Citation Nr: 21012688 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 15-33 265 DATE: March 5, 2021 ORDER Entitlement to service connection for hypertension as secondary to a service-connected disease or injury is denied. FINDING OF FACT Hypertension is unrelated (causation or aggravation) to service connected disease or injury. CONCLUSION OF LAW Hypertension is not proximately due to or a result of or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310.   REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from October 1967 to May 1970. This matter comes before the Board of Veterans’ Appeals (Board) from a June 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. The Veteran contends that his hypertension is secondary to his service-connected sleep apnea or PTSD. The evidence of record does not show that he has any hypertension disability related to any remaining service-connected diseases or injuries. Pertinent Legal Criteria Veterans are entitled to compensation from VA if they develop a disability “resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty.” 38 U.S.C. § 1110 (wartime service), 1131 (peacetime service). To establish a right to compensation for a present disability, a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service”-the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). The Board notes that the Veteran has not claimed that his disabilities on appeal are the result of combat with the enemy. Therefore, the combat provisions of 38 U.S.C. § 1154 are not for consideration. Service connection is warranted for disability which is proximately due to or the result of a service-connected disease or injury. 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). Any increase in severity of a non-service-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 or injury will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. Part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). For secondary service connection to be granted, generally there must be (1) evidence of a current disability; (2) evidence of a service-connected disease or injury; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). After the evidence is assembled, it is the Board’s responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a) (2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2019). Secondary Service Connection The Board has carefully evaluated the evidence and, for reasons stated immediately below, finds that a preponderance of the evidence is against a finding that the hypertension is due to or aggravated by his sleep apnea, PTSD or any service connected disease or injury and service connection is therefore not warranted on a secondary basis. Secondary service-connection to PTSD and sleep apnea The Board notes that in January 2014 Veteran filed a supplemental claim arguing that Veteran was entitled to secondary service connection for hypertension from his service-connected sleep apnea. The Veteran was provided a VA examination on May 2014. While the Veteran was diagnosed with hypertension the VA examiner opined that Veteran’s hypertension was not secondary to his service-connected sleep apnea. The VA examiner commented this conclusion by stating that she was unable to find any evidence based in scientific literature that definitively reports that sleep apnea causes hypertension. The Veteran filed a subsequent notice of disagreement (NOD) arguing that a quick search of the internet reveals articles linking hypertension as a byproduct of sleep apnea. The Veteran also filed a private medical opinion where the doctor stated he believed that there is a link between Veteran’s sleep apnea, hypertension and sleep problems with PTSD. The private doctor did not state any rational or explanation to his statement besides the fact that the Veteran had been a patient of his for a long time. An additional VA examination was provided to Veteran on August 2015. The VA examiner created his opinion by interviewing the Veteran, reviewing an article from the Journal of Sleep Medicine and reviewing Veteran’s records of outpatient visits. The VA examiner concluded that the Veteran’s hypertension is not likely proximately due to or the result of sleep apnea and PTSD. The examiner commented that the literature suggests that treatment for underlying sleep apnea may help control an individual’s blood pressure, but that one does not cause the other to occur. The VA examiner further concluded that there was not clear evidence regarding a cause and effect relationship of PTSD to either sleep apnea or hypertension. The matter was before the Board again in April 2020, to which the Board remanded for a VA opinion. The Board referenced that the previous VA examiner failed to provide an opinion on the aggravation factor and therefore the opinion was inadequate. Another VA examination was provided to the Veteran May 2020. On the issue of PTSD, the VA examiner stated that the Veteran’s hypertension was not at least as likely as not aggravated beyond its natural progression by PTSD. The examiner commented that there is no evidence of hypertension being aggravated by PTSD more than its natural progression due to aging and hyperlipidemia. On the issue of Veteran’s hypertension being aggravated, the VA examiner opined that hypertension was not aggravated and more than likely improved by using continuous positive airway pressure (CPAP) therapy used to treat sleep apnea. The examiner stated that there was a bidirectional association between sleep apnea and systemic hypertension since CPAP treatment significantly reduces blood pressure in patients. The examiner further noted that several meta-analyses have demonstrated a concordant mild effect of CPAP on systemic hypertension. While the Board notes that Veteran’s private doctor has submitted a favorable decision, the fact that no rational was provided to it decreases its probative value. In comparison to the unfavorable VA examinations, the VA examinations provide more probative value on the matter due to their analysis and rational. Here, we find the VA opinions to be based upon the record and contain reasoning. Such opinions are far more probative than the private medical opinion or any article that the Veteran may have referenced. Here the preponderance of the evidence is against the claim and there is no doubt to be resolved.   For the reasons and bases expressed above, the Board finds that the preponderance of the evidence is against the Veteran’s claims of entitlement of hypertension as secondary to a service-connected disease or injury. The benefits sought on appeals are accordingly denied. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Konieczny, Adam 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.