Citation Nr: 21009823 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 08-33 979A DATE: February 23, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected allergic rhinitis or posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The Veteran’s hypertension is not directly related to service, or secondary to service-connected allergic rhinitis or posttraumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension, in include as secondary to service-connected allergic rhinitis or service-connected PTSD have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310, 4.14. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from June 1972 to June 1975 and from August 2004 to January 2006. Between the two periods of active duty, the Veteran had service in the Army Reserve. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a May 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2017, the Board denied service connection for hypertension. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (the Court). In an April 2019 memorandum decision, the Court vacated the Board’s July 2017 decision and remanded the matter for further development and adjudication. The case was then remanded by the Board in February 2020 and September 2020 for further development. That development having been completed, the case is once again before the Board. Under 38 U.S.C. § 7104 (2018), Board decisions must be based on the entire record, with consideration of all the evidence. The law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, supra. 1. Entitlement to service connection for hypertension, in include as secondary to service-connected allergic rhinitis or posttraumatic stress disorder (PTSD) The Veteran contends the presumption of soundness should attach prior to his second tour of duty in August 2004. Alternatively, the Veteran believes service connection for hypertension is warranted on a secondary basis due to service-connected allergic rhinitis, and/or due to service-connected PTSD. See February 2020 Appellant’s Brief. Presumption of Soundness Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. See 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Therefore, where there is evidence showing that a disorder manifested or was incurred in service, and this disorder is not noted on the Veteran’s entrance examination report, this presumption of soundness operates to shield the Veteran from any finding that the unnoted disease or injury preexisted service. See Gilbert v. Shinseki, 26 Vet. App. 48 (2012); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991); 38 C.F.R. § 3.304(b). Such presumption is only rebutted where the evidence clearly and unmistakably shows that the Veteran’s disability (1) existed before acceptance and enrollment into service and (2) was not aggravated by service. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby, 1 Vet. App. at 227; VAOPGCPREC 3-2003 (July 16, 2003). The two parts of this rebuttal standard are referred to as the “preexistence prong” and the “aggravation prong.” Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). To satisfy this second-prong requirement for rebutting the presumption of soundness, the government must show by clear and unmistakable evidence either that there was no increase in disability during service or that any increase in disability was “due to the natural progression” of the condition. Joyce v. Nicholson, 443 F.3d 845, 847 (Fed. Cir. 2006). The April 2020 VA examiner opined that the claimed condition, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury or illness. Regarding the preexistence prong, the examiner noted a diagnosis of hypertension in October 2002 when the Veteran was started on medication. The examiner noted the Veteran’s blood pressure to be well-controlled on a two-drug regimen in October 2003 and May 2004. This evidence clearly and unmistakably shows that the Veteran’s hypertension existed before acceptance and enrollment into service in August 2004. Regarding the aggravation prong, the examiner noted that the Veteran’s hypertension was well-controlled with one medication while on active duty service. Several blood pressure readings were listed, which showed no upward trend in readings from November 2004 to December 2005. Treatment records listed the Veteran’s condition as “controlled” in February 2006, April 2007, August 2012, July 2012, and December 2019. The Veteran was on the exact same dose of lisinopril/HCTZ in May 2004, before service, and February 2006, after service. No worsening, or exacerbation of the Veteran’s condition was noted. The medication was only changed from lisinopril due to the Veteran developing a dry cough as a side effect. The Veteran was noted to be on losartan and metoprolol in December 2019. The examiner indicated that any progression of this disease is due to the natural progression of the condition, stating “Blood pressure readings tend to increase due to stiffening of the arterial walls as one ages.” This medical opinion is highly probative because it was based upon a thorough review of the claims file, medical literature, and a well-reasoned rationale. The Board finds this opinion to be factually accurate, fully articulated, and containing sound reasoning. A medical opinion that is factually accurate, fully articulated, and based on sound reasoning carries significant weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board finds that service connection is not warranted for hypertension on a direct basis. However, pursuant to the September 2020 Board remand, an addendum medical opinion was obtained to determine whether the Veteran’s hypertension is related to his service-connected rhinitis, by taking allergy medication which the Veteran alleges elevates his blood pressure, or his service-connected PTSD on a secondary basis. Secondary service connection Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). As noted above, the first element of service connection, a current disability is met. Next, he is service connected for allergic rhinitis and also PTSD. The second element of service connection on a secondary basis is also met. However, the third element, a medical nexus, must be resolved. As directed by the September 2020 Board remand, the VA examiner was asked to opine whether it is at least as likely as not (50 percent or greater probability), that the Veteran’s hypertension is related to, or aggravated by his service-connected allergic rhinitis, and to specifically address whether his blood pressure elevation is related to allergy medication. The examiner opined that the condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service connected condition. In support of this opinion, the examiner cited medical literature that lists several risk factors for hypertension, including advancing age, obesity, family history, and diet, to name a few. It was noted that allergic rhinitis is not listed as a risk factor for the development of essential hypertension. The examiner addressed the VA treatment records that indicates the Veteran’s blood pressure is increasing due to consuming allergy therapy for his intermittent sinus complaints. The examiner explained, “Decongestants, such as phenylephrine and pseudoephedrine that are used to treat allergy symptoms can cause temporary elevated blood pressure readings and resolve once medication is stopped. Therefore, the veteran's primary hypertension is not caused by allergic rhinitus(sp) or allergy medication that the veteran took in 2007.” In regards to whether it is at least as likely as not that the Veteran’s hypertension is related to, or aggravated by his service-connected allergic rhinitis, the examiner reiterated that the Veteran’s blood pressure has been well-controlled, and had an elevated blood pressure reading due to taking an over-the-counter allergy medication in 2007. The examiner explained that those types of medications that are used to treat allergy symptoms “can cause temporary elevated blood pressure readings and resolve once medication is stopped. The veteran's blood pressure normalized once off the OTC medication as noted during his followup visits.” This shows that the condition was not worsened, but rather had an elevated reading that resolved once the medication was stopped. The examiner has also considered whether service connection can be granted secondary to PTSD. The examiner opined that the condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran’s service-connected condition. The examiner addressed medical literature that discussed PTSD and cardiovascular disease specific to heart ischemia and heart failure, not hypertension. The examiner mentioned other medical studies that indicate a possible relationship between untreated PTSD and hypertension, or increased prevalence of hypertension in untreated PTSD. It must be noted that although an association might be shown, there is no evidence of a direct causal relationship. The examiner opined that the Veteran’s known risk factors, such as age and weight gain, outweighs the singularity of PTSD. In regards to whether it is at least as likely as not that the Veteran’s hypertension is related to, or aggravated by his service-connected PTSD. The examiner opined the Veteran’s hypertension is less likely than not aggravated beyond its natural progression by PTSD. The examiner stated that the Veteran’s hypertension was generally well-controlled before and after the diagnosis of PTSD. There is no objective medical evidence of aggravation of hypertension by PTSD or its treatment. This medical opinion is highly probative because it was based upon a thorough review of the claims file, medical literature, and a well-reasoned rationale. The Board finds this opinion to be factually accurate, fully articulated, and containing sound reasoning. A medical opinion that is factually accurate, fully articulated, and based on sound reasoning carries significant weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board finds that service connection is not warranted for hypertension on a direct basis, or secondary to service-connected allergic rhinitis or PTSD. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Nelson, 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.