Citation Nr: 21028865 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-32 949 DATE: May 12, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected irritable bowel syndrome (IBS)/ulcerative colitis, is denied. FINDING OF FACT The Veteran's hypertension did not manifest during active service or within one year of discharge from active service, and there is no indication that his hypertension is otherwise related to his active service or a service-connected disability. CONCLUSION OF LAW The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1101, 1112, 1131, 1137, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from March 1985 to October 1987 in the United States Marine Corps (USMC). This case initially came before the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). In February 2018, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In an August 2018 decision, the Board denied service connection for hypertension. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In a February 2020 Memorandum Decision, the Court vacated that portion of the Board's decision and remanded the matter back to the Board for additional consideration and readjudication. In October 2020, the Board remanded the claim for additional development. The case has since been returned to the Board for further appellate review. Service Connection Hypertension The Veteran maintains that his hypertension manifested during service and went undiagnosed/untreated for many years. Alternatively, he asserts that his hypertension is caused or aggravated by his service-connected IBS/ulcerative colitis. For VA purposes, hypertension is generally defined as diastolic pressure, which is predominantly 90 mm or greater and isolated systolic hypertension is defined as systolic blood pressure predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. Hypertension or isolated systolic hypertension must generally be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 (2020). The Veteran's service treatment records are unremarkable for a diagnosis of hypertension. The Veteran's blood pressure was 144/100, 152/94, and 110/68 in May 1985. His blood pressure was 120/72 and 120/68 in August 1985; 120/70 in September 1985; 126/74 in October 1985; 100/60 in January 1986; 144/70 and 98/60 in February 1986; 102/60 in March 1986; 130/80, 120/78, and 120/72 in April 1986; 138/80, 102/76, 130/60, and 120/74 in May 1986; 130/80, 104/70, 126/70, and 128/70 in June 1986; 110/72 in September 1986; 116/70 and 104/66 in August 1986; 130/60, 118/56, 110/70, and 120/60 in October 1986; 120/70 in March 1987; 130/80 in April 1987; 110/80 and 130/80 in June 1987; 142/76 and 144/80 in July 1987; and 144/80 in September 1987. A record with an illegible date noted that his blood pressure was 124/60. In the year following separation from active service, VA treatment records indicated that the Veteran's blood pressure was 112/88 and 136/54 in March 1988. During an August 1988 VA examination for his back, his blood pressure was 120/64, 130/70, and 130/70. A November 2005 VA treatment record indicated that the Veteran denied a history of hypertension. An August 2009 VA treatment record noted that the Veteran's blood pressure was 145/75. The clinician noted that they would concentrate on his hypertension and lipids. He was counseled regarding his diet and it was recommended that follow a low-calorie, low-fat diet with no added salt. Regular exercise was also recommended. It was noted that he was assessed with hypertension and that his blood pressure was at ideal without medication. At a February 2009 follow-up appointment, his blood pressure was 134/82. It was noted that his blood pressure was at ideal with no medication. An October 2010 VA nursing record indicated that the Veteran reported a history of hypertension. An October 2012 VA dental record indicated that the Veteran reported that he had just been diagnosed with hypertension; however, the clinician indicated that he was not being treated for hypertension. His pre-operative blood pressure was 162/82, and he was directed to consult with his primary physician. An October 2012 telephone record indicated that he reported that he had been told off and on for 27 years that he was hypertensive but was never treated for it. An October 2012 VA treatment record noted that the Veteran was concerned about his blood pressure. He stated that he went to the dental clinic and that his blood pressure was evaluated. He indicated that the dental clinic opted not to continue with the dental procedure and that he was told to see his primary care provider. The clinician reviewed the data and noted that the Veteran's blood pressure had been elevated at times but not to the point requiring long term treatment. The clinician noted that he had reviewed all the medications and that the Veteran had no past history of any prescriptions for blood pressure. On examination, his blood pressure was 137/68, 126/60, and 110/60. The clinician noted that the suspected elevated blood pressure of 162/80 was possibly apprehension about the dental procedure and that there was no evidence at that time to suspect he had hypertension that needed to be treated. During a March 2017 VA examination, the Veteran reported that he had numerous high blood pressure readings but had never been diagnosed with hypertension or placed on medications. The examiner noted that his blood pressure was 128/74 in December 2016, 144/91 in January 2017, and 128/81 in March 2017, and that his average blood pressure reading was 133/82. When asked if the Veteran now had or had been diagnosed with hypertension, the examiner indicated "yes," but noted that the Veteran had never been given medication for that diagnosis. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale, the examiner stated that the Veteran had not been diagnosed with hypertension. A May 2017 VA treatment record indicated that the Veteran did not meet the Care Coordination Home Telehealth (CCHT) criteria for hypertension. It was noted that he did not take any hypertension medications. The clinician suggested that he self-monitor his blood pressure and bring a written log to his Patient Aligned Care Team (PACT) appointment. A June 2018 VA treatment record indicated that the Veteran's blood pressure was 159/93. It was noted that he had elevated blood pressure and he was started on hydrochlorothiazide (HCTZ). He returned in two weeks for a blood pressure check. His blood pressure was 130/80. He stated he was taking his medications every day. It was noted that he would continue with HCTZ and a low-salt diet. In February 2019, it was noted that the Veteran's hypertension was stable and that he was taking HCTZ and on a low-salt diet. In a February 2020 Memorandum Decision, the Court noted that the parties agreed that the March 2017 VA examination report contained conflicting findings as to whether the Veteran had hypertension, which the Board did not address. Therefore, the Court vacated the portion of the Board's decision that denied service connection for hypertension and remanded the matter. In October 2020, the Board remanded the claim for an additional VA examination. A VA examination was conducted in January 2021. The Veteran reported that his hypertension began in 1985 after an injury in boot camp. He stated that he had chronic pain, chest inflammation, light headache, blurred vision, confusion, night sweats, sleep problems, and blood in his urine. He stated that he was put on HCTZ in 2018. The examiner noted that the Veteran's blood pressure was 154/80, 164/84, and 164/84 in January 2020, and that he was diagnosed with hypertension in 2018. The examiner opined that it was less likely than not that hypertension was incurred in or caused by service. The examiner noted that the Veteran had several elevated blood pressure readings during service but that those readings were episodic and isolated occurrences. The examiner stated that the elevated readings were likely due to flare-ups of his chronic low back pain. The examiner further noted that he was not put on HCTZ until 2018, several years after exiting service. The examiner also opined that his hypertension was less likely than not proximately due to or the result of his service-connected IBS/ulcerative colitis. The examiner noted that the conditions were not medically related and that they were separate disorders. The examiner noted that the medical literature did not support a relationship between the two conditions. Regarding whether his hypertension was aggravated by his service-connected IBS/ulcerative colitis, the examiner indicated that she could not determine a baseline level of severity based on the available medical evidence, noting that the medical records did not provide enough history regarding the onset and/or progression of hypertension to determine a baseline level of severity. In addition, she opined that it was less likely as not that his hypertension was aggravated beyond its nature progression by his service-connected IBS/ulcerative colitis, noting that there was no evidence of permanent aggravation beyond the normal progression identified. In this case, the Board finds the most probative evidence weighs against the claim. Although the Veteran had several elevated blood pressure readings during active service, his blood pressure readings were predominantly within normal range. In addition, there is no evidence of hypertension within one year of separation from active service. The first objective evidence of the claimed disability occurred many years after service. The passage of time between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Furthermore, the January 2021 VA examiner opined that the Veteran's hypertension was less likely than incurred in or related to service, and was less likely than not caused or aggravated by his service-connected IBS/ulcerative colitis. Although the Veteran's attorney argues that the examiner did not review all the medical evidence, the examiner noted in her report that she reviewed the electronic claims file and noted several elevated blood pressure readings during active service, which the Veteran asserts was evidence of hypertension left undiagnosed and untreated. However, the examiner explained that those were isolated readings and likely related to chronic pain. The examiner considered and addressed the relevant evidence of record, the Veteran's contentions, and provided rationale for her opinions. For this reason, the Board finds the VA examiner's opinion significantly probative. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). While the Veteran's attorney may disagree with the VA examiner's conclusion, he has offered no medical opinions to the contrary. (Continued on the next page) The Board has also considered the lay evidence of record. The Veteran is competent to describe what he has personally observed or experienced. However, to the extent his statements conflict with the contemporaneous medical evidence, the Board does not find them credible. Furthermore, the ultimate questions of diagnoses and etiology in this case extend beyond an immediately observable cause-and-effect relationship and are beyond the competence of lay witnesses. Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for hypertension is not warranted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Mishalanie, 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.