Citation Nr: 21077590 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 19-30 689 DATE: December 30, 2021 ORDER Entitlement to service connection, to include on secondary and presumptive bases, for hypertension is denied. FINDING OF FACT The Veteran's hypertension did not originate in service or until years thereafter and is not otherwise etiologically related to service, to include on a presumptive basis, and was not proximately due to or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for entitlement to service connection, to include on secondary and presumptive bases, for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1116, 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 from October 1966 to July 1970 with additional service in the Reserves. This case comes before the Board of Veterans' Appeals (Board) on appeal from February 2018 and July 2018 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The appeal was last remanded by the Board in August 2021 for additional development. A review of the claims file shows that there has been substantial compliance with the Board's prior remand directives and thus, no further action in this regard is warranted. See Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that this matter has been advanced on the docket pursuant to 38 C.F.R. § 20.900(c). Entitlement to service connection, to include on secondary and presumptive bases, for hypertension The Veteran's DD 214 indicates that the Veteran served overseas or on sea service for more than 3 years to include service aboard the USS Norton Sound. The Veteran's DD 214 further indicates that his military specialty was as a chef/cook. A December 1973 report of medical examination noted that the Veteran's blood pressure was 114/78 and a contemporaneous report of medical history noted that the Veteran did not have high or low blood pressure. A March 1976 report of medical examination noted that the Veteran's blood pressure was 124/84 and a contemporaneous report of medical history noted that the Veteran did not have high or low blood pressure. An October 1978 report of medical examination noted that the Veteran's blood pressure was 116/76 and a contemporaneous report of medical history noted that the Veteran did not have high or low blood pressure. A July 1981 report of medical examination noted that the Veteran's blood pressure was 110/72 and a contemporaneous report of medical history noted that the Veteran did not have high or low blood pressure. An April 1982 report of medical examination noted that the Veteran's blood pressure was 120/80 and a contemporaneous report of medical history noted that the Veteran did not have high or low blood pressure. An April 1983 report of medical examination noted that the Veteran's blood pressure was 118/72 and a contemporaneous report of medical history noted that the Veteran did not have high or low blood pressure. A March 1984 report of medical examination noted that the Veteran's blood pressure was 110/6 and a contemporaneous report of medical history noted that the Veteran did not have high or low blood pressure. A March 1986 report of medical examination noted that the Veteran's blood pressure was 120/72 and a contemporaneous report of medical history noted that the Veteran did not have high or low blood pressure. A March 1987 report of medical examination noted that the Veteran's blood pressure was 110/72 and a contemporaneous report of medical history noted that the Veteran did not have high or low blood pressure. A March 1988 report of medical examination noted that the Veteran's blood pressure was 130/76 and a contemporaneous report of medical history noted that the Veteran did not have high or low blood pressure. An April 1989 report of medical examination noted that the Veteran's blood pressure was 124/80 and a contemporaneous report of medical history noted that the Veteran did not have high or low blood pressure. A February 1990 report of medical history noted that the Veteran did not have high or low blood pressure. A March 1990 report of medical examination noted that the Veteran's blood pressure was 132/86. An April 1993 annual certificate of physical condition noted that the Veteran's blood pressure was 130/80. The first VA treatment record to mention hypertension was an April 2007 VA treatment record. The Veteran was afforded a VA examination in February 2018. The VA examiner noted a diagnosis of hypertension. The VA examiner noted that the following blood pressure readings were used to establish an initial diagnosis of hypertension: 160/85 in January 2005, 144/94 in January 2007, and 165/80 in January 2008. The VA examiner noted the Veteran's history including that he had successive, elevated blood pressure readings on multiple visits in 2006-2007, that he initially tried to control his hypertension with diet and exercise that was unsuccessful, and that he started on medication in 2009. The VA examiner noted that the Veteran's records indicated that often his blood pressure readings were not at but that his hypertension was well controlled at the time of examination. No nexus opinion was provided. A March 2020 VA memorandum determined that the Veteran's exposure to herbicides was conceded based on his nautical service in one or more of the approved Republic of Vietnam bays or harbors. An addendum VA opinion was obtained in June 2018. The VA examiner determined that it was less likely than not that the Veteran's hypertension was proximately due to or the result of the Veteran's service-connected diabetes mellitus, type 2. The VA examiner explained that there was clear evidence that the Veteran's hypertension was onset in 2005, 5 years before the onset of the Veteran's diabetes mellitus, type 2. Therefore, the VA examiner concluded that the Veteran's hypertension could not be caused by his service-connected diabetes mellitus, type 2, since it preceded it in onset. In September 2020, the Veteran submitted a VA article discussing herbicide exposure and high blood pressure among veterans of the Army Chemical Corps. The Veteran was afforded another in-person VA examination in April 2021. The VA examiner noted that hypertension was diagnosed in 2005. The Veteran reported that his hypertension was found as a result of routine blood pressure checks and that he began medication in 2007. The VA examiner determined that the Veteran's hypertension was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner explained that the Veteran's hypertension was diagnosed in 2005, 35 years following separation from active-duty service, and that hypertension was not a presumptive condition associate with Agent Orange exposure, therefore, a nexus had not been established. The VA examiner also determined that the Veteran's hypertension was less likely than not (less than 50 percent probability) proximately due to or the result of a service-connected condition. With regard to the Veteran's diabetes mellitus, type 2, the VA examiner explained that the Veteran was diagnosed with hypertension in 2005 and diabetes mellitus, type 2 in 2010. Therefore, the VA examiner determined that hypertension could not be secondary to diabetes mellitus, type 2. Likewise, the VA examiner also noted that the Veteran's 2005 hypertension diagnosis predated his 2009 erectile dysfunction diagnosis so hypertension could not be secondary to erectile dysfunction. With regard to the Veteran's service-connected tinnitus and bilateral hearing loss, the VA examiner noted that there was no causal relationship between these disabilities. And lastly, with regard to the Veteran's service-connected prostate cancer, the VA examiner explained that there was insufficient evidence of renal dysfunction related to prostate cancer that would contribute to hypertension. Finally, the VA examiner noted that the record indicated that the Veteran smoked 1 pack of cigarettes per day for 45 years. The Veteran was afforded an in-person VA examination in May 2021. The VA examiner noted a diagnosis of hypertension diagnosed in 2005. The VA examiner provided a series of secondary service connection opinions addressing each of the Veteran's service-connected disabilities. The VA examiner determined that the Veteran's hypertension was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected tinnitus or his service-connected bilateral hearing loss. The VA examiner explained that hypertension and tinnitus were not medically related or was hypertension and hearing loss. In addition, hypertension was a separate entity entirely from tinnitus or hearing loss and unrelated to either. A thorough review of medical literature failed to demonstrate a causal relationship. A nexus was not established. Next, the VA examiner determined that the Veteran's erectile dysfunction was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected erectile dysfunction. The VA examiner stated that a relationship between hypertension and erectile dysfunction did exist but that the Veteran's hypertension was diagnosed in 2005 before the diagnosis of erectile dysfunction in 2009. Therefore, the VA examiner determined that hypertension could not be secondary to erectile dysfunction since hypertension came first. With regard to the Veteran's service-connected prostate cancer, the VA examiner stated that a correlation existed between prostate cancer and hypertension but that a causal relationship could only be determined in the presence of renal dysfunction from prostate cancer. The VA examiner noted that urinary dysfunction was not the same as renal dysfunction and that there was insufficient evidence that the Veteran's service-connected prostate cancer resulted in renal dysfunction. Accordingly, a secondary causation nexus was not established with regard to the Veteran's service-connected prostate cancer. Lastly, the VA examiner determined that the Veteran's hypertension was less likely than not due to or the result of the Veteran's service-connected diabetes mellitus, type II. The VA examiner explained a relationship existed between hypertension and diabetes mellitus, type II; however, the Veteran's diagnosis of hypertension was made in 2005 prior to the diagnosis of diabetes mellitus, type 2 in 2010. Therefore, hypertension could not be secondary to diabetes mellitus, type 2 since the Veteran's hypertension came first. An addendum opinion was obtained in November 2021. The VA examiner determined that the Veteran's hypertension was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected conditions. The VA examiner explained that the Veteran's hypertension was not medically related to any of his service-connected conditions and was an entirely separate entirely. The VA examiner stated that "a thorough review of the medical literature failed to demonstrate a causal relationship" and that causes of hypertension did not include the Veteran's service-connected disabilities. The VA examiner specifically determined that hypertension and diabetes mellitus, type 2 were not medically related. The VA examiner noted that evidence indicated that hypertension began in 2005, 5 years prior to onset of the Veteran's diabetes mellitus, type 2. The VA examiner explained that hypertension caused by diabetes mellitus occurred in the presence of diabetic neuropathy but the record did not show a diagnosis of diabetic neuropathy for the Veteran. Accordingly, a nexus between the Veteran's hypertension and his service-connected disabilities was not established. The VA examiner went on to list causes of hypertension including obstructive sleep apnea, kidney problems, adrenal gland tumors, thyroid problems, certain congenital defects in blood vessels, and certain medications (including birth control pills, cold remedies, decongestants, over-the-counter pain relievers, some prescription drugs, and illegal drugs such as cocaine and amphetamines. With regard to the Veteran's prostate cancer, hearing loss, tinnitus, and erectile dysfunction, the VA examiner explained that these conditions were separate entities entirely from the Veteran's hypertension and unrelated to it. The VA examiner also determined that the baseline level of severity of the Veteran's hypertension based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation could not be determined. The VA examiner stated that regardless of an established baseline, the Veteran's hypertension was not at least as likely as not aggravated beyond its natural progression by a service-connected condition. The VA examiner also provided a direct nexus opinion. The VA examiner determined that the Veteran's hypertension was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner explained that while recent studies showed an association between hypertension and veterans assigned to the chemical corps who had high exposure to herbicides, there was no association with the Veteran's military occupational specialty. The VA examiner further explained that the prospect of exposure to 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) from Agent Orange in ground troops in Vietnam was unlikely because of environmental dissipation of TCDD and limited bioavailability of any residual TCDD present in soil or vegetation suggesting that dioxin concentrates in ground troops who served in Vietnam would have been small and indistinguishable from background levels even if they had been in recently treated areas. The VA examiner stated, "The evidence of environmental fate and poor bioavailability of TCDD from Agent Orange is consistent with the observation of little or no exposure in the Veterans who served in Vietnam." The VA examiner further stated, "Appreciable accumulation of TCDD in veterans would have required repeated long-term direct skin contact of the type experienced by United States (US) Air Force Ranch Hand and US Army Chemical Corps personnel who handled or otherwise had direct contact with liquid herbicide, not from incidental exposure under field conditions where Agent Orange had been sprayed." Accordingly, the VA examiner determined that no nexus existed between the Veteran's hypertension and his exposure to Agent Orange. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection generally requires evidence satisfying three criteria: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the current disability and the disease or injury incurred or aggravated during service. Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013). Secondary service connection may be granted when a disability is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 447-48 (1995). The Veteran is presumed to have been exposed to herbicides. VA laws and regulations provide that if a Veteran was exposed to herbicides during service, certain listed diseases are presumptively service connected. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.309(e). 38 C.F.R. § 3.309(e) lists the diseases covered by the regulation. The Secretary of VA has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-46 (1994); Notice, 61 Fed. Reg. 41, 442-49 (1996); Notice, 72 Fed. Reg. 32, 395-32, 407 (Jun. 12, 2007); Notice, 74 Fed. Reg. 21,258-21, 260 (May 7, 2009); Notice, 75 Fed. Reg. 32540 (June 8, 2010). At the outset, the Board notes that 38 C.F.R. § 3.309(e) specifically lists those diseases covered by the provision, and the list does not include hypertension. Therefore, service connection for the Veteran's hypertension cannot be granted on a presumptive basis. Notwithstanding the presumption, service connection for a disability claimed as due to exposure to herbicides may be established by showing that a disorder resulting in disability was in fact causally linked to such exposure. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Meaning, the Board must still consider whether the Veteran's hypertension is directly related to service. No medical evidence suggests that the Veteran's hypertension is directly related to service, to include conceded exposure to herbicides. The Veteran's medical records, including medical records while he was in the Reserves, are negative for any evidence of hypertension until approximately 2005. In fact, the Veteran's blood pressure readings were all normal while serving in the Reserves. The Board acknowledges the Veteran's argument that his hypertension is related to his service, to include exposure to herbicides. However, as a layperson lacking in medical training and expertise, the Veteran cannot provide a competent opinion on matters as complex as the diagnosis and etiology of his hypertension. As such, his lay assertions regarding a diagnosis and causation of his hypertension are of no probative value. Further, even if his opinion regarding the etiology of a current diagnosis of hypertension was afforded some probative value, it is far outweighed by the opinions provided by the VA examiners who have greater training and expertise than the Veteran in diagnosing and assessing hypertension. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). To determine the cause of such a condition requires medical training and expertise that the Veteran does not possess. 38 C.F.R. § 3.159 (a)(1), (2) (2018). Accordingly, there is no competent evidence of a link between the Veteran's hypertension and his active service. Instead, the Board affords greater probative value to the April 2021 and November 2021 VA examiners' reports which determined that there was no nexus between the Veteran's hypertension and his military service, including herbicide exposure. The April 2021 VA examiner noted that a 35-year gap existed between the Veteran's separation from active duty service and his diagnosis of hypertension. The VA examiner further noted that the Veteran smoked a pack of cigarettes per day for 45 years. The November 2021 VA examiner considered current medical literature suggesting a sufficient association between herbicide exposure and hypertension in Vietnam veterans; however, the VA examiner explained that the Veteran's military occupational specialty, which was a chef/cook, would not have exposed the Veteran to herbicides to the level discussed in the medical literature. Accordingly, even after consideration of the medical literature, the November 2021 VA examiner determined a direct nexus did not exist between the Veteran's herbicide exposure and his hypertension. Therefore, the Board finds that the preponderance of the evidence is against a direct nexus between the Veteran's active-duty service, to include exposure to herbicides, and his hypertension. Next, the Board also finds that entitlement to service connection for hypertension is not warranted on a secondary basis either. The Board again acknowledges the Veteran's arguments in favor of secondary service connection but affords greater probative value to the VA examiners who have greater training and expertise than the Veteran in diagnosing and assessing hypertension, to include on a secondary basis. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board emphasizes that the Veteran's hypertension was diagnosed in 2005 and preceded the Veteran's diagnoses of erectile dysfunction in 2009 and diabetes mellitus, type 2, in 2010. The Board agrees with the June 2018, May 2021, and November 2021VA examiners who found against secondary service connection on these bases. The Board also affords great probative value to the November 2021 VA examiner's report which found against secondary causation and secondary aggravation. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim for entitlement to service connection for hypertension based on presumptive, direct, or secondary bases. The claim is denied. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Palombi, 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.