Citation Nr: 21008670 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 18-51 280 DATE: February 17, 2021 ORDER Service connection for hypertension is denied. FINDING OF FACT The preponderance of competent evidence tends to show that it is less likely than not that the Veteran’s current hypertension disability was incurred during or as a result of active service, to include as due to herbicide exposure, or proximately due or aggravated by the Veteran’s service-connected disabilities. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1965 to September 1967. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a September 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This appeal has been before the Board previously. In December 2019, the Board remanded the issue on appeal to obtain a VA examination and opinion related to the Veteran’s exposure to Agent Orange and to address the National Academy of Science (NAS) 2018 publication, which suggests an association between them. Additionally, the VA opinion must address whether the Veteran’s hypertension is proximately due or aggravated by his service-connected disabilities, such as PTSD and/or diabetes mellitus. After this remand, VA obtained a medical examination in September 2020. However, in November 2020 the Board again remanded the issue on appeal because the examiner did not cite to specific evidence of record or the medical history of the Veteran to justify the opinion. After this remand, VA obtained a medical opinion and addendum that discussed the Veteran’s medical history, to include exposure to Agent Orange and aggravation by his service-connected disabilities. This matter has now returned to the Board for appellate consideration and the Board finds substantial compliance with the prior remand directives. Service Connection Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Where a disease is first diagnosed after discharge, service connection will be granted when all the evidence, including that pertinent to service, establishes it was incurred in active service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.30(d). Service connection requires evidence showing: (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 condition incurred or aggravated by service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Regulations provide that service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439, 449 (1995); 38 C.F.R. § 3.310(b). In order to establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection for hypertension. The Veteran contends that his hypertension disability is due to exposure to Agent Orange in Vietnam. See 10/24/2019 Hearing Transcript at page 11. In the alternative, the Veteran contends that his service-connected diabetes mellitus type II has aggravated his hypertension beyond its natural progression. Id. at page 12. At the outset, the Board notes that the Veteran has a current diagnosis of hypertension. See 11/8/2012 VA Examination at page 11; see also 5/22/2018 C&P Examination; 3/24/2020 CAPRI at page 675; 9/17/2020 C&P Examination. The Board will now analyze whether service connection is warranted by analyzing the second and third elements of service connection. As to the second element of service connection, the Veteran’s service records confirm service in Vietnam during the Vietnam Era; therefore, exposure to herbicide agents is presumed. See 9/21/2020 SSOC at page 13. Additionally, the record shows that the Veteran is service connected for diabetes mellitus type II. Thus, the second element of service connection has been met on both direct and secondary bases. The question before the Board therefore becomes whether there is a so-called “nexus” between the Veteran’s current hypertension disability and service or to a service-connected disability. The Veteran underwent a VA examination in November 2012. At the conclusion of the examination, the examiner provided a negative nexus opinion – stating that the Veteran’s hypertension was diagnosed nearly a decade prior to the service-connected diabetes. See 11/8/2012 VA Examination. However, the examiner’s opinion is speculative as it described the probability that the Veteran’s service-connected diabetes “can” aggravate his hypertension. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (holding that medical opinions are speculative and of little probative value when a physician makes equivocal findings such as “the veteran’s death may or may not have been averted”). Thus, the Board affords this opinion little weight. The Veteran underwent another VA examination in May 2018. The examiner diagnosed the Veteran with hypertension and opined that the Veteran’s hypertension was less likely than not aggravated by the service-connected diabetes. See 5/22/2018 C&P Examination. However, the examiner did not consider direct service connection, to include as due to herbicide exposure. Additionally, the examiner did not consider 2018 NAS report submitted by the Veteran, which found “sufficient evidence” of an association between hypertension and exposure to herbicide agents, such as Agent Orange. See 9/16/2019 Correspondence. As such, the Board affords this opinion little weight. In accordance with the December 2019 Board remand, the Agency of Original Jurisdiction (AOJ) obtained a VA medical opinion in September 2020. At the conclusion of the examination, the examiner opined that the Veteran’s hypertension was less likely than not related to service. As rationale, the examiner stated that other factors unrelated to exposure to Agent Orange, such as aging and obesity, increase the risk of developing hypertension. Additionally, with regard to the 2018 NAS report, the examiner stated that there is no current objective medical evidence that shows a direct cause and effect relationship between exposure to Agent Orange and hypertension. Further, with regard to secondary service connection, the examiner stated that the physiological determinants of blood pressure are the vascular volume and peripheral vascular resistance, and that there is no documentation that posttraumatic stress disorder (PTSD) has any permanent effect on these two determinants. In addition, the examiner stated that there is no medical evidence of poor diabetes control with the development of significant renal dysfunction to cause hypertension. See 9/17/2020 C&P Examination. However, the examiner seemed to point at factors, such as aging and obesity as possible causes for the Veteran’s hypertension but did not cite to specific medical evidence of record or medical history of this Veteran to justify it. Additionally, the examiner did not directly discuss exposure to herbicide agents as a factor for hypertension. Further, the rationale for the secondary service connection opinion was general (again it did not discuss this Veteran’s medical history) and did not cite to specific medical evidence of record to justify it. As such, the Board affords this opinion little weight. After the November 2020 Board remand, in November 2020 an addendum opinion was obtained. The Board finds the November 2020 VA opinion to be highly persuasive and worthy of much weight regarding the issue of whether the Veteran’s current hypertension disability is related to service for the reasons explained next. The November 2020 VA physician opined that the Veteran’s current hypertension disability was less likely than not aggravated by the Veteran’s service-connected diabetes, PTSD, tinnitus, and hearing loss. Specifically, the physician indicated that 90 percent of individuals with hypertension have no identified cause. Additionally, there is no medical documentation that psychological or hearing disorders cause or aggravate hypertension. Further, the physician stated that hypertension secondary to diabetes occur with long standing and poorly controlled blood glucose levels. The examiner stated that records from November 10, 2010, to October 1, 2020, showed that the Veteran’s A1c levels (21 in readings total) were an average of 6.1, which reduces diabetic complications. The examiner stated that the recommendation for diabetes control is to maintain an A1c of 7.0. In addition, the physician stated that the record showed no diabetic retinopathy (one of the earliest manifestations of diabetic complication), which would be expected prior to kidney damage from diabetes. Regarding the 2018 NAS report, the clinician stated that epidemiologic research results suggest an association between exposure to herbicide agents and hypertension. The examiner further stated that hypertension is a common disease in the general population. Additionally, it was noted that the Veteran has multiple risk factors unrelated to herbicide exposure that increase the risk for development and aggravation of hypertension, such as age (the Veteran was 65 years when diagnosed), obesity (the Veteran was obese at the time of diagnosis), and reduced nephron numbers due to left nephrectomy. Based on this, the Board finds that the rationale is logically supported, based on familiarity with the Veteran’s relevant medical history and deserves great weight.   Additionally, the Board places great probative weight on the November 2020 VA opinion in this case, as it is consistent with the evidence of record and based upon medical knowledge and skill, as well as a review and analysis of the Veteran’s specific disability picture, to include consideration of relevant facts such as the post-service medical record. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (stating that a medical report must be read as a whole in the context of the claim and, even an opinion lacking in detail may be provided some probative value based upon the amount of information and analysis contained therein). The Board also acknowledges the lay statements from the Veteran. Such statements assert that the Veteran’s hypertension is due to exposure to Agent Orange in Vietnam. Additionally, the Veteran contends that his service-connected diabetes mellitus type II has aggravated his hypertension beyond its natural progression. See 10/24/2019 Hearing Transcript at pages 11 and 12. However, the Veteran is not competent to attribute his hypertension to herbicide exposure or aggravation by a service-connected disability as the record does not reflect that he has medical training and/or experience. Therefore, the Veteran’s opinion on the etiology of the current hypertension disorder is not competent and it lacks weight. The competent medical evidence, such as the September 2020 medical opinion, heavily outweighs the Veteran’s opinion and tends to show that the Veteran’s hypertension is not due to his exposure to herbicide and is not proximately due to or aggravated by his service-connected disabilities. As discussed above, the Board finds the September 2020 opinion to be probative and deserving weight as there is a supporting rationale why, to include reference to relevant facts in the record. (Continued on the next page)   In sum, service connection for hypertension is not warranted on any theory of entitlement. As the preponderance of the evidence is against the claim, reasonable doubt does not arise, and the claim is denied. 38 U.S.C. § 5107(b). Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Fuentes, 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.