Citation Nr: 21028713 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 14-00 077 DATE: May 11, 2021 ORDER Entitlement to service connection for hypertension, secondary to service-connected schizophrenia, is granted. FINDING OF FACT The evidence of record is at least in equipoise as to whether the Veteran's hypertension was caused, at least in part, by his service-connected schizophrenia. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension, secondary to service-connected schizophrenia, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from November 1989 to September 1990. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In February 2016, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the claims file. This case was previously before the Board in June 2016 and April 2018. In April 2018, the Board resolved other issues on appeal and remanded the issue of entitlement to service connection for hypertension for additional development of the evidence. The case has now returned to the Board for further appellate review. The Board notes that the Veteran has raised other appeals on other issues, but each other matter currently in appellate status is awaiting a Board hearing in accordance with the Veteran's requests. The Board notes that the Veteran's other appeal in VA's Legacy system was perfected with an April 2020 submission of a VA Form 9 on which the Veteran specifically requested an opportunity to testify at a Board hearing. 1. Entitlement to service connection for hypertension, secondary to service-connected schizophrenia, is granted. Service connection is warranted if it is shown that a veteran has a disability resulting from an injury incurred or a disease contracted in active duty service or for aggravation of a pre-existing injury or disease in active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing direct service connection generally requires competent evidence of: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Alternatively, a veteran can receive compensation via secondary service connection, which can be established when a disability is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. To be awarded secondary service connection, there must be evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Generally, the degree of probative value that may be attributed to a medical opinion issued by a VA or private treatment provider accounts for such factors as the opinion's thoroughness, degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians physically examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Here, the Veteran seeks entitlement to service connection for his hypertension, to include as secondary to his service-connected schizophrenia. The Board finds that the evidence is at least in equipoise as to whether the Veteran's hypertension was caused by or aggravated by his service-connected schizophrenia. As an initial matter, the record confirms that the Veteran has a current diagnosis of hypertension, including as confirmed by a November 2016 VA examination report. The Board additionally notes that the Veteran has established that his schizophrenia is a service-connected disorder, rated 100 percent disabling. The Board remanded this issue in April 2018 for additional development to inform a determination as to whether the Veteran's hypertension has been caused or aggravated by his service-connected schizophrenia. As noted by the Board in the April 2018 remand, a November 2016 VA examiner presented a medical opinion stating: most of this Veteran's inpatient admissions from 1993 to present have been Psychiatric treatment... And a result of his having either a manic, combative problem or having suicidal/homicidal ideations. Most of his admission drug screens were + for cocaine. Any one of these problems would raise his blood pressure. Having all three would almost guarantee a hypertensive range blood pressure. The Board notes that the November 2016 VA medical opinion is accompanied by a discussion citing and informed by the Veteran's pertinent medical history and the evidence of record. Significantly, after the Board's April 2018 remand, new caselaw has indicated that "[a] 'permanent worsening' standard has no application in cases involving an incremental increase in disability of a non-service-connected condition proximately due to or the result of a service-connected disease or injury." Ward v. Wilkie, 31 Vet. App. 233, 240 (2019). The Board notes that the January 2021 supplemental statement of the case (SSOC) states that "aggravation of a disability must be permanent" to establish entitlement to service connection, but the Board recognizes that permanence of worsening is not necessary to establish aggravation in a secondary service connection analysis. A May 2019 VA examiner explained that "[b]lood pressure can be elevated during acute phases of mental stress and/or in association with consumption of alcohol or cocaine; also mental health conditions can affect compliance with medications taken for blood pressure control." The May 2019 VA medical opinion reasoned: "Based on thus, it is as likely as not that hypertension can be aggravated by his mental health condition," although the VA examiner was unable to "determine baseline manifestations and additional manifestations due to aggravation without resorting to speculation." The May 2019 VA medical opinion includes citation on pertinent medical history and evidence of record. The May 2019 VA examiner remarked that "[t]he aggravation should not be permanent," but the Board again notes that permanence of worsening is not a requirement for aggravation to be shown for the purposes of establishing entitlement to service connection on a secondary basis. A January 2021 VA medical opinion concluded that it was unlikely that the Veteran's hypertension was caused or aggravated by his service-connected mental health disability, finding: "There is NO evidence of any aggravation beyond natural progression of HTN by SC psychiatric disorder." The author of the January 2021 VA medical opinion acknowledged the November 2016 VA medical opinion (by merely copying the text from the Board remand directing attention to the 2016 opinion), but does not meaningfully discuss it or rebut its analysis. The author of the January 2021 VA medical opinion does not acknowledge, discuss, or rebut the May 2019 VA medical opinion. The Board finds that each of the three VA medical opinions are competent medical evidence adequately informed by the Veteran's pertinent history and the most pertinent evidence of record. The Board finds that the November 2016 VA medical opinion links the Veteran's schizophrenia to his causes hypertension. The May 2019 VA medical opinion indicates that it is at least as likely as not that the Veteran's hypertension has been aggravated, with at least acute worsening, by the service-connected schizophrenia. The January 2021 VA medical opinion finds that such aggravation is unlikely, but the Board does not find that the January 2021 VA medical opinion has presented a sufficiently persuasive discussion of rationale or rebuttal of the contrary VA medical opinion to compellingly contradict them. The Board notes that the February 2021 SSOC indicates that the Agency of Original Jurisdiction (AOJ) considered the May 2019 VA medical opinion "to be inadequate as not all evidence had been received." However, the Board does not find that any significant information informing the January 2021 VA medical opinion's analysis that was not considered by the prior contrary VA medical opinions, and the Board does not find that the January 2021 VA medical opinion has persuasively contradicted the analysis of the prior contrary VA medical opinions. The Board finds that the November 2016 VA medical opinion indicates that the Veteran's "manic, combative problem[s]" and "suicidal/homicidal ideations" are among the elements contemplated when the expert concluded that "[a]ny one of these problems would raise his blood pressure." Furthermore, the November 2016 VA medical opinion indicates that combining these factors with the Veteran's substance abuse problems "would almost guarantee a hypertensive range blood pressure." Even setting aside any questions regarding the extent to which the Veteran's substance abuse issues may or may not be considered as part of the service-connected pathology for the purposes of this analysis, the Board finds that the November 2016 VA medical opinion strongly suggests that the manifestations of the Veteran's service-connected schizophrenia result in hypertension. The Board observes that if (1) any one of the three cited elements would raise the Veteran's blood pressure, and (2) all three together would "almost guarantee a hypertensive range blood pressure," the analysis reasonably suggests that two of the three elements (excluding consideration of substance abuse) would significantly raise blood pressure and would significantly increase the probability of a hypertensive range blood pressure to a degree less than "almost guarantee." The Board finds that this information supports a finding that the Veteran's service-connected schizophrenia is medically shown to have caused hypertension. The Board finds that the supportive November 2016 VA medical opinion is competent and probative evidence prepared by a qualified medical professional and citing the Veteran's medical history and general medical principles. The Board notes that 38 C.F.R. § 3.310(b) contemplates a baseline to assess the severity of a nonservice-connected disability that is aggravated by a service-connected disability. The evidence of record does not establish a precise pre-aggravation baseline level of severity of hypertension in this case. As a baseline has not been established, service connection on a secondary aggravation basis is not warranted. The November 2016 VA medical opinion reasonably suggests that the Veteran's psychiatric symptomatology can cause "a hypertensive range blood pressure" independent of the Veteran otherwise having developed essential hypertension, as discussed above. The Board is satisfied that such is sufficient to warrant entitlement to service connection for hypertension in this case. The Board finds that the evidence is at least in equipoise as to whether the Veteran's hypertension has been caused, at least in part, by his service-connected schizophrenia. Resolving any remaining doubt in the Veteran's favor, the Board finds that service connection for hypertension is warranted. The claim is therefore granted. 38 C.F.R. § 5107(b). M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Barone, 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.