Citation Nr: 21076917 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 12-25 949 DATE: December 28, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD) and/or as due to herbicide exposure, is denied. FINDING OF FACT The Veteran's hypertension did not begin during active service and is not otherwise related to an in-service injury or disease, to include his service-connected PTSD and/or herbicide exposure. CONCLUSION OF LAW The criteria for service connection for hypertension, to include as secondary to service-connected PTSD and/or as due to herbicide exposure, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1968 to October 1975. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in March 2017. A transcript of the hearing is associated with the electronic claims file. The Board issued three prior remands on this claim in August 2017, March 2019, and April 2021. Service Connection Generally, to establish service connection 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." Davidson v. Shinseki, 581 F.3d 1313, 131516 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established based on herbicide exposure. 38 C.F.R. § 3.307(a)(6). For VA purposes, an "herbicide agent" includes the chemicals 2,4D; 2,4,5T and its contaminant TCCD; cacodylic acid; and picloram. 38 C.F.R. § 3.307(a)(6)(i). For the purposes of determining herbicide exposure, a veteran who served in qualifying locations is presumed to have been exposed to an herbicide agent. 38 C.F.R. § 3.307(a)(6)(iii). If the veteran is presumed to have been exposed to herbicides, the veteran is entitled to a presumption of service connection for certain disorders. See 38 C.F.R. § 3.309(e). This presumption is specifically limited to those diseases listed; hypertension is not included. Id. 1. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD and/or as due to herbicide exposure. In December 2011, the Veteran requested service connection for high blood pressure. The RO issued a July 2012 rating decision denying service connection noting that there was no evidence of a diagnosis within one year of active service. The Veteran appealed this issue up to the Board. On his Form 9 appeal, the Veteran wrote that he did not believe his medical records were looked at completely and contended that his hypertension was a result of his service-connected PTSD medication. The Veteran noted that he did not have hypertension when he got out of the military, but that "all of the problems that I have had with PTSD has caused this problem." At his Board hearing the Veteran's representative argued that the Veteran's prescribed PTSD medication, Wellbutrin, caused a prominent side effect of hypertension. In August 2017, the Board remanded the claim instructing the RO to provide the Veteran with a VA examination for his hypertension and obtain an opinion as to its etiology including any relationship to the Veteran's service-connected PTSD or the medication prescribed for such. The Veteran was given a VA examination for his hypertension in February 2018. The examiner opined that "review of the current medical literature indicates that PTSD does not cause hypertension." The examiner went on to explain that there is no evidence of rapid progression of the Veteran's hypertension due to his PTSD medications because there is no evidence to support that the Veteran's hypertension has worsened. In fact, the Veteran has been on the same dosage of medication for his hypertension since he was first diagnosed with it in 2009. Finally, the examiner noted that in most cases the exact cause of hypertension is not ever determined but that it is known to become more common with age and in those who are overweight or obese (the examiner pointed out that at the time the Veteran was overweight, but was previously obese), those who are physically inactive, or in those who have a positive family history of hypertension. The Board noted that the Veteran's DD214 listed service in Vietnam from 7 Jun 70 to 30 Apr 71. Thus, herbicide exposure is presumed. As this theory of entitlement had not previously been considered, in March 2019 the Board issued another remand in order to obtain an addendum opinion regarding such. In November 2019 an addendum opinion was uploaded into the Veteran's electronic claims file. Here, the examiner opined that it was less likely than not that the Veteran's hypertension was due to his presumed herbicide exposure. Specifically, the examiner wrote that the "Veteran was diagnosed with hypertension about 5 years ago at the age of 65. His hypertension is controlled with HCTZ only. He has numerous risk factors for hypertension including his age, activity, chronic alcohol use (fifth every 3 days) and family history." The examiner went on to discuss the National Academy of Sciences 11/15/18 update moving hypertension to the sufficient category indicating that there was enough epidemiologic evidence to conclude a positive association with herbicide exposure. However, the examiner wrote "The background risk of hypertension (in the absence of herbicide exposure) is still much higher than in this association (72.2% of Vietnam deployed non sprayers and 72.2% of non-Vietnam deployed non sprayers). In addition, there is no compelling evidence in this case that herbicide exposure is casually related to the development in hypertension." Based on this opinion, the Board remanded the claim again in April 2021 to obtain another opinion regarding the Veteran's hypertension and whether it was caused or aggravated by the Veteran's service-connected alcohol dependency associated with PTSD. In August 2021 another addendum opinion was uploaded into the Veteran's electronic claims file. Here, the examiner opined that it was less likely than not that the Veteran's hypertension was caused or aggravated by his service-connected alcohol dependency associated with PTSD. As rationale for his opinion the examiner wrote "There's no identifiable cause of high blood pressure. High blood pressure has many risk factors, including: age, family history, being overweight or obese, not being physically active, using tobacco, diet, stress, drinking too much alcohol and certain chronic conditions; however, data available cannot confirm that any of these risk factors definitely causes HTN either as it is multifactorial in etiology. The Veteran had some of these known risk factors. A thorough review of the Veteran's medical records failed to demonstrate a causal relationship. A nexus has not been established." With regard to aggravation, the examiner wrote "The Veteran has not had a change in his HTN medication since 2009, he continues to take HCTZ 25mg daily for his HTN. There is no evidence of aggravation or his blood pressure worsening." The Board finds this opinion and the others all to be well-reasoned and consistent with the record. In a November 2021 brief, the Veteran's representative again argues that his hypertension is secondary to his service-connected PTSD or the medication taken for such, or that it is due to herbicide exposure. In support of these claims, the Veteran's representative provides several links to articles on these topics, however copies of the articles were not provided for the record. The Board notes that medical articles or treatises can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least a plausible causality based upon subjective facts rather than an unsubstantiated lay opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999). However, treatise evidence alone is usually "too general and inconclusive" to establish a medical nexus. Sacks v. West, 11 Vet. App. 314, 317 (1998). In this case, the treatise evidence submitted is not accompanied by a medical opinion. Neither the Veteran nor his representative has provided any medical evidence in support of his claim or in contradiction to the above discussed VA opinions. There is also no persuasive medical evidence or persuasive credible lay evidence that the Veteran's claimed disorder manifested to a compensable degree within a year of his separation from service or had its onset in service and continued ever since service. Therefore, service connection based on presumptive service connection for a chronic disease or based on a theory of continuity of symptomatology is not warranted. The benefit of the doubt rule does not apply as the evidence is not in "approximate balance" or "nearly equal." Accordingly, entitlement to service connection for hypertension, to include as secondary to service-connected PTSD and/or as due to herbicide exposure, is denied. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Ruiz, 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.