Citation Nr: 21010052 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 10-37 650 DATE: February 23, 2021 ORDER 1. Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD) is denied. REMANDED 2. Entitlement to service connection for a low back disability is remanded. FINDING OF FACT Hypertension was not manifested in, or within a year following the Veteran’s separation from, service, and his current hypertension is not shown to be etiologically related to his active duty service, or to have been caused or aggravated by his service-connected PTSD. CONCLUSION OF LAW Service connection for hypertension, to include as secondary to service-connected PTSD is not warranted. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from October 2001 to January 2002, and from February 2003 to May 2004, and had additional National Guard service. These matters are before the Board on appeal from December 2009 (that denied service connection for hypertension) and March 2010 (that denied service connection for a low back disability) rating decisions. In September 2012, a Travel Board hearing was held before the undersigned; a transcript is in the record. In December 2013 and May 2018, the case was remanded for further development. [In October 2020 these matters were remanded for further development, along with the claim of service connection for a neck disability. A November 2020 rating decision granted service connection for a neck disability, resolving that appeal. Accordingly, that matter is no longer before the Board.] 1. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD is denied. Service connection may be established for disability due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish service connection for a claimed disability, there must be evidence of: (i) a present claimed disability; (ii) incurrence or aggravation of a disease or injury in service; (iii) and a causal relationship between the present disability and the disease or injury in service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303 (a). Certain chronic diseases (to include hypertension) may be presumed to be service connected if manifested to a compensable degree within a specified period of time following separation from service (one year for hypertension). 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. For chronic diseases listed in 38 C.F.R. § 3.309 (a), nexus to service may be established by showing continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that it was incurred in service. 38 C.F.R. § 3.303 (d); See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). 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 layperson. 38 C.F.R. § 3.159 (a)(2). Competent medical evidence is necessary where the determinative question requires medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). An April 1995 treatment record notes the Veteran’s blood pressure was 130/80. On January 1999 medical examination, the Veteran’s blood pressure was 132/84. In a February 2003 report of medical history, the Veteran denied history of high or low blood pressure. In a February 2003 health questionnaire for dental treatment the Veteran did not endorse having an issue with high blood pressure. On February 2003 examination for active duty service, the Veteran’s blood pressure was 120/90. On April 2004 examination, his blood pressure was 138/87. In an April 2004 medical history report, he denied having an issue with high or low blood pressure. A January 2007 primary care record notes the Veteran’s blood pressure was 140/90. A January 2009 treatment record notes a history of hypertension which was not well controlled, and that he was on medication for hypertension. In November 2012 correspondence, the Veteran’s private physician stated they did not believe the Veteran’s hypertension was related to anxiety or PTSD. On November 2015 hypertension DBQ, the diagnoses was hypertension, and essential hypertension (diagnosed in 2006). Veteran reported being found to have high blood pressure about 2005 to 2006. The clinician opined that it was less likely than not that the Veteran’s hypertension is related to service. It was noted the Veteran has a family history of hypertension (for both parents), and did not have hypertension in service or at release from active duty. The provider opined that it was less likely than not that the Veteran’s hypertension was caused or aggravated by his PTSD, and noted that PTSD is not an etiological factor for hypertension and that the Veteran’s blood pressure was controlled with medication, (and that momentary elevations of blood pressure were situational and returned to base level). On December 2018 hypertension DBQ, the diagnoses were hypertension, and isolated systolic hypertension. The clinician opined that it was less likely than not that the Veteran’s hypertension was either caused or aggravated by his service-connected PTSD. The clinician noted that any aggravation of the Veteran’s hypertension is more likely due to non-compliance with (not adhering to his prescribed medications) and less likely due to his service-connected PTSD. In an October 2020 medical advisory opinion, the consulting clinician opined that it was less likely than not that the Veteran’s hypertension was caused or aggravated to his service-connected PTSD. The clinician noted observational studies suggesting PTSD may contribute to hypertension, but noted such studies as merely observational and not considered main-stream medical knowledge. The clinician noted generally accepted medical literature does not include PTSD as a list of secondary/contributory causes of hypertension. The Veteran contends that his hypertension is secondary to his service-connected PTSD. As noted above, STRs are silent for any complaints, findings, treatment, or diagnosis of high blood pressure/hypertension. On April 2004 service separation examination, his blood pressure was 138/87; in a contemporaneous report of medical history, he denied having any history of high blood pressure. As hypertension was not manifested in service and was not clinically noted within a year following the Veteran’s discharge from active duty, service connection for hypertension on the basis that such disability became manifest in service and persisted, or on a presumptive basis (as a chronic disease under 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309(a)) is not warranted. It is not otherwise shown by the record that the Veteran’s hypertension is related directly to his active duty service. The November 2015, December 2018, and October 2020 examiners opined that it is less likely than not that the Veteran’s hypertension is related to his service, or that it was caused or aggravated by the service-connected PTSD. There is no competent evidence in the record to the contrary. The Veteran’s primary theory of entitlement is one of secondary service connection, i.e., that his hypertension was caused or aggravate by his PTSD. Whether one disability (such as the service-connected PTSD) caused or aggravated another disability (here, hypertension) is a medical question beyond the scope of common knowledge/lay observation. It requires medical expertise. See Jandreau v. Nicholson, 492 F. 3d, 1372, 1377. In November 2012, the Veteran’s own private provider opined that his hypertension is unrelated to his PTSD. Moreover, VA examiners and medical opinion providers have opined, in essence, that the Veteran’s hypertension has not been caused or aggravated by his PTSD. The Board finds the examinations and medical opinions are (cumulatively) entitled to substantial probative weight, as they reflect a thorough review of/accurate familiarity with the Veteran’s record/medical history, are based on physical adequate examinations, and include rationale that accurately cites to supporting factual data and medical principles. The explanations identified alternate risk factors for hypertension in the Veteran that included family (maternal and paternal) history of the disease. Regarding aggravation, it was explained that that temporary blood pressure elevations were situational (as blood pressures returned to normal), and therefore did not constitute a permanent increase in level of severity of the disability. It was also noted that they were due to alternate factors (such as noncompliance with prescribed medication. The Board finds particularly probative (and persuasive) the October 2020 consulting provider’s opinion (that addresses the specific theory of entitlement presented in this matter), i.e., that PTSD caused or aggravated the hypertension. Invoking medical principles, The provider explained that prevailing medical literature does not endorse PTSD as a cause of hypertension. The provider further explained that while observational studies have suggested that PTSD may contribute to hypertension, such studies (by being observational/not conducted in a controlled clinical setting) are not considered mainstream medical knowledge. The Veteran is a layperson; consequently, his own opinion is not competent evidence in this matter. Considering the foregoing, the Board finds that the preponderance of the evidence is against the claim of service connection for hypertension. Therefore, the appeal in the matter must be denied. REASONS FOR REMAND 2. Entitlement to service connection for a low back disability is remanded. The Board notes that this claim was previously remanded three times for additional development, and regrets the delay inherent with yet another remand. However, the Board nonetheless finds that additional development is necessary for the proper adjudication of this claim. Initially, the Board notes that a veteran is presumed 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 examination, acceptance, enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304. In an October 2020 medical opinion, the consulting provider opined that it was less likely than not that the Veteran’s low back disability is related to his service. The clinician notes a 1996 MVA listed in the Veteran’s record. See February 2003 Report of Medical History. Notably, a back disability due to such MVA was not noted on the Veteran’s active duty service entrance examination. The provider also pointed to the Veteran’s participation in sports prior to service. However, no back injuries associated with such participation are note din the record, and the Veteran is entitled to the presumption of soundness on entry in service with respect to a back disability. The clinician also opines that the back disability may be related to injuries after service which are not documented (or were treated, based on the record). The opinion appears based on speculation and not factual evidence in the record. What was not adequately addressed by the consulting provider are the Veteran’s lay statements attributing his back disability to the daily repetitive trauma in service of heavy lifting of pack and body armor and loading weaponry onto Humvees. Accordingly, development for an addendum (fully adequate) medical advisory opinion (that adequately addresses the Veteran’s lay statements) is necessary. The matter is REMANDED for the following: Arrange for the Veteran’s record to be forwarded to an appropriate clinician (other than the provider of the October 2020 opinion) for review and an addendum medical opinion regarding the etiology of his current low back disability. [If further examination of the Veteran is deemed necessary for an opinion sought, such should be arranged.] Upon review of the record (to specifically include the Veteran’s lay statements regarding repetitive lifting back trauma in service, and noting that the Veteran is presumed to have been sound (with respect to back disability) on entry on active duty, the consulting provider should respond to the following: (a.) Identify (by diagnosis) each low back disability found or shown by the record during the pendency of the instant claim. (b.) Identify the likely etiology for each low back disability diagnosed. Specifically, is it at least as likely as not (a 50% or better probability) that such disability began in (or is otherwise etiologically related to) the Veteran’s service, to include his reports of daily repetitive lifting trauma to the daily therein? (c.) If a diagnosed back disability is determined to be unrelated to service, identify the etiology for the disability considered to be more likely, and explain why that is so. All opinions must include rationale that cites to supporting factual data and medical principles. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Staskowski, 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.