Citation Nr: 20054876 Decision Date: 08/19/20 Archive Date: 08/19/20 DOCKET NO. 13-23 277 DATE: August 19, 2020 ORDER Service connection for hypertension is denied. FINDING OF FACT The preponderance of the evidence weighs against finding that the Veteran’s hypertension manifested during service or within one year of separation from service; or is causally related to his service or is proximately due to or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from July 1972 to February 1978. He had additional service with the Army National Guard from June July 1972 to January 1993 and with the United States Army Reserve from January 1993 to August 2001. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. This matter was previously remanded in January 2017, November 2017 and June 2019. This matter is again before the Board for adjudication. Service connection for hypertension Legal Criteria 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. To establish service connection for a disability, the evidence 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. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The absence of any one element will result in denial of service connection. 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). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. The term “active military, naval, or air service” includes active duty, any reserve service periods of ACDUTRA during which the individual concerned was disabled from a disease or injury incurred or aggravated in the line of duty. 38 U.S.C. §§ 101 (22), 101(24); 38 C.F.R. § 3.6. For certain chronic disorders, including hypertension, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. See 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. When a disease listed at 38 C.F.R. § 3.309 (a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303 (b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309 (a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For VA disability rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm, which must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Note (1) to Diagnostic Code 7101. Finally, a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). See also Bostain v. West, 11 Vet. App. 124, 127 (1998). 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 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 the claimant. Factual Background & Analysis The Veteran seeks service connection for hypertension, to include as secondary to his service-connected PTSD. The Veteran service treatment records (STRs) do not indicate high blood pressure. More specifically, in the context of a separation examination dated February 1978, the Veteran checked “no” to high or low blood pressure. A June 1978 National Guard enlistment examination indicates a blood pressure reading of 100/76. His period of service in the National Guard showed elevated blood pressure readings in February 1986 and September 1990. Intermittently, treatment records spanning from 1994 to 2002 show some reports of high blood pressure while also intermittently documenting no symptoms of high blood pressure. A 2001 examination showed mildly elevated blood pressure with a reading of 130/89. A September 1994 periodic physical documented a blood pressure reading of 136/82. An October 1994 Report of Medical History indicated no issues with high or low blood pressure. A September 1999 Report of Medical History documents a diagnosis of hypertension and a blood pressure reading of 121/79. High blood pressure was indicated on the Past/Current Medical History portion of a September 1999 physical examination. In a March 2018 VA medical opinion, the VA examiner stated that it was less likely than not that his hypertension was proximately due to or the result of the Veteran’s service-connected disability. He stated that there is no evidence in his medical record to support that hypertension is secondary to his PTSD, and while stress from PTSD can cause elevated blood pressure, the increase is transient and will return to normal once the stress has passed. He further reported the Veteran did not believe there was a connection between his hypertension and PTSD and concluded that it was less likely than not related to PTSD. The VA examiner did not render an opinion addressing aggravation. With respect to direct service connection, the examiner opined that “although it is noted on a periodic examination that he is on Lotrel for hypertension, there is no indication that the condition was caused by or incurred in service.” January 2019 through December 2019 VAMC treatment records shows ongoing treatment for hypertension with intermittent blood pressure readings in the mildly hypertensive range. An addendum VA medical opinion was procured in December 2019. The examiner determined that they could not determine a baseline level of severity of the Veteran’s hypertension noting that the Veteran had a long history of hypertension with fluctuations over time. The examiner explained that there was no clear pre-PTSD and post-PTSD averages to compare. The examiner also indicated multiple variable to blood pressure measurement, including changes to medications, concurrent illness and comorbidities and differences in measurement techniques. Regarding aggravation of the Veteran’s hypertension by his service-connected PTSD, the examiner found it to be less likely than not that the Veteran’s hypertension was aggravated beyond its natural progression by his service-connected PTSD. The examiner opined “While PTSD can cause transient increases in the claimant’s blood pressure, there is no evidence that it has caused a sustained increased measurement of blood pressure, nor has it aggravated a preexisting hypertension beyond its natural course. The claimant has essential hypertension, which is a separate and distinct condition from his PTSD. The claimant has multiple medical issues, each of which may contribute to his hypertension. There is no clear evidence that the PTSD has served to increase the claimant’s blood pressure beyond what it would be from the hypertension alone.” Initially, the STRs and medical evidence of record does not reflect blood pressure readings that qualify as hypertensive for VA disability rating purposes during service or within one year of separation from service. Therefore, service connection for hypertension on a presumptive basis is not warranted. 38 C.F.R. § 3.309. The evidence of record also does not support service connection on a direct basis. There is no evidence of hypertensive blood pressure readings during the Veteran’s period of active service. After a review of the medical evidence of record, a qualified VA examiner in March 2018 found there to be no medical nexus between the Veteran’s hypertension and active service. The Veteran has submitted multiple lay statements positing a direct link between his hypertension diagnosis and his active duty service. In an October 2010 notice of disagreement (NOD) the Veteran stated that he was treated on active duty for hypertension. The Board finds that this is not consistent with the evidence of record and such allegation is not credible. As one example, the Board notes that an August 1994 Report of Medical History indicates that the Veteran had and had never had high blood pressure or low blood pressure, which is consistent with the information provided in February 1978 at separation from active duty. Moreover, while the Veteran posits an etiological connection between his hypertension and his service, his lay statements alone are not adequate to meet the nexus requirement to substantiate a finding of service connection. This determination is medically complex and requires specialized medical training and expertise which the Veteran has not demonstrated he possesses. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence, specifically the March 2018 VA examiner’s findings and opinion. The Board also finds that the preponderance of the evidence of record weighs against finding that the Veteran’s hypertension is proximately due to or aggravated by his service-connected PTSD. The March 2018 VA medical opinion found it to be less likely than not that the Veteran’s hypertension was proximately due to his PTSD stating that “while stress from PTSD can cause elevated blood pressure, the increase is transient and will return to normal once the stress has passed.” With respect to aggravation, the December 2019 VA addendum medical opinion found it to be less likely than not that the Veteran’s hypertension is aggravated beyond its natural progression by PTSD. To restate, the examiner explained “While PTSD can cause transient increases in the claimant’s blood pressure, there is no evidence that it has caused a sustained increased measurement of blood pressure, nor has it aggravated a preexisting hypertension beyond its natural course. The claimant has essential hypertension, which is a separate and distinct condition from his PTSD. The claimant has multiple medical issues, each of which may contribute to his hypertension. There is no clear evidence that the PTSD has served to increase the claimant’s blood pressure beyond what it would be from the hypertension alone.” Again, while the Veteran has submitted lay contentions positing an etiological link between his hypertension and PTSD, such a determination is medically complex, and the Veteran’s statements are not competent to form a nexus because he does not possess the requisite medical training and expertise. Jandreau, 492 F.3d at 1377. Consequently, the Board gives more probative weight to the competent medical evidence, specifically the March 2018 and December 2019 VA examiners’ findings and opinions. In sum, the preponderance of the competent medical evidence weighs against finding that the elements of service connection for hypertension have been met. Consequently, as the preponderance of the evidence weighs against the claim, the benefit of the doubt rule is inapplicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102, 3.309, 3.310; Gilbert, 1 Vet. App. at 55-57. Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Kyle McKone 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.