Citation Nr: 20041547 Decision Date: 06/18/20 Archive Date: 06/18/20 DOCKET NO. 10-13 856 DATE: June 18, 2020 ORDER Service connection for hypertension is denied. FINDING OF FACT The Veteran’s hypertension was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise causally related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The veteran had active service from August 1972 to November 1974. This matter is on appeal from a February 2009 rating decision. In January 2017, the Board of Veterans’ Appeals (Board) denied the claim. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veteran Claims (Court). Pursuant to a Joint Motion for Partial Remand (JMPR) dated in February 2018, the Court in a February 2018 Order remanded the matter to the Board. The Board remanded the matter in July 2018 and August 2019. 1. Service connection for hypertension Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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 shown 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, as identified in 38 C.F.R. § 3.309(a), 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). Service connection may also 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). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as hypertension, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In order to prevail on the issue of service connection, there must be medical evidence of current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1990). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1990); 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, 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 a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran asserts that his hypertension is related to his military service. The service treatment records show blood pressure readings of 134/88 in June 1972, 122/88 in September 1973, 114/92 in January 1974, and 122/88 in October 1974 at his separation examination. After a careful review of his service treatment records, they do not document high blood pressure treatment recorded by medical professionals; however, in August 1974 the Veteran reported he was being treated or had been treated for high blood pressure. At separation, on his October 1974 report of medical history, the Veteran indicated he did not know if he had high or low blood pressure. A September 1981 treatment record noted the Veteran was moderately obese and had a blood pressure reading of 100/60. The first indication that he had hypertension was in March 1988, where the Veteran admitted to a history of hypertension and a questionable history of myocardial infarction. Later that month, a treatment record noted mild elevation of left ventricular end-diastolic pressure probably secondary to obesity. In April 2008, the Veteran claimed his current hypertension was related to service because he was treated and diagnosed with hypertension while on active duty. The Veteran was afforded a VA examination in November 2014. The examiner noted the diagnosis of hypertension in 1972, per the Veteran’s report. The Veteran reported that he was in the Army when he was diagnosed with hypertension and he continued to be on blood pressure medication. The examiner opined that it was less likely than not that the Veteran’s hypertension was incurred in or caused by his military service. The examiner explained that while the Veteran had hypertension there was no documentation in the service treatment records that it had been diagnosed in service. Therefore, the examiner could not determine that the Veteran’s hypertension was related to or caused by service. The Veteran’s representative argued that the examiner’s opinion was inadequate because it did not address any in-service blood pressure readings and whether those readings were indicative of a link between his current hypertension and active service. Further, the examiner did not address the August 1974 dental record where the Veteran noted he was being treated for high blood pressure. Finally, the examiner did not address the Veteran’s report that he was diagnosed with hypertension in 1972. In June 2018, an addendum opinion was received. The examiner noted that the Veteran’s blood pressures in service were normal and no records of hypertension were noted in the service treatment records. The examiner noted some blood pressure readings in service and then concluded that Veteran did not have hypertension in service. The examiner observed the Veteran was treated for hypertension since 2007 and was most likely due to obesity since he had been diagnosed with obesity since his initial visit with VA in 2007. The examiner opined the Veteran’s hypertension was not due to and did not incur in service per the medical records; a nexus could not be established. The addendum opinion did not discuss the Veteran’s lay statements in service that he had hypertension or whether the elevated blood pressure would be a precursor for hypertension. The Veteran was afforded another VA examination in October 2019 at the Board’s request and addressed multiple and distinct facts in this case. The examiner noted a diagnosis of hypertension since June 1988. The examiner opined the Veteran’s hypertension was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained there was no record of repeated blood pressure readings after the initial reading while on active duty. This was and still is the standard of care to determine the diagnosis of hypertension. The examiner further explained the Veteran’s testing results were occasionally elevated and this could have been due to several reasons such as illness, diet (including caffeine and salty foods), anxiety with routine exams, or other factors. The examiner noted the official VA blood pressure definition of hypertension was not met while on active duty or within a year after discharge. Finally, the examiner noted the first recorded treatment for hypertension with medication was in 1988, which was 14 years after discharge from active duty. The examiner also opined it was less likely than not the Veteran’s hypertension was related to active service because there was no apparent concern by his providers that his readings required follow-up testing, as there was no documentation for the Veteran to return to the clinic for three days to recheck his blood pressure. The examiner explained this order was a clinical decision by the provider at the time of assessment to diagnosis of hypertension. Further, the examiner noted exit readings were normal and no medication was ordered while on active duty. The service treatment records, including the entry at a Dental Medical Questionnaire in June 1972, did not confirm there was a diagnosis of hypertension. The examiner noted the answers to that specific dental questionnaire contained additional inconsistent answers including answering “yes” to unusual bleeding and stomach, liver or intestinal problems. None of the issues were confirmed in the service treatment records, which invalidated the majority of the affirmative answers to the questions that were asked. There was not a confirmation of hypertension within the service treatment records nor within the first year following service. The final review of systems from service indicated the Veteran did not know if he had high or low blood pressure at the conclusion of service. The examiner also addressed the possibility that the readings in service were indicative of the hypertension that was later diagnosed. The examiner opined it was less likely than not that the Veteran’s readings were a precursor to a compensable degree while in active duty or within a year of service. The examiner explained both diastolic and systolic readings were not consistently elevated while on active duty or within a year of discharge. There was a major gap in health care records between 1972 and 1988, when the Veteran was taking Visken for his blood pressure. During this interval, it was unknown what medical conditions and/or activities the Veteran was engaged in except that he was working as a truck driver, which requires controlled blood pressure readings to continue work with a valid Commercial Driver’s Certified (CDC) license. The examiner pointed to the subsequent 2011, Department of Transportation Physical and multiple private evidence in which hypertension was not documented and the Veteran apparently did not share a diagnosis or treatment of any hypertension with the many clinicians he encountered. The examiner noted individual readings in service did not indicate a diagnosis of hypertension, which indicated an increased resistance to the flow of blood through the circulatory system when the heart was resting between beats. The examiner explained that individual sporadic elevations of blood pressure did not provide diagnostic confidence of a subsequent diagnosis or precursor of a diagnosis of hypertension. Further, the examiner noted that after a very careful review of the record there was no mention of the Veteran being prescribed any hypertension medication or counseled to increase exercise and/or reduce salt intake which was often advised as initial treatment for hypertension. Therefore, without this evidence and blood pressure readings of 122/88, the Veteran’s lay assertions of hypertension from service to present, to include specific discussion of the August 1974 record where the Veteran noted he was being treated for high blood pressure, was less likely than not true. The examiner noted it was unclear how or why the Veteran came to indicate that he did not know if he might have high blood pressure at the time on the October 1974 separation examination. The examiner imagined scenarios such as the Veteran was told this when he was examined, he read about normal blood pressure readings, or was told by a provider to return to the clinic for additional testing. However, the examiner observed there was not enough evidence from documentation of the provider’s notes while on active duty to determine a definitive diagnosis of hypertension was present. Finally, the examiner considered whether the Veteran’s lay statements presented sufficient evidence of the nature of the Veteran’s disability such that his claim of service connection could be proven without contemporaneous medical evidence. The examiner opined the Veteran’s statement and belief that he had hypertension while in service was based solely on his report and was not supported by the evidence of record. The examiner noted the medical history provided to a dental examination in service was obviously in error. The examiner noted at the same time the history by the Veteran stated he had high blood pressure he also answered that he was being treated for unusual prolonged bleeding from cuts per previous tooth extractions, and stomach, liver or intestinal problems, none of which were factual or credible based on service treatment records. The separation examination also indicated the Veteran did not know whether or not he had high or low blood pressure at the time of discharge from service. Therefore, the examiner opined it was less than likely there was any hypertension at discharge or that hypertension was manifested to a compensable degree within one year of discharge. The examiner noted consideration of the elevated blood pressure readings in service but opined that this alone was not diagnostic confirmation of a diagnosis of hypertension. The examiner noted the elevated blood pressure in January 1974 was consistent with abdominal pain and not consistent with a diagnosis of hypertension. Further, the Veteran’s blood pressure reading of 120/80 in October 1975 did not indicate blood pressure elevation. The examiner also looked at the private records submitted in the case and noted Freeman Health System records, including Emergency Room visits and hospitalizations, specifically in 2005, did not list or diagnose hypertension in addition to multiple medical and psychiatric conditions. A cardiology consultation March 2005 did not include hypertension with blood pressure measured at 155/72, nor did the cardiologist list any hypertensive medications nor provide hypertensive medications to the Veteran. July 2005 emergency room records listed the Veteran as having a diagnosis of hypertension which was inconsistent with the cardiologist records. In the electronic VA records, a diagnosis of hypertension was first listed in July 1998, and listed in the active problem list in August 2010. In July 2011, a Department of Transportation (DOT) physical does not include any diagnosis of hypertension or medications for hypertension. The blood pressure reading at that evaluation was 138/70 mmHg. The service treatment records, private records from multiple sources and the DOT physical alone do not support that hypertension existed in service and continued as a confirmed diagnosis for many years following the military. The examiner noted it was not clear when an actual diagnosis of hypertension was confirmed, but a preponderance of evidence did not support there was hypertension manifested in military service or within the first year following military service. The examiner further noted the diagnosis and treatment of hypertension is confirmed and determined by consistent readings both in the office and at home and a preponderance of evidence did not support the Veteran’s claim of high blood pressure readings and/or treatment of hypertension that began in service and continued post service. The examiner mused that if there was some evidence of treatment in the 14 years between the Veteran’s discharge from active duty and treatment for a heart condition, there was lack of evidence and the existing post-service records did not support the continuous existence of hypertension between service or the first year after service and the eventual diagnosis of hypertension years later. The examiner then opined that even without supportive documentation for the 14 years in question, any hypertension that might have been related to service would more likely than not have shown a change in left ventricular size and documentation of antihypertensive medication in the interim. However, there was no chronic finding documented to support there was hypertension that began in service, continued to be present nor was finally diagnosed years later. Finally, the examiner noted there was no chronic physical examination finding of hypertension in service to years after discharge that would support long standing existence of hypertension. The Board concludes that, while the Veteran has a current diagnosis of hypertension, and evidence shows elevated blood pressure readings occurred in-service, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of hypertension began during service or is otherwise related to an in-service injury, event, or disease. To the extent the Veteran believes that his hypertension is the result of his military service, such a medical opinion requires medical expertise, and that determination cannot simply be made by lay observation alone; and the Veteran is not considered competent (meaning medically qualified by training or experience) to provide a medical opinion. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). His statements were specifically considered by the most recent medical examiner. Here, VA provided the Veteran with an examination, but the examiner unfortunately provided a negative nexus opinion after a complete thorough review of the record. The Board notes that the Veteran has not offered any medical evidence to refute the VA examiner’s medical opinion. The October 2019 VA examiner opined that the Veteran’s hypertension is less likely than not related to an in-service injury, event, or disease, including elevated blood pressure readings during service. The examiner further opined it was less likely than not that the Veteran’s readings were a precursor to a compensable degree while on active duty or within a year of service. The examiner provided an extensive rationale as detailed above and addressed the Veteran’s contentions and theories of service connect. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Consequently, the Board gives probative weight to the October 2019 VA examiner’s opinion. Accordingly, service connection for hypertension is denied. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Kelly A. Gastoukian The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.