Citation Nr: 21072194 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 17-10 001 DATE: December 2, 2021 ORDER Entitlement to service connection for hypertension is granted. REMANDED Entitlement to service connection for skin disability is remanded. FINDING OF FACT The evidence is at least evenly balanced that the Veteran's hypertension had its onset in service. CONCLUSION OF LAW The criteria for service connection for hypertension are met. 38 U.S.C. §§ 1110, 1131, 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 August 1980 to August 1995. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from a January 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) that, among other things, denied the claims of service connection for hypertension and rash. In September 2019, the Board remanded the claims for further development, to include obtaining VA examinations. As the Board is granting the claim of service connection for hypertension in full, discussion of compliance with the Board's September 2019 remand instructions in regard to that claim is unnecessary. However, as discussed further below, the January 2020 VA examination obtained for the Veteran's skin disability did not substantially comply with the September 2019 Board remand directives. Thus, in order to provide an adequate examination and ensure substantial compliance with the previous remand directives, another remand is necessary to obtain a VA medical opinion in regard to that claim. Stegall v. West, 11 Vet. App. 268 (1998). As a final preliminary matter, in light of the favorable decision to grant the Veteran's claim for entitlement to service connection for hypertension on a direct incurrence basis, a discussion of any other theory of entitlement is not necessary. Entitlement to service connection for hypertension Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, air, or space service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including hypertension, may be also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307, and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For VA rating purposes, "hypertension" means that diastolic blood pressure is predominately 90 mm. or greater; "isolated systolic hypertension" means that the systolic blood pressure is predominately 160 mm. or greater with a diastolic blood pressure of less than 90 mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. A 10 percent disability rating is warranted when diastolic pressure is predominantly 100 or more, or when continuous medication is shown necessary for control of hypertension with a history of diastolic blood pressure predominantly 100 or more, or when systolic pressure is predominantly 160 or more. The Veteran's service treatment records reveal the following blood pressure readings: May 1981 at 120/72; September 1982 at 120/80; May 1984 at 110/67; December 1984 at 110/70; January 1985 at 140/94; January 1985 at 112/88; March 1985 at 120/76; June 1985 at 124/80; March 1989 at 120/80; July 1989 at 120/90; July 1991 at 116/80; January 1993 at 140/84; July 1994 at 128/82; and August 1994 at 126/76. These records do not reveal a diagnosis of hypertension. The post-service medical treatment records show multiple diagnoses of hypertension with treatment that includes Lisinopril. In January 2017, a private physician indicated that she reviewed the Veteran's military treatment records and verified that the Veteran had high blood pressure since his military service. In January 2020, a VA physician found that it was at least as likely as not that the Veteran's hypertension manifested within one year of his separation from service in August 1995. In October 2020, another VA physician found that it was less likely than not that the Veteran's hypertension was related to service or manifested within one year of separation from service. The physician reasoned that the Veteran's service treatment records did not show evidence of diagnosis, treatment, or symptoms suggestive of hypertension while on active duty or within one year of separation, or that the Veteran met Joint National Committee (JNC) criteria for the diagnosis of hypertension. The Veteran has been given the diagnosis of hypertension, however, there is no evidence standard medical protocol (JNC criteria) was used to make this diagnosis. At best, the VA physician indicated that the Veteran's diagnosis of hypertension is stage 1. There was no evidence it was uncontrolled or resistive. Moreover, the Framingham study revealed that 90 percent of people 55 and over will eventually develop hypertension. For the following reasons, entitlement to service connection for hypertension is warranted. Post-service treatment records note multiple diagnoses of hypertension. Thus, the Veteran meets the current disability requirement. Furthermore, although the private physician and VA physician did not provide detailed rationales for their January 2017 and January 2020 opinions, they nonetheless concluded that based upon examination of the Veteran and review of his reported history, the Veteran's hypertension developed during service, and it is as likely as not related to his military service. The physicians' opinions are thus entitled to some probative weight. Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). Although a VA physician in February 2020 rendered the opinion that the Veteran's current hypertension was not related to his active duty service because there was no diagnosis of hypertension when in active duty or within a year of discharge per available records, such an opinion is inadequate because the lack of a diagnosis in service or within the presumptive period is not dispositive as to whether a disease had its onset during that time period. Traut v. Brown, 6 Vet. App. 495 (1994) (establishing service connection on a presumptive basis does not require that a chronic disease be diagnosed within the applicable time period; rather, symptoms that manifest within this time period may subsequently be determined to have been early manifestations of a chronic disease). For the foregoing reasons, the evidence is at least evenly balanced as to whether the Veteran's hypertension had its onset in service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for hypertension is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for skin disability In a September 2019 remand, the Board instructed the AOJ to afford the Veteran a VA examination for his claimed skin disability, and to obtain a medical opinion as to whether any such identifiable disability is related to service or whether any current skin symptom that is not a manifestation of an identifiable disability represents an objective indication of chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI). Pursuant to the Board's remand, the Veteran was afforded a VA skin examination in January 2020. The examiner concluded in the examination report that there was no pathology to render a diagnosis, and no objective findings on the day of the examination that the Veteran had a skin condition. In addition, the examiner did not provide an opinion as to whether the Veteran's skin symptoms were the result of an undiagnosed illness or MUCMI. However, the Veteran reported during the January 2020 examination that his skin condition started in 1993 when he experienced blisters and tiny bumps on the forearm that appeared and spontaneously resolved. His skin lesions were recurrent, look like small bumps or "whelps," are itchy, and appear on the arms, legs, ankle and back for a few minutes to hours. He experienced the lesions randomly and had them on his arms and ankle the day prior to the examination. The Veteran reported that he mentioned the skin condition to a doctor in 1993, but nothing was done. There was never a time that he saw a physician when the lesions were present as they already resolved. The requirement for current disability is satisfied if there is evidence of the disability at any time during or approximate to the claim period even if the disability is subsequently in remission or has completely resolved. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In this case, the Veteran's reports of a skin disability occurring throughout the claim period are competent and credible. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (a veteran is competent to testify regarding continuous pain since service, and lay evidence, when credible, is competent to establish the presence of continuous symptoms for a claimed disability during and since separation from military service). Moreover, the Court has recognized that some disabilities, like rashes, wax and wane due to their inherent nature. Ardison v. Brown, 6 Vet. App. 405, 408 (1994). Thus, a remand is necessary to obtain an appropriate medical opinion as to the nature and etiology of the Veteran's claimed skin disability. Accordingly, the matter is REMANDED for the following action: An appropriate clinician should provide an opinion as to whether the Veteran's skin symptoms since approximately May 2013, the date of the filing of the claim, are attributable to a known clinical diagnosis, or if not, whether they are due to an undiagnosed illness or MUCMI. If attributable to a known clinical diagnosis, the clinician should then determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran's skin disability had its onset in or is related to service, to include exposure to environmental hazards consistent with service in Southwest Asia. The claims file should be provided to and reviewed by the clinician. A complete rationale should accompany any opinion provided. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Styer, 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.