Citation Nr: 21073899 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 18-45 830 DATE: December 13, 2021 ORDER Service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is denied. Service connection for a lung condition, including COPD and restrictive lung disease, to include as secondary to service-connected PTSD, is denied. FINDINGS OF FACT 1. The evidence of record is insufficient to show that the Veteran's hypertension is related to an in-service injury or disease, including presumed exposure to herbicide agents, or secondary to his service-connected PTSD. 2. The evidence of record is insufficient to show that the Veteran's lung condition, to include COPD and restrictive lung disease, is related to an in-service injury or disease, or is secondary to his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for a lung condition, to include COPD and restrictive lung disease have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the Army from September 1966 to September 1969, to include service in the Republic of Vietnam from September 1967 to February 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in March 2015 by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. These matters were most recently before the Board in April 2021 where the Board remanded the claims for further development, to include new VA examinations and opinions. The Board is satisfied that there has been at least substantial compliance with the remand directives. In light of the Veteran's most recent VA examination diagnosing the Veteran with restrictive lung disease rather than COPD, the Board finds it appropriate to expand the Veteran's claim for COPD to include all lung conditions. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). As reflected above, such claims have been recharacterized as entitlement to service connection for a lung condition. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.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 granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. In addition, service connection can be established based on herbicide exposure. 38 C.F.R. § 3.307(a)(6). A veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962 and ending on May 7, 1975, in the Republic of Vietnam is presumed to have been exposed to herbicides and the veteran is entitled to a presumption of service connection for certain diseases listed under 38 C.F.R. § 3.309(e). 1. Service connection for hypertension The Veteran contends that his hypertension is due to his presumed exposure to herbicide agents. Alternatively, he contends that his hypertension is secondary to his service-connected posttraumatic stress disorder (PTSD). The Veteran's service treatment records are silent for treatment or symptoms of hypertension. For example, in September 1966 at his entrance examination the Veteran's blood pressure reading was 110/70. The Veteran's separation examination in July 1969 showed a blood pressure reading of 126/68. Both of these readings are within normal limits and there is no mention on either examination, or in any medical treatment notes during service, showing that the medical officers found any symptoms of hypertension. In March 2015, the Veteran was afforded a VA examination where he was diagnosed with hypertension. The Veteran reported that this condition was first diagnosed approximately 10 years prior (2005) at a Miami VA medical facility. The VA examiner opined that the Veteran's hypertension was not caused by his PTSD. The examiner indicated that the hyperadrenergic state PTSD may cause hypertension, but that there was no observable pattern of correlation between his hypertension symptoms and his PTSD symptom fluctuations to support PTSD being the cause. In February 2020, the Veteran was afforded a VA examination where the diagnosis of hypertension was confirmed. The VA examiner opined that the Veteran's hypertension was less likely than not (less than 50 percent probability) proximately due to or the result of his exposure to herbicides for boots on the ground troops in Vietnam because of the environmental dissipation of herbicides once application occurs made exposure too limited to result in hypertension. The VA examiner also opined that it was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's PTSD. The examiner indicated that there was no medical literature to support a causal medical relationship between hypertension and PTSD despite some evidence that PTSD is a risk factor for developing hypertension, PTSD would not cause his hypertension. Finally, the examiner opined that the Veteran's hypertension was not aggravated (made worse) by his PTSD given that his blood pressure is well-controlled and medical literature does not support a causal relationship between stress and hypertension. In July 2021, the Veteran was afforded a VA examination for his hypertension. The Veteran indicated that he did not present for hypertension during military service. The examiner opined that the Veteran's hypertension was less likely than not (less than 50 percent probability) due to his service-connected obstructive sleep apnea (OSA) given that OSA causes resistant hypertension that fails conservative treatment. The Veteran's blood pressure is well-controlled with treatment and therefore the examiner opined that the Veteran's tobacco use and history of AAA repair surgery are more likely causes of his hypertension. The examiner also opined that the Veteran's hypertension was not aggravated (made worse) by his PTSD, because while PTSD may increase the risk for hypertension, the Veteran presents with more consistent medical processes that caused his hypertension. Additionally, since the Veteran's blood pressure is well-controlled currently the examiner found it is less likely that PTSD is the cause of his increased blood pressure. VA treatment records show treatment for hypertension beginning in 2007. A January 2009 treatment note indicates that the Veteran has had a diagnosis of hypertension for the past three years. The Veteran has a current diagnosis of hypertension. The Board concludes that while he is presumed to herbicide agents during his military service, the preponderance of the evidence weighs against finding that the Veteran's diagnosis of hypertension began during service or is otherwise related to an in-service injury, event, or disease. At the outset, the Board recognizes the Veteran's honorable service in the Republic of Vietnam from September 1967 to February 1968. As a result of this service, he is presumed to have been exposed to herbicide agents, such as Agent Orange, in service. See 38 C.F.R. § 3.307 (a)(6). As discussed below, the Veteran's hypertension is not a disease listed under 38 C.F.R. § 3.309(e), as such, service connection cannot be established on a presumptive basis, meaning that the Veteran must proffer direct evidence of how his hypertension was the result of his military service, to include any herbicide exposure therein. VA treatment records and the VA examinations of record show the Veteran was not diagnosed with hypertension until approximately 2005 or 2006, more than three decades after his separation from service. At his July 2021 VA examination, the Veteran specifically acknowledged that he did not have a diagnosis of hypertension during military service, stating that the condition had gradually onset after military service. Further, the February 2020 VA examiner opined that the Veteran's hypertension is not at least as likely as not related to an in-service injury, event, or disease, including herbicide agent exposure. The rationale was based on the evidence that the environmental dissipation of herbicides once application occurs made exposure too limited to result in hypertension. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Moreover, this opinion has not been challenged or undermined by any competent medical evidence. The Veteran believes his hypertension is related to his exposure to herbicide agents. However, 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 anatomical relationships and pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials 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 VA medical examinations of record. Accordingly, direct service connection for hypertension is denied. As noted above, 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. The Board concludes that the preponderance of the evidence is against finding that the Veteran's hypertension is proximately due to or the result of, or aggravated by a 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 July 2021 VA examiner opined that the Veteran's hypertension is instead more likely due to his tobacco use and history of AAA repair. The examiner opined that given that both OSA and PTSD lead to less controlled blood pressure readings and hypertension that fails conservative treatment, the more likely cause of the Veteran's hypertension was his prior tobacco use and AAA repair. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran believes his hypertension is proximately due to or the result of his service-connected PTSD. However, the Veteran 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. 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). Consequently, the Board gives more probative weight to the medical evidence of record, including the July 2021 opinion. Accordingly, entitlement to service connection for a hypertension, to include as secondary to service-connected PTSD, is denied. 2. Service connection for a lung condition, to include chronic obstructive pulmonary disease (COPD) and restrictive lung disease The Veteran asserts that his lung condition is related to service, including due to his basic training hospitalization for an upper respiratory infection and alleged exposure to dust and burning excrement or in the alternative is secondary to his service-connected PTSD. In June 1968, the Veteran received in-service treatment for an upper respiratory infection (URI). Additionally, the Veteran's STRs indicate treatment for complaints of sore throat, cough, fever, headaches, burning of eyes, nausea, and nasal congestion. A March 2020 VA examination noted a diagnosis of COPD. The examiner opined that the Veteran's COPD is less likely than not related to his period of active service, to include his in-service upper respiratory infection. Unfortunately, the examiner did not provide a rationale in support of the opinion. The examiner also opined that the Veteran's COPD is less likely than not proximately due to or aggravated by his service-connected PTSD, indicating that the medical literature does not support a relationship between the conditions and that the Veteran's treatment records do not show changes in the Veteran's COPD that would indicate aggravation. Pursuant to a Board remand, in July 2021 the Veteran was afforded another VA examination. The Veteran was not diagnosed with COPD at this examination and instead was diagnosed with restrictive lung disease (ILD). The July 2021 examiner opined that the Veteran's restrictive lung disease was less likely than not caused by his military service nor his service-connected disabilities and instead was likely caused by a lifetime of smoking. The examiner indicates that the Veteran's in-service experiences, including brief exposure to burning excrements or dust do not explain the Veteran's current respiratory condition. Instead, the examiner indicates that medical literature supports that the Veteran's disease process is more likely the result of smoking which is known to cause both COPD and ILD. VA treatment records do not show a clear date of diagnosis for the Veteran's lung condition. However, a February 2009 treatment note indicates that the Veteran has a history of COPD. Additionally, a November 2015 treatment note indicates a change of diagnosis from COPD to chronic obstructive lung disease. Based on these records, it is clear that the Veteran's lung condition began many years after military service. The Board concludes that, while the Veteran has a current lung disability, the preponderance of the evidence is against finding that the Veteran's lung condition is (1) not at least as likely as not related to an in-service injury, event, or disease, and (2) not proximately due to or aggravated by the Veteran's service-connected PTSD. Here, the Veteran's hypertension began decades after service and no competent medical opinion has been presented to link the conditions to his in-service experiences or to his service-connected PTSD. The July 2021 VA examiner instead opined that the Veteran's lung condition is instead more likely due to his history of tobacco use. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran believes his COPD was caused or aggravated by his service-connected PTSD. However, 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. 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 competent medial evidence of records. Accordingly, entitlement to service connection for a lung condition, including COPD and restrictive lung disease, to include as secondary to service-connected PTSD, is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jennifer M. Narvaez, 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.