Citation Nr: 21042176 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 13-01 431 DATE: July 12, 2021 ORDER Service connection for hypertension, to include as secondary to service-connected type II diabetes mellitus, is denied. VETERAN'S CONTENTIONS The Veteran contends that he has hypertension secondary to service-connected type II diabetes mellitus, to include as a result of medication prescribed to treat his service-connected type II diabetes mellitus. REMANDED The issue of entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT The Veteran's hypertension is not attributable to his active service or any incident of service, to include as secondary to service-connected type II diabetes mellitus and prescribed medications. CONCLUSION OF LAW The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1968 to January 1970. These matters come to the Board of Veteran's Appeals (Board) on appeal from a July 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. Jurisdiction is currently with the RO in Portland, Oregon. The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) via videoconference in March 2017. A transcript of the hearing is of record. These claims were previously before the Board at which times the Board remanded them for additional development. Entitlement to service connection for hypertension, to include as secondary to service-connected type II diabetes mellitus Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (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 Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Service connection may also be granted through the application of statutory presumptions for chronic conditions. See 38 U.S.C. §§ 1101 (3), 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303 (b), 3.307(a)(3), 3.309(a). Cardiovascular-renal disease is classified as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) also applies. 38 C.F.R. § 3.307; Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013). Presumptive service connection for "chronic diseases" must be considered on three bases: chronicity during service, continuity of symptomatology since service, and manifestations within one year of the claimant's separation from service. 38 C.F.R. § 3.303(b); Walker, 708 F.3d at 1336-38. The application of these presumptions operates to satisfy the "in-service incurrence or aggravation" element and establish a nexus between service and a current disability, which must be found before entitlement to service connection can be granted. Further, service connection may be established on a secondary basis for a disability which was either caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical evidence. VA must also consider all favorable lay evidence of record. See 38 U.S.C. § 5107 (b); see also Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (a Veteran is competent to report on that of which he or she has actually observed and is within the realm of his or her personal knowledge). Here, in addressing the criterion of a current disability, May 2010, October 2017, and March 2021 VA Hypertension examination reports confirm a current diagnosis of hypertension. In addressing in-service incurrence, the Veteran's service treatment records (STRs) are void of diagnosis of or treatment for hypertension. He is, however, service-connected for diabetes mellitus. In addressing nexus, to the extent that the Veteran has stated that he has hypertension attributable to service, the Board finds that he is competent to report on his symptoms and that of which he has personal knowledge, but he is not competent to provide an opinion as to the etiology of his disability because such a question is not answerable by the application of knowledge within the realm of a lay person. See Layno, 6 Vet. App. at 469-70; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Here, because the etiology of hypertension may be multifactorial, and the Veteran lacks the requisite expertise, he is not competent to offer an opinion as to a relationship to service. The evidence of record otherwise includes a May 2010 VA opinion that the present diagnosis of hypertension was less likely than not secondary to diabetes. The examiner reasoned that the Veteran's renal functions were normal. In July 2017, the Board remanded the Veteran's claim to obtain an addendum opinion addressing aggravation. In an October 2017 addendum, a VA examiner opined that it was less likely than not that the Veteran's hypertension was related to service. The examiner reasoned that the Veteran's service records do not support a diagnosis of hypertension. The examiner also opined that it was less likely than not that the Veteran's hypertension was caused or aggravated (permanently worsened beyond the natural progression) by the Veteran's service-connected diabetes mellitus. The examiner reasoned that the Veteran's microalbumin/creatinine ration has been less than 5. There is no proteinuria or renal insufficiency to determine his hypertension was aggravated or permanently worsened beyond the natural progression by the Veteran's service-connected diabetes mellitus. In August 2020, the Board remanded the Veteran's claim to obtain an addendum opinion addressing whether the Veteran has hypertension secondary to medication used to treat his service-connected type II diabetes mellitus. In a March 2021 addendum, a VA examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition. The examiner reasoned that the Veteran reported during his 2001 VA examination that his diabetes started in 1988 and his hypertension started about ten years prior to that encounter, which would have been in 1991. During his VA examination in 2010, the Veteran reported an onset of hypertension and diabetes 22 years prior which puts the diagnosis for both in 1988, however, there are no records from this time period. The first documentation of elevated blood pressure was in November 2001 during a VA outpatient visit, but no diagnosis was given. The first diagnosis of hypertension was in December 2001 and it is unclear whether the diagnosis was due to the Veteran's report or due to review of previous blood pressure. The record also documents a diagnosis of diabetes from this point onward. The examiner also opined that it was less likely than not that the Veteran's hypertension was caused by his diabetes or his medication. The examiner reasoned that secondary hypertension should be suspected in the presence of suggestive signs and symptoms such as severe or resistant hypertension, onset before 30 years of age (especially before puberty), and malignant or accelerated hypertension. Common causes of secondary hypertension include renal parenchymal disease, renovascular disease, drug-induced causes, pregnancy primary aldosteronism, and obstructive sleep apnea. Uncommon causes of secondary hypertension include, acromegaly, hyperthyroidism, hypothyroidism, hyperparathyroidism, Cushing syndrome, apparent mineralocorticoid excess, carcinoid syndrome, congenital adrenal hyperplasia, coarctation of the aorta, and neurological causes. At the time of his diagnosis the only diabetes medication prescribed was glipizide which is not considered one of the medications that causes drug induced secondary hypertension. The examiner further reasoned that the Veteran was diagnosed with essential hypertension. This means that the etiology of his hypertension remains "essential" in nature and not explained by underlying cause. Additionally, diabetes and hypertension have significant overlap in etiology and disease mechanisms which would include shared risk factors such as obesity, inflammation, oxidative stress, insulin resistance, and atherosclerosis and commonly occur together with no causal relationship. Lastly, the examiner opined that it was less likely than not that the Veteran's hypertension was aggravated beyond its natural progression by his service-connected diabetes mellitus. The examiner reasoned that the record documents that the Veteran required an increase in his blood pressure medication in 2008. At the time the Veteran was taking glipizide and metformin for his diabetes. Metformin is associated with hypotension not hypertension and glipizide has a less than 1 percent change of causing hypertension, Given that Metformin is not associated with hypertension and the Veteran had taken glipizide for years with no change in dosage at the time of increase in blood pressure, and the low risk of hypertension, it is less likely than not that the Veteran's hypertension was aggravated by his medication for diabetes. The Board finds the May 2010, October 2017, and March 2021 VA examiner opinions to be highly probative. The opinions were based on a review of the claims file, relevant facts, and peer reviewed medical literature, and the examiners provided a detailed rationale. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). There is no competent evidence to the contrary. In sum, without any competent evidence that the Veteran has hypertension related to service, direct service connection is not warranted. Additionally, there is no indication that the condition manifested within one year of service. The Board finds that the Veteran's hypertension did not have its clinical onset in service, or within one year of his discharge from active service and is not otherwise related to a period of active service, including secondary to service-connected type II diabetes mellitus; therefore, service connection is not warranted. There is no doubt to be resolved in this case. 38 U.S.C. § 5107. REASONS FOR REMAND Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. To ensure that there is a complete record, the Board will remand the issue of entitlement to a TDIU in order for the Veteran to provide a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, which is needed to adjudicate the claim, and to conduct any other necessary development related to establishment of a TDIU. Additionally, a TDIU may be assigned, if the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability it is ratable at 60 percent or more, and that if there are two or more such disabilities at least one is ratable at 40 percent or more and the combined rating is 70 percent or more. 38 C.F.R. § 4.16 (a). Here, the Veteran is service connected for posttraumatic stress disorder rated as 30 percent disabling; type II diabetes mellitus rated as 20 percent disabling; pilonidal cyst postoperative rated as 10 percent disabling; glaucoma rated as 10 percent disabling; shell fragment wound, left arm, with retained foreign bodies rated as 10 percent disabling; residuals, left knee injury rated as 10 percent disabling; and shell fragment wounds, left leg rated as noncompensable. As the Veteran does not have one disability ratable at 60 percent or more, or two or more disabilities with at least one ratable at 40 percent or more and the combined rating is 70 percent or more, he does not meet the threshold requirements for TDIU under 38 C.F.R. § 4.16(a). However, where the percentage requirements for a schedular TDIU are not met, entitlement to the benefits on an extraschedular basis may be considered where the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. See 38 C.F.R. § 4.16(b). In this regard, in a July 2010 correspondence, the Veteran reported limitation in motion and inability to lift or push anything heavy due to pilonidal cyst scar. He further reported that the scar was unstable and painful and constantly draining with infection. A May 2010 VA examiner documented draining serous fluid on the right side of the scar. An October 2017 VA examiner opined that the Veteran's service-connected impacts his ability to work in that the Veteran reported recurrent inflammation causes pain and drainage. As he sits or bends, the natal cleft stretches, damaging or breaking hair follicles and opening a pore or 'pit'. The pores collect debris and serve as fertile environment for roots of hairs shed from the head, back, or buttocks to lodge and become embedded. As the skin is drawn taut over the natal cleft with movement, negative pressure is created in the subcutaneous space, drawing hair deeper into the pore, and the friction causes the hairs to form a sinus. Pilonidal disease typically develops in people with deep natal clefts as this veteran. Given that the record reflects that the Veteran's service-connected disability may have presented an exceptional disability picture and may have prevented him from obtaining or maintaining substantially gainful employment, the Board finds that the case should be referred to the Director of Compensation & Pension Service for extraschedular consideration. 38 C.F.R. § 4.16(b) (rating boards should submit to the Director, Compensation Service, for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the TDIU threshold percentage standards.) Along with the claims file, a full statement should be provided that includes the Veteran's service-connected disabilities, employment history, educational and vocational attainment, and any other factors having a bearing on the issue. Id. The matters are REMANDED for the following action: 1. Request that the Veteran provide or authorize VA to obtain records of his relevant treatment and employment that have not yet been associated with the claims file, and associate with the claims file any outstanding VA treatment records. 2. Send the appropriate Veterans Claims Assistance Act (VCAA) notice advising the Veteran of the requirements for substantiating a TDIU and ask the Veteran to complete a VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability) to provide relevant information concerning his work and educational history. 3. Notify the Veteran that he may submit statements from himself and others who have first-hand knowledge as to the impact that his service-connected disabilities have had on his ability to work. 4. Refer the issue of entitlement to a TDIU to the Director, Compensation Service, for extra-schedular consideration. S.C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Smith-Jennings, 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.