Citation Nr: 21076077 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 16-48 617 DATE: December 22, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to service connected diabetes mellitus type II (DM) is denied. FINDING OF FACT The evidence does not support a finding that the Veteran's hypertension is proximately related to his service connected DM or was aggravated beyond its natural progression. Hypertension did not manifest to a compensable degree within one year of separation from service. CONCLUSION OF LAW The criteria for service connection for hypertension, to include as secondary to service connected DM are not met. 38 U.S.C. §§ 1101, 1131; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1967 to February 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran submitted an April 2015 notice of disagreement. In September 2016 the Veteran submitted a Form 9. In November 2018 and June 2021, the Board remanded the Veteran's claim for additional development. The Veteran's claim was most recently adjudicated in an August 2021 supplemental statement of the case (SSOC). The Veteran continues to assert entitlement to service connection for hypertension, to include as secondary to service connected DM. As noted above, in June 2021, the Board remanded the claim for further development, which has since been substantially completed. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Laws and Regulations Service Connection 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, 1131; 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a Veteran must show: "(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" the so-called "nexus requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). With regard to the element of a current disability, current means near the time a claim is filed or at any time during its pendency. McClain v. Nicholson, 21 Vet. App. 319 (2007). Disability refers to the functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d. 1356 (Fed. Cir. 2018) (holding that pain can constitute a current disability, even without an underlying diagnosis, if it causes sufficient functional impairment). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, a preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Board must determine the value of all pertinent lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). The evaluation of evidence generally involves three steps: competency, credibility and weighing the evidence as a whole. First, the Board must determine whether the evidence comes from a "competent" source. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n. 4 (Fed. Cir. 2007). However, laypersons have generally been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). The Board must then determine if the evidence is credible; in determining whether documents submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. For Veterans with 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, including arthritis, may be presumed to have been incurred in service if they manifest to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); see Allen v. Brown, 7 Vet. App. 439, 448. 1. Entitlement to service connection for hypertension, to include as secondary to service connected diabetes As indicated in an October 2019 VA hypertension examination, the clinical records in this case establish that the Veteran has an ongoing hypertension disorder since 2008. The Veteran contends that the onset of his hypertension disorder is proximately related to or was aggravated beyond its natural progression by his service connected diabetes. Specifically, the Veteran assets that his prescribed diabetes medication proximately caused or aggravated the onset of his hypertension disorder; on his VA Form 9 he stated he believed his blood pressure was higher after taking the medication. STRs do not reveal any complaints, diagnosis, or treatment for hypertension. At a May 1967 enlistment examination report of medical history, normal blood pressure findings was noted. At a February 1970 separation examination, normal blood pressure findings was noted. September 2000 private treatment records reveal that the Veteran underwent an insurance physical. The examiner noted elevated blood pressure. In a January 2015 VA hypertension examination, the examiner diagnosed the Veteran with hypertension. During the examination the Veteran reported an onset of 2004. The Veteran also reported that he has been on a well-controlled anti-hypertensive regimen for the past six to seven years. The examiner noted no other physical findings, complications, or symptoms related to the Veteran's hypertension. However, the examiner did not squarely address the Veteran's assertions. May 2017, 2018 and 2019 VA treatment records show controlled blood pressure readings. At the 2019 appointment, the clinician noted the Veteran was not taking the diabetes medication as instructed, however the Veteran declined medication adjustment. In an October 2019 VA hypertension examination, the examiner diagnosed the Veteran with hypertension, but the overall opinion was inadequate, as explained in the last Board remand. The opinion is assigned no weight. In an August 2021 VA addendum opinion, the examiner opined that the Veteran's hypertension was less likely than not aggravated beyond its natural progression. The examiner also opined that the Veteran's hypertension was less likely than not caused by an in-service injury, event, or illness. Lastly, the examiner opined that it is less likely than not that the Veteran's hypertension is proximately due to or the result of his service connected DM. The examiner noted that the side-effects of the Veteran's prescribed DM medication does not include hypertension. The examiner also noted that DM can contribute to the etiology of hypertension in the setting of chronic kidney disease. However, the Veteran has not been diagnosed with a chronic kidney disease. The examiner explained that the Veteran's hypertension has been well controlled without any medication and there is no evidence of organ damage. The Veteran is competent to report what happened in service as well as competent to report symptoms from hypertension. See Jandreau v. Nicholson, 492 F. 3d at 1377, n. 4. However, hypertension is a complex disease process where some of the symptoms may be silent and it requires expertise regarding its etiology. See Woehlaert v. Nicholson, 21 Vet. App. 456. The Veteran's representative discussed a PubMed article in the informal hearing presentation without providing a specific citation or context. It is not clear how the information pertains to this particular Veteran. The Board assigns this information less weight as result. The Board finds that the August 2021 VA opinion, unlike prior medical opinions given, considers all pertinent facts in explaining the conclusion that it is less likely as not that the Veteran's current hypertension is related to service or any service-connected disability. See Nieves-Rodriguez v Peake, 22 Vet. App. 295 (2008). The opinion is fully adequate as it accounts for the Veteran's assertions, included file review and is fully responsive to the questions at issue. It is consistent with the information in the record as a whole. As such, there is no possibility for service connection for a hypertension proximately related to the Veteran's service connected DM or associated DM medications. Moreover, there is no evidence in the record to support a finding that the Veteran's hypertension was aggravated beyond its natural progression by his service connected DM or associated DM medications. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). (Continued on the next page) As the claims file lacks evidence of a hypertension disorder secondary to the Veteran's service connected DM disorder, the Board finds that the evidence of the record indicates that the onset of the Veteran's hypertension disorder is less likely than not related to or aggravated by his service connected DM disorder. As a pathology for a hypertension disorder has not been shown to be related to the Veteran's service connected DM disorder, the Board finds that the clinical evidence does not support the Veteran's contentions. Based on this evidence, the Board finds service connection is not warranted. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. The preponderance of the evidence is against the claim, the doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 3.102. Emily Tamlyn Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Elliot Harris 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.