Citation Nr: 21001422 Decision Date: 01/08/21 Archive Date: 01/08/21 DOCKET NO. 13-14 711 DATE: January 8, 2021 ORDER Service connection for hypertension, based on secondary aggravation to service-connected diabetes mellitus, type II, is granted.   FINDING OF FACT The Veteran’s hypertension was aggravated by his service-connected diabetes mellitus, type II. CONCLUSION OF LAW The criteria for service connection for hypertension, based on secondary aggravation, have been met. 38 U.S.C. § §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1969 to September 1971. The case is on appeal from a June 2009 rating decision. In April 2017, the Veteran testified at a Board hearing. In December 2017, the Board remanded the case for further development. While the case was in remand status, in an August 2020 rating decision, the RO granted service connection for heart disease. As that benefit sought was granted in full, the issue is no longer before the Board. Service connection for hypertension. 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. A veteran seeking compensation under these provisions must establish three elements: “(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.” Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Analysis The Veteran contends his hypertension was caused or aggravated by his service-connected diabetes mellitus. Alternatively, he asserts his hypertension is directly related to service, to include his in-service exposure to herbicides. The Board notes the Veteran has been service connected for diabetes mellitus since November 2007. The Veteran’s service treatment records (STRs) contain a blood pressure reading of 132/80 at his April 1968 induction examination and a reading of 118/76 at his September 1971 separation examination. Following his November 2008 claim, the Veteran was afforded a July 2010 VA examination. The examiner found the Veteran’s blood pressure at that time was 120/68. He also stated the Veteran has diabetes mellitus for the last seven years, has been treated for arthralgias and he has hypertension. However, no opinion was provided as to a potential relationship between the Veteran’s diabetes and hypertension. The Veteran testified at the April 2017 Board hearing that his hypertension is related to his diabetes. The claim was remanded by the Board in December 2017 for further development, including a VA examination to determine the etiology of the disorder. Pursuant to the Board’s remand, the Veteran was afforded a June 2018 VA examination in which the examiner indicated he was diagnosed with hypertension from 2002. The examiner determined the Veteran’s hypertension is not related to service, including as due to his service in Vietnam. She indicated there are no records to support a causal connection and no established presumed connection between Vietnam service and hypertension. Further, the June 2018 examiner opined the Veteran’s hypertension was not caused by his diabetes, as his hypertension pre-dated his diabetes. However, she indicated the Veteran’s hypertension was aggravated beyond its natural progression by his diabetes. In this regard, the examiner reported that following the diagnosis of diabetes in 2003 there was an increase in the Veteran’s hypertension. She noted additional medication was prescribed to help manage the Veteran’s hypertension, which indicates progression of the disability. She indicated the Veteran’s hypertension was diagnosed in 2002 and his diabetes was found in 2003. She stated in July 2010, the Veteran was taking 20 mg of lisinopril daily and 12.5 mg of metoprolol daily. By September 2012, she noted, the Veteran’s prescription was increased to 25 mg of metoprolol daily. Moreover, she opined when there is a pre-existing condition of hypertension which co-exists with diabetes, hypertension is likely a target for aggravation, as is the Veteran’s situation. Based on this medical opinion, the Board finds service connection for hypertension is warranted based on secondary aggravation. The Board finds the June 2018 VA opinion to be persuasive as to a secondary aggravation nexus, at least to an equipoise standard. The examiner’s opinion is accurate, as it is based on her review of the entire record and reflects consideration of the relevant medical evidence, including such related to the Veteran’s hypertension and diabetes mellitus. Her opinion provides a detailed rationale and comprehensive explanation which clearly supports that the Veteran’s service-connected diabetes mellitus aggravated his hypertension. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Although it was explained why secondary causation was not shown from a medical basis, it was further explained that secondary aggravation was shown. When reasonable doubt is resolved in the Veteran’s favor, the Board finds that his hypertension was aggravated by his service-connected diabetes mellitus. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the Board determines service connection for hypertension is warranted on a secondary aggravation basis. The Board notes that 38 C.F.R. § 3.310(b) contemplates a baseline to assess the severity of a nonservice-connected disability that is aggravated by a service-connected disability. However, the Board determines that this is more akin to a downstream rating aspect of the claim that should be addressed in the first instance by the RO following implementation of the instant decision. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Isaacs, Counsel 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.