Citation Nr: 1813836 Decision Date: 03/08/18 Archive Date: 03/14/18 DOCKET NO. 14-24 710A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. Isaacs, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1971 to November 1973 and had additional service in the National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). A Travel Board hearing was held in March 2015 before the undersigned Veterans Law Judge. In March 2016, the Board denied service connection for diabetes mellitus. At that time, the Board also remanded the hypertension claim for additional evidence. FINDING OF FACT The Veteran's hypertension did not have its onset during service and is not otherwise related; the disorder is also not related to a service-connected disability. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. "To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Certain chronic diseases, including hypertension, may be presumed to have been incurred during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Analysis The Veteran contends his hypertension was incurred in service or is otherwise related. He has also contended that his hypertension was related to a service-connected disability. Initially, the Board notes the Veteran has a current diagnosis of hypertension, seen in the VA treatment records and in the April 2016 VA examination report. However, his service treatment records are silent for complaints, treatment or a diagnosis of hypertension. During the Veteran's September 1970 enlistment examination, his blood pressure was noted as 120/78. In the October 1973 separation examination, blood pressure of 130/80 was found. Thereafter, in March 1989, the Veteran underwent an examination associated with his service in the Army National Guard, which included blood pressure readings of 130/102 and 138/92. In April 1989, however, blood pressure readings were noted as 128/76; 126/78 and 126/76. The Veteran was first diagnosed with hypertension in a January 2007 VA treatment record and the examiner indicated the condition was well controlled with medication. In February 2007, a blood pressure reading of 117/74 was found and in May 2011 blood pressure of 129/79 was noted. In the Veteran's initial October 2011 claim, he contended that his hypertension was related to his diabetes mellitus. In December 2012, the RO denied service connection for diabetes mellitus, as well as hypertension. Thereafter, the Veteran's claim centered on his hypertension being directly related to service. As noted previously, the Board denied service connection for diabetes mellitus in the March 2016 decision. Thus, service connection for hypertension is not warranted on a secondary basis because the underlying disability of diabetes mellitus is not service connected. Although the Veteran is also service connected for hearing loss and tinnitus, there is no indication of a relationship between those disabilities and the hypertension. Therefore, the claim turns on the theory of direct service connection. At the March 2015 Board hearing, the Veteran's representative asserted that he had high blood pressure readings in service and that his hypertension had its onset during such service. The claim came before the Board in March 2016 and was remanded for further development, including a VA examination to determine the etiology of his diagnosed hypertension. The Veteran was afforded an April 2016 VA examination in which the examiner diagnosed the Veteran with essential hypertension. He indicated the Veteran requires continuous medication for the disorder, including daily Lisinopril. He found the Veteran's blood pressure in April 2016 to be 130/80 and that there was no impact on the Veteran's ability to work. The examiner concluded the Veteran's hypertension was less likely than not incurred in or caused by service. He indicated he reviewed all the available evidence, including the Veteran's service treatment records. He noted the blood pressure readings on the Veteran's entrance into and separation from active service, as well as the post-service blood pressure readings from 1989 associated with the Veteran's National Guard service. The examiner reported that although the March 1989 examination documented elevated blood pressure of 130/102 and 138/92, a flight examination less than one month later, on April 1, 1989, noted blood pressure of 128/76. The examiner concluded that the isolated elevated blood pressure readings from March 1989 resolved in less than one month and therefore, such readings are not diagnostic evidence of hypertension per the current medical literature, including www.UpToDate.com. He indicated such literature supports a "Need for multiple measurements." In the absence of end-organ damage, he noted, a diagnosis of hypertension should not be made until the blood pressure has been measured on at least three visits, spaced over a period of one week or more. Therefore, he concluded, the Veteran's hypertension is not related to service, including the elevated blood pressure readings documented. The Veteran submitted a July 2016 statement in which he indicated he was on flight status while serving with the Army National Guard when hypertension was indicated. He stated he did not report any abnormalities because he did not want to be taken off flight status. He contends that his records exhibited high blood pressure readings and he was unsure why he was not required to take three readings. He indicated if the medical professionals at the time had followed up and taken additional readings, a diagnosis of hypertension would have been established. While the Board acknowledges the elevated March 1989 blood pressure readings and the Veteran's contentions as to the onset of his hypertension, it finds the April 2016 VA examiner's opinion to be the most probative evidence of record as to the etiology of his hypertension. The Board determines the examiner's opinion holds more weight than the lay evidence of record and there is no positive medical evidence in support of the claim. Therefore, the Board finds the preponderance of the evidence is against the claim and service connection for hypertension is not warranted. While the Veteran provides a well-reasoned statement that his hypertension is related to service, as a lay person, he has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In this regard, the etiology of hypertension is a matter not capable of lay observation and requires medical expertise to determine. Specifically, the question of the causation or onset of such disorder involves a medical subject concerning an internal process extending beyond an immediately observable cause-and-effect relationship. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Therefore, the Veteran's opinion as to the etiology of his hypertension is afforded less probative weight than the April 2016 medical opinion. The Board notes that the initial confirmation of a hypertension diagnosis requires two or more blood pressure readings on at least 3 different days. See Gill v. Shinseki, 26 Vet. App. 386, 391 (2013) (interpreting Note (1) to 38 C.F.R. § 4.104, Diagnostic Code 7101). As stated above, the Board determines the April 2016 VA examiner's opinion is entitled to significant probative weight as he adequately addressed the evidence, as well as the Veteran's contention. He acknowledged the Veteran's elevated blood pressure readings from March 1989 associated with his service in the National Guard. However, he determined an examination less than one month later showed normal blood pressure readings of 128/76, 126/78 and 126/76. Thus, he indicated, the isolated elevated blood pressure readings from March 1989 resolved in less than one month and are not diagnostic evidence of hypertension, based on current medical literature. Therefore, he concluded, the Veteran's hypertension is not related to service. The April 2016 opinion is persuasive as it considered all of the pertinent evidence of record, including the blood pressure readings, and included a complete rationale relying on and citing to the records reviewed. The examiner offered clear conclusions with supporting data, as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). As noted, there are no medical opinions of record supporting that the Veteran's hypertension had its onset during service. In sum, while the Board acknowledges the Veteran's contention regarding the etiology of his hypertension, it finds that the preponderance of the evidence is against the claim; the benefit-of-the-doubt doctrine is not applicable; and the claim of service connection for hypertension must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for hypertension is denied. ____________________________________________ RYAN T. KESSEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs