Citation Nr: 21006730 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 06-15 032 DATE: February 5, 2021 ORDER Entitlement to service connection for hypertension, including as secondary to the service-connected disabilities including posttraumatic stress disorder (PTSD) and depression disorder, coronary artery disease, or diabetes mellitus type II is denied. FINDING OF FACT Hypertension was not shown in service, did not manifest to a compensable degree within one year of service separation, is not otherwise related to service and is not caused or aggravated by a service-connected disability. CONCLUSION OF LAW Hypertension was not incurred in service, nor may it be presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131, 5103, 5103(A) (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1964 to October 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2005 rating decision issued by a VA Regional Office (RO), which denied the claim for service connection for hypertension, initially claimed as secondary to service-connected diabetes mellitus, type II. This matter was remanded by the Board in January 2010, February 2012, November 2017 and August 2019 for further development. Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). 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.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain diseases, to include hypertension may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2020). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden for certain chronic disabilities such as hypertension is through a demonstration of continuity of symptomatology. In relevant part, 38 U.S.C. § 1154(a) requires that the VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (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 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Under 38 C.F.R. § 3.310(a), service connection may be granted for disability that is proximately due to or the result of a service- connected disease or injury. Such permits a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation to a nonservice- connected disability by a service- connected disability. Id. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310(b). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Factual Background and Analysis The Veteran seeks entitlement to service connection for hypertension including as secondary to service-connected disabilities including PTSD and depression disorder, coronary artery disease, or diabetes mellitus type II. Notably, for hypertension, regulations provide that hypertension for VA purposes means that the diastolic blood pressure is predominantly 90 or more or systolic blood pressure is predominantly 160 or more. Hypertension must be confirmed by readings taken two or more times on three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). The Veteran’s service treatment records are negative for treatments or complaints of hypertension or high blood pressure. Notably, the Veteran’s April 1967 separation and immediate reenlistment examination demonstrated a blood pressure reading of 134/84. The Veteran underwent a VA examination in May 2005. The examiner noted that the Veteran had longstanding hypertension which was diagnosed in about 1995 which predated his diabetes diagnosis. As a result, the Veteran’s hypertension was not secondary to his diabetes. The Veteran underwent a VA examination in January 2009. The examiner noted a history of hypertension for approximately 10 years. The Veteran underwent a VA diabetes examination in January 2010. The examiner noted that the Veteran had hypertension since at least 1995. The Veteran underwent a VA examination in June 2010. The examiner noted that there was clear medical evidence that the Veteran’s blood pressures were of concern in 1997 which was prior to his diagnosis of diabetes. Therefore, the Veteran’s hypertension was not due to his diabetes and there was no evidence that the diabetes exacerbated his hypertension. A VA examiner provided a records review in February 2016. The examiner opined that it was less likely than not that the Veteran’s hypertension was caused or aggravated by his service-connected coronary artery disease. The examiner noted that the Veteran was diagnosed with coronary artery disease in 1997 upon a hospital admission. At the time of the admission, his blood pressure was already severely elevated and remained abnormally high even after treatment. It was not clear from the VA treatment records that the Veteran’s coronary artery disease preceded his high blood pressure or that his high blood pressure worsened significantly after the time of his coronary artery disease diagnosis. Additionally, while hypertension was well known to be a risk factor and aggravating factor for coronary artery disease, a review of the medical literature did not show the reverse to be true. As a result, the examiner opined that it was less likely than not that the Veteran’s coronary artery disease had caused or exacerbated his hypertension. A VA addendum medical opinion was obtained in May 2018. The examiner opined that it was less likely as not that the Veteran’s hypertension was caused or aggravated by his service-connected PTSD and depression disorder, or the Veteran’s active duty exposure to herbicide agents. The VA examiner opined that the weight of the medical literature did not support a claim that PTSD and depression or active duty exposure to herbicide agents cause or aggravate hypertension. In April 2019, the Veteran’s representative submitted scholarly articles as treatise evidence supporting the Veteran’s claim there is a link between hypertension to other service-connected disabilities. Per the August 2019 Board remand, a VA examiner provided a records review in December 2019. The examiner opined that it was less likely than not that the Veteran’s hypertension was caused or aggravated by his service-connected PTSD and depression disorder, his service-connected coronary artery disease or his service-connected diabetes. The examiner noted that hypertension was a contributing cause of coronary artery disease but that coronary artery disease was not a cause of hypertension. Diabetes could also accompany hypertension but could not cause hypertension. The examiner noted that while the articles submitted by the Veteran’s representative in April 2019 discussed links between PTSD and hypertension and that the reduction of hypertension did not always reduce the risk of coronary artery disease, the articles did not provide causation for hypertension as association did not equal causation. When considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that service connection for hypertension is not warranted. As there is a current hypertension disability, the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D’Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). As noted above, service connection may be granted on a presumptive basis for certain chronic diseases, including hypertension, if such disabilities are shown to be manifest to a degree of 10 percent or more within one year following the Veteran’s separation from active military service. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this instance however, service connection for hypertension on a presumptive basis is not warranted as the record does not show evidence of hypertension within one year of the Veteran’s separation from active duty. To the extent that the Veteran is asserting that he experienced continuing symptoms of hypertension thereafter, the Board acknowledges that a layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board’s categorical statement that “a valid medical opinion” was required to establish nexus, and that a layperson was “not competent” to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, as the Veteran was not diagnosed with hypertension until many years after service and there was a significant period between his service and his post-service complaints where the medical record was silent for complaints of hypertension, the Board concludes that the weight of the evidence is against a finding of any continuity of symptomatology. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Regarding service connection on a direct basis, the Board again notes that the Veteran’s service treatment records are negative for complaints or treatments of hypertension or high blood pressure. Furthermore, the only medical opinion addressing the etiology of the hypertension disability weigh against the claim. As noted above, the May 2018 VA examiner indicated that it was less likely than not that the Veteran’s hypertension was incurred in or caused by the claimed in-service event, injury or illness to include as due to conceded herbicide exposure. Further, there is no competent evidence or opinion even suggesting that there exists a medical nexus between current hypertension and the Veteran’s service and neither the Veteran nor his representative have presented or identified any such existing medical evidence or opinion. The Board finds that the competent evidence of record, while showing the currently diagnosed hypertension disability, does not demonstrate that the Veteran’s hypertension is related to the Veteran’s service. Finally, the Veteran is also claiming service connection for a hypertension disability as secondary to his service-connected PTSD and depression disorder, coronary artery disease, or diabetes mellitus type II. As noted above, service connection may be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310 (2020). However, the Board finds that the weight of the evidence is against a finding that a current hypertension disability was related to service or caused or aggravated by a service-connected disability. As noted above, the Veteran has submitted treatise evidence which support his claim, that there is a link between hypertension to other service-connected disabilities. Notably, the submitted articles support the idea that treatment for PTSD reduced the PTSD associated hypertension risk which as a result demonstrated a link between heart disease and PTSD. However, multiple VA examiners including most recently a VA examiner in December 2019 specifically opined that it was less likely than not that the Veteran’s hypertension disability was caused or aggravated by his service-connected PTSD and depression, diabetes or coronary artery disease disabilities. The Board finds the most recent VA examination report in December 2019 to be highly probative, as it was based on a thorough review of the Veteran’s medical records and cited to relevant medical principles. The opinion is also consistent with the other evidence of record and is supported by a detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion.). Notably, per the August 2019 remand instructions, the December 2019 VA examiner specifically addressed the submitted treatise articles as he noted that while the articles discussed links between PTSD and hypertension and that the reduction of hypertension did not always reduce the risk of coronary artery disease, the articles did not provide causation for hypertension as association did not equal causation. In this regard, the Board may favor the opinion of one competent medical professional over that of another so long as an adequate statement of reasons and bases is provided. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). An evaluation of the probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the examiner’s knowledge and skill in analyzing the data, and the medical conclusion reached. The credibility and weight to be attached to such opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one physician’s opinion over another depending on factors such as reasoning employed by the physicians and whether or not and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert’s qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). As a result, the Board finds that the December 2019 opinion of the VA examiner to be the most probative. Consequently, entitlement to service connection for a hypertension disability is not warranted on a direct or secondary basis. In sum, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection. The benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b). The Board notes the Veteran’s contentions regarding the etiology of his claimed hypertension. To the extent that the Veteran himself contends that a medical relationship exists between his claimed current hypertension disability and service, the Board acknowledges that the Veteran is competent to testify as to his observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board’s categorical statement that “a valid medical opinion” was required to establish nexus, and that a layperson was “not competent” to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). In the instant case, however, the Board finds that hypertension is not a disability subject to lay diagnosis as this diagnosis requires medical training. More significantly, the Veteran and his representative do not have the medical expertise to provide an opinion regarding the claimed hypertension etiology. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Additionally, the VA examiner provided detailed rationale in support of his opinions and cited to the relevant evidence. For this reason, the VA examiner’s opinions are the most probative evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that a factor for assessing the probative value of a medical opinion includes the thoroughness and detail of the opinion). In sum, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran’s claims of entitlement to service connection for hypertension. The benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b). MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James A. DeFrank, 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.