Citation Nr: 22018702 Decision Date: 03/30/22 Archive Date: 03/30/22 DOCKET NO. 16-33 280 DATE: March 30, 2022 ORDER 1. Entitlement to service connection for hypertension, to include as secondary to the service-connected posttraumatic stress disorder (PTSD) is denied. 2. Entitlement to service connection for aortic aneurysm, to include as secondary to hypertension is denied. 3. Prior to September 23, 2020, a compensable disability rating for erectile dysfunction is denied. 4. Since September 23, 2020, a rating in excess of 20 percent for erectile dysfunction with penile abnormality is denied. 5. Entitlement to a compensable disability rating for bilateral hearing loss is denied. FINDINGS OF FACT 1. The evidence of record is against a finding that the Veteran's hypertension is caused or aggravated by his service or his service-connected disabilities. 2. The evidence of record is against a finding that the Veteran's aortic aneurysm is caused or aggravated by his service or his service-connected disabilities. 3. The evidence of record establishes that the Veteran experiences Level I hearing loss bilaterally. 4. Prior to September 23, 2020, the Veteran's erectile dysfunction has been manifested by loss of erectile power without deformity of the penis; since that date, there is no unusual or exceptional disability picture. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension, to include as secondary to service-connected PTSD, have not been met. 38 U.S.C. §§ 1101, 1110; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385. 2. The criteria for service connection for aortic aneurysm, to include as secondary to service-connected disabilities, have not been met. 38 U.S.C. §§ 1101, 1110; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385. 3. The criteria for a compensable disability rating evaluation for the service-connected bilateral hearing loss are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.10, 4.21, 4.85, 4.86 Diagnostic Code (DC) 6100. 4. Prior to September 23, 2020, the criteria for an initial compensable initial rating for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; C.F.R §§ 4.3, 4.7, 4.115b, DC 7599-7522. 5. Since September 23, 2020, the criteria for a rating in excess of 20 percent for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; C.F.R §§ 4.3, 4.7, 4.115b, DC 7599-7522. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1967 to September 1970. These matters come before the Board of Veterans' appeals (Board) on appeal from April 2014, May 2014, and November 2017 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2021 the Board remanded the issues of entitlement to service connection for hypertension, right ear hearing loss, and an aortic aneurysm as well as the claims for increased ratings for left ear hearing loss, residuals of prostate cancer, and erectile dysfunction for further development. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). To establish compensation for a particular disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). In determining whether service connection is warranted for a disability, the VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant 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; 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, the benefit of the doubt is afforded the claimant. 1. Hypertension The Veteran asserts that his hypertension is due to his service, to include as secondary to his service-connected PTSD. A claim for secondary service connection includes a claim for direct service connection. The elements for service connection were previously noted herein. The Veteran has satisfied the first prong of service connection by showing a present disability hypertension. The question then turns on whether there is an in-service event and on whether there is a nexus between such an in-service event and the Veteran's present hypertension. The Board finds that there is no in-service event regarding the Veteran's hypertension. Specifically, there is no documentation in the service treatment records (STRs) of the Veteran ever having been treated for any hypertensive disability. The Veteran has not presented any evidence showing an in-service event or a link between such an in-service event and his present hypertension. As such, the Veteran's claim for direct service connection for hypertension is not warranted. Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. To prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran has satisfied the first two elements for a secondary service connection through a qualifying disability hypertension, and a service-connected disability of PTSD. Thus, the determinative question is whether there is a nexus between the Veteran's hypertension and his service-connected PTSD. The record reflects that the Veteran underwent a VA hypertension examination in May 2014. The examiner opined that the Veteran's hypertension was less likely than not caused or aggravated by his PTSD. The rationale was that the Veteran had issues with PTSD for over 40 years, but that his hypertension did not become an issue until around 2008. The examiner also stated that there was no indication in the medical documents to suggest that high blood pressure was caused or aggravated by his PTSD, and that it was likely a consequence of excess weight and advancing age. No other explanation was provided. The Veteran provided a private medical opinion from October 2017. Here the examiner cited medical research supporting a link between mental health conditions, like depression and anxiety, and hypertension. The examiner also noted that the May 2014 VA examiner did not discuss these comorbidities when reaching their conclusion. The examiner concluded with the statement that the Veteran's PTSD "contributes materially and substantially to both the onset and permanent aggravation" of the Veteran's hypertension. In February 2019, the Board found this examination inadequate as the examiner did not provide a clear explanation as to why it was less likely than not that the Veteran's hypertension was aggravated by his PTSD. Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (an adequate examination must support its conclusion with an analysis that can be weighed against contrary opinions). A new VA opinion was obtained in November 2021. Here the examiner provided a negative secondary causation and aggravation opinions. The examiner provided the rationale that the current, widely accepted, peer-reviewed literature has not established PTSD and related psychological comorbidities, including anxiety, depression, panic disorders, etc. as a cause of essential hypertension. By definition, essential hypertension is not caused by any other condition. This includes a respected professional medical resource wherein one may access current professional treatises and studies. No articles were returned supporting a cause or aggravation link for the psychological conditions and hypertension. The examiner addressed the articles that the Veteran submitted, stating that the articles cited noted a possible association between PTSD, and related psychological comorbidities, and depression but did not establish cause or aggravation. The authors merely concluded that further research with appropriately designed studies is required to determine the relationship between these conditions and hypertension. Though anxiety, stress, activity, panic attacks, a startling event, etc. may temporarily elevate one's blood pressure, this resolves following the abatement of the stimulus and the autonomic. It does not constitute aggravation as it does not impact the baseline condition. Furthermore, there is no evidence of aggravation of the veteran's hypertension beyond its natural course due to any cause, including PTSD and related psychological comorbidities. Adjustments and dosages or changes in medication are common throughout the course of essential hypertension and do not constitute aggravation beyond the natural course. In summary, it is less likely than not that the veteran's hypertension is due to or incurred in PTSD and related psychological comorbidities. It is less likely than not that it has been aggravated beyond its natural course due to any cause, including PTSD and related psychological comorbidities. The Board finds the November 2021 VA examiners opinion of significant weight for the following reasons. First, the examiner made their opinion after a complete and thorough review of all the Veterans records. Secondly, the examiner addressed the Veteran's psychological comorbidities regarding the etiology of the Veteran's hypertension. Third, the examiner addressed the private medical articles presented by the Veteran and noted that the articles only raise the possibility of a relationship and recommend further research be conducted. The Board notes that the Veteran has resented a positive medical opinion in October 2017, however, the Board finds this medical opinion of lesser weight than the November 2021 VA medical opinion for the following reasons. First, the examiner references two medical articles that discuss how mental disabilities can be predictive factors in hypertension, but not that the mental disabilities are the cause of the hypertension or that they aggravate the hypertension. Secondly, the examiners provided a conclusory statement that the Veteran's PTSD "contributes materially and substantially" to the onset and aggravation of the Veteran's hypertension. The examiner does not discuss how the Veteran's predictive factors of PTSD cause and aggravate the Veteran's hypertension. Even if there is a possible link between mental disabilities and hypertension, the examiner failed to discuss how this particular Veteran's PTSD causes or aggravates his particular hypertension. Lastly, while the private examiner noted that the May 2014 VA examiner failed to address comorbidities, the private examiner also failed to address the comorbidities that the May 2014 VA examiner addressed. The examiner simply states that the Veteran's disability is due to hus service-connected PTSD even when accounting for external risk factors including the Veteran's age, weight, and family history. However, the examiner does not discuss how these comorbidities were evaluated. Accordingly, in view of the totality of the evidence, the Board finds that service connection for hypertension, to include as secondary to service-connected PTSD, is not warranted. 2. Aortic aneurysm The Veteran asserts that he is entitled to an aortic aneurysm disability, to include as secondary to hypertension. The elements for direct and secondary service connection are discussed above. The Veteran's was afforded a VA examination in May 2020. Here the examiner provided a negative direct service connection opinion. The examiner stated that it was less likely than not that the Veteran's aortic aneurysm was directly related to service, to include his exposure to herbicides while in-service. The examiner supported their opinion with the rational that there is no medical literature that supports a finding that Agent Orange is an established primary etiology of thoracic aortic aneurysm. Additionally, the examiner noted that there was no treatment for the Veteran's condition in service or until 2007. The examiner, however, did find that the Veteran's thoracic aortic aneurysm was proximately due to his hypertension. The Board finds that there is no in-service event regarding the Veteran's aortic aneurysm. Specifically, there is no documentation in the service treatment records (STRs) of the Veteran ever having been treated for any such disability. The Veteran has not presented any evidence showing an in-service event or a link between such an in-service event and his present disability. The Veteran's symptoms did not first manifest until many years after service and there is no established connection between the Veteran's herbicide exposure and the disability. As such, the Veteran's claim for direct service connection for an aortic aneurysm is not warranted. Regarding secondary service connection, the Veteran has satisfied the first element for a secondary service connection through a qualifying disability an aortic aneurysm. Unfortunately, the Veteran's aortic aneurysm is shown to be proximately due to a disability that is not service-connected, hypertension. The Veteran has presented a private medical opinion from October 2019 in which the examiner states that the Veteran's hypertension contributed materially and substantially to his aortic aneurysm. This opinion is supported by the May 2020 VA examiner's opinion that also found that the Veteran's aortic aneurysm is proximately due to the Veteran's hypertension. As the medical opinions are in agreement that the Veteran's aortic aneurysm is due to the Veteran's hypertension, and as the Veteran's hypertension is not currently service connected; the Board finds that service connection for an aortic aneurysm, to include as secondary to hypertension, is not warranted. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if that disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the initial rating assigned following an award of service connection, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous...." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. 1. Hearing Loss The Veteran is service connected for bilateral hearing loss. He seeks entitlement to a higher disability rating as he believes that his hearing loss is more severe than it is rated. The RO has rated the Veteran's hearing loss as noncompensable. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85, Diagnostic Code 6100. To evaluate the degree of disability from service-connected hearing loss, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII. An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86 (a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86 (b). The Veteran was afforded VA examinations in October 2013 and December 2020. At the VA examinations, The Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, for each exam were as follows: October 2013 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 10 20 30 35 24 100% LEFT 10 20 35 40 26 96% December 2020 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 25 45 50 55 44 100% LEFT 20 30 40 50 35 100% Applying the results of the examinations to Table VI, the findings yield a numeric designation of Level I bilaterally. Entering the resulting bilateral numeric designation of Level I bilaterally to 38 C.F.R. § 4.85, Table VII, equates to a noncompensable disability rating under Diagnostic Code 6100. The Veteran's medical records also contain an audiological examination from 2017. The examiner stated that the Veteran experienced a 15 dB decrease at 6000 Hz and 25 dB decrease at 8000 Hz in the right ear only compared to previous audio from 2013, and that all other results were similar. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. Based on the evidence above, a compensable rating for the Veteran's bilateral loss is not warranted. 2. Erectile dysfunction The Veteran asserts that he is entitled to a compensable disability rating for his erectile dysfunction (ED) with penile abnormality. The Veteran is currently assigned an initial noncompensable evaluation for his erectile dysfunction under DC 7599-7522 prior to September 23, 2020, and a 20 percent rating thereafter. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. When an unlisted disease or injury is encountered, it will be rated by analogy under a diagnostic code built up using the first 2 digits from that part of the Rating Schedule most closely identifying the body part or system affected and by using "99" for the last 2 digits. DC 7522 provides for a 20 percent rating for deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115b, DC 7522. Deformity here means "a distortion of the penis, either internal or external." Williams v. Wilkie, 30 Vet. App. 134, 138 (2018). The Board notes that the Veteran is already in receipt of special monthly compensation based on loss of use of a creative organ. The Veteran's medical records from September 2013 indicate that he experienced ED as a result of his service-connected prostate cancer. There was no indication that there was any deformity of the penis. The Veteran underwent a VA examination on September 23, 2020. At this examination the examiner was diagnosed with penal shrinkage. Penal shrinkage is a noted possibility of radical prostatectomy. This condition is considered a deformity. As delineated above, prior to September 23, 2020, the Veteran's service-connected erectile dysfunction has been manifested by, at worst, loss of erectile power. There is no competent evidence of an internal or external deformity of the penis. Without deformity of the penis, an initial compensable rating under DC 7599-7522 is not warranted. After September 23, 2020; the earliest date in the record that the deformity is noted, the Veteran is rated as 20 percent disabled under DC 7599-7522, the maximum schedular rating. For the period since September 23, 2020, there is no evidence of an unusual or exceptional disability picture that would trigger the analysis or development for an extraschedular rating. As such, the Veteran's claim for entitlement to an increased disability rating for erectile dysfunction with penile abnormality is denied. R. Erdheim Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lent, Edward 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.