Citation Nr: 1806930	
Decision Date: 02/02/18    Archive Date: 02/14/18

DOCKET NO.  14-08 276	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs (VA) Regional Office (RO) 
in Indianapolis, Indiana


THE ISSUE

Entitlement to service connection for hypertension, including as secondary to the service-connected diabetes mellitus type II.


REPRESENTATION

Appellant represented by:	The American Legion


WITNESSES AT HEARING ON APPEAL

The Veteran (Appellant) and spouse


ATTORNEY FOR THE BOARD

E. Choi, Associate Counsel
INTRODUCTION

The Veteran, who is the appellant, served on active duty from June 1967 to January 1970.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision of the RO in Indianapolis, Indiana, which denied service connection for hypertension.

In October 2017, the Veteran testified at a Travel Board hearing in Indianapolis, Indiana, before the undersigned Veterans Law Judge (VLJ).  A transcript of the hearing has been associated with the electronic file.  The Board has reviewed the electronic file on "Virtual VA" and the Veterans Benefits Management System (VBMS) to ensure a complete review of the evidence in this case.


FINDINGS OF FACT

1.	The Veteran is currently diagnosed with hypertension.

2.	The current hypertension is the result of the service-connected diabetes mellitus.


CONCLUSION OF LAW

Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for hypertension as secondary to the service-connected diabetes mellitus have been met.  38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017).




REASONS AND BASES FOR FINDINGS AND CONCLUSION

Duties to Notify and Assist

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. §§ 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2017).  As the instant decision grants service connection for hypertension, no further discussion of VA's duties to notify and to assist is necessary.

Service Connection for Hypertension

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. § 1110; 38 C.F.R. § 3.303(a).  Service connection may 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).  Service connection generally requires 
(1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability.  See 38 C.F.R. § 3.310(a).  When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition.  See id.; Harder v. Brown, 5 Vet. App. 183, 187 (1993).  The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability.  See Allen v. Brown, 7 Vet. App. 439, 448 (1995).  In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury.  To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability.  Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995).

The Veteran is currently diagnosed with hypertension which is listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) for "chronic" in-service symptoms and "continuous" post-service symptoms apply.  Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).  

Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service.  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.  With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes.  If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection.  38 C.F.R. § 3.303(b).

Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as hypertension, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service.  38 C.F.R. §§ 3.307, 3.309(a).  While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time.  Id.

Throughout the course of this appeal, the Veteran has contended that hypertension is the result of the service-connected diabetes mellitus (diabetes).  During the October 2017 Board hearing, the Veteran testified to being diagnosed with diabetes first, then being diagnosed with hypertension approximately one year later.  

Initially, the Board finds that the Veteran is currently diagnosed with hypertension.  A September 2012 VA examination report reflects a diagnosis for hypertension.

Next, after a review of all the evidence of record, both lay and medical, the Board finds that the evidence is at least in equipoise as to whether the current hypertension is the result of the service-connected diabetes.  A November 2009 private treatment record reflects recent laboratory test results were reviewed with the Veteran.  The private provider's assessment was diabetes mellitus type II, which was discussed with the Veteran.  The Veteran reported that he had already ceased consuming any alcohol, and the private provider ordered a glucose monitoring device and testing strips.

A June 2010 VA treatment record shows the Veteran denied being on any medication for elevated blood pressure and that the VA provider prescribed Lisinopril to control high blood pressure.  A July 2010 VA treatment record shows the Veteran was given a blood pressure monitoring device and instructed on how to use it.  A subsequent August 2010 VA treatment record reflects the Veteran had started keeping a log of blood pressure measurements and that he just started taking the prescribed Lisinopril earlier that month.

In September 2012, the Veteran underwent a VA examination for hypertension.  As discussed above, the September 2012 VA examiner diagnosed the Veteran with hypertension.  The September 2012 VA examination report also contains the opinion that the hypertension is at least as likely as not aggravated by the service-connected diabetes, but the VA examiner did not provide a rationale.

The Veteran underwent another VA examination in June 2013, the report for which notes the VA examiner was unable to ascertain whether the Veteran's hypertension predated his diabetes.  Nonetheless, the VA examiner opined that it is less likely than not that the current hypertension is the result of the service-connected diabetes because the medical evidence showed that the Veteran was simultaneously diagnosed with diabetes and hypertension, which is contrary to the medical evidence of record discussed above.  See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that an opinion based upon an inaccurate factual premise has no probative value).  Additionally, the VA examiner noted the Veteran's normal renal function excluded any causal connection between the service-connected diabetes and hypertension.  

A VA addendum opinion was provided in December 2013.  Like the June 2013 VA examiner, the December 2013 VA examiner asserted that the Veteran was diagnosed with diabetes and hypertension simultaneously, and opined that it is less likely than not that the hypertension is the result of diabetes given the simultaneous diagnoses and the Veteran's normal renal function; together those factors exclude any causal connection between diabetes and hypertension.  The December 2013 VA examiner also noted that medical records show the Veteran was consuming alcohol, had elevated triglycerides, and is obese, which play a crucial role in blood pressure management; however, the medical evidence of record shows the Veteran ceased consuming alcohol by November 2009.  Because both the June 2013 and December 2013 VA opinions were based upon inaccurate factual premises, the Board finds the VA opinions are of no probative value in establishing the etiology of the current hypertension.  See Reonal, 5 Vet. App. 458.

During the October 2017 Board hearing, the Veteran also submitted several medical articles discussing several studies on the relationship between diabetes and hypertension.  The medical literature discussion includes: how diabetes and hypertension are comorbid diseases and one makes the other more likely to occur; studies showing that 40 percent of individuals diagnosed with diabetes mellitus type II, who did not also have any kidney problems, nonetheless had high blood pressure; that hypertension is twice as likely to occur in individuals diagnosed with diabetes; that there is substantial overlap between diabetes and hypertension in etiology and disease mechanisms; and that in the United States population, hypertension occurs in 50-80 percent of patients with diabetes mellitus type II.

Based on the foregoing, the Board finds the September 2012 VA examiner's opinion, together with the medical literature submitted during the October 2017 Board hearing, places the evidence in relative equipoise as to the question of whether the current hypertension is the result of the service-connected diabetes mellitus.  Resolving all reasonable doubt in favor of the Veteran, the Board finds that the current hypertension is caused by, or related to, the service-connected diabetes mellitus, and that service connection for hypertension is warranted as secondary to the service-connected diabetes mellitus.  38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310.  Because the Board is granting service connection on a secondary basis, all other theories of entitlement to service connection are rendered moot.


ORDER

Service connection for hypertension, as secondary to the service-connected diabetes mellitus type II, is granted.





____________________________________________
J. PARKER
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs