Citation Nr: 21004682 Decision Date: 01/27/21 Archive Date: 01/27/21 DOCKET NO. 17-27 128 DATE: January 27, 2021 ORDER Entitlement to service connection for hypertension, claimed as due to herbicide exposure or secondary to service-connected coronary artery disease (CAD), is denied. FINDING OF FACT The most probative evidence reflects that the Veteran’s hypertension is not the result of any incident of active duty, to include herbicide exposure, or caused or aggravated by his service-connected CAD. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served active duty service from August 1969 to March 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2016 rating decision by the Department of Veteran Affairs (VA) Regional Office (RO). In the March 2020 Board remand, the RO was requested to provided supplemental medical opinions regarding the etiology of the Veteran’s hypertension. In March 2020, adequate VA medical opinions with sufficient rationales were provided. Therefore, there has been substantial compliance with the Board’s remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Entitlement to service connection for hypertension due to herbicide exposure, including as secondary to service-connected CAD, is denied. The Veteran contends his hypertension is due to in-service herbicide exposure or, in the alternative, caused or aggravated to his service-connected CAD. In particular, he has provided several medical articles linking hypertension to Agent Orange exposure. For example, the National Academy of Medicine article states that a report affirms limited or suggestive evidence that herbicides could cause hypertension. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first 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). A veteran is entitled to the benefit of the doubt, standard of proof for benefit claim decisions. 38 U.S.C. § 5107(b). The benefit of the doubt is applicable when there is an approximate balance of positive and negative evidence. 38 C.F.R. § 3.102. When a veteran seeks benefits and the evidence is in relative equipoise, the veteran prevails. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). A. Herbicide Exposure VA regulations provide that a veteran who had active military, naval, or air service in the Republic of Vietnam during the Vietnam Era shall be presumed to have been exposed to herbicides unless there is affirmative evidence to establish that the veteran was not exposed. 38 C.F.R. § 3.307 (a)(6)(iii). Certain diseases are deemed associated with herbicide exposure under current law. 38 C.F.R. § 3.309 (e). Here, the Veteran had active duty in Vietnam and is presumed to have been exposed to herbicide. However, hypertension is not a disease eligible for presumptive service connection. Because the Veteran is not entitled to a presumptive service connection for his claim, it does not preclude him from establishing entitlement to direct service connection for his hypertension. Combee v. Brown, 34 F.3d 1039 (Fed Cir. 1994). In the March 2020 VA medical opinion, the VA examiner opined that the Veteran’s hypertension is less likely than not related to his herbicide exposure. The VA examiner referenced that the Veteran has “essential hypertension.” Further, the VA examiner explained that essential hypertension may be attributed to multiple factors, including genetic predisposition, excess dietary salt intake, and adrenergic tone, that may interact to produce hypertension. Also, essential hypertension accounts for 90 percent of human hypertension. The VA examiner reasoned that although it is claimed that there is evidence linking hypertension to Agent Orange exposure, the condition of hypertension has not been added to the list of diseases presumed for service connection for veterans exposed to Agent Orange. Thus, concluding the Veteran’s hypertension is not related to his herbicide exposure. Based upon review of the record, the Board finds the Veteran’s hypertension is not related to herbicide exposure. The March 2020 VA medical opinion is probative because it is based on complete review of the medical record. Also, the VA examiner provided a rationale based on clinical experience. The Board places less probative weight on the Veteran’s medical articles linking hypertension to Agent Orange exposure because it generally indicates “limited” or “suggestive” evidence of a link between hypertension and Agent Orange. Therefore, service connection for hypertension due to herbicide exposure is denied. B. Secondary Service Connection Service connection may also be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Veteran was provided two VA medical opinions addressing his hypertension being related to his service-connected CAD. First, in the March 2016 VA medical opinion, the VA examiner opined that the Veteran’s hypertension is less likely than not secondary to his heart condition. The VA examiner reasoned that typically the heart condition does not cause hypertension. Instead, hypertension in poor control can cause a heart condition. Also, the VA examiner opined that the Veteran’s hypertension is less likely than not aggravated beyond its natural progression by his service-connected heart condition. The VA examiner reasoned that the Veteran’s ejection fraction is within normal limits, which indicates that his heart pumping capability is within normal limits. Second, in the March 2020 VA medical opinion, the VA examiner opined that the Veteran’s hypertension is less likely than not proximately due to or the result of the Veteran’s service-connected CAD. The VA examiner reasoned that the Veteran’s hypertension is a major modifiable risk factor for all clinical manifestations of CAD and not the other way around. Also, the VA examiner referenced that there is an association between CAD and hypertension; however, hypertension may be attributed to multiple factors, including genetic predisposition, excess dietary salt intake, and adrenergic tone, that may interact to produce hypertension. Also, the VA examiner opined that the Veteran’s hypertension is less likely as not aggravated beyond its natural progression by his service-connected CAD. The VA examiner referenced that there is an association between CAD and hypertension; however, the Veteran is currently on treatment and has had good control of his blood pressure. Further, the VA examiner determined that there are no objective findings indicating any aggravation beyond the natural progression of the Veteran’s hypertension. The Board finds the March 2020 VA medical opinion is probative evidence against granting direct or secondary service connection for the Veteran’s sleep apnea. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The VA examiner’s opinion was based on review of the Veteran’s complete medical record. Also, it provides a sufficient rationale for the negative etiology of the Veteran’s hypertension based on clinical experience. Id. No probative weight is given to the March 2016 VA medical opinion because it did not provide a rationale. Given that the preponderance of the evidence is unfavorable to the claim, VA’s benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.1. Accordingly, the Board finds the preponderance of the evidence is against the claim and service connection is denied. SCOTT W. DALE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Willoughby, 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.