that "disability which is proximately due to or the result of a service-connected disease or injury shall be service connected." Such secondary service connection is also warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(b). The Board notes that the term 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. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 (2017). The record contains no evidence of hypertension in any of the Veteran's service treatment records from 1969 to 1972, and no notes of symptoms such as high blood pressure in service. Blood pressure was 117/70 on the October 1971 separation examination. There is also no evidence suggesting a possible association between the Veteran's hypertension and his military service in the post service treatment records. The Veteran has been diagnosed with hypertension and has thus met the current disability requirement. The above evidence reflects, however, that the Veteran's hypertension did not manifest in service, within the one year presumptive period, or for many years thereafter. There is also no evidence or argument that the Veteran's hypertension is otherwise related to service. The Veteran reported being diagnosed with hypertension around the same time he was diagnosed with diabetes in 2006, roughly one year after the diabetes onset, and did not indicate that he experienced symptoms in or near service that were early manifestations of hypertension. Cf. 38 C.F.R. § 3.307(c); Traut v. Brown, 6 Vet. App. 495 (1994) (establishing service connection on a presumptive basis does not require that a chronic disease be diagnosed within the applicable time period; rather, symptoms that manifest within this time period may subsequently be determined to have been early manifestations of a chronic disease). Consequently, service connection is not warranted on a direct basis. In March 2010, the Veteran had a VA examination to determine whether his hypertension was caused by his service-connected diabetes. There, the examiner concluded that it is less likely than not that the Veteran's hypertension is aggravated by the service-connected disability of diabetes. The examiner reasoned that diabetes is not an established cause of hypertension and has never been determined to be a cause of secondary hypertension. Additionally, there was no evidence of nephropathy, which could potentially complicate or aggravate the control of hypertension. This examination was found inadequate by the Board in its June 2015 remand because it did not consider the theory advanced by the Veteran and his representative that his diabetes caused his arteries to narrow and that led to his hypertension. In October 2015, pursuant to the Board's June 2015 remand, a new VA examination was conducted. The examiner opined that it is less likely than not that the Veteran's hypertension was caused or aggravated by his service-connected diabetes. The examiner reasoned that because the Veteran's diagnosis of 'essential HTN' at or about the same time he was diagnosed with diabetes, it was less likely that his hypertension was caused by the diabetes. The examiner added that the weight of available medical literature is against the idea that narrowing arteries can cause hypertension and that diabetes is only recognized to cause or aggravate hypertension in the context of diabetic nephropathy, which the Veteran did not have. As the VA examiner explained the reasons for his conclusions based on an accurate characterization of the evidence of record, his opinion is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). In the February 2015 appellate brief, the Veteran's representative noted that a May 2008 VA treatment record indicated that the Veteran's diabetes was not under control, and contended that this caused the Veteran's continued and consistent high blood glucose levels, resulting in a narrowing of his arteries and thus leading to hypertension. The Veteran's representative contended that this theory is one held by many physicians and the American Diabetes Association. The Veteran's representative is competent to report a contemporaneous medical diagnosis and to cite relevant medical literature. Such medical literature is generally not a sufficient basis to establish nexus. See Sacks v. West, 11 Vet. App. 314, 317 (1998) (noting that treatise materials generally are not specific enough to show nexus); Herlehy v. Brown, 4 Vet.App. 122, 123 (1993) (noting that medical opinions directed at specific patients generally are more probative than medical treatises). In addition, the Veteran's representative did not indicate how he concluded that this theory was one held by many physicians and the American Diabetes Association, i.e., a particular document or website indicating that this is the position of that group or entity. Given the lack of specific citation and specific application to the Veteran's particular symptoms, the general reference to the theory of narrowing arteries is insufficient to establish a link on a causation or aggravation basis between the service connected diabetes and the hypertension. Moreover, the October 2015 specifically addressed this theory, noted that the weight of the medical literature did not support this theory, and that diabetes was only recognized to cause or aggravate hypertension in the context of diabetic neuropathy, which the Veteran did not have. Given that the October 2015 VA examiner is a health care professional who offered a reasoned opinion, his conclusion of a lack of nexus is of greater probative weight than the general medical materials cited by the Veteran's representative. Moreover, to the extent that the Veteran or his representative assert a nexus between diabetes and hypertension, they do not have the requisite medical expertise to competently opine on complex medical matters such as whether a disease that affects internal medical processes caused or aggravated another disease. See, e.g., Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). Their statements in this regard are therefore not competent. The Board also notes that VA has acknowledged in the Federal Register that there is "limited or suggestive evidence," see 79 Fed. Reg. 20308, 20310 (Apr. 11, 2014), of an association between Agent Orange exposure and hypertension. In this case, given the above evidence, this limited or suggestive evidence is not by itself enough to warrant a finding of service connection, and such has not been argued by the Veteran or his representative. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). For the foregoing reasons, the preponderance of the evidence is against service connection on a direct and secondary basis. The benefit of the doubt doctrine is thus not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for hypertension is denied. ____________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs