Citation Nr: 21029744 Decision Date: 05/14/21 Archive Date: 05/14/21 DOCKET NO. 16-09 258 DATE: May 14, 2021 ORDER Entitlement to service connection for hypertension is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his hypertension is at least as likely as not related to active service. CONCLUSION OF LAW The criteria for establishing entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had honorable active duty service with the United States Navy from November 1984 to November 1988, with an additional period of service in the Navy Reserves. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2019, the Veteran and his spouse testified at a hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the Veteran's electronic claims file. Pursuant to an October 2019 Board decision, this matter was remanded for additional development to include scheduling the Veteran for a new VA examination. As the requested development is now complete, this matter has been returned to the Board for appellate consideration. Duty to Assist and to Notify The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2020). As the Board's decision to grant service connection for hypertension herein constitutes a complete grant of the benefits sought on appeal, no further action is required to comply with the VCAA and the implementing regulations. Service connection, generally Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C. § 1110, 1131 (2012); 38 C.F.R. §§ 3.303 (a), 3.304 (2020). Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the medical 'nexus' requirement). See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a) (2020). Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2020); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. Id. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant). Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue. 1. Entitlement to service connection for hypertension The Veteran contends that he is entitled to service connection for hypertension as causally related to active service. Resolving all doubt in the Veteran's favor, the Board finds that the evidence is in relative equipoise with his claim for service connection for a hypertension. On review of the record, the Board concludes that the Veteran's current diagnosis of hypertension began during or is otherwise etiologically related to active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). Review of service treatment records found no physical abnormalities at enlistment in July 1984. However, the Veteran's weight was documented as 209 pounds (lbs.) and his blood pressure (BP) was 138/80. A blood pressure reading of 120/80 or above is considered Stage 1 hypertension. Nevertheless, the Veteran was deemed qualified for active service. Subsequent blood pressure readings included a BP of 130/82 in July 1985. During a separation examination in October 1988, the Veteran's blood pressure was 130/72. This reading is consistent with an elevated systolic blood pressure. During a separate period of Reserve service, treatment records show a history of elevated blood pressure. A physical examination revealed a blood pressure of 142/76. His cardiovascular system was deemed within normal range in April 1993. An annual certification of physical condition, dated June 1995, listed a BP of 138/60. In June 1997, participation in a wellness program was recommended. The Veteran endorsed current treatment for hypertension with use of oral prescription medications. A weight reduction plan with blood pressure monitoring was also recommended. His blood pressure was listed as 148/110. In July 1997, a hypertension assessment from baxter medical clinic listed the Veteran's condition as well-controlled with oral medication. His weight was listed as 272 lbs. with a BP of 142/92. A separate annual certification, dated February 1998, recorded the Veteran's blood pressure as 147/110. Post service treatment records indicate that the Veteran continued to receive treatment for hypertension. In January 2006, the Veteran was admitted to the hospital for an acute stroke, with white matter in the left hemisphere. Current diagnoses of hypertension and morbid obesity were also noted. Other treatment records document current diagnoses of benign essential hypertension; malignant hypertension, hyperlipidemia, and morbid obesity. In November 2018, the Veteran's hypertension was described as well controlled with oral medications and a low fat/low cholesterol diet. Pursuant to a Board remand decision, the Veteran's claim was remanded to obtain a VA etiological opinion. In October 2020, following a review of the available medical evidence and the Veteran's lay assertions, the VA examiner opined that it is at least as likely as not that the Veteran's hypertension manifested during active duty service. In support of the stated conclusion, the examiner noted that service records show elevations in pressure, particularly diastolic readings in the 90s and one noted at 100. No blood pressure readings were noted during a separation physical. According to the Veteran, an initial diagnosis of hypertension was rendered within one month of separation; oral medications were prescribed to manage his condition. Given the Veteran's lay assertions (taken as credible), along with elevated blood pressures in service and the short period of time between separation (one month) and the alleged prescription of hypertensive medications, a causal linkage was established. Two months later, in December 2020, an addendum medical opinion was prepared to resolve the apparent conflicting findings. Therein, the examiner noted that the opinion was based upon review of currently available medical records to include service treatment records that show a BP of 138/80 at enlistment in July 1984, with no reference to a current diagnosis of hypertension. Other service treatment records note elevated blood pressures in July 1987 and October 1987. In July 1985, a dental questionnaire indicated that the Veteran denied any experience with high blood pressure. His BP was listed as 130/82. At separation, in September 1988, no diagnosis of hypertension was indicated. His BP was listed as 130/72. Treatment records related to the Veteran's period of reserve service document the Veteran's blood pressure as 138/60, in September 1991. The Veteran denied any current problem with hypertension in April 1993. In June 1996, a family medicine consultation suggested a current diagnosis of hypertension. The Veteran's blood pressure was listed as 162/112 and 160/104. Periodic physical notes, dated April 1997, indicated a favorable response to an inquiry regarding hypertension and suggested prescribed medications. The Veteran's blood pressure was listed as 166/118. Continued weight and BP monitoring was noted. In June 1997, the Veteran's blood pressures were listed as 148/110, 162/114, and 158/112. In July 1997, prescribed medications included antihypertensive Sular and Dyazide. Blood pressures were listed as 150/100, 140/92. In September 1998, the Veteran's blood pressure was 108/76. Considering the documented active duty service from November 1984 to November 1988, the examiner opined that it is less likely than not that the Veteran's hypertension was incurred in or is otherwise causally related to active service. As an established diagnosis of hypertension was first listed on or about 1997, to include use of oral prescription medication and an onset of symptomology on or about 1996, a nexus could not be established as separation occurred 8 to 9 years earlier. Upon careful review of the record and resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for hypertension is warranted. While the December 2020 VA examiner's negative etiological opinion is acknowledged, the Board must fully consider all medical evidence and lay assertions of record. Generally, the Veteran is presumed competent to report on the onset of current symptoms, their impact on daily living and employment, and such reporting is deemed credible. See Charles v. Principi, 16 Vet. App. 370 (2002). In this case, a favorable VA opinion was provided in October 2020. Therein, the examiner acknowledged a review of the claims file, to include the documented elevated blood pressures in service and lay reporting of a formal diagnosis of hypertension within one month of separation. In support of the stated conclusion, the examiner noted that service records show elevations in pressure, particularly diastolic readings in the 90s and one noted at 100. According to the Veteran, an initial diagnosis of hypertension was rendered within one month of separation and oral medications were prescribed to manage his condition. Under the circumstances, his lay contentions were deemed credible. Although consideration has been given to the negative opinion provided in December 2020, to include its conclusion that a formal diagnosis was first rendered in 1997, the Board cannot ignore the Veteran's lay contention that oral medications were prescribed to treat hypertension within one year of separation from his initial period of service, or in 1988 (8 or 9 years earlier). Accordingly, the October 2020 VA opinion is accorded great probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Specifically, the Board observes that the examiner failed to fully address service treatment records suggesting elevated blood pressures in-service or provide a rational for discounting the Veteran's lay assertion of a post-service diagnosis of hypertension within one month of separation. As the record shows in-service complaints of symptoms and a self-reported diagnosis in close proximity to separation, it is not necessary to address the contention that an initial diagnosis was first rendered in 1997. See 38 U.S.C. § 5103 (d) (2012); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Further, the Court has cautioned VA against seeking a medical opinion where favorable evidence in the record is unrefuted. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003). (Continued on the next page) In summary, the evidence is at least in equipoise that the Veteran's currently diagnosed hypertension had its onset during his active duty service. Accordingly, the Veteran is afforded the benefit of the doubt; therefore, service connection is granted. See 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 3.102 (2020); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Whitaker, 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.