Citation Nr: 1815012 Decision Date: 03/13/18 Archive Date: 03/19/18 DOCKET NO. 09-26 110 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Entitlement to service connection for hypertension. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. M. Jordan, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from June 1977 to June 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2007 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. The Veteran presented sworn testimony at a hearing before the undersigned in February 2013. FINDINGS OF FACT The preponderance of the medical evidence of record shows that the Veteran's hypertension was not present in service or until many years thereafter and is not related to service. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran asserts that service connection for hypertension is warranted because the disease is either related to or had its onset in service. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with active service in the Armed Forces; or, if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303 (a); see Flynn v. Brown, 6 Vet. App. 500, 503 (1994) (noting that, in the context of service-connected disability compensation, "the element of cause and effect has been totally by-passed in favor of a simple temporal relationship between the incurrence of the disability and the period of active duty"). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104 (a). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also 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."). The Veteran testified that his hypertension was discovered at a physical examination in 1993 or 1997. See February 2013 Video Conference Hearing Transcript. As to a current disability, the post-service medical records show a diagnosis of hypertension. See October 2005 Internal Medicine Note. For VA purposes, hypertension means that the diastolic blood pressure (BP) is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic BP is predominantly 160mm. or greater with a diastolic BP of less than 90mm. As to service incurrence under 38 C.F.R. § 3.303 (a), service treatment records show the Veteran had elevated blood pressure readings of 120/90 in June 1983, 120/90 in May 1994, 120/90 in October 1995, and during a medical visit for right back pain, he had an initial blood pressure of 130/80, with a lying blood pressure of 150/90 and standing blood pressure of 150/115. The elevated blood pressure readings, standing alone, cannot provide the diagnosis of hypertension because VA requires that blood pressure readings must be taken two or more times on at least three different days to support a diagnosis of hypertension. See 38 C F R § 4.104, Diagnostic Code 7101 (Note 1) (2017). Similarly, and as will be explained in more detail below, the Board finds that the most probative evidence of record is the August 2013 VA examination, September 2015 addendum opinion, and June 2017 addendum opinion, in which the VA examiner opined that it is less likely as not that the Veteran's hypertension is related to or had its onset in service. As noted above, the Veteran was afforded a VA examination in connection with this claim in August 2013. The examiner concluded that it is less likely as not that the Veteran's hypertension is related to or had developed its onset in service or developed within one year of his discharge. The VA examiner acknowledged and considered the administrative notes from the Veteran's primary care physician (PCP) which highlighted the Veteran's elevated blood pressure readings during service. See August 2013 VA examination. However, the VA examiner noted that the Veteran's PCP did not report the Veteran's other blood pressures that were done at that same medical visit for his back in February 1995, including one blood pressure reading that was normal at 130/80. The examiner further reported that the Veteran's elevated blood pressure readings were at least as likely due to the back pain the Veteran was experiencing at the time of the visit. See August 2013 VA examination and February 1995 Screening Note of Acute Medical Care. The VA examiner noted that although the Veteran had isolated episodes of elevated blood pressures on several occasions, the overwhelming majority of the blood pressures recorded were normal. See August 2013 VA examination. Additionally, the Veteran's blood pressure recorded at his military discharge was within normal range, 123/81. See February 1997 Report of Medical Examination (Retirement). The VA examiner explained that blood pressures can be transiently elevated on a sporadic basis for a multitude of reasons. He further opined that a limited period of relaxing before a blood pressure reading, adrenaline, nicotine, caffeine, or other reasons can transiently elevate blood pressure. In these instances, elevated blood pressure is not considered hypertension. He added, there is no medical literature which would support the contention that chronic back pain, or chronic pain of any cause, results in eventual fixed hypertension. In February 2016, the Board remanded the appeal for additional development, to include obtaining additional records related to substantiating this claim and also to obtain an addendum opinion addressing the new records. In September 2016, the same VA examiner offered the addendum opinion that, it is less likely as not that the Veteran's hypertension is related to or had its onset in service. To support this conclusion, the examiner explained that he based his opinion on the same rationale that he provided in the August 2013 VA examination. Additionally, he indicated that the new medical records that had been submitted since the August 2013 examination did not contain any new information that would change his opinion. In April 2017, the claim was again deferred because an addendum opinion was needed based upon the submission of additional evidence. In June 2017, the VA examiner rendered another addendum opinion. He concluded that it is less likely as not that the Veteran's hypertension is related to or had its onset in service. The examiner opined that the new medical records since the addendum opinion in September 2016 do not contain any new information concerning the date of onset of the hypertension. He stated that, it is still at least as likely as not that his diagnosis of hypertension did not occur until 2000, over 3 years after his military discharge, as documented by the examiner in the compensation and pension examination done in November 2007. The examiner stated his opinion was based on the same rationale that he provided in the VA examination in August 2013 and in the addendum opinion in September 2013. The Board finds these opinions to be persuasive, given that they are consistent with the evidence of record, were based on a physical examination and review of the claims file, and supported by a sufficiently clear and well-reasoned rationale that was based on objective, supporting clinical data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board finds that as a lay person, the Veteran lacks the requisite education, training, and experience needed to self-diagnose hypertension or render an opinion as to its etiology. While he is competent to speak on matters such as possible symptomatology, to include dizziness or headaches, but the Veteran has not done so. See Davidson v. Shinseki, 581 F.3d 1313 (2009); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Instead, he merely asserted that hypertension is related to service or a service-connected disability. For example, he testified that in 1993 or 1997 physical examinations, it was discovered that he had hypertension; but was not informed of it. See February 2013 Video Conference Hearing Transcript. Additionally, he has provided no supporting documentation to substantiate this assertion. As previously noted, while the Veteran did have sporadic elevated blood pressure readings during service, most of his blood pressure readings were normal during service. Further, the evidence contradicts that hypertension existed prior to 2000. For example, the November 2007 VA examination reported the "presumed onset" of the Veteran's hypertension to be the year 2000. Accordingly, the more competent evidence related to the nature and etiology of the Veteran's hypertension is the August 2013 VA examination, and the September 2016 and June 2017 VA addendum opinions. Absent any competent evidence against the examiner's opinions, the Board finds that the preponderance of the evidence is against the claim for service connection for hypertension, to include as secondary to a service-connected disability; there is no doubt to be resolved; and service connection for hypertension is not warranted. ORDER Service connection for hypertension is denied. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs