Citation Nr: 22065166 Decision Date: 11/21/22 Archive Date: 11/21/22 DOCKET NO. 15-14 341A DATE: November 21, 2022 ORDER Entitlement to service connection for hypertension is granted. REMANDED Entitlement to service connection for rheumatoid arthritis or gouty arthritis, to include as secondary to service-connected lumbar spine disability and residuals of aspergillosis status post partial right upper lobectomy with restrictive ventilatory defect, is remanded. Entitlement to service connection for a cervical spine disorder, to include as secondary to service-connected thoracic and lumbar spine disabilities and residuals of aspergillosis status post partial right upper lobectomy with restrictive ventilatory defect, is remanded. Entitlement to service connection for benign prostatic hypertrophy (BPH), to include as secondary to service-connected renal lithiasis, is remanded. Entitlement to service connection for penis deformity and loss of erectile power, to include as secondary to service-connected thoracic and lumbar spine disabilities and renal lithiasis, is remanded. FINDING OF FACT The Veteran's hypertension manifested during active service. CONCLUSION OF LAW Hypertension was incurred in active service. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1976 to May 1998. This case comes before the Board of Veterans' Appeals (Board) on appeal from October 2011 and November 2012 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in November 2018. A transcript is of record. The record was held open for 60 days to allow for the submission of additional evidence. The Board remanded the case for further development in July 2019. The case has since been returned to the Board for appellate review. Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. As hypertension is considered to be a chronic disease for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including hypertension, are presumed to have been incurred in service if they manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); 38 C.F.R. § 3.310. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (benefit-of-the-doubt rule not for application when evidence persuasively favors one side or the other). In this decision, the blood pressure measurements are noted in units of pressure in millimeters of mercury (mmHg). For VA compensation purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 or greater; and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 or greater with diastolic blood pressure less than 90. In addition, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to service connection for hypertension. During a November 1976 enlistment examination, the Veteran's blood pressure was recorded as 150/88. He also denied having a medical history of high or low blood pressure, and a diagnosis of hypertension was not noted at that time. Therefore, the presumption of soundness applies in this case. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). There is also insufficient evidence to rebut the presumption of soundness. Indeed, a September 1980 retention examination shows the Veteran's blood pressure was normal level, and hypertension was not diagnosed at that time. Thereafter, a June 1987 service treatment record indicates that the Veteran had a blood pressure reading of 130/92. In March 1990, he was referred for a blood pressure check at which time his readings were recorded as 154/112, 130/100, and 140/98. A December 1990 service treatment record later documented him as having mild hypertension with two elevated blood pressure readings, and it was noted that he should be started on five milligrams of Enalapril, an ACE inhibitor used to treat high blood pressure. Subsequent records show that the Veteran's blood pressure was lower following the recommended prescription. The Veteran also reported having a medical history of high or low blood pressure in September 1997 and February 1998, and a November 1997 examination report documented a diastolic pressure reading of 90. Post-service treatment records show that the Veteran was treated for hypertension in September 1999, and he has a current diagnosis of hypertension. See e.g., August 2020 private medical record. Based on the foregoing, the Board finds that the Veteran's hypertension manifested in service. To determine that a chronic disease was "shown in service," the disease identity must be established and the diagnosis not subject to legitimate question. 38 C.F.R. § 3.303(b); Walker, supra. In this case, the Veteran's service treatment records show that he was documented as having hypertension during service for which medication was recommended. In reaching this determination, Board does acknowledge that a September 2020 VA examiner provided negative nexus opinions. However, the examiner did not address the blood pressure readings in service or the notation of mild hypertension and recommendation of medication documented in the service treatments records. Therefore, the Board finds that the opinion is inadequate. Based on the foregoing and resolving any reasonable doubt in favor of the Veteran, the Board concludes that service connection is warranted for hypertension. REASONS FOR REMAND Upon review, the Board finds that additional development is needed prior to adjudication of the issues remaining on appeal. Following the July 2019 remand, a March 2020 VA examiner provided negative nexus opinions regarding the Veteran's rheumatoid arthritis and gouty arthritis. However, the examiner did not address evidence suggesting that the Veteran's service-connected aspergillosis may have triggered reactive arthritis. Moreover, in a December 2020 appellate brief, the Veteran's representative challenged the examiner's reliance on a medical article, which addressed whether rheumatoid arthritis causes lung disease. Therefore, the Board finds that an additional VA medical opinion is needed. The Board also notes that a September 2020 VA examiner provided negative nexus opinions regarding the claim for service connection for a cervical spine disorder. In so doing, she stated that the Veteran has a cervical spine autoimmune condition of ankylosing spondylitis and explained that autoimmune conditions are not caused by external events and are instead conditions in which the immune system mistakenly attacks the body. However, a September 2011 VA examiner had diagnosed the Veteran with degenerative changes of the cervical spine, marked kyphosis and straightening of the cervical spine, and ankylosing spondylitis of the cervical spine. Thus, it is unclear as to whether the September 2020 VA examiner addressed all current cervical spine disorders. Therefore, the Board finds that an additional VA medical opinion is needed. In addition, a September 2020 VA examiner provided negative nexus opinions regarding BPH and erectile dysfunction, but the Board finds that they are inadequate. For example, regarding the aggravation prong of secondary service connection, the examiner merely stated that they are not related. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013); Atencio v. O'Rourke, 30 Vet. App. 74 (2018 (finding a medical opinion inadequate because it did not address aggravation and causation separately with rationale specific to those findings). Moreover, the Veteran's representative asserted that the VA examiner should have addressed the Veteran's reported environmental exposures in service, as well as his history of urinary tract infections, "intermittent episodes of gross hematuria" with "multiple small renal calculi," and the known side effects of medication(s) prescribed for the Veteran's service-connected disabilities. Therefore, the Board finds that an additional VA medical opinion is needed. The matters are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should obtain any outstanding VA medical records. 2. After completing the foregoing development, the AOJ should refer the Veteran's claims file to a VA examiner for a medical opinion as to the nature and etiology of any rheumatoid arthritis or gouty arthritis that may be present. A physical examination is only needed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, November 2018 hearing transcript, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should provide an opinion as to whether the Veteran has current rheumatoid arthritis or gouty arthritis that is causally or etiologically related to his military service. The examiner should also opine as to whether the Veteran has rheumatoid arthritis or gouty arthritis that is caused by or aggravated by his service-connected thoracic and lumbar spine disabilities and residuals of aspergillosis status post partial right upper lobectomy with restrictive ventilatory defect. The examiner should address whether the infection of aspergillosis may have triggered a reactive arthritis causing seronegative inflammatory arthritis and spondyloarthropathy resulting in limited mobility in the cervical and thoracic spine. See September 2005 and July 2006 private medical records. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After obtaining any outstanding records, the AOJ should refer the Veteran's claims file to a VA examiner for a medical opinion as to the nature and etiology of any cervical spine disorder that may be present. A physical examination is only needed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, November 2018 hearing transcript, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should identify all current cervical spine disorders, including any degenerative changes of the cervical spine, marked kyphosis and straightening of the cervical spine, and ankylosing spondylitis of the cervical spine. If he or she determines that the Veteran does not have one of those disorders, he or she should discuss whether they were misdiagnosed or resolved and provide an explanation. For each diagnosis identified, the examiner should opine as to whether the disorder is causally or etiologically related to his military service. The examiner should also opine as to whether the Veteran has a cervical spine disorder that is caused by or aggravated by his service-connected thoracic and lumbar spine disabilities and residuals of aspergillosis status-post partial right upper lobectomy with restrictive ventilatory defect. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. After obtaining any outstanding records, AOJ should refer the Veteran's claims file to a VA examiner for a medical opinion as to the nature and etiology of any penis deformity, loss of erectile power, and benign prostatic hypertrophy may be present. A physical examination is only needed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, November 2018 hearing transcript, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether the Veteran has a penis deformity, loss of erectile power, and benign prostatic hypertrophy that is causally or etiologically related to his military service, to include any environmental exposures therein. The examiner should also opine as to whether the Veteran has a penis deformity, loss of erectile power, and prostatic hypertrophy that are caused by or aggravated by any service-connected disabilities, including thoracic and lumbar spine disabilities and renal lithiasis. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. The AOJ should ensure compliance with the preceding directives and conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Kuczynski, 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.