Citation Nr: 21002710 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 15-40 161 DATE: January 14, 2021 ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for a skin disorder of the groin is denied. FINDINGS OF FACT 1. 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 etiologically related to an in-service injury, event, or disease, to include as due to exposure to herbicide agents or a service-connected disability. 2. The preponderance of the evidence is against finding that a skin disorder of the groin began during active service, or is otherwise related to an in-service injury, event, or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have not been satisfied. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for skin disorder of the groin have not been satisfied. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from April 1971 to April 1973, to include service in the Republic of Vietnam. He has additional service in the Air Force Reserve. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a March 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing with the undersigned in April 2019. In March 2020, the Board remanded the matters to the Agency of Original Jurisdiction (AOJ) for additional development, and they have returned for further appellate review. Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called “nexus” requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. VA has established certain rules and presumptions for chronic diseases, such as hypertension. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Certain diseases associated with exposure to certain herbicide agents used in support of military operations in Vietnam during the Vietnam era will be considered to have been incurred in service and service connection will be presumed. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.307(a)(6). This presumption only applies to disorders which the Secretary of VA determines to be the result of in-service exposure to herbicide agents, such as Agent Orange. 38 U.S.C. § 1116; 38 C.F.R. § 3.309(e). 1. Hypertension The Veteran contends that his hypertension is secondary to his service-connected diabetes or due to his exposure to herbicide agents in Vietnam. See April 2019 Hearing Tr. at 2, November 2015 Statement of Accredited Representative in Appealed Case. Under the law as it now stands, a presumption of service connection based on the Veteran’s exposure to Agent Orange cannot be granted in this case because hypertension does not appear on the list of diseases considered presumptively associated with herbicide exposure. However, in addition to the presumptive regulations, a Veteran may establish service connection based on exposure to herbicide agents with proof of actual direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). Hypertension is defined as diastolic blood pressure of predominantly 90 or greater, or systolic blood pressure of predominantly 160 or greater with a diastolic blood pressure of less than 90. Hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). The Veteran has a current hypertension disability. See May 2018 VA Treatment Record. Thus, the remaining question is whether the current hypertension disability is related to service. Service treatment records show no complaints, diagnosis, or treatment related to hypertension. In an October 1972 dental patient x-ray container and medical history form, the Veteran reported not being treated for a heart condition, high blood pressure, or any blood disease. During the March 1973 separation examination, evaluation of the heart was normal. His blood pressure reading upon separation was 110/74. A hypertension disability is not shown by medical evidence until many years after the Veteran’s separation from service. As hypertension is not shown to have been present during service or in the first year after separation of service, and continuity of symptomatology leading to a diagnosis of hypertension is not shown, in-service incurrence of hypertension cannot be presumed. See 38 C.F.R. §§ 3.307, 3.309(a). The Veteran presented for a VA examination in January 2013 for his diabetes, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. The examiner opined that the Veteran hypertension was not at least as likely as not due to his diabetes mellitus. In support of this conclusion, the examiner explained that the Veteran’s essential hypertension preceded his diabetes mellitus by a number of years. The examiner noted that there is no evidence of diabetic nephropathy (normal urinary microalbumin) and thus no cause of or aggravation of his high blood pressure. The Board finds this opinion highly probative as it was made by a medical professional with consideration of the specific facts in this case and after examination of the Veteran. The opinion is also supported by other evidence of record. There is no medical opinion or competent and credible evidence in significant conflict with the VA medical opinion. In a May 2020 VA medical opinion, a VA examiner reviewed the Veteran’s claim file and addressed whether his hypertension was caused by his active duty service. The examiner opined that his hypertension was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of this conclusion, the examiner explained that there was no evidence of hypertension in the Veteran’s service treatment record while in service and that his blood pressure reading upon separation was 110/74. The examiner noted that the Veteran’s hypertension began in 2007 which currently appears well-controlled with medication as his May 2019 blood pressure reading was 133/72. The examiner noted that there was no evidence of end organ damage attributed to hypertension. Thus, the examiner opined that there is no evidence of aggravation of hypertension due to any cause to include diabetes beyond the natural course. The Veteran’s diagnosis was essential hypertension, denoting no secondary cause. The examiner also opined that is it less likely than not that his hypertension has been aggravated by any cause to include diabetes or Agent Orange exposure. In support of this conclusion, the examiner explained that the onset of his hypertension was in 2007, while diabetes was in 2010. The examiner addressed the most recent National Academies of Sciences, Engineering, and Medicine (NAS) study which suggested an association between Agent Orange and hypertension. The examiner noted that the current widely accepted peer reviewed literature has not established a link as to the cause and effect of hypertension and exposure to Agent Orange. The examiner noted that the Veteran does not have any evidence of premature hypertension or aggressive or malignant hypertension. Rather, the examiner indicated that age, race, salt intake, genetics, and other factors all play a role in the development of hypertension. The Board finds this opinion highly probative as it was made by a medical professional with consideration of the specific facts in this case and after examination of the Veteran. The opinion is also supported by other evidence of record. There is no medical opinion or competent and credible evidence in significant conflict with the VA medical opinion. The Board has considered the Veteran and his representative’s statements, to include the assertion that the Veteran’s hypertension was caused by his active duty service, to include as due to exposure to herbicide agents as supported by the NAS study. As the Veteran is not shown to have medical education or experience, he is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., chest pain; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues. Thus, his lay assertions do not constitute evidence upon which service connection can be granted. Notably, the VA examiner considered the NAS study but opined that overall the medical literature does not support a finding that the Veteran’s hypertension is related to his exposure to Agent Orange. The Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinions rendered by trained medical professional based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. For the above reasons, the preponderance of the evidence is against the claim and service connection is denied. 2. Skin Disorder of the Groin The Veteran contends that his skin disorder of the groin was caused by his active duty service. See April 2019 Hearing Tr. at 2-3. The Veteran has a current skin disorder of the groin. For example, at his May 2014 VA examination he was diagnosed with tinea cruris. Thus, the remaining question is whether the current skin disorder of the groin is related to service. Service treatment records show no complaints, diagnosis, or treatment related to a skin disorder. During the March 1973 separation examination, evaluation of the skin was normal. A skin disorder of the groin is not shown by medical evidence until approximately 1980, many years after the Veteran’s separation from service. The Veteran presented for a VA examination in May 2014, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. As noted above, the Veteran was diagnosed with tinea cruris. However, a medical opinion was not provided, and the Board, as part of the March 2020 remand, requested a VA medical opinion to address the Veteran’s claim. Thereafter, in May 2020, a VA medical examiner reviewed the Veteran’s claims file and addressed the Veteran’s claim. The examiner opined that the Veteran’s skin disorder of the groin was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of this conclusion, the examiner explained that despite the history given by the Veteran, there is no evidence of a skin condition while in service. The examiner noted that the Veteran’s separation exam was negative for skin complaints, including a signed attestation regarding no new medical conditions. The examiner indicated that the first record of a skin condition arose in 1980 where an incomplete note suggests a groin condition. The examiner noted that given the Veteran’s significant records with respect to symptoms and follow-up, it is unlikely the Veteran would not have sought care in the ensuing seven years from separation. Accordingly, the examiner concluded that it is less likely than not that the Veteran’s currently diagnosed conditions, to include recurrent fungal infections and lichen simplex chronicus, claimed as groin rash, had its onset during service. The Board finds this opinion highly probative as it was made by a medical professional with consideration of the specific facts in this case and after examination of the Veteran. The opinion is also supported by other evidence of record. There is no medical opinion or competent and credible evidence in significant conflict with the VA medical opinion. The Board has considered the Veteran’s statements, to include his assertions that symptoms began during service. As the Veteran is not shown to have medical education or experience, he is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., skin rash; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues. Thus, his lay assertions do not constitute evidence upon which service connection can be granted. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinion rendered by a trained medical professional based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. To the extent the Veteran asserts he has had a skin condition affecting the groin on and off since service, the Board finds these statements to lack credibility. The Veteran reported other ailments related to his groin and skin during service, such as discharge from the penis, pseudofolliculitis barbae, and a rash on his cheek. Thus, skin problems of the groin are the type of problem the Board would expect the Veteran would have reported during service had they been present yet there are no such reports. When the Veteran sought treatment for a rash on his penis in March 1980, he reported he had not had anything like it before. Moreover, the VA examiner in May 2020 found that given the Veteran’s significant records with respect to symptoms and follow-up, it is unlikely he would not have sought care in the ensuing seven years from separation had he been experiencing a skin condition related to the groin. For the above reasons, the preponderance of the evidence is against the claim and service connection is denied. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Mathew 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.