Citation Nr: 21072364 Decision Date: 12/03/21 Archive Date: 12/02/21 DOCKET NO. 15-21 519 DATE: December 3, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to a liver disability and/or hepatitis C, is denied. FINDING OF FACT The Veteran's hypertension did not manifest to a compensable degree within one year of separation from service; continuity of symptomatology is not established; the disability is not otherwise etiologically related to an in-service injury, disease, or event; and the disability is not proximately due to or aggravated by a liver disability and/or hepatitis C. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 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 United States Army from January 1965 to January 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision issued by an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). In April 2017, the Veteran and his spouse testified before the undersigned. In December 2017, the Board requested a Veterans Health Administration (VHA) expert opinion regarding the Veteran's hepatitis C and hypertension claims, which was furnished in March 2018. The Veteran did not waive AOJ review of this evidence, and in July 2018 the Board remanded the appeal pursuant to this request and for additional development. In August 2019, the AOJ granted increased ratings for the Veteran's radiculopathy disabilities and granted a total disability rating due to individual unemployability (TDIU) effective May 20, 2017, the earliest date of schedular eligibility. In November 2019, the Board denied increased ratings for the Veteran's back and radiculopathy disabilities; remanded the issues of entitlement to service connection for hypertension and a liver disability, to include hepatitis C and cirrhosis; and remanded the issue of entitlement to an extraschedular TDIU prior to May 20, 2017. In March 2021, the Director of Compensation Service (Director) denied entitlement to an extraschedular TDIU prior to May 20, 2017. See March 2021 VA Memorandum. In August 2021, the Board granted entitlement to service connection for hepatitis C and a liver disability, as well as entitlement to an extraschedular TDIU effective February 1, 2013, but no earlier. This decision was implemented by a September 2021 rating decision. The Board remanded the sole remaining issue on appeal, entitlement to service connection for hypertension, to secure updated treatment records and an addendum medical opinion addressing secondary service connection for hypertension. There has been substantial compliance with the August 2021 Board remand directives. Updated VA treatment records were secured in September 2021 and an adequate addendum opinion was obtained in October 2021. Thus, the Board will address the merits of the remaining issue on appeal. The Veteran asserts that his hypertension is secondary to his service-connected liver cirrhosis, which in turn is due to service-connected hepatitis C. See April 2017 Board Hearing Transcript at 21. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. To establish entitlement to direct service connection, a veteran must show (1) a present disability; (2) an 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 (Fed. Cir. 2004). For veterans who have served continuously for 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including hypertension, are presumed to have been incurred in service if manifest to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. If symptoms of a chronic disease are noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required to presumptively establish service connection. 38 C.F.R. § 3.303. However, the presumption of service connection may be rebutted where there is evidence of an intercurrent injury or disease. 38 U.S.C. §§ 1113, 1137; 38 C.F.R. § 3.307(d). Secondary service connection may be granted for a disability that is proximately due to or aggravated by a service-connected disability. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.310. Initially, the Board observes that no medical opinion has been secured addressing direct service connection. While the Veteran has a current disability, see January 2020 VA Hypertension Examination Report, he does not assert, and the evidence does not show or suggest a direct relationship between the current hypertension and an injury, disease, or event in service. To the contrary, the Veteran asserts that his hypertension began decades after service and is due to his liver disability. See June 2011 VA Form 21-4138; April 2017 Board Hearing Transcript at 21. Moreover, the Veteran does not assert, and the evidence does not show, that symptoms of hypertension were present in service or that hypertension manifested to a compensable degree within one year of separation from service. See id. Thus, the duty to secure a medical opinion addressing direct service connection and presumptive service connection has not been triggered and entitlement to direct service connection and presumptive service connection are not warranted. The Board will therefore focus on the Veteran's assertions and the probative evidence regarding secondary service connection. As noted above, the Veteran has a current diagnosis of hypertension for VA purposes. Moreover, he is service-connected for cirrhosis of the liver due to hepatitis C. Thus, the key question is whether there is an etiological relationship, or "nexus," between the Veteran's current hypertension and these service-connected disabilities. The probative evidence of record as to nexus consists of a January 2020 VA examination report and medical opinion, as well as an October 2021 addendum opinion from a VA-contracted examiner. In this regard, the August 2021 Board remand did not find that the January 2020 examiner's opinion was not probative, but instead recognized that it did not "squarely" address the Veteran's newly service-connected cirrhosis. Essentially, the Board determined that while the January 2020 opinion was probative, additional development was necessary. The January 2020 VA examiner opined that the Veteran's hypertension was less likely than not proximately due to or aggravated by his liver disability or hepatitis C. The examiner explained that while hepatitis C and cirrhosis can lead to portal hypertension, which is high blood pressure in the portal vein, most hypertension is of unknown etiology. However, per the examiner, some hypertension is secondary to medications, illicit drug use, primary renal disease and primary aldosteronism. The examiner emphasized that liver cirrhosis and hepatitis C are not known to cause secondary hypertension, and thus the Veteran's hypertension is less likely than not due to these conditions. See January 2020 VA Hypertension Examination Report (Remarks). The October 2021 VA-contracted examiner likewise opined that the Veteran's hypertension was less likely than not proximately due to or the result of liver cirrhosis and hepatitis C. The examiner explained that while liver disease can cause portal hypertension, the Veteran's hypertension is "arterial hypertension" or "essential hypertension," which is seldom found in patients with liver disease. The examiner further explained that the clinical course of most liver diseases is characterized by low arterial blood pressure. See October 2021 Medical Opinion. The examiner also stated that as hypertension is unrelated to cirrhosis, the Veteran's hypertension is not aggravated by his liver cirrhosis and hepatitis C. The January 2020 VA medical opinion and October 2021 VA contractor medical opinion are probative. The January 2020 examiner is a medical doctor and the October 2021 examiner is physician assistant, and thus the examiners have the knowledge, training, and expertise necessary to provide a medical opinion. Moreover, their opinions are based on the evidence of record and the rationales for the opinions consider medical literature and provide a readily-comprehensible rationale. In sum, these opinions show that while portal hypertension is caused by liver cirrhosis, the Veteran's hypertension is a not portal hypertension and his type of hypertension is not related to liver cirrhosis. The Board acknowledges the Veteran's sincere belief that his hypertension is related to his liver cirrhosis and hepatitis C. However, he is not shown to have the training, knowledge, or expertise necessary to provide a competent medical opinion as to the etiology of hypertension. In this regard, hypertension is a complex internal process and the etiology of hypertension is not something that can be competently addressed by a lay person. Although the Veteran is competent to report his symptoms, that is not the issue in this case, as there is no dispute that hypertension arose decades after service. Accordingly, as the evidence of record does not show that the Veteran's hypertension is actually or presumptively related to his service, or that hypertension is proximately due to or has been aggravated by a service-connected disability, the appeal as to this issue is denied. The Board has considered the benefit of the doubt doctrine, but it is not applicable here as the weight of the evidence of record is against the claim. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.M. Badaczewski, 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.