Citation Nr: 18145762 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 04-09 988 DATE: October 30, 2018 ORDER Service connection for hypertension, based on aggravation by service-connected Type II diabetes mellitus, is denied. FINDING OF FACT Hypertension is not aggravated by service-connected type 2 diabetes mellitus. CONCLUSION OF LAW Disability due to hypertension is not proximately due to or the result of service connected diabetes mellitus. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1965 to November 1967. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a July 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. This case has an extensive history before the Board. In September 2006, March 2009, January 2014, and September 2017, the Board remanded the claim for further development. In August 2012, the Board, in pertinent part, denied the Veteran’s claim for service connection for hypertension. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (“Court”). In a May 2013 Order, the Court granted a Joint Motion for Partial Remand (“Joint Motion”) which vacated the August 2012 Board’s decision to the extent that it denied entitlement to service connection for hypertension and remanded such claim to the Board for further development and readjudication. In January 2014, the Board remanded the claim for hypertension consistent with the findings of the May 2013 Joint Motion (obtain a VA medical opinion addressing a potential nexus between the Veteran’s hypertension and Agent Orange exposure). Thereafter, in a June 2016 decision, the Board denied service connection for hypertension, to include as a result of exposure to herbicides and/or secondary to service-connected PTSD and Type II diabetes mellitus. The Veteran appealed the Board’s June 2016 decision to the Court. In a June 2017 Joint Motion, the parties requested that the Court vacate and remand the Board’s decision. The June 2017 Joint Motion left undisturbed the Board’s denial of service connection for hypertension for presumptive service connection, direct service connection, and secondary service connection under a causal theory due to type 2 diabetes mellitus and posttraumatic stress disorder (PTSD). Thus, the issues remaining on appeal were those of service connection for hypertension based on aggravation due to PTSD, and service connection for hypertension based on aggravation by type 2 diabetes mellitus. In September 2017, the Board denied entitlement to service connection for hypertension based on aggravation by PTSD and remanded the issue of aggravation by type 2 diabetes mellitus for further development. The development has been completed and the case is now before the Board for further appellate review. 1. Service connection for hypertension based on aggravation by type 2 diabetes mellitus. I. Due Process VA has a duty to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C. §§ 5103, 5103A (2012) and 38 C.F.R. § 3.159 (2016). In the instant case, VA provided adequate notice in a letter sent to the Veteran in March 2002, January 2004, August 2009, and October 2006. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of relevant treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service and VA treatment records are associated with the claims file as are records associated with his claim for disability benefits from the Social Security Administration (SSA). VA provided relevant examinations as discussed further on in the decision. There is no indication of additional existing evidence that is necessary for a fair adjudication of the claim that is the subject of this appeal. Hence, no further notice or assistance to the Veteran is required to fulfill VA’s duty to assist. II. Service Connection Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2017). Secondary service connection may also be established for a nonservice-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) (2017); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on a 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 between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Temporary or intermittent flare ups of symptoms of a condition, alone, do not constitute sufficient evidence aggravation unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). III. Analysis In this case, the preponderance of evidence is against a finding that hypertension is aggravated by the Veteran’s service-connected type 2 diabetes mellitus. An April 2002 VA general medical examination report indicates the April 2002 VA examiner suggested that in order to have better control over his hypertension, the Veteran should lose weight. There was no opinion provided with regard to whether hypertension was aggravated by service-connected diabetes. Therefore, the examination is of no probative value on the question of whether the Veteran’s diabetes aggravated his hypertension. An August 2006 VA treatment record notes the Veteran has “metabolic syndrome,” consisting of obesity, diabetes type 2, hypertension, and dyslipidemia. A July 2008 VA treatment report notes that the Veteran did not have microalbuminuria, which is defined as, “urinary excretion of albumin in quantities that are above the reference interval but too low to be measured by conventional dipstick tests; it is an early indicator of glomerulopathy.” Dorland’s Illustrated Medical Dictionary, 1156 (32nd ed. 2012). “Glomerulopathy” is “any disease of the renal glomeruli,” meaning a kidney problem. Id. at 787. A March 2009 VA treatment record notes his diabetes was well controlled with no evidence of nephropathy. A July 2009 treatment record noted no microalbuminuria. Subsequent laboratory testing records did not show elevated albumin in the Veteran’s urine, and no health care provider stated that microalbuminuria was present. In June 2011, the Veteran was afforded a VA examination. The examiner opined, in part, that hypertension was not aggravated by diabetes. The examiner explained that the Veteran’s anti-hypertensive medication doses were lowered with continued good blood pressure control in the context of some weight loss and increased physical activity, illustrating the importance of these factors in his blood pressure control. The examiner further reasoned that diabetes is not a major risk factor for hypertension, and that the Veteran’s hypertension preceded the diagnosis of diabetes by many years. The Board acknowledges that the rationale stated appears to apply more to diabetes as a causative factor in the development of hypertension, rather than an aggravating factor in already established hypertension. Thus, the conclusion itself is not afforded probative weight. However, the examiner also explained that the Veteran’s blood pressure was well controlled for many years. This statement is probative evidence against a finding that aggravation occurred because it shows that the Veteran’s blood pressure remained steady over time as opposed to becoming worse. A March 2014 addendum medical opinion did not address whether hypertension is aggravated by service-connected diabetes. Thus, this opinion is of no consequence in this case. A September 2017 addendum medical opinion stated that hypertension was not worsened by service connected type 2 diabetes mellitus. The examiner stated that he reviewed the medical evidence of record. The examiner reasoned that there is no objective evidence of a worsening, and that “[m]ost recent labs do not show any renal component, which would be elevated if the T[ype] 2 D[iabetes] M[ellitus] was to affect the Veteran’s hypertension.” This opinion is adequate because the examiner reviewed the relevant evidence of record, including laboratory testing. The examiner also provided a sound reason for his conclusion based upon clinical testing. The explanation provided by the examiner is probative evidence against the claim. In light of the forgoing, the Board finds that entitlement to service connection for hypertension is not warranted. As discussed above, there is no probative evidence that hypertension is aggravated by service-connected diabetes. The most probative evidence of record is the September 2017 VA opinion which is unfavorable to the claim and is supported by persuasive rationale. It indicates that there is no worsening and that diabetes does not aggravate the Veteran’s hypertension based on the lack of renal involvement. The Board acknowledges the Veteran’s contentions that his hypertension is related to his service-connected diabetes. A review of the record evidence shows there is no indication that the Veteran has medical expertise or other types of skills that would render him competent to provide an opinion regarding whether his hypertension was aggravated by his diabetes. In this regard, the Board notes that whether lay opinions of this nature are competent evidence depends on the question at issue and the particular facts of the case. Whether one medical condition aggravates another is not a simple question amenable to lay opinion evidence. Thus, to the extent that the Veteran contends that his hypertension is aggravated by another medical condition, his opinion is not competent evidence and is less probative than the September 2017 examiner. The Board acknowledges a May 2004 Decision Review Officer hearing transcript in which the Veteran reported that a doctor told him diabetes complicates hypertension. The Board finds this report, which is very generalized and subject to misinterpretation by the Veteran, holds much less probative weight than does the opinion of the September 2017 VA examiner. For the above reasons, the Board concludes that the preponderance of the evidence is against granting service connection for hypertension based on aggravation by his service-connected diabetes. Thus, there is no reasonable doubt to be resolved in this case, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Rocktashel, Counsel