Citation Nr: 21064319 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 16-11 423 DATE: October 19, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or posttraumatic stress disorder (PTSD) or medications for the treatment of PTSD, is denied. FINDING OF FACT The preponderance of the evidence weighs against a finding that the Veteran's hypertension had its onset during active duty service, manifested within one year of separation, is otherwise etiologically related to service, or was caused or aggravated by service-connected diabetes mellitus and/or PTSD or medications for the treatment of PTSD. CONCLUSION OF LAW The criteria for service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or PTSD or medications for the treatment of PTSD, have not been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from April 1969 to November 1970, including service in the Republic of Vietnam. The Veteran is in receipt of the Bronze Star Medal. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this matter in May 2019, September 2020, March 2021, and July 2021 for additional development. As the actions specified in the most recent remand have been substantially completed, the case has been properly returned to the Board for appellate consideration. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). In October 2018, the Veteran and P.M. testified before the undersigned Veterans Law Judge at a video conference hearing. A transcript of the hearing is of record. Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. Neither the Veteran nor his representative has 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). Service Connection 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). Generally, service connection requires: (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. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic disorders, to include hypertension, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In such cases, the disease is presumed under the law to have had its onset in service even if there is no evidence of such disease during service. 38 C.F.R. § 3.307(a); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker, 708 F.3d at 1331. In addition, service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or the medication or symptoms of service-connected PTSD The Veteran seeks service connection for hypertension, which he contends is a result of his stressful military experiences as a combat medic responsible for the lives of his fellow servicemembers and/or was caused or aggravated by his service-connected diabetes mellitus or the medication or symptoms of his service-connected PTSD. The Veteran was granted service connection for PTSD and diabetes mellitus effective January 2012. The Veteran's service treatment records (STRs) are silent as to any complaint, treatment, or diagnosis of hypertension or high blood pressure during service. At his April 1969 entrance examination, the Veteran was noted to have clinically normal heart and vascular systems. His blood pressure reading was normal at 136/74. At his November 1970 separation examination, the Veteran's heart and vascular systems were both noted to be clinically normal. His blood pressure reading was normal, measured at 126/76. March 2009 VA treatment records diagnosed the Veteran with hypertension, and VA treatment records continued to diagnose hypertension. An October 2012 VA examination by a VA nurse practitioner reviewed the Veteran's claims file and conducted an interview. She diagnosed hypertension and stated that the Veteran related that routine blood tests originally noted he had hypertension and in 1980 he started taking hypertension medication. The October 2012 VA nurse practitioner opined that the Veteran's hypertension was less likely than not incurred in or caused by the Veteran's service because it was diagnosed after service. An August 2013 VA addendum opinion by a VA physician indicated that he reviewed the Veteran's claims file. He diagnosed hypertension and repeated that the Veteran stated that his routine blood tests originally noted he had hypertension and in 1980 he started taking hypertension medication. The August 2013 VA physician opined that the Veteran's hypertension was less likely than not proximately due to or the result of the Veteran's service-connected diabetes mellitus because lab tests indicated that the Veteran's diabetes mellitus did not produce chronic kidney disease, which causes hypertension. A November 2019 VA examination by a VA physician indicated that she reviewed the Veteran's claims file and conducted an interview. She diagnosed hypertension and noted the date of the diagnosis as 2015. The November 2019 VA physician opined that the Veteran's hypertension was less likely than not incurred in or caused by his service because there were no medical records showing that he was diagnosed with or treated for hypertension during his service. She opined that the Veteran's hypertension was less likely than the result of or aggravated by his service-connected diabetes mellitus because the conditions are not related and do not have a pathophysiological relationship. The November 2019 VA physician stated that the Veteran has idiopathic hypertension with no identifiable cause, which affects 95 percent of patients with hypertension. She explained that hypertension tends to be familial and a consequence of the interaction between environmental and genetic factors rather than caused by one disease. An October 2020 VA examination by a VA physician indicated that he reviewed the Veteran's claims file and conducted an interview. He diagnosed hypertension and related that the Veteran reported his hypertension started during his military service. The October 2020 VA physician opined that the Veteran's hypertension was less likely than not caused or aggravated by his service-connected PTSD. He explained that there was no evidence in medical literature that PTSD can aggravate the anatomical-neuro-vascular condition responsible for primary hypertension, and he related that the Veteran was diagnosed with hypertension 39 years after his discharge and subsequently diagnosed with PTSD 3 years later. The October 2020 VA physician stated that PTSD was not on the list of risk factors that may aggravate hypertension, and he related that the Veteran's blood pressure levels before and after the Veteran's PTSD diagnosis were similar. He explained that hypertension is caused by an interaction of genes and environmental factors mostly due to disturbances in the kidney's function, abnormality in the sympathetic nervous system, endothelial dysfunction, and vascular inflammation. The October 2020 VA physician stated that the Veteran started taking quetiapine, a medication for his PTSD, after his hypertension diagnosis, so it therefore was not the cause of his hypertension, and he asserted that the Veteran's blood pressure level before and after he started taking quetiapine were similar, so therefore the medication did not aggravate his hypertension. An April 2021 addendum opinion by the October 2020 VA examiner repeated everything stated in the October 2020 VA examination and added that there was no documented evidence of the Veteran experiencing high blood pressure during his military service in his STRs and that there is no evidence found in medical literature that symptoms of PTSD such as anxiety, suspiciousness and/or chronic sleep impairment are the direct cause or etiology for the anatomical-neuro-vascular condition responsible for primary hypertension. He also added that there was no documented evidence that those conditions aggravated the Veteran's hypertension. A July 2021 VA addendum opinion by a VA physician indicated that she reviewed the Veteran's claims file. She opined that the Veteran's hypertension was less likely than not incurred in or caused by his military service because treatment records supported that the onset of his hypertension occurred over 30 years after his service, so he did not experience chronicity of an in-service condition. The July 2021 VA physician stated that the Veteran's STRs did not include any signs or symptoms of chronic hypertension, so he therefore didn't experience the continuity of symptoms between his service and the present. She also opined that the Veteran's hypertension was less likely than not caused or aggravated by his PTSD or treatment of his PTSD. She explained that while stress, including symptoms like anxiety and insomnia, may cause episodic elevations in blood pressure, this was a normal physiologic response that does not lead to the development of chronic hypertension or alter the pathophysiology of chronic hypertension. The July 2021 VA physician additionally related that medical literature supports that quetiapine causes orthostatic hypotension, not hypertension. Based on a careful review of the evidence of record, the Board finds that the preponderance of the evidence weighs against finding that service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or the medication or symptoms of service-connected PTSD, is warranted. As a preliminary matter, the Board has considered whether the Veteran is entitled to service connection for hypertension on a presumptive basis. Hypertension is a chronic disease under 38 C.F.R. § 3.309. Although the Veteran has a current diagnosis of hypertension, the evidence of record weighs against a finding that hypertension manifested during or within one year of service. The Veteran's STRs are silent as to any complaint, treatment, or diagnosis of hypertension or high blood pressure during service. At the Veteran's November 1970 separation examination his heart and vascular systems were both noted to be clinically normal and his blood pressure reading was normal, measured at 126/76. The first medical evidence of record diagnosing the Veteran with hypertension are the VA medical treatment records from March 2009, many years after he left the military. The Board has considered the Veteran's lay contentions that he had hypertension during service and alternatively starting in the early 1970s, but he lacks the training and credentials to provide a competent opinion as to a medical diagnosis or etiology. His lay opinion accordingly does not constitute competent and probative evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Therefore, the Board finds that the evidence does not show that the Veteran's hypertension manifested during service or within one year of separation, nor does it show that the Veteran had continuous symptoms of hypertension following service. Accordingly, the Veteran is not entitled to presumptive service connection for hypertension as a chronic disease. Notwithstanding the provisions relating to presumptive service connection, a Veteran may establish service connection for a disability with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Board now turns to the question of direct service connection. In addition to the absence of medical evidence of hypertension during active service, a year post-service, or continuity of symptomology, the Board notes that all the VA examiners who offered an opinion on whether the Veteran's hypertension was more or less likely than not incurred in or caused by the Veteran's military service, specifically the October 2012 VA nurse practitioner, the November 2019 VA physician, and the July 2021 VA physician, provided a negative opinion. The November 2019 VA physician explained that the Veteran had idiopathic hypertension with no identifiable cause, which affects 95 percent of patients with hypertension. She asserted that hypertension tends to be familial and a consequence of the interaction between environmental and genetic factors. The Veteran has not provided any medical evidence suggesting a positive nexus between his hypertension and his military service. The only evidence supporting a nexus are the Veteran's lay statements, which as stated previously do not constitute competent and probative evidence because he lacks the training and credentials to provide a competent opinion as to a medical diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Therefore, the Board finds that the available evidence does not support a finding that service connection for hypertension on a direct basis is warranted. Finally, the Board must address whether the Veteran is entitled to service connection on a secondary basis. All the VA examiners who offered an opinion on whether the Veteran's hypertension was more or less likely than not caused or aggravated by service-connected diabetes mellitus and/or the medicine or symptoms of service-connected PTSD, specifically the October 2013 VA physician, the November 2019 VA physician, the October 2020 VA physician, and the July 2021 VA physician, provided a negative opinion. Regarding secondary service connection to diabetes mellitus, the August 2013 VA physician opined that the Veteran's hypertension was less likely than not proximately due to or the result of the Veteran's service-connected diabetes mellitus because lab tests indicated that the Veteran's diabetes mellitus did not produce chronic kidney disease, which causes hypertension. The November 2019 physician opined that the Veteran's hypertension was less likely than the result of or aggravated by his service-connected diabetes mellitus because the conditions are not related and have no pathophysiological relationship. She stated that the Veteran has idiopathic hypertension with no identifiable cause, which affects 95 percent of patients with hypertension. The November 2019 VA physician explained that hypertension tends to be familial and a consequence of the interaction between environmental and genetic factors rather than caused by one disease. Regarding secondary service connection related to PTSD or the medication taken for the treatment thereof, the October 2020 VA physician opined that the Veteran's hypertension was less likely than not caused or aggravated by his service-connected PTSD because there was no evidence in medical literature that PTSD can aggravate the anatomical-neuro-vascular condition responsible for primary hypertension, and the Veteran was diagnosed with hypertension 39 years after his discharge and subsequently diagnosed with PTSD 3 years later. He stated that PTSD is not on the list of risk factors that may aggravate hypertension, and he related that the Veteran's blood pressure levels before and after the Veteran's PTSD diagnosis were similar. The October 2020 VA physician explained that hypertension is caused by an interaction of genes and environmental factors mostly due to disturbances in the kidney's function, abnormality in the sympathetic nervous system, endothelial dysfunction, and vascular inflammation. He stated that the Veteran started taking quetiapine, a medication for his PTSD, after his hypertension diagnosis, so it therefore was not the cause of his hypertension, and he asserted that the Veteran's blood pressure levels before and after he started taking quetiapine were similar, so therefore the medication did not aggravate the Veteran's hypertension. The October 2020 VA physician added in an April 2021 addendum opinion that there was no evidence found in medical literature that symptoms of PTSD such as anxiety, suspiciousness and/or chronic sleep impairment are the direct cause or etiology for the anatomical-neuro-vascular condition responsible for primary hypertension. He also added that there was no documented evidence that those conditions aggravated the Veteran's hypertension. The July 2021 VA physician also opined that the Veteran's hypertension was less likely than not caused or aggravated by his PTSD or treatment of his PTSD. She explained that while stress, including symptoms like anxiety and insomnia, may cause episodic elevations in blood pressure, this was a normal physiologic response that does not lead to the development of chronic hypertension or alter the pathophysiology of chronic hypertension. The July 2021 VA physician additionally related that medical literature supports that quetiapine causes orthostatic hypotension, not hypertension. Significantly, neither the Veteran nor his representative has presented or identified any contrary medical opinion that supports the claim for service connection for hypertension. VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). (Continued on the next page) Indeed, the Veteran has not provided any persuasive medical evidence suggesting a positive nexus between his hypertension and his service-connected diabetes mellitus and/or the medicine or symptoms of his service-connected PTSD. The only evidence supporting a nexus are the Veteran's lay statements, which as stated previously do not constitute competent and probative evidence because he lacks the training and credentials to provide a competent opinion as to a medical diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Taking into consideration the collective VA opinions discussed above and the lack of any medical evidence to the contrary, the Board finds that the evidence does not support finding entitlement to service connection for hypertension is warranted on a secondary basis. In summary, the Board finds that the preponderance of the evidence weighs against finding in favor of service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or the medication or symptoms of service-connected PTSD. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ahuva D. Sunshine 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.