Citation Nr: 21015950 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 16-58 605A DATE: March 18, 2021 ORDER Entitlement to service connection for hypertension, claimed as high blood pressure, is granted. REMANDED Entitlement to service connection for a hiatal hernia is remanded. Entitlement to service connection for acid reflux disease associated with hiatal hernia is remanded. Entitlement to service connection for a neurological condition claimed as right lower extremity peripheral neuropathy is remanded. Entitlement to service connection for a neurological condition claimed as left lower extremity peripheral neuropathy is remanded. Entitlement to service connection for a neurological condition claimed as left upper extremity peripheral neuropathy is remanded. Entitlement to service connection for a neurological condition claimed as right upper extremity peripheral neuropathy is remanded. FINDING OF FACT The Veteran’s hypertension has had continuous symptomatology since he separated from service. CONCLUSION OF LAW The criteria for establishing service connection for hypertension have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from April 2009 to February 2013. This matter comes before the Board of Veterans’ Appeals (Board) from rating decisions from a Department of Veterans Affairs (VA) regional office (RO) issued in April 2014 and February 2014. In pertinent part, these decisions denied service connection for hypertension, hiatal hernia, acid reflux, and neurological conditions claimed as peripheral neuropathy of the bilateral upper and lower extremities. The Veteran perfected an appeal of these issue to the Board. The Veteran was provided a hearing on the above issue in June 2020 via videoconference. A transcript of that hearing was associated with the claims file. After reviewing the evidence of record, and in light of Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the claims relating to peripheral neuropathy have been recharacterized to appropriately address the scope of the Veteran’s claim. The medical evidence suggests that the condition the Veteran has claimed as peripheral neuropathy may be due to different or multiple neurological conditions, to include peripheral neuropathy or a seizure disorder. Service Connection for Hypertension The Veteran has filed a claim asserting he should be granted service connection for hypertension. Generally, service connection may be granted for disability or injury incurred in, or aggravated by, active military service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for a claimed disorder, there must be (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Hickson elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be supported by lay evidence. See Hickson at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Hypertension is considered a chronic disease. 38 C.F.R. § 3.309(a) Here the record is at least in equipoise as to whether the Veteran has a current disability of hypertension. VA rating regulations provide the disability of hypertension requires predominant diastolic blood pressure over 90 mmHg or greater or systolic blood pressure over 160 mmHG documented over three days with two readings. 38 C.F.R. § 4.104, DC 7101, Note 1. The Veteran reports that he was diagnosed with hypertension shortly after leaving service. The record indicates he had elevated blood pressure and was prescribed lisinopril to control his blood pressure as early as February 2013, the same year he left service. A treatment note from October 2013 notes his blood pressure is still going up to 150 mmHG/100 mmHG. Later in the record, the diagnosis is changed to hypertension. In November 2018, the Veteran’s medication is increased because his blood pressure is no longer controlled with the prior dosage. This evidence is persuasive that absent the Veteran’s medication his blood pressure readings would meet the definition of hypertension. Further, the diagnoses of hypertension by medical professionals in the record are presumed to have conformed with the definition of hypertension. C.f. Cohen v. Brown, 10 Vet. App. 128, 140 (1997) (finding a mental health professional’s diagnosis is presumed to conform to the DSM requirements). Thus, the absence of the specific blood pressure readings to support the diagnosis of hypertension is not, in and of itself evidence, against finding a current disability of hypertension. Given the formal diagnosis, consistent treatment with medication, the need to increase medication, and notation on the Veteran’s uncontrolled blood pressure readings, the evidence is at least in equipoise as to whether the Veteran has a current disability of hypertension. The current disability is preceded by continuous symptomology of high blood pressure that date back to the Veteran’s active service. There are at least four instances in the service treatment records where the Veteran’s diastolic blood pressure is above 90 mmHG. His blood pressure was officially monitored with 3-day checks. One of these checks occurred in December 2011, the Veteran’s records note the Veteran had isolated elevated blood pressure. This is sufficient to show the condition was noted in service. This elevated blood pressure has been continuously documented since separation of service. The Veteran separated on February 5, 2013. On February 13, 2013, eight days later, he filled his first prescription for lisinopril to treat elevated blood pressure. Records continue to note treatment until the diagnosis is changed to hypertension. Thus, the evidence is at least in equipoise as to whether the Veteran experienced continuous symptoms of high blood pressure since service. As the Veteran has the current chronic disability of hypertension and has experienced continuous symptoms since service, it is presumed that the disability is etiologically related to his service. Therefore, service connection for hypertension is warranted. REASONS FOR REMAND Service Connection for Hiatal Hernia and Acid Reflux. A remand is necessary to obtain an examination to determine the etiology of the Veteran’s hiatal hernia and acid reflux. VA is obligated to provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies; and (3) an indication that the disability or persistent/recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability; but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). Here the Veteran’s treatment records show both a diagnosis of a hiatal hernia and acid reflux, supported by a May 2013 EGD. The Veteran testified in June 2020 he had symptoms associated with his hiatal hernia and acid reflux, with nausea and heart burn for which he was told to take Pepcid. Given this testimony and the proximity of the EGD to the Veteran’s separation to service, it is reasonably plausible the hiatal hernia and acid reflux are related to service. Nevertheless, there is insufficient competent evidence in the claims file to show a medical nexus. Therefore, VA should have provided the Veteran with an examination to determine the etiology of the Veteran’s hiatal hernia and acid reflux. Additionally, the Veteran has submitted that his symptoms of hiatal hernia and acid reflux decreased when he began receiving treatment for his service-connected B-12 deficiency. This is sufficient to raise the theory of secondary service connection. This should be addressed in any opinion obtained from an examination. Service Connection for a Neurological Disability of the Right Upper, Left Upper, Right Lower, and Left Lower Extremities A remand is necessary to obtain a new examination to determine the nature and etiology of any neurological disability of the bilateral upper and lower extremities, which was claimed as peripheral neuropathy. An examination was performed in February 2016; however, this examination was inadequate for adjudicating the matter before the Board. When VA undertakes to provide an examination or obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, a new examination is necessary. The February 2016 examination concludes the Veteran does not have peripheral neuropathy. The examiner states that the Veteran’s August 2014 EMG showed normal results for the right upper, left upper, right lower, and left lower extremities; however, the only report on the EMG in the record notes that only nerves of the left lower extremity were tested. The same report also notes the results were suggestive of peripheral neuropathy, a diagnosis that is active in current treatment records. The examiner does not resolve these discrepancies. Further, the examiner does not address any other neurological conditions that may be present. Multiple notes indicate the symptoms the Veteran claims as peripheral neuropathy may be due to a seizure disorder. A January 2014 note states this expressly. An April 2014 note says a possible seizure disorder is suggested on an EMG. The Veteran is prescribed gabapentin for his symptoms and the record indicates this is for a seizure disorder. As the examination report is inconsistent with the record and does not address a possible seizure disorder, it is not adequate for adjudicating the matter before the Board. Thus, a remand is required. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. Schedule the Veteran for a VA examination for his hiatal hernia. The examiner must review the claims file. The examiner is asked to provide a response to the following: (a.) Is the Veteran’s hiatal hernia at least as likely as not related to service, including reports of nausea and acid reflux during service? (b.) Is the Veteran’s hiatal hernia at least as likely as not proximately due to any service-connected disability, to include a Vitamin B-12 and Vitamin D deficiency? (c.) Is the Veteran’s hiatal hernia at least as likely as not aggravated, i.e., worsened beyond its natural progression, by any service-connected disability, to include a Vitamin B-12 and Vitamin D deficiency? 3. Schedule the Veteran for a VA examination for his acid reflux. The examiner must review the claims file. The examiner is asked to provide a response to the following: (a.) Is the Veteran’s acid reflux at least as likely as not related to service, including reports of nausea and acid reflux during service? (b.) Is the Veteran’s acid reflux at least as likely as not proximately due to any service-connected disability, to include a Vitamin B-12 and Vitamin D deficiency? (c.) Is the Veteran’s acid reflux at least as likely as not aggravated, i.e., worsened beyond its natural progression, by any service-connected disability, to include a Vitamin B-12 and Vitamin D deficiency? 4. Schedule the Veteran for a VA examination to determine the nature and etiology of any neurological disability of the bilateral upper and lower extremities. The examiner must review the claims file. The examiner is asked to provide a response to the following: (a.) Identify any neurological disability of the bilateral upper and lower extremities, to include peripheral neuropathy and a seizure disorder. (b.) For each neurological disability identified, is the condition at least as likely as not related to service, including reports of nausea and acid reflux during service? (c.) For each neurological disability identified, is the condition at least as likely as not proximately due to any service-connected disability, to include cervical and lumbar disabilities and a Vitamin B-12 and Vitamin D deficiency? (d.) For each neurological disability identified, is the condition at least as likely as not aggravated, i.e., worsened beyond its natural progression, by any service-connected disability, to include a cervical and lumbar disabilities and a Vitamin B-12 and Vitamin D deficiency? K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Reed, 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.