Citation Nr: 21004088 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 12-16 469 DATE: January 26, 2021 ORDER Entitlement to service connection for hypertension is denied. FINDING OF FACT The Veteran’s hypertension is not secondary to service-connected diabetes mellitus, type II, or ischemic heart disease and is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably in the United States Marine Corps from November 1968 to August 1971. He is the recipient of the Combat Action Ribbon. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. The Veteran’s appeal was remanded a new examination by the Board in December 2017. The appeal has been returned to the Board for appellate review. The Veteran testified before the Board at a June 2017 travel Board hearing. A transcript has been associated with the claims file. The Board notes that the Veterans Law Judge who presided over the June 2017 hearing is no longer available to participate in the adjudication of this appeal. The Veteran was notified of this fact in a November 2020 letter from the Board, and was offered an opportunity to testify at another hearing if he wished to do so. The November 2020 letter informed the Veteran and his representative that if no response was received within 30 days, the Board will assume he did not want to appear at another hearing. Indeed, the Veteran did not respond to the letter, and the Board will proceed with adjudication. Entitlement to service connection for hypertension is denied. The Veteran contends that his hypertension is related to his service-connected diabetes mellitus, type II and ischemic heart disease (also referred to in the record as coronary artery disease). Alternatively, the Veteran contends that his hypertension is related to Agent Orange exposure. See June 2017 Board Hearing Transcript. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). With respect to hypertension, service connection may also be awarded on a presumptive basis if shown to have manifest to a compensable degree within on year of separation from service. See 38 C.F.R. § 3.309(a). Service connection may also be established if there is a showing of a continuity of symptoms since service. See 38 C.F.R. § 3.303(b). Finally, service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. In this case, the Veteran does not assert that his hypertension began during service, or within one post-service year, and the evidence of record does not indicate as much. At his hearing he indicated that he had no problems with hypertension during service, and such was not identified for decades thereafter. As such, service-connection is not established based on in-service incurrence, incurrence within his first post-service year, or by a showing of continuity of symptoms since service. Rather, the key questions at issue in this case are whether the Veteran’s hypertension is at least as likely as not due to in-service herbicide exposure, or is otherwise caused or aggravated by his service-connected diabetes and/or heart disease. In support of his claim, the Veteran has obtained a medical opinion letter from Dr. M.M., dated in June 2017. Dr. M.M. opined that it is at least as likely as not that the Veteran’s hypertension is proximately due to or the result of his service-connected diabetes mellitus, type II and ischemic heart disease. Notably, Dr. M.M. acknowledged that “while diabetes and coronary artery disease do not cause hypertension, hypertension often accompanies both diabetes and coronary artery disease.” Dr. M.M. added that the Veteran did not have hypertension prior to serving in the military. Subsequently, upon in-person examination of the Veteran, an April 2019 VA examiner opined that it was less likely than not that the Veteran’s hypertension was caused or aggravated by his service-connected disabilities, or by exposure to herbicidal agents. After reviewing the Veteran’s claims file—to include the medical opinion of Dr. M.M.—and the current medical literature, the examiner determined that there is no objective evidence to support a cause and effect relationship between ischemic heart disease, Agent Orange exposure and essential hypertension. The examiner added that “associations” of these conditions do not represent “cause and effect” relationships. The examiner also determined that these conditions would not have aggravated the Veteran’s hypertension either. Concerning hypertension and diabetes mellitus type II in particular, the examiner found that the Veteran’s hypertension was not caused by or aggravated beyond its normal progression by his service connected diabetes mellitus type 2 because the Veteran does not have any objective evidence of renal impairment as a result of his diabetes mellitus type 2. Moreover, in support of all conclusions, the examiner also explained that essential hypertension, by definition, is a primary condition and not secondary to any other condition. The Board notes that the April 2019 VA examiner’s opinion is only medical opinion of record addressing whether the Veteran’s hypertension may be related to in-service exposure to herbicides. The Board finds the opinion probative, as the examiner indicated that he reviewed current medical literature and found no research that would support such a connection. The Veteran has not submitted any evidence that calls the observations, research or conclusions of the April 2019 VA examiner into question. As such, the Board finds that the evidence in this case weighs against a finding that a relationship exists between the Veteran’s hypertension and his in-service herbicide exposure. Thus, service-connection cannot be awarded on that basis. With respect to secondary service connection, the Board has considered both the opinion of Dr. M.M. and the opinion of the April 2019 VA examiner, and finds the opinion of the VA examiner more probative. While both physicians appear to be in agreement that the Veteran’s diabetes and heart disease would not cause hypertension, Dr. M.M. concluded that a relationship exists based on observations that the disabilities frequently exist at the same time. In other words, because there is a statistical comorbidity, an “association” exists. While such may be true, whether the conditions are frequently present together is not the question before the Board. Dr. M.M.’s rationale does not include discussion as how this Veteran’s diabetes or heart disease actually causes or aggravates the Veteran’s hypertension. As such, the opinion is afforded little probative weight. While the opinion of the April 2019 VA examiner is short, it is responsive to the conclusions of Dr. M.M., and recognizes the differences between comorbidity and cause and effect relationships. The April 2019 VA examiner’s opinion addresses the key questions at issue, and is accompanied by adequte3 medical explanation in support of the conclusions reached. The April 2019 examiner referenced review of medical literature, and explained that the Veteran’s specific diagnosis (essential hypertension), and the fact that his diabetes in particular was not causing kidney impairment (suggesting that such would be necessary to show that diabetes was causing or aggravating hypertension), supports a medical conclusion that his diabetes and heart disease are not causing or aggravating his hypertension. For these reasons, the Board places a higher probative value on the opinion of the April 2019 VA examiner. The Board adds that the only other medical opinion of record addressing any of these potential relationships is that of a March 2010 examiner, who specifically explored whether the Veteran’s hypertension may be caused or aggravated by the Veteran’s diabetes. The March 2010 examiner opined against a causal relationship because the Veteran’s hypertension existed prior to the development of diabetes. In addition, the examiner opined against a relationship based on aggravation, based on an observation similar to that of the April 2019 examiner, that the Veteran’s diabetes was not causing abnormal renal functioning. The consistency between the two opinions lends support to the finding that no such relationship exists for this Veteran. Review of the Veteran’s private and VA treatment records do not otherwise suggest that the Veteran’s diabetes or heart disease are causal or aggravating factors for his hypertension. To the extent the Veteran himself asserts that a relationship exists between his service-connected disabilities or his in-service herbicide exposure and his hypertension, he lacks the medical training to competently opine as to those relationships. (Continued on Next Page) In sum, after considering all of the evidence discussed above, the preponderance of the evidence is against finding that the Veteran’s hypertension is related to his active duty military service, or to his service-connected diabetes and/or heart disease. As such, the claim must be denied. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Hennessy, Associate 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.