Citation Nr: 25003751 Decision Date: 03/19/25 Archive Date: 03/19/25 DOCKET NO. 19-35 778 DATE: March 19, 2025 ORDER Entitlement to service connection for hypertension, prior to the passage of the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxins Act of 2022 (PACT Act), is denied. FINDING OF FACT The persuasive weight of the evidence is against a finding that the Veteran's hypertension was incurred in service, manifested to a compensable degree within the applicable time limits for chronic diseases, or is secondary to a service-connected disability. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension, prior to the passage of the PACT Act, have not been met. 38 U.S.C. § 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from February 1969 to July 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in June 2023 and April 2024. In April 2024, this matter was remanded to obtain a VA medical opinion addressing the theories of direct and secondary service connection. See April 2024 Board Decision. In May 2024, a VA medical opinion to that effect was obtained by the RO. Accordingly, the Board finds that the Agency of Original Jurisdiction (AOJ) has substantially complied with the April 2024 remand directives. See Stegall v. West, 1 Vet. App. 368 (1998). 1. Entitlement to service connection for hypertension, prior to the passage of the PACT Act, is denied. At the outset, the Board notes that this decision will not affect the status of the Veteran's currently service-connected hypertension. The Veteran will continue to be service connected for hypertension with an entitlement date of August 10, 2022, the date of passage of the PACT Act. The purpose of this decision is solely to address whether entitlement to service connection arose prior to August 10, 2022. As explained below, this decision contemplates theories of entitlement which were not adjudicated in previous Board decisions. Service Connection Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained in the line of duty during active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for a disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection on a direct basis requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Service connection on a secondary basis may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service connection, the record must show: (1) a current disability; (2) a service-connected disability; and (3) a medical nexus between the current disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509 (1998); Allen v. Brown, supra. For certain chronic conditions, an alternative method of establishing the third Shedden element is through a demonstration of?continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331?(Fed. Cir. 2013); Fountain v. McDonald, 27?Vet. App. 258 (2015); 38?C.F.R. §?3.309. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.? See 38?U.S.C. §?5107;?38?C.F.R. §?3.102. Relevant Factual Background In February 1969, the Veteran underwent an enlistment physical which noted no abnormalities upon clinical evaluation. See February 1969 Report of Medical Examination. The Veteran's blood pressure reading was recorded as 122 for systolic pressure and 76 for diastolic pressure (122/76). Id. In July 1972, the Veteran underwent a separation physical, and his blood pressure was recorded as 106/68. See July 1972 Report of Medical Examination. The record does not contain any VA or private treatment records for more than 30 years after the Veteran's separation from service. Private treatment records reveal an initial diagnosis of hypertension in December 2003. See December 2003 Pueblo Family Medicine Note. In January 2004, the Veteran's blood pressure was recorded as 152/98. See January 2004 Pueblo Family Medicine Note. Private records further reflect that the Veteran was prescribed Lisinopril to treat his hypertension. See March 2004 Pueblo Family Medicine Note. VA treatment records consistently document a diagnosis of hypertension. See i.e. February 2017 H&P Note; January 2019 Primary Care Note. In February 2020, the Veteran was afforded a VA examination for his heart conditions. See Heart Conditions Disability Benefits Questionnaire (DBQ). The Veterans blood pressure was recorded as 145/86. Id. In February 2024, the Veteran was afforded a VA examination for his hypertension. See February 2024 Hypertension DBQ. The Veteran reported being placed on blood pressure medication since 2014. Id. Three blood pressure readings were taken with readings of: 112/60, 106/60, and 112/61. Id. In February 2024, a VA medical opinion was obtained addressing the Veteran's hypertension. See February 2024 Medical Opinion DBQ. The examiner opined: The Veteran's diagnosis of (a) hypertension (for reasons other than pursuant to the PACT Act) is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of coronary artery disease, status post myocardial infarction with cardiomyopathy and valvular heart disease. Given pathology of illnesses, Veteran's service-connected conditions of status post myocardial infarction with cardiomyopathy and valvular heart disease were more likely than not caused by uncontrolled hypertension, not the opposite which was the bases of this claim. Id. In May 2024, a VA addendum opinion was obtained. See May 2024 Medical Opinion DBQ. Regarding the theory of direct service connection, the examiner opined that the Veteran's hypertension was less likely than not incurred in or caused by an in-service injury, event, or illness. Id. In support of this opinion, the examiner stated: The [V]eteran's hypertension did not have its nexus in service, other than due to presumptive Agent Orange exposure. Stated differently, absent Agent Orange exposure, there would be no relationship between the [V]eteran's service and the development of hypertension. The medical history of elevated blood pressures and treatment dating from 2003 places the onset ~ 30 years post-service and is therefore irrelevant, except to establish the date of onset. The [V]eteran's blood pressure at separation was 102/68. The [V]eteran was not diagnosed with hypertension until in or around 2003. Therefore, the [V]eteran's hypertension did not arise in service and is not due directly to service. It is conceded that it is due to Agent Orange exposure but would not predate the diagnosis in 2003. Though Congress has determined that Agent Orange causes hypertension, approximately 90% of individuals the [V]eteran's age when diagnosed will have hypertension, regardless of military service or Agent Orange exposure (Framingham). Id. With respect to the theory of secondary service connection, the examiner opined that the Veteran's hypertension was not due to his service-connected conditions. Id. In support of this conclusion, the examiner explained that "coronary artery disease and hypertension are separate anatomically and pathophysiologically." Id. The examiner elaborated that "hypertension is due to increased vascular resistance [and] coronary artery disease is due to atherosclerosis of the vessels supplying blood to the muscle of the heart." Id. The examiner summarized by noting that valvular disease plays no role in the development of hypertension or its progression. Id. Lastly, the examiner opined that the Veteran's hypertension had not been aggravated by his service-connected heart conditions as the conditions are separate anatomically and pathophysiologically. Id. Analysis Direct Service Connection As noted above, service connection on a direct basis requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. Shedden v. Principi, supra. Here, the Veteran's current diagnosis of hypertension is conceded. Notably, the evidence reflects a diagnosis of hypertension dating back to 2003. See December 2003 Pueblo Family Medicine Note. The Veteran's diagnosis was also confirmed at his February 2024 VA examination for hypertension. See February 2024 Hypertension DBQ. Thus, the next question is whether the Veteran's condition was incurred in or aggravated during service. The Board finds that the persuasive weight of the evidence is against such a finding. Importantly, the Veteran's enlistment and separation physical both show normal blood pressure readings. In February 1969, the Veteran underwent his enlistment physical which noted no abnormalities upon clinical evaluation. See February 1969 Report of Medical Examination. The Veteran's blood pressure reading was recorded as 122/76. Id. In July 1972, the Veteran underwent a separation physical, and no abnormalities were noted upon clinical evaluation. The Veteran's blood pressure was recorded as 106/68. See July 1972 Report of Medical Examination. The Veteran's service treatment records (STRs) contain no additional blood pressure readings or notations of hypertension. See STR - Medical. The Veteran's private treatment records further refute any indication of an in-service incurrence. Significantly, a December 2003 treatment note indicates that hypertension is a "new diagnosis." See December 2003 Pueblo Family Medicine Note. The Board notes that more than 30 years elapsed between the Veteran's separation from service and the initial diagnosis of hypertension. Medical treatment records, both VA and private, are silent to hypertension related complaints from the time of separation until 2003. Such a prolonged period without complaint or diagnosis weighs heavily against any assertion that hypertension was incurred in service. See Maxson v. Gober, 230 F.3d 1330, 1333 (2000). For the foregoing reasons, the Board finds that the second element of service connection, an in-service incurrence, has not been satisfied. Accordingly, based on the theory of direct service connection, the claim of entitlement to service connection for hypertension, prior to the passage of the PACT Act, is denied. In coming to this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the persuasive weight of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Secondary Service Connection To prevail on the issue of secondary service connection, the record must show: (1) a current disability; (2) a service-connected disability; and (3) a medical nexus between the current disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509 (1998); Allen v. Brown, supra. Here, the first two elements of secondary service connection are conceded. As discussed above, the Veteran's current diagnosis of hypertension was confirmed during a February 2024 VA examination. See February 2024 Hypertension DBQ. With regard to the second element, a service-connected disability, the Board notes that the Veteran is service connected for coronary artery disease. See June 2024 Codesheet. Thus, the remaining question is whether there is a medical nexus between the Veteran's hypertension and his service-connected disability. In April 2024, the Board remanded this matter, in part, to obtain a medical opinion addressing that very question. See April 2024 Board Decision. In May 2024, a VA examiner opined that the Veteran's hypertension is less likely than not proximately due to or the result of the Veteran's service-connected condition. See May 2024 Medical Opinion DBQ. In support of this opinion, the examiner stated: Coronary artery disease and hypertension are separate anatomically and pathophysiologically, though the risk factors are similar. CAD, status post MI, and/or valvular conditions do not cause and do not aggravate hypertension. Hypertension is due to increased vascular resistance. Coronary artery disease is due to atherosclerosis of the vessels supplying blood to the muscle of the heart. They are separate anatomically and pathophysiologically. Valvular disease plays no role in the development of hypertension or its progression. Therefore, the veteran's hypertension is not due to the veteran's coronary conditions. Id. The VA examiner also opined that the Veteran's hypertension had not been aggravated by his service-connected heart conditions as the conditions are separate anatomically and pathophysiologically. Id. Generally, the degree of probative value which may be attributed to a medical opinion is determined by such factors as thoroughness, degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the Board finds that the May 2024 medical opinion is thorough and well-reasoned. Further, the examiner confirmed that the Veteran's claims file had been reviewed and cited to relevant records contained therein. As such, the Board finds the May 2024 medical opinion highly probative. The Board further notes that there are no countervailing opinions of record which suggest that hypertension was caused by the Veteran's service-connected disabilities. To the contrary, the February 2024 VA examiner offered a similar opinion in stating that: The Veteran's diagnosis of (a) hypertension (for reasons other than pursuant to the PACT Act) is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of coronary artery disease, status post myocardial infarction with cardiomyopathy and valvular heart disease. Given pathology of illnesses, Veteran's service-connected conditions of status post myocardial infarction with cardiomyopathy and valvular heart disease were more likely than not caused by uncontrolled hypertension, not the opposite which was the bases of this claim. See February 2024 Medical Opinion DBQ. Although the February 2024 VA medical opinion was deemed inadequate for adjudication purposes, the information and analysis contained therein may still be considered and assigned probative weight in the matter at hand. See Monzingo v. Shinseki, 26 Vet. App. 97 (2012). The Board finds this opinion probative insofar as it forms a consensus that the Veteran's hypertension was not caused by his service-connected heart condition. In light of the foregoing, the Board finds that the persuasive weight of the evidence is against a finding that the Veteran's hypertension was caused, or aggravated, by his service-connected heart condition. In coming to this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the persuasive weight of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, the claim of entitlement to service connection for hypertension, prior to the passage of the PACT Act, is denied on a secondary basis. Presumptive Service Connection Lastly, the Board will address presumptive service connection prior to the passage of the PACT Act. As noted above, for certain chronic conditions, an alternative method of establishing service connection is through a demonstration of?continuity of symptomatology. See Walker v. Shinseki, supra. Continuity of symptomatology is established if (1) a chronic condition was "noted" during service, (2) there are post-service manifestations of the same symptomatology, and (3) medical or, sometimes, lay evidence shows a nexus between the present disability and post-service symptomatology. Id. Here, there is no evidence that hypertension was chronic in service or noted during service. To the contrary, the Veteran's enlistment and separation examinations documented blood pressure within the normal range. See STR - Medical. As hypertension was not chronic or noted during service, chronicity cannot be established and the nexus element of service connection may not be satisfied based on the theory of continuity of symptomatology. (Continued on the next page) ? In coming to this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the persuasive weight of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Zachary J. Ellis, Associate 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.