Citation Nr: 23044239 Decision Date: 08/09/23 Archive Date: 08/09/23 DOCKET NO. 19-37 459 DATE: August 9, 2023 ORDER Entitlement to service connection for hypertension is denied. REMANDED Entitlement to service connection for a prostate disability, diagnosed as benign prostatic hypertrophy/hyperplasia (BPH) is remanded. FINDING OF FACT The Veteran's hypertension did not have its onset in service, or manifest to a compensable degree within one year of service discharge and is not related to service or service-connected disability. CONCLUSION OF LAW The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from April 1975 to July 1993. In June 2021, he testified at a virtual hearing held before a Veterans Law Judge (VLJ). A transcript of the hearing is of record. The case was remanded by the Board of Veterans' Appeals (Board) in September 2022 for additional development. Service Connection The Veteran seeks service connection for hypertension. At his June 2021 Board hearing, he testified that his high blood pressure problems were caused or made worse by the pain from his service-connected neck and back disabilities. Service connection may be granted for a disability resulting from 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 a right to compensation for a present 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 - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). Continuity of symptomatology may also provide a basis for a grant of service connection for those diseases defined as "chronic" by VA. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 446 (1995) (en banc). In order to establish service connection for a claimed secondary disorder, there must be medical evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). hypertension Service treatment records fail to reveal any evidence of elevated blood pressure readings sufficiently high to require treatment, or to result in a diagnosis of hypertension prior to his retirement from service in 1993. At his separation physical, the Veteran denied a history of high blood pressure and clinical evaluation showed a blood pressure reading of 106/70. This evidence weighs against a finding that the Veteran's hypertension had its onset during active duty service. There is also insufficient evidence of continuity of symptoms in the immediate years after service to enable an award of service connection under the provisions for "chronic diseases." Walker, 708 F.3d at 1338. The first reference of hypertension is found in private treatment records beginning in 2012, almost 20 years after service. See psychiatric medical consult from JFK Medical Center, dated August 25, 2012. These records do not suggest that hypertension originated during military service and there is no indication that the Veteran related his symptoms to service or any event of service at that time. Because there is no objective evidence that the Veteran was diagnosed with hypertension within one year of service discharge, service connection may not be made on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309(a). There is also no medical opinion linking hypertension to the Veteran's military service or service-connected disability. Following VA examination in December 2022, an examiner determined that the Veteran's hypertension was less as likely as not (less than 50 percent probability) incurred in or caused by service. They noted that there were no entries of the Veteran being seen for blood pressure problems or any entries of elevated blood pressure during service. At his March 1993 separation exam, the Veteran's blood pressure was 106/70 and there was no mention of blood pressure medications. Therefore, a nexus has not been established. In a January 2023 opinion, another VA examiner concluded that it was less likely than not that the Veteran's benign essential hypertension is due to or aggravated by his service-connected cervical and lumbar spine disabilities. It was explained that benign essential hypertension, is a primary condition, meaning it is not secondary or caused by other illness. In addition, the Veteran is only on one blood pressure medication without any sign that it is difficult or refractory to control. The examiner also explained that although pain from the Veteran's service-connected cervical and lumbar spine disabilities can cause transient elevation of blood pressure, this is controlled with pain medications rather than blood pressure medications as it is not the vascular source of the elevated blood pressure. Based on the foregoing, the Board finds that the Veteran's hypertension is not related to service, nor is it due to or aggravated by his service-connected neck and back disabilities. The VA opinions are both probative and persuasive medical evidence in this case, as they are based upon a review of the claims file including lay statements and supported by sufficiently clear and well-reasoned medical rationale. The VA opinions address both direct and secondary service connection and aggravation by the service-connected disabilities was also considered. In providing the rationale, the examiners considered the Veteran's specific medical history, the onset and course of the pertinent symptoms, and the results of the clinical evaluations. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). The claims file contains no favorable competent medical evidence refuting them. To the extent the Veteran's statements attempt to provide a nexus opinion between his hypertension and his service-connected disabilities, such an assertion treads into the realm of medical expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In this case, the probative value of the Veteran's belief is outweighed by that of the examiners, who clearly have the education, training, and experience to address the etiology of cardiovascular disorders. Because the Veteran's hypertension was not present in service or within a year of service, and there is no competent medical evidence relating it to service or service-connected disability, the claim cannot be granted. 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310; Allen, supra; see also, Wallin, Reiber, supra. The Board also notes that in February 2023, the Regional Office (RO) submitted a Toxic Exposure Risk Activity (TERA) memorandum. The memorandum indicated that the Veteran does not qualify for a presumption of exposure for herbicide agents, ionizing radiation, mustard gas, or Camp Lejeune Water Contamination. There is no Individual Longitudinal Exposure Record (ILER) entry for the Veteran and the record does not contain Persian Gulf War service nor toxic exposure covered under 38 U.S.C. §§ 1117 and 1119. Additionally, there is no evidence of other deployment related exposure and/or ILER consistent with the circumstances of the Veteran's service. However, it appears the RO mistakenly checked the box that indicated the Veteran participated in a TERA during active service rather than the box indicating that he did not participate in a TERA, as none of the preceding entries were answered in the affirmative. Moreover, the Veteran has not contended, nor does the evidence indicate, that his hypertension may be related to toxic exposure risk activity. He has consistently asserted that his hypertension was caused or made worse by his service-connected back and neck disabilities. The Veteran has never asserted in-service toxic exposure of any kind and a review of his military personnel record does not indicate toxic exposure risk activity. Accordingly, the evidence is persuasively against the claim and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). REASONS FOR REMAND prostate condition The Veteran is seeking service connection for a prostate disorder. As noted above, the issue was remanded by the Board for additional development in September 2022. Unfortunately, the development remand has not been completely performed. Stegall v. West, 11 Vet. App. 268, 271 (1998). Per the Board's September 2022 remand, the agency of original jurisdiction (AOJ) was asked to obtain a medical opinion to determine the etiology of the Veteran's claimed prostate condition. The examiner was to assess the medical probability that any diagnosed prostate condition including BPH had its onset during or is otherwise related to the treatment for recurrent prostatitis/urethritis and epididymitis documented throughout service. Following VA examination in December 2022, the examiner determined that there were no entries of the Veteran being seen for urinary problems or his prostate issues while in service. Therefore, it is less likely as not (less than 50 percent probability) that his BPH had its onset during or is otherwise related to service. The Board notes that while the examiner indicated a full review of the file, pertinent medical evidence was overlooked as they did not reference or even acknowledge the specific incidents of treatment for recurrent prostatitis/urethritis and epididymitis during service. Given the failure of the examiner to fully consider the evidence as documented, the VA opinion is inadequate. Therefore, an addendum opinion is needed. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the etiology of the Veteran's BPH. The need for an additional examination is left to the discretion of the medical professional providing the addendum. Following additional review of the entire record, the clinician should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's current BPH is related to his treatment for recurrent prostatitis/urethritis and epididymitis during service. If it is the clinician's opinion that the BPH is not related to the documented in-service treatment, he or she must explain why that is. In providing this opinion the examiner should discuss: a) the objective medical findings in service treatment records including the documented treatment for recurrent prostatitis/urethritis and epididymitis; and b) the likelihood that such in-service treatment was the possible onset of or early manifestation/precursor to the currently diagnosed BPH. The opinion should be accompanied by a clear rationale consistent with the evidence of record, including discussion of the facts of this case and any medical studies or references relied upon. If the clinician is unable to provide an opinion without resorting to speculation, they must provide a reasoned explanation for such conclusion. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.R. Bryant 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.