Citation Nr: 21013416 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 18-47 729 DATE: March 9, 2021 ORDER Entitlement to service connection for hypertension, including secondary to service-connected diabetes mellitus, type II, is denied. FINDING OF FACT The probative evidence reflects that the Veteran’s hypertension did not manifest in service or within one year thereafter, and it is not related to his active service, to include herbicide exposure or his service-connected diabetes mellitus, type II. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.10. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1966 to January 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2019 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The issue was previously before the Board in November 2020 and remanded for the RO to provide the Veteran with his requested telephone call. A Report of General Information dated in December 2020 indicates that two calls were placed to the Veteran on December 4th and one on December 7th. Messages were left all three times for the Veteran to return the calls. In this regard, the Board finds that there has been substantial compliance with the Board’s remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). The remand also mandated that the Veteran was afforded an adequate supplemental VA opinion to determine the nature and etiology of his hypertension. The examiner addressed direct service connection, to include based on herbicide exposure, as well as secondary service connection. The opinion of January 2021 is adequate for adjudication, and there has been substantial compliance. Id. VA’s duty to notify was fulfilled by a June 2010 letter, as well as with the October 2018 filing of VA Form 21-526EZ, Fully Developed Claim. 38 U.S.C. §§ 5102, 5103 (2012); 38 C.F.R. § 3.159; Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Thus, the Board finds that the VA has complied with its duty to notify. Concerning the duty to assist, the Veteran’s service treatment records and VA medical treatment records have been obtained. Hurd v. West, 13 Vet. App. 449, 452 (2000). The Veteran was provided with an adequate VA examination in January 2021. Entitlement to service connection for hypertension, including secondary to service-connected diabetes mellitus, type II, is denied. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1131 (2012); 38 C.F.R. § 3.303. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity for certain diseases. 38 C.F.R. §§ 3.303 (a), (b), 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection may also be granted for chronic disabilities if such are shown to have been manifested to a compensable degree within one year after the Veteran was separated from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309 (a), to include hypertension. Walker, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013). To establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303; Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The requirement of a current disability is “satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim.” McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Secondary service connection may also be established for a nonservice-connected disability aggravated by a service-connected disability. 38 C.F.R. § 3.310 (b); Allen v. Brown, 7 Vet. App. 439 (1995). To establish entitlement to service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509 (1998). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a competent source. The Board must then determine if the evidence is credible or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007). The third step of this inquiry requires the Board to weigh the probative value of the evidence considering the entirety of the record. The standard of proof to be applied in decisions on claims for veterans’ benefits is outlined in 38 U.S.C. § 5107 (2012). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran contends that his hypertension is related to his service. Specifically, he avers that he was exposed to herbicide agents in Vietnam. The AOJ has presumed herbicide exposure. In the alternate, he argues that his hypertension is secondarily related to his service-connected diabetes mellitus, type II. The Veteran’s service treatment records (STRs) are silent for any complaint, diagnosis of, or treatment for heart or chest complaints; nor does he so contend. The Veteran’s separation examination in January 1968, although noted blood pressure reading of 130/80, the heart was noted as normal, and he answered “no” to whether he had high or low blood pressure. A review of the Veteran’s post-service private treatment records dated in September 2008 indicates diagnoses of hypertension and diabetes mellitus. An Assessment and plan therein note that the diabetes was controlled and hypertension benign essential. A May 2010 correspondence from the Veteran’s private physician at South Coast Medical Group indicates that the Veteran had hypertension and diabetes mellitus and was on medication for both. The Veteran was afforded a VA examination in January 2021. The examiner provide a negative nexus to service. He explained that the Veteran’s STRs [were] also devoid of diagnosis of hypertension. Both entrance and separation exams did not show diagnose hypertension, and [he] identified “No” for “High or low blood pressure” [during his separation physical] in January 1968. Thus, the Veteran’s claim for hypertension did not begin during active service or related to an incident of service. The Veteran was diagnosed with hypertension and diabetes mellitus, type II, per VA notes in approximately 2008. The Veteran was followed by a private primary care physician for hypertension from 2008 to 2010. Thus, the Veteran’s claim for hypertension did not begin within one year after discharge from active service. The examiner found that the Veteran’s hypertension was neither caused nor aggravated beyond its natural progression by his diabetes. The examiner noted that private medical records did not note “‘[c]ardiovascular’ which includes hypertension as a complication from diabetes mellitus.” The examiner went on to explain that instead, “this [p]hysician’s statement annotates ‘ankle swell.’ There is no identifying the etiology or pathophysiology of this ‘ankle swell.’ There is no identifying the etiology or pathophysiology of this ‘ankle swell.’” The examiner also explained that medical records contain serologic studies regarding glomerular filtration rate (GFR), a sensitive study for nephropathy, were all normal from 2009 to 2010. Also, the serologic study GFR from VAMC Charleston was normal. The examiner concluded that there is no evidence prov nephropathy. Addressing the submitted article, “Summer 2017 VA Public Health/Agent Orange: Findings on Blood Pressure from the Army Chemical Corps Vietnam-Era Veterans Health Study,” the examiner opined that the study “was NOT a definitive study.” He explained that the survey requested information from these Veterans on their exposure to herbicides, whether they were ever diagnosed with hypertension by a physician, and their health behaviors, such as cigarette smoking and alcohol use. To confirm self-reported hypertension, researchers conducted in-home blood pressure measurements and a medical records review for a portion of the study participants...[to determine] the association between herbicide exposure and hypertension [and] to gain a better understanding of whether hypertension is related to military service in Vietnam. Self-reported hypertension was the highest among Veterans who distributed or maintained herbicides (sprayers) in Vietnam, followed by Veterans who sprayed herbicides and served during the Vietnam War but never in Southeast Asia (non-Vietnam Veterans) Veterans who served in Vietnam but did not spray herbicides(72.2%), and Veterans who did not spray herbicides and were non-Vietnam Veterans (64.6%). He concluded that the study was NOT a definitive study ... [because] self-reported hypertension is NOT diagnostic, and medical records review for a portion of the study participants is NOT a strong survey. [Furthermore,] this article is not the gold standard for the association between herbicide exposure and hypertension amongst Veterans who distributed or maintained herbicides (sprayers) in Vietnam versus Veterans who sprayed herbicides and served during the Vietnam War but never in Southeast Asia (non-Vietnam Veterans), Veterans who served in Vietnam but did not spray herbicides, and Veterans who did not spray herbicides and were non-Vietnam Veterans. After considering the record, the Board finds that service connection for hypertension is not warranted. The record lacks any competent evidence of a relationship between the Veteran’s hypertension and service, including due to a disease, injury, or incident therein, herbicide agents, and his service-connected diabetes mellitus, type II. The evidence of record does not show that hypertension began in service or manifested to a compensable degree within one year thereof, nor does the Veteran so contends. Rather, his hypertension was diagnosed in approximately 2008, 40 years after service. Moreover, there is no showing that hypertension was caused and/or aggravated by service-connected diabetes mellitus, type II. The Board finds the examiner’s January 2021 conclusion most probative against a finding that the Veteran’s diagnosed hypertension was incurred in service and continued or was caused or aggravated by his service-connected diabetes mellitus, type II. The examiner, in support of his findings, acknowledged a review of the relevant evidence of record, including the submitted article. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Further, there is not any competent medical evidence of record that contradicts the comprehensive findings of the VA examiner. The Board acknowledges the Veteran’s service in Vietnam. H hypertension is not amongst the exclusive list of conditions presumptively service-connected under 38 C.F.R. § 3.309 (e), based on presumed exposure to herbicide agents. Here, the medical examiner opined that the Veteran’s hypertension is less likely than not related to service, including his presumed exposure to herbicide, as discussed above. Specifically addressing the evidentiary article submitted by the Veteran in support of his claim, Summer 2017 VA Public Health/Agent Orange: Findings on Blood Pressure from the Army Chemical Corps Vietnam-Era Veterans Health Study, the examiner noted that the participants’ self-reported hypertension. Thus, the study “was NOT a definitive study” and was not the gold standard for the association between herbicide exposure and hypertension. While the Veteran is deemed competent and credible to report observable symptoms, the specific issue in this case is, whether his currently diagnosed hypertension, is etiologically related to service or his service-connected diabetes mellitus, type II. Such a determination falls outside the realm of common knowledge of the Veteran. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428 (2011). Determining the etiology of hypertension is a medically complex task and is not within the competence of the Veteran who, in this case, has not been shown by the evidence of record to have the training, experience, or skills needed to diagnose and determine the etiology of his hypertension. Further, his contentions were investigated by a credible medical examiner who found no relationship to service, including his herbicide exposure and diabetes mellitus, type II. As a result, the persuasive value of the lay etiology opinion is low. The Board finds no competent medical or lay evidence showing a nexus to service or his service-connected diabetes mellitus, type II. Shedden, 381 F.3d at 1166-67; Wallin, 11 Vet. App. 509 (1998). Accordingly, the preponderance of the medical evidence of record is against finding that the Veteran’s hypertension was incurred in service or in any way related to his service and his diabetes mellitus, type II. Therefore, service connection is not warranted. In reaching this decision, the Board considered the doctrine of reasonable doubt. As the preponderance of the evidence is against the claim, the doctrine is not for application. Gilbert, 1 Vet. App. 49. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Stevens, 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.