Citation Nr: 21069756 Decision Date: 11/19/21 Archive Date: 11/19/21 DOCKET NO. 14-29 975 DATE: November 19, 2021 ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for chronic bronchitis is denied. REMANDED Entitlement to service connection for a bilateral eye condition is remanded. FINDINGS OF FACT 1. The Veteran's hypertension is not secondary to service-connected hearing loss, allergic rhinitis and/or headaches, and is not otherwise related to an in-service injury or disease. 2. The Veteran's chronic bronchitis is not secondary to service-connected sleep apnea, bilateral hearing loss, allergic rhinitis, and/or headaches, and is not otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for entitlement to service connection for chronic bronchitis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1956 to January 1960. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2013 and January 2014 rating decisions. The Veteran was afforded a hearing before the undersigned Veterans Law Judge in February 2017. A transcript of the hearing is associated with the electric claims file. In June 2017 and November 2020, the Board remanded the issues for further development. That development was completed, and the case has since been returned to the Board for appellate review. Service Connection Under applicable law, service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). 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 determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App. 370, 374 (2002). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. 1. Entitlement to service connection for hypertension The Veteran contends that his hypertension is due to service-connected hearing loss, allergic rhinitis and/or service-connected headaches. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board's adjudication will consider only entitlement to secondary service connection. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or was aggravated beyond its natural progress by service-connected disability. The Board concludes that, while the Veteran has a current disability of hypertension the preponderance of the evidence is against finding that the Veteran's hypertension is proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The September 2017 VA examiner noted the Veteran's hypertension did not manifest during the Veteran's period of active service. The examiner opined the Veteran's hypertension was not at least as likely as not caused or aggravated by service-connected allergic rhinitis. The December 2018 VA examiner opined the Veteran's hypertension was less likely than not proximately due to or the result of the Veteran's service-connected hearing loss or service-connected allergic rhinitis. The examiner opined it is less likely than not the Veteran's hypertension was aggravated by the Veteran's service-connected hearing loss, tinnitus, or allergic rhinitis. The rationale was that there is no medical literature to support the claim. The July 2020 VA examiner opined the Veteran's hypertension was less likely than not proximately due to or the result of the Veteran's service-connected tinnitus. The rationale was that there is no medical literature to support this claim. The examiner noted that known etiological factors in essential hypertension including obesity, insulin resistance, high alcohol intake, high salt intake, aging and perhaps a sedentary lifestyle stress, low potassium intake and low calcium intake. The August 2021 VA examiner opined it is less likely than not that the Veteran's hypertension was proximately due to or the result of, or aggravated by, the Veteran's service-connected tension headaches. The rationale was that hypertension is not clinically associated with tension headaches, and tension headaches are not a medically recognized contributing cause of hypertension. Hypertension etiology is multifactorial with risk factors such as smoking, genetics, high-sodium diet, and alcohol consumption. The Board finds the VA opinions to be the most probative opinions and are dispositive of the nexus question presented in this case. The VA opinions reflect the expert's knowledge and skill in analyzing the data. The opinion contains clear conclusions with supporting data and a reasoned medical explanation connecting the two. The experts were familiar with the Veteran's pertinent medical history. The experts provided a thorough and detailed opinion about an area within their expertise. The opinion is the product of reliable principles and methods, and is the result of principles and methods reliably applied to facts. The Veteran believes his hypertension is proximately due to or the result of, or aggravated beyond its natural progression by a service-connected disability. The Veteran in this case 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 pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training 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 medical opinions of record. Therefore, entitlement to service connection for hypertension is not warranted. 2. Entitlement to service connection for chronic bronchitis The Veteran contends that his chronic bronchitis, to include chronic obstructive pulmonary disorder (COPD), is due to service-connected sleep apnea, bilateral hearing loss, allergic rhinitis, and/or service-connected headaches. The April 2019 VA examiner noted bronchitis is a type of COPD. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board's adjudication will consider only entitlement to secondary service connection. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or was aggravated beyond its natural progress by service-connected disability. The Board concludes that, while the Veteran has a current disability of chronic bronchitis, the preponderance of the evidence is against finding that the Veteran's condition is proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The September 2017 VA examiner noted the Veteran's chronic bronchitis did not manifest during the Veteran's period of active service. The examiner opined the Veteran's chronic bronchitis was not at least as likely as not caused or aggravated by service-connected allergic rhinitis. The December 2018 VA examiner opined the Veteran's bronchitis and COPD conditions were less likely than not proximately due to or the result of the Veteran's service-connected hearing loss. The examiner opined it is less likely than not the Veteran's COPD was aggravated by the Veteran's service-connected hearing loss, tinnitus, or allergic rhinitis. The rationale was that there is no medical literature to support the claim. Additionally, the examiner noted that the Veteran's COPD is most likely from long term smoking. The Veteran smoked for 38 years. The Veteran was afforded a VA examination in April 2019. The April 2019 VA examiner opined the Veteran's bronchitis condition is less likely than not proximately due to or the result of the Veteran's service-connected sleep apnea. The rationale was that while there may be a correlation of bronchitis causing sleep quality, sleep apnea does not cause or aggravate chronic bronchitis. The April 2019 VA examiner opined the Veteran's bronchitis condition is less likely than not proximately due to or the result of the Veteran's service-connected allergic rhinitis. The rationale was that there is no medical literature which supports causation or aggravation of chronic bronchitis by allergic rhinitis. The April 2019 VA examiner opined the Veteran's bronchitis condition is less likely than not proximately due to or the result of the Veteran's service-connected bilateral hearing loss. The rationale was that there is no medical literature which supports causation or aggravation of chronic bronchitis by bilateral hearing loss. The April 2019 VA examiner opined the Veteran's bronchitis condition was not at least as likely as not aggravated beyond its natural progression by sleep apnea, allergic rhinitis, or hearing loss. The rationale was that there is no medical literature which supports aggravation of chronic bronchitis by sleep apnea, allergic rhinitis, or hearing loss. The August 2021 VA examiner opined it is less likely than not that the Veteran's bronchitis was proximately due to or the result of, or aggravated by, the Veteran's service-connected tension headaches. The rationale was that chronic bronchitis is not clinically associated with tension headaches. Chronic bronchitis is typically caused by a long-term exposure to an irritant such as smoke and pollutants that cause damage to the lungs. Medical literature does not establish a correlation between the two conditions. The Board finds the VA opinions to be the most probative opinions and are dispositive of the nexus question presented in this case. The VA opinions reflect the expert's knowledge and skill in analyzing the data. The opinion contains clear conclusions with supporting data and a reasoned medical explanation connecting the two. The experts were familiar with the Veteran's pertinent medical history. The experts provided a thorough and detailed opinion about an area within their expertise. The opinion is the product of reliable principles and methods, and is the result of principles and methods reliably applied to facts. The Veteran believes his chronic bronchitis is proximately due to or the result of, or aggravated beyond its natural progression by a service-connected disability. The Veteran in this case 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 pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training 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 medical opinions of record. Therefore, entitlement to service connection for chronic bronchitis is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a bilateral eye condition is remanded. The Veteran contends that his bilateral eye condition is due to service-connected allergic rhinitis, hearing loss, tinnitus, and/or headaches. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board's adjudication will consider only entitlement to secondary service connection. The September 2017 VA examiner noted the Veteran's eye conditions did not manifest during the Veteran's period of active service. The examiner opined the Veteran's eye conditions were not at least as likely caused or aggravated by service-connected allergic rhinitis. The December 2018 VA examiner opined the Veteran's eye conditions were less likely than not proximately due to or the result of the Veteran's service-connected hearing loss or service-connected allergic rhinitis. The examiner opined it is less likely than not the Veteran's eye conditions were aggravated by the Veteran's service-connected hearing loss, tinnitus, or allergic rhinitis. The examiner reasoned that the Veteran's cataracts and pseudophakia are caused by age and the removal of prior cataract which was caused by natural age progression. The Veteran's posterior vitreous detachment is caused by natural progression of age. The Veteran's blepharitis is caused by inflammation of the eye lid oil glands. This inflammation of the oil glands in the eyelids can result from an excess growth of bacteria that is normally found on the skin, a blocked oil gland on the eyelid, a hormone imbalance, or allergies. The July 2021 VA examiner opined the Veteran's bilateral eye conditions are less likely than not proximately due to or the result of, or aggravated by, the Veteran's service-connected tension headaches. The examiner reasoned that the Veteran has no medical diagnosis and thus could not be due to the Veteran's service-connected tension headaches. The examiner noted that tension headaches do not cause any known eye conditions. The medical record notes the Veteran has diagnoses of bilateral cataracts and blepharitis of the bilateral eyes. The Board finds the July 2021 opinion inadequate due to factual inaccuracy. The VA examiner did not acknowledge the diagnosis of various eye conditions in the record. As the July 2021 medical opinion is based on factual inaccuracy, on remand, an addendum medical opinion should be obtained. The matters are REMANDED for the following action: 1. Obtain an addendum opinion by an appropriate clinician to determine the nature and etiology of bilateral eye conditions. The entire file must be made available to the examiner, and the report should include discussion of the Veteran's documented history and assertions. The examiner must opine whether it is at least as likely as not the Veteran's bilateral eye conditions are (1) proximately due to service-connected tension headaches, or (2) aggravated beyond its natural progression by service-connected tension headaches. The examiner is requested to provide a clear rationale and explain in detail the underlying reasoning for any opinions expressed. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. (continued on next page) TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Alexia E. Palacios-Peters, 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.