Citation Nr: 21073617 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 17-66 449 DATE: December 9, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is denied. FINDING OF FACT The preponderance of the evidence is against finding that hypertension began during active service, or is secondary to posttraumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for an entitlement to service connection for hypertension, to include secondary to service-connected posttraumatic stress disorder (PTSD), have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b); 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 June 1968 to April 1972. This matter comes before the Board of Veterans' Appeals on appeal from an April 2016 rating decision issued by a Regional Office (RO) of the United States Department of Veterans Affairs (VA). In January 2021, the Veteran testified before the undersigned Veterans Law Judge, and a copy of the transcript is of record. Having reviewed the record, the Board finds there has been substantial compliance with the Board's July 2021 remand instructions, as an adequate VA medical nexus opinion has been obtained in accordance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran has raised any other issues with the duty to notify or duty to assist or with the conduct of his Board hearing. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Thus, the Board need not discuss any potential issues in this regard. In deciding a claim, 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. 38 U.S.C. § 5107; 38 C.F.R. § § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. See Gilbert, 1 Vet. App. at 53. In making this determination, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Although the entire record must be reviewed by the Board, the Court has repeatedly found that the Board is not required to discuss, in detail, every piece of evidence. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (rejecting the notion that the Veterans Claims Assistance Act mandates that the Board discuss all evidence). Rather, the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. Generally, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38U.S.C. §§1110, 1131, 5107; 38C.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). Service connection may also be established for those "chronic diseases" listed in 38 C.F.R. § 3.309 (a) where the evidence shows a diagnosis manifest to a compensable degree within the presumptive period after service, or a continuity of symptomatology since service. See 38 C.F.R. §§ 3.303 (b), 3.307; Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013). Secondary service connection may be granted for a disability that is proximately due to a service-connected disease or injury, or that a service-connected disease or injury aggravated (increased in severity) the nonservice-connected disability for which service connection is sought. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.310. It is not in question that the Veteran has a current disability, as he has been diagnosed with hypertension during the pendency of the appeal period. Here, the Veteran's service records show his qualifying service in the Republic of Vietnam. Thus, his in-service herbicide exposure is presumed. Nonetheless, hypertension is not an enumerated disability entitled to presumptive service connection based on exposure to herbicide agents under 38 C.F.R. § 3.309(e) to date. However, under Combee, service connection may still be awarded based on that exposure on a direct basis. See Combee v. Brown, 34 F. 3d 1039, 1043-44 (Fed. Cir. 1994). There are multiple medical nexus opinions of record obtained during the appeal period. However, the Board assigns no probative value to the March 2016 and April 2021 opinions for the following reasons. As noted in the previous Board remand, although a VA examination/medical nexus opinion (addressing only secondary service connection) for hypertension was first obtained in March 2016, that opinion applied a wrong standard in opining on "aggravation" for secondary service connection. The initial April 2021 opinion did not provide a nexus opinion, incorrectly concluding there was no current diagnosis of hypertension. However, because the Veteran has been diagnosed with hypertension during the appeal period, an addendum opinion was obtained in April 2021, and the VA examiner concluded that the Veteran's hypertension "is less likely due to or aggravated by PTSD," but did not provide a sufficient rationale. Thus, the Board again remanded for a new medical nexus opinion in July 2021. In the most recently obtained medical nexus opinion in October 2021, the examiner opined that the Veteran's hypertension was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, to include the Agent Orange exposure in service. Even after acknowledging the 2018 National Academy of Science (NAS)'s report, "Veterans and Agent Orange" (updating hypertension from its previous classification in the category of "limited or suggestive" to ""sufficient" evidence of an association to chemicals of interest based on new evidence and a review of prior studies), the examiner opined that this study fails to establish a causal relationship (but only suggests a possible association) and emphasized that the current widely accepted, peer-reviewed literature does not attribute hypertension to remote Agent Orange exposure. The examiner also pointed out that the Veteran was first diagnosed with hypertension in the early 2000s, many years after separating from service. With regards to secondary service connection, the examiner indicated that the current widely accepted, peer-reviewed literature does not establish PTSD/related psychological comorbidities as causing/aggravating essential hypertension. The examiner noted that the Veteran's diagnosed essential hypertension, by definition, is not caused by any other condition. The examiner indicated that the articles submitted by the Veteran noted only a possible association between PTSD related psychological comorbidities and hypertension, rather than establishing causation/aggravation, and further explained that the authors therein merely concluded that further research with appropriately designed studies is required to determine the relationship between these psychological conditions and hypertension. The examiner further stated that even though anxiety, stress, anxiety, panic attacks, a startling event, etc, may temporarily elevate one's blood pressure, these resolve following the "fight or flight/white coat hypertension" response, pointing out that these do not constitute aggravation, as it does not impact the baseline condition. Despite acknowledging the Veteran's elevated blood pressure at times, the examiner further explained that such does not necessarily imply aggravation beyond the natural course. The Board assigns the most probative value to this opinion, as this was furnished after extensive review of all pertinent records, supported by concrete factual findings, with citation to medical principles. While the Veteran's claimed hypertension is a "chronic disease" under 38 C.F.R. § 3.309 (a) subject to presumptive service connection consideration, the Veteran is not entitled to service connection under this presumption as well. See 38 C.F.R. §§ 3.303 (b), 3.307, 3.309. The treatment records do not include any persuasive evidence of diagnosis of hypertension having manifested to a compensable degree within one year of service, and the Veteran himself testified that he was first diagnosed with hypertension around 2005, almost 30+ years post-separation, when he was sent to the emergency room for chest pain. The evidence of record provides that the Veteran was first diagnosed with essential hypertension in 2003, when he was sent to the emergency room for his complaint of chest pain, which is consistent with his testimonyand even during that time, the Veteran did not report any onset in service. See March 2003 private treatment records. Even considering the application of continuity of symptomatology, the Veteran has not asserted that he has experienced continuous symptoms relating to hypertension. He has only repeatedly claimed that his condition is due to his service-connected PTSD (which was service-connected only effective 2009). His service records do not show elevated blood pressure readings, and he has not alleged he experienced any possible symptoms of hypertension during service. The Board is also cognizant of the statements provided by the Veteran, noting that his hypertension is related to his military service or with his service-connected disabilities. Although the Veteran is competent to report the symptoms he perceived directly through the senses, he has not been shown to have the appropriate medical training and expertise to offer a competent opinion on the etiology of hypertension. As such, his lay statement is not sufficient to establish a medical nexus between his hypertension and his active service and/or service-connected disabilities. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). To that extent, the Board assigns more value to the probative medical opinion discussed above. While he argues that the submitted articles support his claim, the October 2021 VA medical nexus opinion considered those articles yet provided a negative opinion. Those articles relate, generally, to the claimed condition, but do not specifically relate to his medical history. In light of above, the Board concludes that the evidence preponderates against this claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lee, Catherine 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.