Citation Nr: 21070413 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 16-07 140 DATE: November 23, 2021 ORDER Service connection for hypertension, to include as secondary to exposure to herbicides and/or to service-connected diabetes mellitus type II, is denied. FINDING OF FACT It is less likely than not (less than 50 percent probability) that the Veteran's hypertension was either directly incurred in or otherwise related to his active military service, to include his exposure to herbicides, or was proximately due to, the result of, or aggravated by his service-connected diabetes mellitus type II. CONCLUSION OF LAW The criteria for service connection for hypertension, to include as secondary to exposure to herbicides and/or to service-connected diabetes mellitus type II, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307(a)(3), 3.309(a),(e), 3.310(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from June 1966 to June 1969. The matter is on appeal before the Board from a November 2013 rating decision. The Board previously remanded the issue for further development in September 2018, June 2020, April 2021, and August 2021. The development has been completed, and the issue has returned to the Board for further adjudication. Service Connection Hypertension The Veteran asserts that his hypertension is either related to his presumed exposure to herbicides while serving in the Republic of Vietnam or is secondary to his service-connected diabetes mellitus type II. 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 military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established with certain chronic diseases, based upon a legal presumption, which occurs by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Additionally, service connection may be established under 38 C.F.R. § 3.303(b), when a symptom or symptoms of a chronic disease are noted in service, or within a year of the date of separation from service, and when chronicity is established through a continuity of symptomatology after service. The continuity of symptomatology provision is an alternative method to establishing service connection for the specific chronic diseases listed under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disability which is aggravated by a service-connected disability. In order to prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509 (1998). Service connection may also be granted on a presumptive basis for certain diseases resulting from exposure to an herbicide agent (including Agent Orange) for Veterans who, during active military, naval, or air service, served in the Republic of Vietnam between January 1962 and May 1975, so long as the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii) are met, and the rebuttable presumption provisions of 38 U.S.C. § 1113 and 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). Service in Vietnam includes the landmass and the territorial sea, which is defined as the 12 nautical miles surrounding Vietnam. See Procopio v. Wilkie, 913 F.3d 1375-1376, 1379-1380 (Fed. Cir. 2019). A review of the Veteran's record shows that he served in the Republic of Vietnam from April 1967 to April 1968. Thus, exposure to herbicides is conceded. However, hypertension is not a disease that warrants presumptive service connection under 38 C.F.R. § 3.309(e). Nevertheless, even when a Veteran is not found to be entitled to a regulatory presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on another basis. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). A review of the Veteran's service treatment records (STRs) does not show a diagnosis of hypertension. Nor do they show any complaints or treatments that may be related to hypertension. The Veteran's blood pressure at his enlistment examination in June 1966 was 120/70, and his blood pressure at his separation examination in May 1969 was 114/70. The Veteran's post-service medical treatment records show that the Veteran underwent a VA examination in April 2015, which notes that the Veteran was diagnosed with hypertension in approximately 2002. The Board notes that previous VA medical opinions have been obtained, which all support the conclusion that it is less likely than not that the Veteran's hypertension began in or was otherwise caused by his active military service, to include exposure to herbicides, as well as the conclusion that it is less likely than not that the Veteran's hypertension was either caused or aggravated by his service-connected diabetes mellitus type II. However, these opinions have all been found to be inadequate on some level. Thus, the Board endeavored to further develop the case. A VA opinion addressing the Board's concerns was provided in September 2021. Pertaining to direct service connection, the VA examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's hypertension was incurred in or caused by his active military service, to include exposure to herbicides. The examiner noted that there was no evidence of hypertension in service. The Veteran's blood pressure at separation was 114/70. The examiner reported that the Veteran's hypertension was not diagnosed until around 2002. Thus, the examiner found that it was less likely than not that the Veteran's hypertension had its nexus in service or was due to events in service. The examiner also explained that the current widely accepted peer reviewed literature has not established Agent Orange as a cause of hypertension. The examiner acknowledged that the 2018 National Academy of Sciences (NAS) study noted a possible association between Agent Orange exposure and hypertension, however, the examiner stated it did not establish cause. The examiner indicated that a review of the current literature, including Up to Date, a professional medical resource wherein one may access current professional treatises and studies, failed to return articles establishing Agent Orange as a cause of hypertension. The examiner noted their confidence level to be greater than 99 percent. Thus, the examiner found that it is less likely than not that the Veteran's hypertension is due to exposure to Agent Orange while in the service. Pertaining to secondary service connection, the VA examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's hypertension was proximately due to or the result of the Veteran's service-connected diabetes mellitus. The examiner also opined that it was less likely than not (less than 50 percent probability) that the Veteran's hypertension was aggravated (made worse) by the Veteran's service-connected diabetes mellitus. The examiner stated that the Veteran's hypertension is unequivocally not due to diabetes and has not been aggravated due to any cause, including diabetes. The examiner explained that for diabetes to be implicated as a cause of hypertension or as an aggravating factor, diabetic nephropathy must be present. This is established medical fact (Harrison's and/or Cecil's textbooks of Internal Medicine). The Veteran does not have diabetic nephropathy. His post-service records show normal renal function, including creatinine and GFR from 2017 through 2021. These numbers were also normal in 2008. The Veteran does not have evidence of renal disease sufficient to influence blood pressure either as a cause or aggravation. Furthermore, there is no evidence of aggravation due to any cause. The average readings on the two available VA examinations showed an average blood pressure of 110/73 and 136/75. This is not consistent with aggravation. The natural course of the condition often requires medication changes and dosage adjustments. Therefore, the examiner found that it is less likely than not that the Veteran's hypertension is due to or has been aggravated due to any cause, including diabetes. A review of the Veteran's VA and private treatment records does not provide any findings of any greater significance than those relayed above. That is, the Veteran's VA and private treatment records do not provide any objective medical evidence linking the Veteran's hypertension either directly to his active military service, or to his presumed herbicide exposure; and they did not find it to be secondary to his service-connected diabetes. Consideration is given to the Veteran's contentions that his claimed hypertension was incurred in or caused by his military service, to include his exposure to herbicides, as well as his contention that his hypertension is secondary to his service-connected diabetes mellitus type II. While lay persons are competent to provide opinions pertaining to certain medical issues, the etiology of hypertension, as is specific to this case, is outside the realm of common knowledge for someone, such as the Veteran, who does not possess medical training, specialized expertise, or experience. Jandreau v. Nicholson, 492. F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Therefore, no probative value shall be assigned to the Veteran's assertions pertaining to the etiology of his hypertension. Based upon the foregoing, service connection for hypertension is not warranted. The Veteran's STRs do not show a diagnosis for hypertension, nor do they show any complaints or treatments that may be related to hypertension. The Veteran's record reflects that he was diagnosed with hypertension in approximately 2002, which is about 33 years after his separation from active military service. The September 2021 VA examiner concluded that it was less likely than not (less than 50 percent probability) that the Veteran's hypertension was either incurred in or otherwise related to his active military service, to include his exposure to herbicides, or was caused or aggravated by his service-connected diabetes. In addition, previous VA medical opinions, while not fully sufficient on their own, nevertheless do support the September 2021 conclusions. The record does not show, and the Veteran has not submitted, any objective medical evidence linking the Veteran's hypertension either directly to his active military service, or to his presumed herbicide exposure, or in a secondary fashion to his service-connected diabetes mellitus type II. Accordingly, service connection for hypertension, on either a presumptive, a direct, or a secondary basis, is not warranted, and therefore the claim is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Lutgens-Staley, 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.