Citation Nr: 21012682 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 19-23 445 DATE: March 4, 2021 ORDER Entitlement to service connection for hypertension is denied. FINDING OF FACT The preponderance of the evidence does not reflect that the Veteran’s hypertension had its onset in service, manifested within a year of separation from service, or is otherwise related to service. CONCLUSION OF LAW The criteria for service connection for hypertension are not met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.  REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1944 to January 1946 and August 1950 to May 1951 and received the Combat Infantry Badge. This matter initially came before the Board of Veterans’ Appeals (Board) on appeal from a June 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that, among other things, denied the claim of service connection for hypertension. In September 2019 and October 2020, the matter was remanded by the Board for further development, to include an opinion as to whether the Veteran’s hypertension is secondary to his service-connected peripheral arterial disease and/or peripheral vascular insufficiency. The Agency of Original Jurisdiction (AOJ) has substantially complied with the Board’s October 2020 remand instructions by, as demonstrated by the discussion below, obtaining a VA opinion that is adequate to decide the claim. Thus, no further action is necessary in this regard. Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for hypertension The Veteran contends that his hypertension was incurred in service, or alternatively, that his hypertension was caused by his service-connected peripheral arterial disease and/or peripheral vascular insufficiency. Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service.  38 U.S.C. § 1110; 38 C.F.R. § 3.303(a).  Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018).  Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).   For VA compensation purposes, the term “hypertension” means that the diastolic blood pressure is predominantly 90 mm. or greater, or systolic blood pressure is predominantly 160 or more. 38 C.F.R. § 4.104, DC 7101 n.1. A diagnosis of hypertension ”must be confirmed by readings two or more times on at least three different days.” Id. The requirement of multiple blood pressure readings to be taken over multiple days as specified in Note (1) of DC 7101 applies to confirming the existence of hypertension. Gill v. Shinseki, 26 Vet. App. 386, 391 (2013). The Veteran’s blood pressure readings were 126/74 during his January 1946 separation examination and 114/70 during his April 1951 separation examination. During a May 2018 VA examination, the VA examiner noted that the Veteran was diagnosed with hypertension in 2010. The examiner found the Veteran’s hypertension was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the Veteran’s service treatment records were silent for complaints, evaluation, and/or treatment during his active military service or within two years after his active duty discharge. In December 2019, a VA physician found that the Veteran’s hypertension was less likely than not aggravated by service-connected arterial disease and/or peripheral vascular insufficiency. The VA physician reasoned that hypertension contributes to the pathogenesis of atherosclerosis, the basic underlying pathological process underlying peripheral vascular disease. A December 2020 VA opinion found the Veteran’s hypertension is less likely than not proximately due to or the result of the Veteran’s service-connected condition. The VA physician reasoned that there is no evidence of medical literature of peripheral vascular disease as an etiology for arterial hypertension. In a January 2021 VA addendum opinion, the VA physician found that the Veteran’s hypertension was less likely than not caused by or a result of service-connected peripheral artery disease or peripheral vascular insufficiency as there is no pathophysiological relationship upon review of medical literature. The Veteran did not indicate that he had high blood pressure readings or symptoms indicative of hypertension in the years between service and his post service diagnosis, and he did not relay a diagnosis of hypertension during those years. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (a layperson is competent to report a contemporaneous medical diagnosis). For the following reasons, entitlement to service connection for hypertension is not warranted.    A September 2014 VA treatment record noted the Veteran’s diagnosis of hypertension in January 2010. Thus, the Veteran meets the current disability requirement. While there was an elevated blood pressure reading at the Veteran’s January 1946 separation examination, this blood pressure reading was below the minimum level of systolic and diastolic readings required to show hypertension, and thus does not meet VA’s definition of hypertension. See 38 C.F.R. § 4.104, DC 7101 n. 1. As noted, the Veteran’s service treatment records do not contain any notations relating to symptoms, treatment, or diagnosis relating to hypertension. Post-service records reveal no treatment or diagnosis for hypertension until approximately 60 years after separation from active duty. In this regard, evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, is one factor, along with those above, including the normal separation examinations with regard to relevant blood pressure readings and lack of notations relating to symptoms, treatment, or diagnosis relating to hypertension in the Veteran’s service treatment records, as well as lack of statements indicating continuity of symptomatology, that can be considered as evidence against the claim.  Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000).   In the December 2019 opinion and January 2021 VA addendum opinion, the VA physicians found that the Veteran’s hypertension was less likely than not caused or aggravated by service-connected peripheral artery disease or peripheral vascular insufficiency as hypertension contributes to the pathogenesis of atherosclerosis, the basic underlying pathological process underlying peripheral vascular disease, and there is no pathophysiological relationship between hypertension and the service-connected disabilities upon review of medical literature. As the VA physicians explained the reasons for these conclusions based on an accurate characterization of the evidence, these opinions are entitled to some probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). To the extent that the Veteran’s lay statements suggest a relationship between his current hypertension disability and service or service-connected disabilities, this is the type of complex medical issue relating to an internal medical process which extends beyond an immediately observable cause-and-effect relationship as to which lay evidence is not competent. Jandreau v. Nicholson, 492 F.3d 1372, 1376, n.4 (Fed. Cir. 2007) (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”).   For the foregoing reasons, the preponderance of the evidence is against finding that hypertension had its onset in service, manifested within a year after separation from service, or is related to service. The benefit of the doubt doctrine is therefore not for application, and the claim must be denied.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Styer, 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.