Source: https://va-claim.com/2019/01/03/entitlement-to-service-connection-for-hypertension-to-include-as-secondary-to-diabetes-mellitus-type-ii-denied-citation-nr-18123941-2/
Timestamp: 2019-04-19 08:47:18+00:00

Document:
Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus type II is denied.
Hypertension was not shown in service, diagnosed within a year of service discharge, or otherwise shown to be related to the Veteran’s active service, to include his exposure to herbicide agents or service-connected diabetes mellitus type II.
The criteria for service connection for hypertension have not been met. 38 U.S.C. 1110, 5107; 38 C.F.R. § 3.102, 3.303, 3.307, 3.309, 3.310 (2017).
The Veteran had active service from November 1966 to November 1970. He is shown to have served in the Republic of Vietnam during the Vietnam era.
In May 2017, the Veteran provided sworn testimony at a live videoconference hearing chaired by the undersigned.  A transcript of that hearing is of record.
Under the relevant laws and regulations, 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.  Generally, the evidence 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.  Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995).
Certain chronic diseases, including hypertension, 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. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113 (2012); 38 C.F.R. §§ 3.307 (a)(3), 3.309(a) (2017).
Veterans diagnosed with an enumerated disease who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307 (a)(6)(iii).
Certain disorders, including ischemic heart disease, if manifest to a degree of 10 percent or more for an herbicide exposed veteran may be presumed service connected. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309. The term ischemic heart disease for presumptive service connection purposes under this law does not include hypertension or peripheral manifestations of arteriosclerosis, such as peripheral vascular disease or stroke, or any condition that does not qualify within the generally accepted medical definition of ischemic heart disease. 38 C.F.R. § 3.309, Note 2.
The National Academy of Sciences (NAS) has reaffirmed its decision to place hypertension in “limited or suggestive evidence of an association” category. This category of association is defined to mean that the “evidence suggests an association between exposure to herbicides and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence.” Accordingly, VA has determined that the available evidence does not establish a positive association between herbicide exposure and hypertension that would warrant a presumption of service connection. 79 Fed. Reg. 20308-01 (Apr. 11, 2014).
Even though a disease is not included on the list of presumptive diseases, a nexus between the disease and service may nevertheless be established on the basis of direct service connection. Stefl v. Nicholson, 21 Vet. App. 120 (2007). When a claimed disability is not included as a presumptive disability, direct service connection may nevertheless be established by evidence demonstrating that the disability was in fact incurred during service. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994).
Service connection may also be granted on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disorder.  38 C.F.R.
§ 3.310(a).  Secondary service connection may be found in certain instances in which a service-connected disability aggravates another condition.
The Veteran has been diagnosed with hypertension, meeting the threshold criteria for service connection.  Service treatment records are silent for complaints or treatment of a hypertension or high blood pressure.  There is also no evidence of hypertension being diagnosed until several decades after his service discharge. His treating physician reports that a diagnosis of hypertension was first made in 2005. Accordingly, service connection on a direct basis, a basis of continuity, or the one-year presumption is not warranted.
The Veteran does not argue the contrary. Rather, he states his hypertension was either caused or aggravated by his exposure to herbicide agents or his service connected DM II. His exposure to herbicide agents during service has been conceded by VA and it was the presumptive basis upon which his DM II was service connected.
On VA examination in January 2011, the examiner concluded that it was less likely than not that the Veteran’s hypertension was caused or related to his service-connected DM II because there was no evidence of diabetic microvascular disease or nephropathy, an EGFR greater than 25, and the Veteran’s DM II was well controlled.  The examiner noted the high prevalence of hypertension in individuals of the Veteran’s age group with similar risk factors such as obesity and family history.   The examiner further stated that there is no current documentation that demonstrates a causal role for herbicide agents in development of hypertension and there was no further evidence indicating a specific link to herbicide agents.
The Veteran submitted an August 2011 private medical opinion from Dr. M.A. which stated that his DM II may have contributed to his development of hypertension.  The opinion offered no rationale or evidentiary basis for the conclusion.
On a review VA examination in February 2012, the examiner concluded that the Veteran’s hypertension was less likely than not caused or aggravated by this Veteran’s DM II and reiterated the August 2011 rationale.
On VA examination in July 2016, the examiner determined that it was less likely than not that the Veteran’s hypertension was caused or related to his service-connected illness.  The examiner reiterated the January 2011 opinion regarding the prevalence of hypertension in individuals of the Veteran’s age group with similar risk factors such as obesity and family history; and that there is no current documentation that demonstrates a causal role for herbicide agents in development of hypertension and there was no further evidence indicating a specific link to herbicide agents.
The Veteran submitted a July 2017 private medical opinion by Dr. J.S. who stated that the Veteran’s hypertension is likely related to increased weight, diabetes, and metabolic syndrome and that it is likely that his diabetes in some way caused the hypertension to develop. No further details or rationale was provided.
Following these conflicting opinions, in October 2017, the Board requested a VHA doctor review the case and provide an expert opinion.
The opinion was returned to the Board in May 2018.  Dr. A.H. acknowledged the Veteran’s herbicide agent exposure, and a study suggesting an association with hypertension, but stated that an association is not causality, and there is no other evidence that the Veteran’s hypertension was caused by herbicide exposure.  The opinion also stated that there is an association with DMII, but there is no proof of causality.  Finally, the Dr. A.H. opined that because the record shows that the Veteran’s DM II was well controlled, it would not aggravate his hypertension.
While the Board recognizes that Dr. A.H. did not use specific language that the Veteran’s hypertension is less likely than not related to herbicide exposure and is not related on a secondary basis to his DM II, the opinion supports that finding.
The Board finds the four separate VA medical opinions, including the VHA opinion, persuasive in finding that the preponderance of the evidence is against a finding that Veteran’s hypertension is service related, nor was it caused or aggravated by his service-connected DM II.  Each VA opinion was based on a review of the Veteran’s claims file.  While the Board considered the two private medical opinions, they are both speculative in the language concerning a connection to the Veteran’s hypertension to DM II.  Additionally, the 2011 opinion offers no rationale whatsoever.  An adequate medical opinion must be “accurate and fully descriptive ..., with emphasis upon the limitation of activity imposed by the disabling condition.”  38 C.F.R. § 4.1.  Any opinion ultimately should “sufficiently inform the Board of a medical expert’s judgment on a medical question and the essential rationale for that opinion.”  Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012), Nieves–Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (noting that “a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two”).
Accordingly, despite the Veteran’s in-service herbicide agent exposure, and his contention that DM II caused his hypertension, the Board finds that service connection for hypertension is not warranted.

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