Citation Nr: 21010135 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 14-21 083A DATE: February 24, 2021 ORDER Entitlement to service connection for hypertension is granted. REMANDED Entitlement to service connection for obstructive sleep apnea is remanded. FINDING OF FACT The Veteran’s hypertension first manifested to a compensable degree during his active duty service. CONCLUSION OF LAW Hypertension was incurred during active duty service. 38 U.S.C. §§ 1110, 1112, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from January 1967 to December 1968 and from September 1990 to July 1991. The Board has considered the Veteran’s claims and decided entitlement based on the evidence or record. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Service Connection Service connection may be established for a disability resulting from disease or injury which was clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Certain chronic diseases, such as hypertension, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from active service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. The provisions for establishing service connection through a demonstration of continuity of symptomatology is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (rejecting the argument that continuity of symptomatology in § 3.303(b) has any role other than to afford an alternative route to service connection for specific chronic diseases). In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to service connection for hypertension When a veteran has satisfied the requirements for presumptive service connection for a chronic disease, such as hypertension, that has been “shown in service” (or within the applicable post-service presumptive period), all later manifestations of the same chronic disease are presumed to be service connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.307. Thus, if a veteran can demonstrate a chronic disease that was “shown in service” (or within the applicable post-service presumptive period), the manifestations of the chronic disease present when the veteran seeks benefits establishes service connection for the chronic disease. No medical opinion is required in such a case to confirm that there is a “nexus” between the current disease and that “shown in service” (or within the applicable post-service presumptive period). Walker, 708 F.3d at 1335-36. The requirement that a chronic disease become manifest to a degree of 10 percent during service or the applicable post-service presumptive period does not require that the chronic disease be diagnosed during the presumptive period, but only that there be then shown by acceptable medical or lay evidence characteristic manifestations of the disease to the required degree, followed without unreasonable time lapse by definite diagnosis. Symptomatology shown in the prescribed period may have no marked significance when first observed, but in the light of subsequent developments it may gain considerable significance. 38 C.F.R. § 3.307(c). The record establishes a current diagnosis of hypertension. See March 2020 VA examination. The Veteran essentially claims that he first demonstrated symptoms of hypertension while on active duty and was diagnosed with the disorder soon after his military discharge. “Hypertension” refers to high arterial blood pressure. DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 896 (32nd ed. 2012). Hypertension is evaluated under Diagnostic Code 7101. Note (1) of that provision explains that, for VA rating purposes, hypertension means that the diastolic blood pressure is predominantly 90 mm or greater and “isolated systolic hypertension” means that the systolic blood pressure is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). Note (1) also indicates that those conditions must be confirmed by readings taken two or more times on at least three different days. The provision refers to confirmation of the diagnosis and, because Board decisions are based on the totality of the evidentiary record, is not considered to prescribe an inflexible definition which precludes compensation if it is not met. Gill v. Shinseki, 26 Vet. App. 386 (2013). The Veteran’s service treatment records show elevated blood pressure which meets the definition of “hypertension” under Note (1) of Diagnostic Code 7101 and meets the criteria for a 10 percent disability rating under Diagnostic Code 7101. Specifically, an April 1991 examination reports a blood pressure reading of 167/94. Further, a June 1991 service treatment record notes a diagnosis of history of hypertension. Post-service medical records dated in October 1992 reflect a finding of mild hypertension. Records dating from November 1992 through October 1997 reflect elevated blood pressure readings of 150/100, 140/100, 150/106, 172/100, and 160/100. A February 2000 record notes a blood pressure reading of 160/102 and a diagnosis of hypertension. Together with the post-service diagnoses of hypertension in 1992, the service medical evidence establishes presumptive service connection for hypertension. 38 C.F.R. §§ 3.307, 3.309. The elevated blood pressure readings of 1991 (during service) and 1992 through 1997 (after service) satisfy the criteria contained in Diagnostic Code 7101 for a rating of at least 10 percent, indicative of hypertension that is compensable. 38 C.F.R. § 3.307. Accordingly, service connection for hypertension is granted.   REASONS FOR REMAND Entitlement to service connection for obstructive sleep apnea is remanded. The Board regrets the delay of an another remand, but finds that additional development is warranted with regard to the Veteran’s claim for entitlement to service connection for obstructive sleep apnea. Review of the claims file reflects that the Veteran first began complaining of sleep disturbance symptoms in 2010. A December 2011 VA posttraumatic stress disorder (PTSD) examination notes the Veteran’s reported history of loud snoring, chronic feelings of tiredness, daytime napping, and difficulty with memory and concentration. The examiner opined that the Veteran most likely as not had obstructive sleep apnea based upon his clinical symptoms. A July 2019 polysomnogram documents a diagnosis of obstructive sleep apnea. In a July 2019 VA opinion, the examiner noted that the Veteran was “diagnosed with disordered sleep 2010 due to PTSD.” Although there are several negative VA opinions of record, none of the VA examiners have addressed the possibility that the Veteran’s sleep apnea was caused or aggravated by his service-connected PTSD. Based upon the December 2011 and July 2019 VA opinions, the Board finds that this theory of entitlement has been raised by the record. Accordingly, remand for a VA opinion on secondary service connection is warranted. The matters are REMANDED for the following action: Provide the Veteran with a VA examination by appropriate physician to determine the etiology of his obstructive sleep apnea. The Veteran’s claims file and a copy of this remand must be reviewed by the examiner, and the examiners must state that this evidence was reviewed in the examination report. All pertinent symptomatology and findings must be reported in detail. All indicated tests and studies must be accomplished. Based upon a complete review of the evidence of record, to include the Veteran’s lay statements, the VA examiner must opine whether it is at least as likely as not (i.e., a 50 percent probability or more) that the Veteran’s obstructive sleep apnea is proximately due to, the result of, or aggravated by the Veteran’s service-connected PTSD. Aggravation is defined as any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease. A complete rationale for all opinions must be provided. The examiner is advised that a finding that the sleep apnea disability was aggravated beyond the normal progression due to a service-connected disability does not require evidence of a permanent worsening and may encompass any additional impairment in earning capacity resulting from an already service-connected condition. Also, the examiner is advised that the Veteran is competent to report observable symptomatology. ANTHONY C. SCIRÉ, JR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Katz, 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.