Citation Nr: 23020428 Decision Date: 04/04/23 Archive Date: 04/04/23 DOCKET NO. 14-27 410 DATE: April 4, 2023 ORDER Entitlement to service connection for hypertension is granted. Entitlement to service connection for abdominal aortic aneurysm, secondary to hypertension, on a causation basis, is granted. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam during the Vietnam War era. 2. The evidence is approximately evenly balanced as to whether the Veteran's hypertension was related to service. 3. The Veteran's abdominal aortic aneurysm was caused by his hypertension. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the appellant, the criteria for service connection for hypertension are met. 38 U.S.C. §§ 1110, 1116(f), 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307. 2. The criteria for service connection for abdominal aortic aneurysm, secondary to hypertension, on a causation basis, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1968 to May 1970, which includes service in the Republic of Vietnam. He died and the appellant, who is his surviving spouse, was substituted for the Veteran with respect to the matters on appeal. These matters initially came before the Board of Veterans' Appeals (Board) from a March 2014 rating decision. In February 2016, May 2018, July 2020, and August 2022, the Board remanded these matters for further development. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, air, or space service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). A veteran, who, during active military service, served in the Republic of Vietnam during the period beginning in January 1962 and ending in May 1975, is presumed to have been exposed to herbicide agents, including Agent Orange. 38 U.S.C. § 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii). Service connection is also warranted for disability that is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310 (a). Secondary service connection under 38 C.F.R. § 3.310 (a) is warranted where a non service-connected disability would have been less severe but for a service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the non-service-connected disability. Spicer v. McDonough, __ F.4th __, No. 2002-1239, 2023 U.S. App. LEXIS 5470 (Fed. Cir. March 8, 2023) (holding that 38 C.F.R. § 3.310 (b), which provides for the award of service connection for a non service-connected disability that is aggravated by a service-connected disability, is inconsistent with 38 U.S.C. § 1110 and unlawful to the extent that it excludes the natural progress of a disease from compensation). 1. Entitlement to service connection for hypertension The Board finds, for the following reasons, that the Veteran had current hypertension at the time of his death, and that the evidence is approximately evenly balanced as to whether this disability was related to his exposure to herbicide agents in service. Medical records, including an August 2014 examination report from Sanford USD Medical Center, indicates that the Veteran was diagnosed as having hypertension at the time of his death. Also, as he served in Vietnam during the Vietnam War era, he is presumed to have been exposed to herbicide agents, including Agent Orange. 38 U.S.C. § 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii). Therefore, current hypertension and in-service exposure to herbicide agents has been demonstrated. The remaining question is whether the Veteran's hypertension was related to his herbicide agent exposure in service. In this regard, there is conflicting medical evidence. 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 Veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The Board may favor one medical opinion over another, provided an adequate statement of reasons or bases is provided. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). In November 2020, a VA physician reviewed the Veteran's claims file and opined that it was not likely ("less likely than not") that his hypertension was incurred in or caused by service. There was no further explanation or rationale provided for this opinion. In November 2022, a VA physician reviewed the Veteran's claims file and opined that it was likely ("at least as likely as not") that his hypertension was due to his aging. The physician reasoned that the Veteran's hypertension was not diagnosed or manifested within one year of his separation from service and, based on this information, hypertension would not be considered a chronic disability related to Agent Orange exposure during service. The available evidence in the medical records, in conjunction with feedback from VA, supports the contention that the Veteran's hypertension was due to aging, rather than Agent Orange exposure. In a 2018 National Academy of Sciences (NAS) Update, hypertension was elevated from the "limited or suggestive evidence" category to the "sufficient evidence of an association" category with respect to the association between hypertension and herbicide agent exposure. See Veterans and Agent Orange: Update 11 (2018), available at https://www.nap.edu/read/25137/chapter/1, pages 465, 560, 565. The 2018 Update has been held to be constructively before the Board. See Euzebio v. McDonough, 989 F.3d 1305, 1323 (Fed. Cir. 2021). In this regard, medical article and treatise evidence may suffice to establish nexus in instances where "standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Sacks v. West, 11 Vet. App. 314, 317 (1998). The November 2020 opinion is of little, if any, probative value because it is not accompanied by any specific explanation or rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). In light of the above evidence, the Board finds that the evidence is approximately evenly balanced as to whether the Veteran's hypertension was related to his exposure to herbicide agents in service. As the reasonable doubt created by this approximate balance in the evidence must be resolved in favor of the appellant, entitlement to service connection for hypertension is warranted on a direct basis. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for abdominal aortic aneurysm, secondary to hypertension The Board finds, for the following reasons, that the Veteran had current abdominal aortic aneurysm at the time of his death, and that this disability was caused by his now service-connected hypertension. Medical records, including the August 2014 examination report from Sanford USD Medical Center, indicate that the Veteran was diagnosed as having abdominal aortic aneurysm at the time of his death. In January 2020, a VA physician reviewed the Veteran's claims file and explained, in pertinent part, that his abdominal aortic aneurysm "was the result of probably hypertension ballooning the abdominal aorta." In November 2020, a VA physician reviewed the Veteran's claims file and explained, in pertinent part, that aortic aneurysm is ballooning of the wall of the aorta and "usually that is caused by high blood pressure." The wall gets stretched and slowly gets enlarged. In November 2022, a VA physician reviewed the Veteran's claims file and opined that his abdominal aortic aneurysm was "most likely directly related to" his age, hypertension, and other cardiovascular risk factors (to include cigarette smoking). In light of the above medical opinions, the Board finds that the evidence is in favor of a conclusion that the Veteran's abdominal aortic aneurysm was caused by his now service-connected hypertension. There is no requirement that the service-connected disease be the sole cause of the non-service-connected disability to warrant secondary service connection. There is no medical opinion that is contrary to this conclusion. Therefore, service connection for abdominal aortic aneurysm, secondary to hypertension, on a causation basis, is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Elwood, 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.