Citation Nr: 21061895 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 15-15 510 DATE: October 5, 2021 ORDER The claim of entitlement to service connection for hypertension (HTN), to include as secondary to service-connected disabilities is denied. The claim of entitlement to service connection for gastrointestinal reflux disease (GERD) (hereinafter acid reflux), to include as secondary to service-connected disabilities is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding the Veteran's HTN was incurred in, caused by, or aggravated by active service proximately due to or aggravated beyond its natural progression by his service-connected posttraumatic stress disorder (PTSD), and is not otherwise related to an in-service injury, event, or disease. 2. The Veteran's HTN pre-existed his second tour of service and was not aggravated beyond the natural progression of the disease. 3. The preponderance of the evidence is against finding that the Veteran's acid reflux was incurred in, caused by, or aggravated by active service proximately due to or aggravated beyond its natural progression by his service-connected PTSD, and is not otherwise related to an in-service injury, event, or disease. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for HTN, to include as secondary to service-connected disabilities, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.310. 2. The criteria for establishing entitlement to service connection for acid reflux, to include as secondary to service-connected disabilities, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active-duty service with the United States Army from November 1977 to October 1980, and from December 2003 to March 2005, with additional National Guard service. These matters are before the Board of Veteran's Appeals (Board) from an August 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that denied service connection for HTN and acid reflux, to include as secondary to PTSD. The Veteran testified at a hearing before the undersigned Veterans Law Judge at the RO in Nashville, Tennessee in February 2020. A written transcript of that hearing has been prepared and associated with the evidence of record. The Veteran confirmed and acknowledged proceeding without representation at the hearing. The Board remanded the Veteran's claims in March 2020 for additional development. The Veteran received additional examinations and medical opinions in May 2020. The Board notes that the Veteran's appeal also contained a service connection claim for allergic rhinitis and for dermatitis, which were granted in a July 2021 rating decision, effective December 2011. That award constitutes a full grant of the disabilities sought, and that appeal has been resolved. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (holding that where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of the claim concerning "downstream" issues, such as the compensation level assigned for the disability and the effective date). Secondary Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. Generally, to establish service connection there must be competent evidence showing: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the in-service injury incurred or aggravated during service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In determining whether a disability is to be granted a secondary service connection the VA must find 1) that there is a current disability that is not service connected; and 2) that there is at least one service- connected disability; and 3) evidence that the non-service-connected disability is either, a) proximately due to or the result of a service-connected disability; or b) aggravated beyond its natural progress by a service-connected disability. 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995). 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 (a). VA must consider all favorable lay evidence of record. 38 U.S.C. § 5107. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21. Vet. App. 303 (2007). The Secretary shall consider all information and lay and medical evidence of record in a case and make appropriate determinations as to competence, credibility, and weight. 38 U.S.C. § 5107; 38 C.F.R. § 3.303; Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience, 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. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. When there is an approximate balance between positive and negative evidence, equipoise, the benefit of the doubt doctrine must apply in favor of the Veteran. But when the preponderance of the evidence weighs against the claims of the Veteran the claim will be denied on its merits, and when the preponderance of the evidence weighs for the claims of the Veteran the claim will be granted on its merits. In those cases, the benefit of the doubt doctrine is inapplicable. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for HTN, to include as secondary to service-connected disabilities The Veteran contends that he is entitled to service connection for HTN, to include as secondary to service-connected disabilities. Specifically, the Veteran contends that his HTN is due to, aggravated by, or caused by his PTSD. For VA purposes HTN or isolated systolic HTN must be confirmed by readings taken two or more times on at least three different days, and means that the diastolic blood pressure is predominantly 90 millimeters (mm) or greater, and isolated systolic HTN means that the systolic blood pressure is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. The Veteran has a current diagnosis of HTN and has met the first element of service connection. The Veteran's entrance examination from June 1977 noted a blood pressure reading of 150 over 80 and had periodic readings during this period of service - none of which indicated a blood pressure reading of 160 or more over 90 or more. The Veteran's separation examination in August 1980 noted blood pressure 124 over 78. The Veteran's service treatment records are silent for any treatment, complaint, or diagnosis of HTN during his first period of active duty. The Veteran's medical records noted a blood pressure reading from December 1992 of 144 over 90, and also noted the Veteran taking blood pressure medication starting April 2001. In the Veteran's second period of service his service treatment records also noted blood pressure readings from 2004 and 2005 which indicated HTN and treatment for HTN was also noted. The Veteran received a VA examination in May 2020, pursuant to the March 2020 Board remand. The examiner noted the diagnosis of HTN in approximately 2000, and noted the Veteran's HTN had no functional impact. The examiner found they were unable to find sufficient documentation of high blood pressure with two readings on the same day for 3 different days but found treatment for HTN over the years to show a diagnosis of HTN. The examiner found no direct service connection existed as the Veteran was diagnosed with HTN between 1995 and 2002, between his periods of active duty. The examiner noted that the Veteran had no diagnosis of HTN prior to his entrance into service in 1977 and that HTN did not exist prior to the Veteran's first period of service. However, the examiner noted that per the Veteran's records he was diagnosed with HTN between 1995 and entrance of his last period of active duty, 2003, and the examiner found HTN pre-existed the last period of active duty. The examiner also noted that while on active duty there was no evidence of permanent aggravation of HTN by the last period of active duty from 2003 to 2005. The examiner noted an inability to determine a baseline level of severity for HTN, despite this, the examiner found no aggravation beyond its natural progression by the Veteran's service. The examiner's rationale was there was no medical treatment or additional medical complications from HTN and the note of additional medications was found not to equate a worsening of HTN. The examiner found that blood pressure elevations or temporary aggravations can be due to many factors such as diet, weight, exercise, and other medical conditions. The examiner also found the Veteran's HTN was less likely due to PTSD as there was no causal association between PTSD and HTN. The examiner noted healthline.com literature showed no causal connection, and found they were separate entities entirely and unrelated with no causal relationship. The examiner noted and listed causes of HTN, none of which included PTSD. The examiner did note that studies had identified a risk of developing HTN in untreated PTSD, with risk factors increasing the likelihood a condition would develop but did not find they caused HTN. The Board finds the VA examination to be competent, credible, and with significant probative weight. The Veteran's VA treatment records note treatment of HTN. The Board finds the Veteran's VA treatment records to be competent, credible, and with some probative weight. However, the Veteran's records indicated no connection between the Veteran's HTN and his service, nor his service-connected PTSD. The Veteran testified at a hearing in February 2020, that his being in a hazardous area caused and triggered high blood pressure. The Veteran indicated that being in a combat zone caused the advancement of high blood pressure. The Veteran believes his HTN is related to his PTSD, but he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the competent, probative medical evidence of record denying an etiological relationship. In this case, the Veteran's lay assertions are outweighed by competent and credible medical evidence which evaluated whether the Veteran's HTN was due to his active-duty service, caused by or aggravated by his PTSD. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the etiology of the Veteran's condition, or the possibility of a causal connection. While the Board is sympathetic to the Veteran's report of symptoms, the medical evidence does not support a causal connection nor aggravation of the Veteran's HTN by the Veteran's service-connected PTSD. When there is an approximate balance between positive and negative evidence the benefit of the doubt doctrine must apply in favor of the Veteran. But when the preponderance of the evidence weighs against the claims of the Veteran the claim will be denied on its merits. In this case the preponderance of the evidence is against the claims of the Veteran, therefore the benefit of the doubt doctrine is inapplicable. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's claim of service connection for HTN, to include as secondary to PTSD, is not warranted. Entitlement to service connection for acid reflux, to include as secondary to service-connected disabilities The Veteran contends that he is entitled to service connection for acid reflux, to include as secondary to service-connected disabilities. Specifically, the Veteran contends that his acid reflux is due to or caused by his PTSD. The Veteran has a current diagnosis of acid reflux and has met the first element of service connection. The Veteran's service treatment records are silent as to any treatment, complaints, or diagnosis of acid reflux and were not documented in either of his periods of active duty. Pursuant to the Board remand in March 2020 the Veteran received a VA examination in May 2020. The examiner noted the diagnosis of gastrointestinal reflux disease (GERD) in 2018 and the start of medication. The Veteran reported symptoms of reflux. The examiner found there was no direct connection for the Veteran's acid reflux to active duty, as the examiner found there was no objective evidence of chronic GERD on active duty and the Veteran started on medication for gastritis in 2007. The examiner noted no esophagitis, but found there was treatment for inflammatory bowel disease but not irritable bowel syndrome and noted the Veteran was not diagnosed with GERD until 2018. The examiner additionally found the Veteran's acid reflux was entirely unrelated to PTSD - the examiner indicated there was no causal medical relationship between the two conditions. The examiner noted healthline.com literature showed no causal connection and that a mental health issue is not a cause nor a risk factor for acid reflux. The examiner noted there was no baseline severity for the Veteran's acid reflux, his symptoms were subjective only, and there was no objective evidence of a reflux condition on active duty or after. The examiner documented the medications for gastritis in 2007. The examiner also found there was no aggravation by the Veteran's active duty nor by his PTSD. The Veteran's VA treatment and private records noted treatment for ulcerative colitis in 2015 and noted no prescribed medication for acid reflux, but did note the Veteran reported using over the counter medications for reflux symptoms in March 2020. The Board finds the Veteran's medical treatment records, both VA and private, to be competent, credible, and with significant probative weight. The Veteran testified at a February 2020 hearing that he felt his PTSD and stress caused his acid reflux, and that they were related. The Veteran indicated he could not say for sure that his acid reflux was caused by service and noted there was no doctor who indicated a link between his acid reflux and PTSD. The Veteran believes his acid reflux is related to his PTSD, but he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the competent, probative medical evidence of record denying an etiological relationship. In this case, the Veteran's lay assertions are outweighed by competent and credible medical evidence which determined the Veteran's acid reflux was not due to his active-duty service, nor caused by or aggravated by his PTSD. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the etiology of the Veteran's condition, or the possibility of a causal connection. While the Board is sympathetic to the Veteran's report of symptoms, the medical evidence does not support a causal connection nor aggravation of the Veteran's acid reflux by the Veteran's active-duty service nor his service-connected PTSD. The Board finds that the lack of competent medical evidence of a current disability that was permanently worsened or aggravated due to active-duty service or due to a service-connected disability carries significant probative weight. Since, the Veteran's record is completely silent as to any aggravation or permanent worsening this absence is the determining factor in the Veteran's claims for service connection. See Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (finding that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact, i.e., the lack of evidence is itself evidence). In this case, the absence of any medical evidence of treatment for acid reflux for more than a decade after service also tends to establish that the Veteran's acid reflux was not caused by or due to his active duty, nor aggravated or permanently worsened as a result of his military service or due to or aggravated by his PTSD. When there is an approximate balance between positive and negative evidence the benefit of the doubt doctrine must apply in favor of the Veteran. But when the preponderance of the evidence weighs against the claims of the Veteran the claim will be denied on its merits. In this case the preponderance of the evidence is against the claims of the Veteran, therefore the benefit of the doubt doctrine is inapplicable. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's claim for service connection for acid reflux, to include as secondary to PTSD is not warranted. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C.A. Teich, 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.