Citation Nr: 21011969 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 14-41 374 DATE: March 3, 2021 ORDER Entitlement to service connection for hypertension is denied. FINDING OF FACT The Veteran’s current hypertension was not noted in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; the disability is not otherwise etiologically related to an in-service injury or disease, and such was not caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1965 to May 1967. The Veteran is the recipient of the Combat Infantryman Badge, among other commendations. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon, which, inter alia, denied service connection for hypertension. In July 2018, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. This matter was previously before the Board in February 2019. At that time, the Board, inter alia, remanded the claim for further evidentiary development, to include a VA examination. This matter was most recently before the Board in October 2020. At that time, the Board again remanded the matter for further evidentiary development, to include an addendum medical opinion. Entitlement to service connection for hypertension is denied. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. § 1110. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Disability which is proximately due to or the result of a service-connected disease or injury shall also be service connected. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Service connection for certain chronic diseases, including cardiovascular-renal disease including hypertension, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. 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. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends that his current hypertension is caused by anxiety and is secondary to his service-connected posttraumatic stress disorder (PTSD). See July 2012 NOD. The Veteran’s service treatment records (STRs) are negative for complaints, observations, or treatment regarding elevated blood pressure or hypertension. The Veteran’s blood pressure was 128/88 at the time of entry onto his active duty. See April 1965 Report of Medical Examination. The Veteran’s April 1967 separation examination was essentially normal, including the vascular system. Blood pressure measured 120/80. The Veteran was found to be qualified for separation. On the accompanying Report of Medical History, the Veteran reported that he was in good health and denied having, or having had, high or low blood pressure. A private treatment record dated in June 2003 noted a history of hypertension. See June 2003 Medical Records, S.J.M.C. At the July 2018 Board hearing, noted above, the Veteran stated that he was diagnosed with hypertension in June or July 1967 by a private physician, at which time he began taking medication for his condition. See July 2018 Transcript of Hearing, pages 7-9. Pursuant to the Board’s February 2019 remand instructions, the Veteran was afforded a VA examination in January 2020. After examination of the Veteran and review of the claims file, the examiner determined that the Veteran did not have a current diagnosis of hypertension because there were no findings, signs, and/or symptoms to support a diagnosis, and that he did not take medication for such. The examiner did not provide an etiological opinion. In August 2020, an Acceptable Clinical Evidence (ACE) opinion was obtained. After a telephone interview with the Veteran and review of the claims file, the examiner concluded that the Veteran did not have a current diagnosis of hypertension. The examiner offered a negative etiological opinion regarding direct service connection, indicating that the Veteran had no record of hypertensive blood pressure readings during service. Similarly, he offered a negative etiological opinion regarding secondary service connection, opining that the Veteran did not experience sustained hypertensive blood pressure readings after separation, nor did he require current treatment for hypertension. In an August 2020 addendum medical opinion, the examiner determined that it was at least as likely as not that the Veteran had a current diagnosis of essential hypertension, well-controlled on medications. The examiner cited clinical evidence of record which indicated that the Veteran had been on medications which lower blood pressure during the past 2 years. Regarding secondary service connection, the examiner opined, It is my observation and opinion that his PTSD is less likely than 50% likely to be progressed beyond natural progression by his SC PTSD, as his primary essential hypertension and metabolic syndrome management well control his blood pressures. Pursuant to the Board’s October 2020 remand instructions, an addendum medical opinion was obtained in November 2020. After review of the claims file, the examiner rendered a negative etiological opinion regarding the Veteran’s hypertension. The examiner opined, The veteran’s hypertension is less likely than not (less than 50% probability) incurred in or caused by service. There is no evidence of a diagnosis of hypertension noted during service or within a year of discharge from service. There is no evidence of treatment for hypertension during service or within one year of discharge from service. His separation exam 4/25/67 does not show evidence of hypertension, his blood pressure reading at that time was 120/80. His records show evidence of hypertension circa 12/2005 which is several decades after discharge from active duty. Considering the evidence, his current hypertension is less likely than not (less than 50% probability) incurred in or caused by service. Regarding secondary causation, the examiner opined, The veteran’s hypertension is less likely than not (less than 50% probability) proximately due to or the result of his service connected PTSD. According to Mayo Clinic (2020), the exact cause of primary or essential hypertension is unknown, and the disease tends to develop gradually over many years. Risk factors for hypertension include age over 64, family history, obesity, sedentary lifestyle, tobacco use, increased sodium intake, decreased potassium intake, excessive alcohol consumption, and stress. The veteran has multiple possible risk factors for hypertension. The evidence submitted was reviewed and appreciated; however, medical research does not support a direct causation between PTSD and hypertension. Stress is one of many risk factors for hypertension in the veteran, and a risk factor does not indicate a direct causative link. Considering the evidence, his current hypertension is less likely than not (less than 50% probability) proximately due to or the result of his service connected PTSD. With regard to aggravation, the examiner concluded, The veteran’s hypertension is less likely than not (less than 50% probability) aggravated beyond its natural progression by PTSD. There is no clear and direct medical evidence indicating his PTSD has resulted in aggravation of his essential hypertension. There is no evidence of the need for additional anti-hypertensives related to stress or PTSD. His recent records show good control of hypertension with the use of medication, and there is no direct medical evidence to support his PTSD has aggravated or worsened his hypertension. He has several risk factors for hypertension, and stress is noted as one of many possible risks for hypertension. Considering this evidence, his current hypertension is less likely than not (less than 50% probability) aggravated beyond its natural progression by PTSD. After a review of the evidence, the Board finds that service connection is not warranted for hypertension. As set forth above, disability which is proximately due to or the result of a service-connected disease or injury shall also be service connected. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). With regard to current disability, the Board finds sufficient clinical evidence to establish that the Veteran currently has hypertension. The June 2003 private treatment records, as well as the August 2020 addendum medical opinion, noted above, indicated a diagnosis of hypertension. In addition, the record reflects that service connection is in effect for PTSD. See e.g. June 2012 rating decision granting service connection for PTSD. The remaining issue, therefore, is whether the Veteran’s hypertension was caused or aggravated by his service-connected PTSD. In this case, the Board finds that the probative evidence is against a finding that the Veteran’s hypertension was caused or aggravated by his service-connected PTSD. In that regard, the Board assigns great probative weight to the November 2020 VA medical opinion, as the examiner reviewed the Veteran’s claims file in its entirety. After considering the record, the examiner concluded that the Veteran’s hypertension was not caused or aggravated by his service-connected PTSD. The examiner provided a reasoned conclusion and clear rationale to support her determination that the Veteran’s hypertension was not secondarily related to or aggravated by his PTSD. There is no medical opinion evidence to the contrary. The Board assigns less probative weight to the January 2020 VA examination and August 2020 ACE opinion, which were found to be inadequate in the October 2020 Board remand to the extent the examiner incorrectly determined that the Veteran did not have a current diagnosis of hypertension, despite clinical evidence to the contrary which noted a history of hypertension and current treatment for such. The Board also assigns less probative weight to the August 2020 addendum medical opinion, which was found to be inadequate in the October 2020 Board remand to the extent the examiner failed to provide an opinion regarding direct service connection and addressed only the question of aggravation and did not address a causal relationship. In addition, the Board assigns less probative weight to the Veteran’s statements indicating that his hypertension was caused or aggravated by his service-connected PTSD. Although the Veteran is competent to describe symptoms, he is not competent to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have had medical training or skills. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Questions of competency notwithstanding, the Board assigns more probative weight to the findings of the November 2020 VA examiner, given her clinical expertise and the rationale she provided. Regarding the theory of direct service connection, the Board notes that the record contains no indication that the Veteran’s current hypertension had its inception during active service or is otherwise causally related to an in-service disease or injury. To the extent that the Veteran’s report of a diagnosis of hypertension a few months after service was meant to imply that he believed that his hypertension began in service or was manifest to a compensable degree within one year of separation, competent medical evidence, as well as the Veteran’s own contemporaneous denial at the time of separation, weighs heavily against such a finding. As such, the Board finds that service connection on a direct or presumptive basis is not warranted. In reaching this decision, the Board has considered the fact that the Veteran has been diagnosed as having hypertension, an enumerated disease under 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, the disability was not shown as chronic in service, did not manifest to a compensable degree within the presumptive period, and was not noted in service with attributable continuity of symptomatology. As set forth above, the Veteran’s service treatment records contain no indication of complaints, observations, or treatment regarding elevated blood pressure or hypertension. Notably, at his April 1967 separation examination, the Veteran’s blood pressure was normal, and he denied having, or having had, high or low blood pressure. The post-service clinical record on appeal shows that the Veteran was not diagnosed as having hypertension for decades after his separation from active service and well outside the applicable presumptive period. While the record contains the Veteran’s recollections that he was diagnosed with hypertension in June or July 1967 by a private physician, at which time he began taking medication for his condition, the Board assigns more probative weight to the contemporaneous evidence of record than to the Veteran’s recollections several decades after service separation, made in the context of a claim for monetary benefits. This conclusion is strengthened by the Veteran’s demeanor at his July 2018 Board hearing. Based on the foregoing, as the probative evidence is against the Veteran’s claim of service connection for hypertension, the benefit-of the-doubt rule is not for application. See 38 U.S.C. § 5107, 38 C.F.R. § 3.102. Accordingly, the Board finds that the elements of service connection are not met, and the Veteran’s claim for hypertension is denied. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Ruddy, 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.