Citation Nr: 21014296 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 15-43 971 DATE: March 11, 2021 ORDER Entitlement to service connection for hypertension, including as due to her service-connected disabilities and pain, is denied. FINDING OF FACT The preponderance of the evidence fails to establish that the Veteran’s currently diagnosed hypertension is causally or etiologically related to her service or caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for service connection for hypertension, including as secondary to the Veteran’s migraine headache, diverticulitis, fibromyalgia, and depressive disorder disabilities have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably in the United States Air Force from July 1997 to September 2003. This matter comes before the Board of Veterans’ Appeals (Board) from an August 2013 rating decision by the Department of Veteran Affairs (VA) Regional Office (RO) that denied service connection for hypertension. In July 2020, the Board remanded the case for an addendum opinion related to the issue above, and it now returns for further appellate review. Entitlement to service connection for hypertension, including as due to the Veteran’s service-connected disabilities and pain Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303(a). 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).  Service connection may be granted for any disease initially diagnosed after discharge when all of 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 established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 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) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995)(en banc). Service connection will be presumed for certain chronic diseases, such as hypertension, if manifest to a compensable degree within one year after discharge from service. See 38 C.F.R. §§ 3.307, 3.309. Presumptive service connection for chronic diseases must be considered on three bases: chronicity during service, manifestations within one year of the Veteran’s separation from service, and continuity of symptomatology since service. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The Veteran argues, in pertinent part, that her hypertension was caused or aggravated by her service-connected disabilities. Specific reference has been made with regard to her migraine headache, diverticulitis, fibromyalgia, and depressive disorder disabilities. She also argues that a relationship exists between hypertension and chronic pain. In October 2012, a VA examiner determined that the Veteran’s elevated blood pressure readings from June 2001 to March 2004 did not show in-service hypertension. The examiner noted that there was no treatment for hypertension in service. The examiner stated that elevated blood pressure readings were usually associated with migraine headaches, abdominal pain/cramping, motor vehicle accident, severe pain, fibromyalgia, and depression. A June 2003 service treatment record noted elevated blood pressure without a diagnosis of hypertension. The examiner stated that blood pressure can be elevated without having a diagnosis of hypertension. Further, pain, stress, fear, etc. can result in elevated readings, but if there are not consistently elevated readings, then the condition is not hypertension. The examiner stated that a diagnosis of hypertension appeared on the Veteran’s problem list in January 2009. VA opinions were obtained in May 2017 and September 2017. In both instances the examiner determined that there was no evidence of permanent aggravation due to the Veteran’s service-connected disabilities or medications used to treat those disabilities. The examiner acknowledged that the use of NSAIDS and steroids could aggravate hypertension but that the degree of aggravation could not be determined without resorting to mere speculation as the medical evidence is not sufficient. The Board remanded the matter because it found that both opinions were problematic because they used a “permanent aggravation” standard to assess whether the Veteran’s hypertension was aggravated by her service-connected disabilities or medications. See Ward v. Wilkie, 31 Vet. App. 233 (2019)(holding that, for secondary service connection, “aggravation” need not be permanent in nature). The opinions also did not provide an adequate basis for why a non-speculative opinion could not be reached to determine whether the degree of aggravation caused by the use of NSAIDS and steroids. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). Following the July 2020 remand, an addendum opinion was provided by a VA physician in July 2020. The July 2020 VA examiner found that the Veteran’s current diagnosis of essential hypertension was less likely than not incurred in or caused by an in-service injury, event or illness. The examiner stated that blood pressure readings in service and within 12 months of discharge did not meet the criteria for a diagnosis of essential hypertension. Regarding secondary service connection, the examiner found no evidence that the Veteran’s hypertension was aggravated beyond the natural progression of the disease by her service-connected conditions, including symptoms such as pain. The July 2020 examiner stated that essential hypertension, by definition, is not caused by another disease, process, or condition. The examiner stated that a review of Up To Date research did not list any of the Veteran’s service-connected conditions as causes for hypertension and that none of the treatment modalities for the Veteran’s service-connected conditions are listed as causes of essential hypertension. Regarding the Medscape article about chronic pain associated with an increased prevalence of hypertension submitted by the Veteran in October 2015, the examiner explained that it is common for pain to cause a transient increase in blood pressure, but not a permanent elevation as the blood pressure readings will return to their normal levels as the pain subsides or levels out. The examiner’s review of the Veteran’s blood pressure readings in her medical records did not reveal any dramatic increase in blood pressure readings. The examiner stated that the Medscape article reviewed only one article and that there are no repeated studies that prove pain causes hypertension. The examiner concluded that while “association” was mentioned, that does not mean “causation.” Based on the evidence of record, the Board finds that the Veteran’s claim for entitlement to service connection must be denied. The Board assigns great probative weight to the July 2020 opinion, as it contains not only a clear conclusion with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). Notably, there is no contrary medical opinion of record to . While the Veteran has alleged that her hypertension may be related to her service, the Board finds that the question regarding the potential relationship between the Veteran’s hypertension and any incident in her military service to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (providing that although a veteran is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, a veteran is not competent to provide evidence as to more complex medical questions). Indeed, the question of causation of hypertension is a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion as to the etiology of her hypertension is nonprobative evidence. (Continued on the next page)   The Board has considered whether presumptive service connection is warranted in this case, as the Veteran has been diagnosed with hypertension, which, as noted, is a chronic disease for which service connection may be granted on a presumptive basis. See 38 C.F.R. § 3.309. However, the presumption does not apply in this case because there is no evidence of essential hypertension within one year after the Veteran was discharged from service. For these reasons, the claim for service connection for hypertension must be denied. In reaching its conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Ortiz, supra; Gilbert, supra. The claim is denied. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals J. Morgan, Attorney for the Board Department of Veterans Affairs 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.