Citation Nr: 1805429 Decision Date: 01/26/18 Archive Date: 02/07/18 DOCKET NO. 11-00 296 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for hypertension, as secondary to the service-connected disease or injury. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. Bodi, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1979 to October 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a March 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In May 2016, the Veteran testified at a hearing before the undersigned using videoconferencing technology; a transcript of that hearing is of record. In September 2016 and September 2017, the issue was remanded to the Agency of Original Jurisdiction (AOJ). Also of note, in the September 2017 Board decision and remand, entitlement to service connection for hypertension on a direct and presumptive basis was denied. The issue remained on appeal only as to secondary service connection, as the November 2016 VA examination did not address this theory. A new VA medical opinion has been obtained. The directives having been substantially complied with, the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT 1. Hypertension was not caused or aggravated by service-connected bilateral knee strains and service-connected bilateral ankle sprains. 2. The Veteran is currently on low dose Prednisone (1 mg) for the non-service connected rheumatoid arthritis. CONCLUSION OF LAW Hypertension is not proximately due to, the result of, or aggravated by service-connected disease or injury. 38 C.F.R. §§ 3.102, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2017). The Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). During the hearing, the VLJ clarified the issue, asked if there was outstanding evidence and held the open for the submission of evidence. Such actions comply with 38 C.F.R. § 3.103. II. Service Connection Except as provided in § 3.300(c), 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). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (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, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). III. History In December 1984, shortly before his separation, the Veteran filled out a medical health questionnaire, where he denied having or ever having had high or low blood pressure. The Veteran did not have a separation examination because he submitted a signed document stating that he did not wish to have one. See August 1985 STR's. The record reflects that following his October 1985 separation, the Veteran did not seek medical treatment until January 1991, when private treatment records documented the Veteran's blood pressure at 160/100. The Veteran's blood pressure was then recorded at 120/80 and 130/88 in May 1991. The Veteran's private treatment records show that he began treatment for high blood pressure in 1992, when his physician noticed "slightly elevated blood pressure." Private treatment records from 1992 to 2008 reflect treatment for hypertension. Of note, an October 2008 private treatment record from Dr. A. P. C. shows, "He did start taking prednisone 10 mg a day in the last few months as well as Plaquenil for his rheumatoid arthritis by his rheumatologist." The treatment record shows, "hypertension uncontrolled most likely secondary to prednisone." Of note, an August 2016 VA treatment record shows that the Veteran takes prednisone in the form of a low-dose 1 mg tablet by mouth every day as needed. The Veteran reported being diagnosed with rheumatoid arthritis. A VA examination report dated in November 2016 reflected hypertension for which the Veteran was taking continuous medication. The Veteran reported an onset of symptoms in 1985. After examining the Veteran and reviewing the medical file, the VA examiner determined that the Veteran's earliest treatment of hypertension occurred in 1991. She stated that isolated elevated readings were not sufficient to establish hypertension, or predictive or representative of early stages of hypertension. The VA examiner concluded that the Veteran's hypertension was less likely than not related to his service. She also did not find any other pertinent physical findings, complications, conditions, signs or symptoms related to the Veteran's hypertension. In a September 2017 VA medical opinion, the physician opined that that there is no relation of the Veteran's service connected conditions or medications to cause hypertension or aggravate it beyond natural progression. The physician opined that the Veteran has essential hypertension. She explained that, per Up to Date medical literature, although the exact etiology for HTN remains unclear, a number of risk factors are strongly and independently associated with its developments, such as age, obesity, family history, race, reduced nephron number, high-salt diets, excessive alcohol consumption, physical inactivity, diabetes and dyslipidemia and personality traits and depression. She elaborated that having a joint condition or taking the Veteran's medications are not a risk factor for developing hypertension, therefore, it is less likely as not for the hypertension to be due to the service-connected disabilities, including medication for same. Regarding sodium retention and increase in blood pressure, she opined, "It could have temporarily aggravated the hypertension during that time when he was taking 10 mg of Prednisone." The physician further opined, "however, he currently is still on only 2 medications: carvedilol 25 mg twice daily and Lotrel 5/40 mg daily for blood pressure, and now on low dose Prednisone 1 mg for the non-service connected condition of RA (rheumatoid arthritis)." In the September 2017 decision and remand, the Board conceded that the Veteran has hypertension, as it is noted in private treatment records that he has had hypertension since 1992, and that he has been taking medication for this disability since that time. The Veteran contends that he is entitled to service connection for hypertension as secondary to his service-connected bilateral knee strains and service-connected bilateral ankle sprains. IV. Analysis After careful consideration of the evidence of record, to include the Veteran's arguments, the Board finds that the most probative evidence of record is the September 2017 VA examiner's medical opinion. She reviewed the Veteran's record, to include the private medical evidence, and provided an opinion on secondary service connection based upon her knowledge of the facts of the Veteran's case and known medical principles. A medical opinion will be considered more probative if it includes clear conclusions and supporting data with a reasoned analysis connecting the data and conclusions. A medical opinion that is a factually accurate, fully articulated, and based on sound reasoning carries significant weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board notes that there is no competent opinion supporting the contention that the Veteran's hypertension is due to service-connected disease or injury. The Board acknowledges that lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F. 3d 1372 (2007); see also Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). A layman is competent to report what he or she experiences through one of the senses. See Layno v. Brown, 6 Vet. App 465, 470 (1994). The Veteran is also competent to report what he has been told by his physician. However, the etiology of hypertension is a complex medical matter beyond the expertise of a layperson. Jandreau v. Nicholson, 492 F. 3d 1372 (2007). In this instance, no individual with appropriate expertise has related hypertension to the Veteran's service connect44ed disease or injury, to0 include medications taken therefore. After reviewing the Veteran's medical file, the uncontroverted opinion of the 2017 VA examiner is that there is no relation of the Veteran's service-connected conditions or medications to cause hypertension or aggravate it beyond natural progression. Here, the most probative evidence suggests that the Veteran's hypertension was not proximately due to, the result of, or aggravated by service-connected disease or injury, including the Veteran's service-connected bilateral knee strains and service-connected bilateral ankle sprains. The uncontroverted opinion of the 2017 VA examiner is that there is no relation of the Veteran's service-connected conditions or medications to cause hypertension or aggravate it beyond natural progression. In addition, the VA examiner noted that although the exact etiology for hypertension remains unclear, a number of risk factors are strongly and independently associated with its developments, such as age, obesity, family history, race, reduced nephron number, high-salt diets, excessive alcohol consumption, physical inactivity, diabetes and dyslipidemia and personality traits and depression. Hypertension was not caused or aggravated by service-connected bilateral knee strains and service-connected bilateral ankle sprains. This is consistent with VA treatment records. There is no probative evidence to the contrary. Consequently, entitlement to service connection for hypertension, as secondary to the service-connected disease or injury is not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (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). In reaching this conclusion, the Board finds that the preponderance of the evidence is against this claim. As such, the benefit of the doubt rule is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for hypertension, as secondary to service connected disease or injury, is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs