Citation Nr: 18129152 Decision Date: 08/23/18 Archive Date: 08/23/18 DOCKET NO. 15-34 926A DATE: August 23, 2018 ORDER Entitlement to service connection for hypertension, to include on a secondary basis, is denied. FINDING OF FACT The Veteran’s hypertension did not have its onset in during a period of active duty, to include active duty for training (ACDUTRA), was not manifested to a compensable degree within one year of active duty service of 90 days or more, is not otherwise related to any period of service, and is not caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension, to include on a secondary basis, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the United States Air Force from June 1986 until October 1995, and in the United States Air Force Reserves from February 2001 until February 2009. This matter comes before the Board of Veterans’ Appeals (Board) from a February 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The Veteran filed a notice of disagreement in May 2015 and was provided with a statement of the case in August 2015. The Veteran perfected his appeal with an October 2015 VA Form 9. The Veteran declined a hearing in this case. Service Connection – Generally The Veteran claims that he developed hypertension that has continued to the present time during active duty for training (ACDUTRA) in December 2007. 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(a). 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). The Board has thoroughly reviewed all the evidence in the Veteran’s claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, regarding the Veteran’s claim on appeal. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). Cardiovascular diseases, such as hypertension, are considered “chronic” and, therefore, will be presumed to have been incurred in service if manifested to a compensable degree of 10 percent or more within one year of a Veteran’s separation from service. This presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). This presumption, however, does not apply to ACDUTRA service, only to active duty. Similarly, neither the presumption of sound condition at entrance into service nor the presumption of aggravation during service of pre-existing diseases or injuries that undergo an increase in severity during service apply to periods of ACDUTRA. See Smith v. Shinseki, 24 Vet. App. 40, 45 (2010). Hypertension is defined by the regulations as a disease and, thus, service connection for hypertension is only available if it was incurred during a period of ACDUTRA; in other words, onset after discharge from ACDUTRA and during other reserve service cannot establish entitlement to service connection for this disease. For VA compensation purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 or greater; and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 or greater with diastolic blood pressure less than 90. 38 C.F.R. § 4.104, Diagnostic Code 7101. Under this Code, service connection for pre-hypertension is not warranted when an examiner diagnoses pre-hypertension based on readings not recognized in Diagnostic Code 7101. See VA Adjudication Procedures Manual, M21-MR, III.iv.4.E.20.33. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether instead a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. 38 C.F.R. § 3.102. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, concerning the claim. The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant); see also Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Entitlement to service connection for hypertensive vascular disease The Veteran claims service connection for hypertension. The Veteran has a current diagnosis of hypertension as indicated on a July 2015 VA examination. The Veteran asserted in a May 2014 lay statement that his hypertension began when he was removed from Combat Survival School for symptoms of stress and adjustment disorder in December 2007 at Fairchild Air Force Base in Spokane, Washington. The Veteran’s claim thus turns on whether the Veteran’s current hypertension is related to his in-service stress. First, the Board notes that service treatment records indicate no diagnosis of hypertension during the Veteran’s active service from June 1986 until October 1995. The Veteran was first diagnosed with hypertension in 2006. In January 2008, the Veteran’s blood pressure was evaluated on five, separate occasions with an average reading of 155/93. The Veteran’s blood pressure was also evaluated on five, separate occasions in May 2008, with an average reading of 137/93. In a July 2015 VA examination report, the examiner concluded that the Veteran’s hypertension was less likely than not related to his service-connected anxiety disorder. The examiner considered a June 2015 article in Up to Date entitled Overview of Hypertension in Adults, and explained that age, obesity, family history, and other factors are risk factors for hypertension. The examiner stated that while certain mental health conditions may cause a temporary increase in blood pressure, mental health conditions do not cause hypertension. In an October 2014 VA examination report, the examiner concluded that the Veteran’s hypertension was at least as likely as not incurred in or caused by an in-service event. The examiner referenced the Veteran’s December 2007 and May 2008 hypertension diagnoses as having occurred in service. However, these diagnoses did not occur during active service. Rather, they occurred during the Veteran’s Reserve service, after he had been removed from his ACDUTRA assignment of Combat Survival School. Based on the above, the Board finds that the most competent and credible evidence is against a finding that the Veteran’s current hypertension had its onset in service, manifested to a compensable degree within one year following a period of active duty service of 90 days or more, is not otherwise related to service, and is not caused or aggravated by the service-connected unspecified anxiety disorder. The Board acknowledges the Veteran’s lay assertion that his current hypertension was diagnosed shortly after the stress that he experienced during Combat Survival School in December 2007. However, to the extent that the Veteran asserts a nexus between his prior diagnosis of mental illness and his current diagnosis of hypertension, such statements are outweighed by the July 2015 VA examiner, who explained why he concluded that hypertension was not caused or aggravated by the service-connected unspecified anxiety disorder, which included a citation to a medical article about this subject. Furthermore, the Board finds the July 2015 VA opinion to be highly persuasive to the issue at hand. The Board notes that the probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, his knowledge and skill in analyzing the data, and his medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467. 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the examiner’s access to the claims folder and the thoroughness and detail of the opinion. See Nieves-Rodriguez, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Here, the July 2015 VA opinion was provided by a medical professional who possesses the necessary education, training, and expertise to provide the requested opinion. Additionally, the opinion is shown to have been based on a review of the Veteran’s claims file, and is accompanied by a sufficient explanation. The VA examiner also considered the Veteran’s lay statements of record in reaching his conclusions. The VA examiner noted that age, obesity, family history, and other factors are risk factors for hypertension, and that while mental illness can cause a temporary elevation in blood pressure, it cannot cause chronic hypertension. Notably, the only evidence that the Veteran’s current hypertension is related to his ACDUTRA service is the Veteran’s own lay assertions. To the extent that the Veteran’s statements assert a nexus between his hypertension and his ACDUTRA service, such statements are afforded little probative value, as the Veteran is not shown to possess the expertise necessary to render a nexus opinion regarding the etiology of his hypertension. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, the Veteran’s statements that his hypertension is related to an in-service event are outweighed by a July 2015 VA examination, wherein the VA examiner opines that the Veteran’s hypertension is not related to service. Finally, while hypertension is enumerated under 38 C.F.R. 3.309(a), the Veteran had no diagnosis of hypertension during active service and was not diagnosed until 2006, many years after active service. Thus, service connection based on presumptive service connection or continuity of symptomatology is not warranted. As noted above, neither the presumption of sound condition at entrance into service nor the presumption of aggravation during service of pre-existing diseases or injuries that undergo an increase in severity during service apply to periods of ACDUTRA. See Smith, 24 Vet. App. at 40, 45. In sum, the evidence of record is not sufficient to support the Veteran’s claim of service connection for his hypertension, to include on a secondary basis. The preponderance of the evidence is against the claim, there is no reasonable doubt to be resolved, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Caruso, Associate Counsel