Citation Nr: 21009208 Decision Date: 02/19/21 Archive Date: 02/19/21 DOCKET NO. 15-27 781 DATE: February 19, 2021 ORDER Service connection for hypertension as secondary to service-connected disabilities is granted. Service connection for chronic kidney disease as secondary to service-connected disabilities is granted. Service connection for erectile dysfunction as secondary to service-connected disabilities is granted. FINDINGS OF FACT 1. Resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that the Veteran's hypertension is caused or aggravated by his service-connected disabilities. 2. Resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that the Veteran's chronic kidney disease is caused or aggravated by his service-connected disabilities. 3. Resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that the Veteran's erectile dysfunction is caused or aggravated by his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension as secondary to service-connected disabilities, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to service connection for chronic kidney disease as secondary to service-connected disabilities, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for entitlement to service connection for erectile dysfunction as secondary to service-connected disabilities, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1980 to February 1988. This matter comes before the Board of Veterans’ Appeals (Board), on appeal from a May 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The May 2013 rating decision denied the Veteran’s claims for service connection for hypertension, kidney disease, diabetes mellitus, and erectile dysfunction, as well as his request to reopen a claim for service connection for sleep apnea. The Veteran testified before the Board at a January 2017 hearing before a Veterans Law Judge (VLJ) who is no longer a member of the Board; a transcript of such hearing is of record. Because the Veteran is entitled to an opportunity for a hearing before all Board members who will ultimately decide his appeal, a January 2020 letter was sent to the Veteran notifying him of the option to request an additional Board hearing with a Veterans Law Judge who would decide his appeal, and that failure to respond within 30 days would waive the option of the additional hearing. See Arneson v. Shinseki, 24 Vet. App. 379, 388-89 (2011). Because the Veteran has not responded to the January 2020 letter, no additional hearing is required. The Board previously considered this appeal in November 2018 and remanded this issue for further development. Subsequently, in an August 2020 rating decision, the RO granted service connection for sleep apnea and diabetes mellitus as secondary to sarcoidosis. As the benefit sought was granted in full, these issues are no longer on appeal. See Grantham v. Brown, 114 F.3d. 1156 (Fed. Cir. 1997). The case returned to the Board for further appellate review. The Board notes that the Veteran filed an original claim for entitlement to service connection, in its pertinent part, for hypertension, chronic kidney disease and erectile disfunction as secondary to sarcoidosis; however, the Board has expanded the scope of the Veteran's claim to include as secondary to service connected disabilities. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). This afford the Veteran the broadest and most sympathetic review. Service Connection Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent 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 disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted on a secondary basis for a disability that is proximately due to or the result of an established service-connected disorder. See 38 C.F.R. § 3.310(a). A claim for secondary service connection requires competent medical evidence linking the asserted secondary disorder to a service-connected disability. See Velez v. West, 11 Vet. App. 148, 158 (1998); Wallin v. West, 11 Vet. App. 509, 512 (1998). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated on a secondary basis for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board will assess both medical and lay evidence. The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a competent source. Second, the Board must then determine if the evidence is credible, or worthy of belief. See Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Third, the Board must weigh the probative value of the proffered evidence in light of the entirety of the record. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises, and may also include statements from authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). 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. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). A layperson is not generally capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159 (a)(2); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.102, 4.3. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Service connection for hypertension as secondary to service-connected disabilities 2. Service connection for chronic kidney disease as secondary to service-connected disabilities 3. Service connection for erectile dysfunction as secondary to service-connected disabilities The Veteran contends that his current hypertension, chronic kidney disease and erectile dysfunction are related to his service-connected sarcoidosis, to include medication taken for such disability, as well as due to service-connected disabilities, to include sleep apnea and Diabetes Mellitus. The Veteran's service treatment records do not show any treatments, complaints, or diagnosis for hypertension, chronic kidney disease or erectile dysfunction. Accordingly, since the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board's adjudication will consider only entitlement to secondary service connection. The question for the Board is therefore whether the Veteran's hypertension, chronic kidney disease and erectile dysfunction were caused or aggravated by his service-connected disabilities. A May 2010 examination report confirmed a current diagnosis of hypertension. The VA examiner opined that the Veteran’s hypertension was less likely as not caused by or a result of treatment for his sarcoidosis. However, the VA examiner further indicated that the Veteran’s hypertension is most likely related to his sleep apnea, as pulmonary hypertension is a common complication of sleep apnea. The Veteran provided a private independent medical opinion dated August 2010, in which Dr. C.N.B. indicates a relationship between the Veteran’s current hypertension to medication taken for his service-connected sarcoidosis. However, no rationale for such opinion was provided. See Nieves-Rodriguez v. Peake, 22Vet. App.295, 301 (2008). In an August 2020 medical opinion addendum, the VA examiner opined that it is less likely than not that the Veteran’s hypertension was caused by service, by his service-connected sarcoidosis or the medication used to treat it. The rationale provided is that cause-effect relationship between sarcoidosis and essential hypertension has not been established by preponderance of the medical literature. “Based on review of all available documentation veteran has essential hypertension, obstructive sleep apnea, diabetic nephropathy and has a history of hyperaldosteronism due to an adrenal adenoma. All of the above are well known causes of secondary hypertension. These can cause hypertension on their own or can aggravate existing hypertension. All of these conditions were diagnosed after the [V]eteran's stated diagnosis of hypertension. As discussed above neither sarcoidosis or any steroids used to treat it could precipitate hypertension and by extension aggravate it.” The Veteran’s sleep apnea and diabetes mellitus have been service connected during the pendency of the current appeal. In a February 2012 statement and during the January 2017 Board hearing, the Veteran indicated that his sleep apnea symptoms began in service. Accordingly, the Board finds that there is at least an approximate balance of positive and negative evidence regarding the merits of the issue material to the determination of the matter, and therefore, resolving all reasonable doubt in the Veteran's favor, service connection for hypertension is warranted in this case as secondary to the Veteran's service-connected sleep apnea. In connection with the kidney claim, the Veteran underwent a VA examination in May 2010. The VA examiner diagnosed the Veteran with hypertension and opined that the Veteran’s hypertension was less likely as not caused by or a result of treatment for his sarcoidosis. The VA examiner also found that the Veteran did not have a currently diagnosed kidney disease, and as such provided no opinion on the etiology of the Veteran’s claimed kidney disease. However, in a February 2012 VA opinion, the providing VA physician confirmed that the Veteran had stage II chronic kidney disease, and that it was due to hypertension, not sarcoidosis. The VA examiner explained that the Veteran “has a history of hypertension that was poorly controlled until the laparoscopic removal of a hyperfunctioning aldosterone producing left adrenal adenoma in early 2011. Chronic hypertension is a well-defined cause of CKD. Veteran also has diabetes mellitus which may contribute to CKD. Renal involvement from sarcoidosis has not as yet been demonstrated in this case.” An August 2020 addendum medical opinion, the VA examiner noted that the Veteran has Stage II chronic kidney disease “most likely due to his diabetes although his hypertension may also be a contributing factor.” As set forth above, service connection for the Veteran's hypertension is awarded herein. Given the above, entitlement to service connection for chronic kidney disease as secondary to service-connected disabilities, to include hypertension and diabetes mellitus, is therefore warranted. In connection with the erectile dysfunction claim, the Veteran underwent a VA examination in May 2010. The VA examiner noted the Veteran has a diagnosis of erectile dysfunction and opined that it is at least as likely as not related to the diabetes mellitus and medications for hypertension. The VA examiner’s rationale is that the Veteran “is a known diabetic for several years and has been on multiple [blood pressure] medications including beta-blockers which are very well-recognized cause of ED.” A February 2012 Central Nervous System and Neuromuscular Diseases VA examination report noted that the Veteran has erectile dysfunction due to hypertension. As set forth above, service connection for the Veteran's hypertension is awarded herein. Given the above, entitlement to service connection for erectile dysfunction as secondary to service-connected disabilities, to include hypertension and diabetes mellitus, is therefore warranted. There can be no doubt that further medical inquiry could be undertaken with a view towards development of the claims. Specifically, another medical opinion could be obtained that specifically accounted for and discussed all the evidence and all service-connected disabilities. However, under the "benefit-of-the- doubt" rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993). In this case, the Board finds that there is "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter." As such, this is a situation where the benefit of the doubt rule applies. In resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for hypertension, chronic kidney disease and erectile dysfunction as secondary to service-connected disabilities, is warranted. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Romero-Sanchez, 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.