Citation Nr: 21066751 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 12-28 366 DATE: November 2, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to herbicide exposure, is denied. FINDING OF FACT The Veteran's hypertension neither began during nor was otherwise caused by his military service, to include any toxic exposures therein. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension, to include as secondary to herbicide exposure, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1966 to August 1970. The Veteran attended a hearing before the undersigned Veterans Law Judge in May 2016. A transcript of the hearing is of record. This matter was previously remanded by the Board of Veterans' Appeals (Board) in June 2016, April 2018, and April 2021. Entitlement to service connection for hypertension, to include as secondary to herbicide exposure The Veteran contends that his current hypertension condition is related to his active service. Specifically, the Veteran contends that his hypertension was directly caused by his conceded exposure to herbicides during his service at U-Tapao Air Force Base, Thailand, while working near the perimeter. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § § 5107; 38 C.F.R. § § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran served on active duty at U-Tapao Air Force Base, Thailand, while working near the perimeter and is therefore found to have been exposed to herbicide agents, including Agent Orange. 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307. At the May 2016 Board hearing, the Veteran testified that he was first diagnosed with hypertension around 1999, and was put on water pills at the time, before starting on regular blood pressure medicine. The Veteran had an examination for his hypertension in December 2016. The examiner opined that it was less likely than not that the Veteran's hypertension was incurred in or caused by his active service. The examiner stated that the earliest record of the Veteran's hypertension was in 2006. The examiner noted that hypertension is one of the most common worldwide diseases afflicting humans and may be categorized as either primary (essential) or secondary hypertension. It was additionally noted that primary hypertension is diagnosed in the absence of an identifiable secondary cause, and that some secondary causes can be from renal causes, vascular causes, endogenous hormonal causes, neurogenic, and drugs. The examiner indicated that the Veteran does not have any secondary causes. The examiner also noted that extensive research of hypertension due to herbicide exposure cannot find any definitive medical evidence linking hypertension to herbicide exposure nor was the Veteran treated for hypertension during his active military service. The Veteran had another examination for his hypertension in September 2019. The examiner opined that it was less likely than not that the Veteran's hypertension was incurred in or caused by his active service, to include as a result of his presumed exposure to herbicides. The examiner noted that the Veteran's service treatment records do not demonstrate a diagnosis of or treatment for hypertension. The examiner specifically noted that the Veteran's separation examination noted a blood pressure reading of 120/70, which is considered normal, and his enlistment examination noted a blood pressure reading of 124 or 134/77, which is considered normal. The examiner indicated that there was no evidence of a trend of elevated blood pressure readings in the Veteran's service treatment records, and a diagnosis of headaches related to hypertension was not found in the service treatment records. The examiner indicated that there was a note indicating URI and possible sinus related headaches, but there was no imaging or consult for headaches found in the service treatment records. Additionally, the examiner noted an episode of gastroenteritis which clearly notes no headaches, and that there was no headache evaluation or diagnosis of headaches secondary to hypertension found in the service treatment records. It was noted that the service treatment records were silent as far as blood pressure related diagnoses or evaluation for concerns secondary to blood pressure issues. The examiner noted that the separation PULHES were all listed as 1's the highest rating, and the clinical exam included with the separation physical exam was marked as normal. Additionally, the examiner noted that several years post service, the Veteran was reported to have had a NEG cardiac echo and stress test-records were found supporting this. The examiner stated that had the blood pressure been prolongedly elevated such as since the time of service, "the expectation would be that this testing would not be normal". Furthermore, the examiner noted the National Academy of Sciences (NAS) Report: Veterans and Agent Orange: Update 2012, which notes "limited or suggestive" evidence of a relationship between hypertension and herbicide exposure. Additionally, the examiner noted that there were some studies indicating a possible link between herbicide exposure particularly in Army chemical corps members and in USAF enlisted ground crew members with participation in Operation Ranch Hand. However, the examiner noted that many of these studies involved small numbers of participants, self-reported data or lacked analysis taking into account family history and lifestyle factors such as smoking history, nicotine use, alcohol use etc. Furthermore, the examiner noted that there is no scientifically reviewed medical literature found that definitively links herbicide exposure and hypertension. Another medical opinion regarding the etiology of the Veteran's hypertension was obtained in June 2021. The examiner opined that it was less likely than not that the Veteran's hypertension was incurred in or caused by his active service. The examiner stated that there is no evidence of hypertension while in service or at separation. The examiner noted that the Veteran's blood pressure at the time of the separation exam was 120/70, and that the Veteran was diagnosed with hypertension in 2008. Furthermore, the examiner noted that Agent Orange exposure has not been confirmed as a cause of hypertension. The examiner stated that the 2018 NAS review noted a possible association without establishing cause, and that a review of the current, widely accepted, peer-reviewed literature has not established remote Agent Orange exposure as a cause of hypertension. The examiner stated that this "review included Up-to-Date, a respected, professional medical resource wherein one may access current professional treatises and studies", and that no "relevant studies were returned". Upon review of the record, the Board finds that service connection for hypertension is not warranted. The Board finds the September 2019 and June 2021 examiners' medical opinions to be probative because they provided a detailed rationale based on the relevant evidence of record. The examiners fully explained the reasoning underlying the opinion and noted that the Veteran's service treatment records do not suggest that his hypertension had onset in service. The examiners also noted that there is no medical evidence of a hypertension diagnosis until at least the 1980's, which is more than one year after the Veteran's separation. To the extent that the Veteran believes that his hypertension is linked to his active service, the Board notes that he is competent to provide testimony concerning factual matters of which he has fight-hand knowledge and experiences through his senses. Barr v. Nicholson, 21 Vet. App. 303 (2007). However, the question regarding the etiology of his high blood pressure is an issue of causation of a medical condition, which requires a medical determination outside the realm of common knowledge of any lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, his lay statements alone are not sufficient to establish the required nexus in this case. The Board must then rely on the available and probative medical evidence, which have found no nexus between the Veteran's hypertension and his military service. Additionally, the Board finds that entitlement to service connection for hypertension under 38 C.F.R. § 3.309(e), based on his presumed exposure to herbicide agents, is not warranted. As noted, hypertension is not among the exclusive list of conditions which are covered by this presumption. See 38 C.F.R. §§ 3.307, 3.309(e). While hypertension is not on the list of diseases recognized by VA as being presumptively related to exposure to herbicide agents, the National Academies of Sciences, Engineering, and Medicine (NAS) in its most recent Agent Orange update moved hypertension from limited or suggestive of an association between hypertension and herbicide exposure to sufficient evidence of an association. See Veterans and Agent Orange Update 11 (2018). The standard for this new category is epidemiologic evidence is sufficient to conclude that there is a positive association. That is, a positive association has been observed between exposure to herbicides and the outcome in studies in which chance, bias, and confounding could be ruled out with reasonable confidence. For example, if several small studies that are free of bias and confounding show an association that is consistent in magnitude and direction, there could be sufficient evidence of an association. There is sufficient evidence of an association between exposure to the chemicals of interest and hypertension. However, while the NAS has found some connection between herbicide exposure and hypertension, hypertension is not a presumptive condition at this time, which means that the medical evidence in each specific case must be reviewed, and medical opinions reached considering the totality of their health and medical circumstances. Here, the probative medical evidence of record has found that it is less likely than not that the Veteran's hypertension was the result of his exposure to herbicides during his service at U-Tapao Air Force Base, Thailand. The June 2021 examiner found that while the 2018 NAS review noted a possible association without establishing cause, and that a review of the current, widely accepted, peer-reviewed literature has not established remote Agent Orange exposure as a cause of hypertension. As a result, entitlement to service connection for hypertension based on presumed exposure to herbicide agents is not warranted. Finally, service connection may also be granted for chronic disabilities, if such are shown to have been manifested to a compensable degree within one year after the Veteran was separated from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309 (a), to include hypertension. See Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013). However, there is no evidence, nor allegation, that the Veteran's hypertension was diagnosed either in service or within one year after service, let alone to a compensable degree. See 38 C.F.R. § 3.309. The Veteran has testified that he was not formally diagnosed with hypertension until 1999, which is several years after his separation from service. Without evidence supporting a diagnosis in service or within one year of separation, the claim is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt provision does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Service connection is not warranted. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board David M. Sebstead, 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.