Citation Nr: 1806222 Decision Date: 01/31/18 Archive Date: 02/07/18 DOCKET NO. 07-27 717 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for hypertension, to include as due to herbicide exposure and/or secondary to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Robert Chisholm, Esq. WITNESS AT HEARING ON APPEAL The Veteran, his spouse, and his son ATTORNEY FOR THE BOARD J. R. Higgins, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from February 1966 to November 1969. The Veteran served in Vietnam, and was awarded the Purple Heart Medal and Combat Action Ribbon. This matter is before the Board of Veterans' Appeal (Board) on appeal from an October 2006 rating decision issued by the Department of Veteran Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In April 2008, the Veteran presented testimony in a travel board hearing before the Board. In February 2017, the Board remanded this matter for further development, and the case has been returned for appellate consideration. This appeal was processed using the Virtual VA/VBMS paperless claim processing system. Accordingly, any future consideration of this Veteran's case should take into account the existence of this electronic record. FINDING OF FACT The Veteran's hypertension was not present in service or until many years thereafter, and is not related to service or to an incident of service origin, to include exposure to herbicide agents therein; nor is it proximately due to, or chronically aggravated by his service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1111, 1116, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION 1. Veterans Claims Assistance Act of 2000 (VCAA) Neither the Veteran nor his representative has raised any other 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 a duty to assist argument). Additionally, in February 2017, this matter was remanded to have an addendum opinion associated with the file addressing the etiology of the Veteran's hypertension. The addendum opinion was completed in March 2017 and associated with the record. Subsequently, the claim was readjudicated in the August 2017 Supplemental Statement of the Case. Thus, there is compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). 2. Merits of the Claim The Veteran seeks service connection for hypertension, to include as due to herbicide exposure and/or secondary to service connected PTSD. Service connection may be granted for a disability resulting from disease or injury incurred in, or aggravated by, active military service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (a) (2017). Service connection may also be granted for any disease initially diagnosed after service when the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2017). To establish direct service connection for such a disability, the record must reflect: (1) Competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Shedden v. Principi, 381 F.3d 1163 (2004). Service connection may also 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) (2016). Establishing secondary service connection 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). In addition, for Veterans who have served 90 days or more of active service after December 31, 1946, there is a presumption for certain chronic diseases, to include hypertension, if the disability is manifest to a compensable degree within one year of discharge from service. 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, as distinguished from merely isolated findings or a diagnosis including the word "chronic." If there is not sufficient evidence that the currently diagnosed chronic disease was chronic in service or within presumptive period, a veteran may still be entitled to presumptive service connection if continuity of symptomatology is demonstrated. 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic as per 38 C.F.R. § 3.309 (a)). In applying these standards to the Veteran's claim, the Board first finds competent evidence of a current disability. The objective medical evidence revealed medical treatment records related to hypertension since January 1996. Accordingly, the Board finds that the first Shedden element has been met. Furthermore, the Board finds that the Veteran was exposed to herbicide agents during military service in Vietnam. In claims for service connection due to Agent Orange exposure, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam between January 1962 and May 1975 shall be presumed to have been exposed during such service to certain herbicide agents, including Agent Orange, unless there is affirmative evidence to the contrary. 38 U.S.C. § 1116 (a) (2011); 38 C.F.R. §§ 3.307, 3.309 (2017). Here, the Veteran's service personnel records confirm his presence in Vietnam during service. Available service personnel records indicate that the Veteran was present in Vietnam from approximately June 1968 to July 1969. Thus, the Board finds that the Veteran was exposed to herbicide agents during military service. Such a finding triggers an analysis into the application of presumptive service connection in this case. To that end, if a veteran was exposed to Agent Orange during service, certain diseases are presumed to have been incurred in-service if they manifest to a compensable degree within specified periods, and even if there is no record of such disease during service. 38 U.S.C. § 1116 (a) (2) (2012); 38 C.F.R. §§ 3.307 (a) (6), 3.309(e) (2017). However, hypertension is not among the diseases presumptively linked to herbicide exposure. Additionally, the Veteran contends that he experienced a head injury during service to leading to his hypertension. For purposes of this decision, the Board finds that the Veteran is competent and credible with regard to his assertions as to a head injury. Accordingly, the second Shedden element has been met. The question for the Board is whether the Veteran's hypertension is related to his military service, to include exposure to herbicide agents and his asserted head injury therein, and/or secondary to the Veteran's service-connected PTSD. The Veteran's service treatment records are absent of any diagnosis, notation, or treatment related to hypertension. The Veteran's available post-service medical treatment records related to hypertension began in 1996, which detailed treatment related to hypertension since that time. The Veteran underwent a VA examination in July 2009 to determine the nature and etiology of his hypertension. The July 2009 examiner opined that the Veteran's hypertension was less likely than not caused by or a result of his service-connected PTSD. The examiner found no objective evidence that the Veteran's service-connected PTSD aggravated his hypertension. The examiner provided that based on her review of medical literature, the Veteran's medical records, and her clinical experience that PTSD does not cause hypertension. The examiner recognized that during an episode of distress related to PTSD, the Veteran's blood pressure may be elevated but the blood pressure returned to normal once the episode was over. Moreover, there was no permanent blood pressure elevation or diagnosis of hypertension due to PTSD. The examiner further provided that the Veteran's essential hypertension has no specific cause, but lifestyle factors, such as a high salt diet, lack of exercise, and obesity contribute to hypertension. Furthermore, the examiner noted that the Veteran's blood pressure readings in both his VA and private medical records since November 2005 were not elevated, but well controlled. Therefore, she concluded that there is no objective evidence that the Veteran's PTSD chronically worsened or permanently increased the severity of his hypertension. A similar opinion was asserted in an August 2016 VA examination, wherein the examiner opined that the Veteran's hypertension was less likely as not caused by or a result of his service-connected PTSD. The examiner found no objective evidence that Veteran's service-connected PTSD aggravated his hypertension. The examiner provided that based on her review of medical literature, the Veteran's medical records, and her clinical experience that PTSD does not cause hypertension. The examiner recognized that during an episode of distress related to PTSD the Veteran's blood pressure may be elevated, but the blood pressure returned to normal, once the episode was over. Moreover, the examiner asserted that there was no permanent blood pressure elevation or diagnosis of hypertension due to PTSD. The examiner provided that hypertension was very common and generally considered to be "essential," meaning it has no specific cause, but lifestyle factors, such as a high salt diet, lack of exercise, and obesity were contributory factors. Furthermore, the examiner noted that the Veteran's blood pressure readings in both his VA and private medical records since November 2005 were not elevated, but well-controlled. Therefore, there was no objective evidence that the Veteran's PTSD chronically worsened or permanently increased the severity of his hypertension. The August 2016 VA addendum opinion provided that the Veteran's hypertension was less likely as not incurred in, cause by or aggravated by service, or exposure to Agent Orange during service. The examiner opined that the medical evidence was against the presence of hypertension within one year of separation from service and noted that hypertension is not amongst those disorders presumptively associated with Agent Orange exposure. The examiner noted that the Veteran's service treatment records were absent for hypertension. The examiner concluded that there is no other evidence associated with the record to indicate or suggest that hypertension, or a related condition, is the causal result of presumed hazardous chemical exposure close to two decades prior. The examiner highlighted that the Veteran's post-service health records began in 1996 and a December 2005 medical note reflected the Veteran's report of elevated blood pressure readings for at least 20 years. Furthermore, the examiner provided that hypertension is generally essential in nature, thus without a specific cause, but lifestyle factors, such as a high salt diet, lack of exercise, and obesity were contributory factors. Moreover, the examiner provided that according to the medical records the Veteran had been obese since at least 1996, which contributed to his current condition. Additionally, the examiner cited academic articles to demonstrate the link between obesity and hypertension. The March 2017 VA addendum opinion provided that the Veteran's hypertension was less likely than not related to service, to specifically include as due to an alleged in-service head injury. The examiner provided that hypertension was not diagnosed anywhere throughout the service record and there was no other evidence associated with the record to indicate or suggest that the Veteran had hypertension or was treated for hypertension in-service or in any close proximity to service. The examiner highlighted that the Veteran's post-service health records began in 1996 and a December 2005 medical note showed that the Veteran's report of elevated blood pressure readings for at least 20 years. Furthermore, the examiner provided that essential hypertension had no specific cause. The examiner noted that essential (or idiopathic) hypertension accounted for 95 percent of all cases of hypertension, but lifestyle factors, such as a high salt diet, lack of exercise, and obesity were contributory factors. Moreover, the examiner provided that according to the medical records the Veteran had been obese since at least 1996. The examiner cited academic articles that linked hypertension to obesity. The March 2017 VA addendum opinion also asserted that the Veteran's hypertension was not caused or permanently aggravated beyond the natural progression by his service-connected PTSD. The examiner cited to medical and scientific evidence that did not establish that PTSD as the proximate cause of the Veteran's hypertension. She specifically stated there was no proof that stress by itself causes long-term high blood pressure. The examiner acknowledged an association between PTSD/stress and cardiovascular disease however association was not the same as causation. Causation indicated that one event was the result of the occurrence of the other event; i.e. there is a casual relationship between two events, however the examiner's review of the medical literature did not find a cause and effect relationship between PTSD/stress and chronic hypertension. The examiner highlighted that stressful situations could cause the blood pressure to spike temporarily, however when the stress went down, the blood pressure comes back down to its usual levels. The examiner also noted the essential nature of hypertension and the linkage between obesity and hypertension. When assessing the probative value of a medical opinion, the access to the claims file and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean, 13 Vet. App. at 448-9. Claims file review, as it pertains to obtaining an overview of a claimant's medical history, is not a requirement for medical opinions. A medical opinion that contains only data and conclusions has reduced probative weight. Further, a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez, 22 Vet. App. at 304. In this case, as to the issue of whether the Veteran's hypertension was related to his military service, and/or cause or aggravated by the Veteran's service-connected PTSD, the Board finds the combination of the August 2016 VA examination report, and the August 2016 and March 2017 VA addendum opinions are the most probative evidence of record as they were definitive, based upon a complete review of the Veteran's entire claims file, in consideration of the Veteran's reported history, contemporaneous physical evaluation of the Veteran, and pursuant to the Board's remand instructions. Furthermore, the examiner provided a complete and thorough rationale in support of her opinion. The examiner based her opinion on review and evaluation of the record; and she provided rationale for her findings. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Regarding the presumption in favor of chronic diseases and the continuity of symptomatology, the Board notes that the Veteran has been diagnosed with hypertension. For VA purposes, diagnosis of hypertension is a chronic disease, thus warranting consideration under 38 C.F.R. § 3.309(a). However, in order for the presumption under 38 C.F.R. § 3.309 to apply the disability must manifest to a compensable degree within one year of discharge from service. However, in this case the objective evidence available does not show treatment for hypertension until about 1996. The VA examiner cited that the Veteran reported an onset of hypertension of 20 years ago in December 2005, which would be around 1985. In any case, the objective medical evidence indicates that the Veteran's hypertension did not manifest to a compensable degree within one year of discharge from service. The Board does note the Veteran's contention that he has sought treatment for hypertension within one year of discharge from service. However, the August 2016 and March 2017 VA examiner addressed that contention and found no evidence that hypertension was treated in service or in close proximity to service. Since the Veteran's hypertension did not manifest to a compensable degree within one year of discharge from service and there is no evidence of a chronic disability in service, the presumption in favor of chronic diseases is not warranted in this case. Walker, 708 F.3d 1331; 38 C.F.R. §§ 3.303 (b), 3.307, 3.309(a) (2017). The absence of post-service complaints, findings, diagnosis, or treatment for many years after service is one factor that tends to weigh against a finding of continuous symptoms after service separation. See Buchanan v. Nicholson, 451 F.3d 1336 (Fed. Cir. 2006) (noting that the lack of contemporaneous medical records is one factor the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Thus, any assertions that he may make as to onset during service with subsequent continuity are not supported by the objective evidence of record. The Board acknowledges statement provided by the Veteran, his spouse, and T.H. regarding the onset and symptomology of the Veteran's hypertension. Specifically, the Board notes the statement provided by the Veteran during his April 2008 hearing, wherein the Veteran provided justification as to the absence of hypertension from his exit examination. The Veteran provided that to expedite his separation from service he waited until he had a normal blood pressure reading during the separation examination. The Veteran stated that he went back about six times until he was measured at a normal blood pressure. However, the VA examiner has stated that there is no evidence that the Veteran's hypertension had its onset during service or within a year of separation of service. The Board has considered the Veteran's contentions and those of the individuals that provided statements on the Veteran's behalf asserting that the Veteran's hypertension is due to service, to include herbicide exposure and/or caused/aggravated by his service-connected PTSD. In this regard, the Veteran, his spouse, and T.H. are competent to report the symptoms that the Veteran experienced and history of treatment. See Charles v. Principi, 16 Vet. App. 370, 374- 75 (2002). However, as lay people, they have not been shown to be capable of making medical conclusions, especially as to a complex medical opinion regarding the etiology of hypertension. Given their lack of demonstrated medical expertise, the Board finds that the opinion of the August 2016 and March 2017 VA examiner, a medical professional, to be the most probative evidence of record as to the current nature and etiology of his claimed hypertension, to include the relationship between the Veteran's hypertension and his service-connected PTSD and military service, to include herbicide exposure. The preponderance of the evidence weighs against finding that the Veteran's hypertension is causally related to his service, was caused or aggravated by his service-connected PTSD, or manifested within an applicable presumptive period. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. §5107 (b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); 38 C.F.R. § 3.102 (2017). For these reasons, service connection for hypertension will therefore be denied. ORDER Service connection for hypertension, to include as due to herbicide exposure and/or secondary to service-connected PTSD, is denied. ____________________________________________ LANA K. JENG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs