HYPERTENSION

K. PARAKKAL · 2025 · Case ID: A25017056

DENIED

Summary

The Veteran, a U.S. Army veteran who served from November 1995 to October 2002, sought service connection for hypertension as secondary to his service-connected chronic low back pain or obstructive sleep apnea (OSA). The Veteran claimed his chronic low back pain led to a sedentary lifestyle and weight gain, contributing to hypertension. He also asserted hypercholesteremia during service led to hypertension, though hypercholesteremia is not service-connected. The Board reviewed evidence including the Veteran's statements, a February 2023 VA examination, and subsequent medical opinions from May and July 2023. The VA examiner opined that hypertension was less likely than not related to chronic low back pain, citing a lack of medical literature supporting a causal link and attributing hypertension to sedentary lifestyle and hypercholesteremia. Further opinions also found hypertension less likely than not related to toxic exposure risk activity and OSA, citing the same probable causes. The Board found the July 2023 opinions probative, noting clear conclusions and reasoned medical explanations. However, the Board found the Veteran's hypertension did not manifest during service or within the presumptive period, and the evidence weighed against a finding that service-connected disabilities caused obesity, which could have served as an intermediate step. The Board concluded that the evidence persuasively favored denial, rendering the benefit of the doubt doctrine inapplicable. Service connection for hypertension was denied.

Rationale

No positive nexus opinion linking hypertension to chronic low back pain.; Hypertension attributed to sedentary lifestyle and hypercholesteremia.; Evidence weighs against finding that service-connected disability caused obesity.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

231218-400793

Full Decision Text

Citation Nr: A25017056
Decision Date: 02/26/25 Archive Date: 02/26/25

DOCKET NO. 231218-400793
DATE: February 26, 2025

ORDER

Entitlement to service connection for hypertension as secondary to chronic low back pain or obstructive sleep apnea is denied.

FINDING OF FACT

The Veteran's hypertension was not caused or aggravated by his service-connected chronic low back pain or obstructive sleep apnea.

CONCLUSION OF LAW

The criteria for entitlement to service connection for hypertension as secondary to chronic low back pain or obstructive sleep apnea have not been met. 38 U.S.C. §§ 1110, 5103, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served in the U.S. Army from November 1995 to October 2002.

This case is being reviewed according to the appellate process set forth under the Appeals Modernization Act (AMA). 38 C.F.R. § 19.2. The AMA or modernized review system applies to all claims, requests for reopening of finally adjudicated claims, and requests for revision based on clear and unmistakable error for which VA issues notice of an initial decision on or after February 19, 2019, the effective date of the modernized review system. See 38 C.F.R. § 3.2400.

This matter comes before the Board of Veterans' Appeals (Board) following a decision issued in July 2023 by the Department of Veterans Affairs (VA) Regional Office (RO) which denied entitlement to service connection for hypertension.

In October 2022, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, and requested readjudication of entitlement to service connection for hypertension most recently addressed in a March 2020 rating decision. A May 2023 decision deferred rating. In July 2023, the agency of original jurisdiction (AOJ) issued a supplemental claim decision, which found that new and relevant evidence had been received and denied the claim based on the evidence of record at the time of that decision.

In August 2023, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of a July 2023 decision. In December 2023, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal, which considered the evidence of record at the time of the prior July 2023 decision.

The Veteran filed a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) in December 2023 and elected the Direct Review docket.

Therefore, the Board may only consider the evidence of record at the time of the July 2023 agency of original jurisdiction (AOJ) decision, which was subsequently subject to higher-level review. 38 C.F.R. § 20.301. If evidence was submitted during the period after the AOJ issued the decision, which was subsequently subject to higher-level review the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Law and Analysis

Service connection may be established on a secondary basis for a disability resulting from a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability results from the service-connected disability. 38 U.S.C. §§ 1110, 1131; Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023) (holding that section 1110 "requires compensation when a service-connected disease or injury is a but-for cause of a present-day disability"). The but-for causation standard in a secondary service-connected case is not limited to a single cause and effect, but rather contemplates multi-causal links, including action and inaction. See Spicer, supra.

. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability results from the service-connected disability. 38 U.S.C. §§ 1110, 1131; Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023) (holding that section 1110 "requires compensation when a service-connected disease or injury is a but-for cause of a present-day disability"). The but-for causation standard in a secondary service-connected case is not limited to a single cause and effect, but rather contemplates multi-causal links, including action and inaction. See Spicer, supra.

Certain chronic diseases (including hypertension) will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013).

Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (benefit-of-the-doubt rule not for application when evidence persuasively favors one side or the other).

Hypertension

The Veteran seeks entitlement to service connection for hypertension as secondary to his service-connected chronic lower back pain or obstructive sleep apnea (OSA). In a December 2019 statement, the Veteran reported painful motion and limited range of motion in his back when standing and sitting which restricts his activity level. He also reported onset of high cholesterol during service which he asserts led to the development of hypertension. See December 2019 statement. In an October 2022 statement, the Veteran asserted his chronic lower back disability made it painful for him to exercise and resulted in weight gain which led to health concerns including hypertension. See October 2022 statement.

The December 2023 rating decision made the favorable finding that the Veteran has a current diagnosis of hypertension. The decision also found that the Veteran has participated in a toxic exposure risk activity due to his service position as a power equipment generator repairman which involved exposure to power generator equipment and power plants. Finally, the Veteran's claimed primary disabilities of chronic lower back pain and obstructive sleep apnea are service connected. The Board is bound by the favorable findings of the AOJ, absent clear and unmistakable evidence to the contrary. 38 U.S.C. § 5104A; 38 C.F.R. § 20.801(a). The Board acknowledges the Veteran has also asserted his hypercholesteremia resulted in hypertension, however hypercholesteremia is not service connected.

A VA examination and medical opinion were obtained in February 2023 and additional medical opinions were obtained in May and July 2023.

In February 2023, the Veteran reported onset of hypertension around 2010. The examiner opined the Veteran's hypertension is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of Veteran's service-connected chronic lower back pain. The rationale noted hypertension is a separate entity entirely from the chronic lower back pain and unrelated to it concluding that a thorough review of medical literature failed to demonstrate a causal relationship.

In May 2023, an addendum medical opinion was obtained where the examiner opined the Veteran's low back pain and chronic low back pain are not medically related. The rationale noted the Veteran's hypertension is more than likely related to his sedentary lifestyle and hypercholesteremia.

A medical opinion addressing the Veteran's toxic exposure risk activity was obtained in May 2023. The examiner opined the Veteran's hypertension was less likely than not (likelihood is less than approximately balanced or nearly equal) caused by the conceded toxic exposure risk activity (TERA), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner reasoned the etiology of the Veteran's hypertension was related to his sedentary lifestyle and hypercholesteremia noting high cholesterol leads to hard, narrow arteries and strain on the heart which raises blood pressure. The examiner concluded the etiology of the Veteran's hypertension is not associated with his exposures as a power generator operator.

In July 2023, an addendum opinion opined the Veteran's hypertension is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of Veteran's service-connected chronic lower back disability. The rationale noted that while pain associated with chronic low back pain can temporarily increase blood pressure it is not a known cause of hypertension. The examiner found more probable causes are a sedentary lifestyle, elevated body mass index (BMI), dietary choices, and aging. The examiner also addressed whether the Veteran's chronic low back pain caused the Veteran to have a sedentary lifestyle and thereby develop hypertension. See July 2023 addendum opinion. The examiner further reasoned that though pain associated with the Veteran's lower back disability can limit certain ability for weight bearing activity, this remains only part of the equation for developing obesity or elevated BMI finding there are other forms of exercise that would involve non-weight bearing activity. The examiner noted that the other important factor in developing hypertension is calorie consumption and having back pain does not alter eating habits.

An addendum opinion addressing hypertension as secondary to obstructive sleep apnea (OSA) was also obtained in July 2023 where the examiner opined the Veteran's hypertension is less likely than not due to his OSA as his hypertension was diagnosed years before his OSA which would not make it possible for OSA to cause hypertension. The examiner further noted more probable causes of hypertension are a sedentary lifestyle, elevated BMI, dietary choices, and aging. The Board notes the Veteran reports onset of hypertension in 2010 and private medical records document treatment for hypertension as early as February 2011. The Veteran participated in a sleep study in March 2011 which did not result in a diagnosis and a December 2016 sleep study which resulted in a diagnosis of obstructive sleep apnea. See private medical records.

The Board affords no probative weight to the February 2023 medical opinion and May 2023 addendum addressing chronic lower back pain. The February 2023 opinion is inadequate as the examiner's rationale did not include an analysis or basis which the Board may consider. Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (stating that a medical opinion must support its conclusion with an analysis that the Board can weigh, and a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision). Additionally, the May 2023 addendum misstated the requested opinion as the examiner opined the conditions of lower back pain and chronic low back pain are not medically related. Though the rationale noted the Veteran's claimed condition of hypertension, the Board affords no probative weight to the examiner's unclear conclusion.

The Board finds the May 2023 opinion regarding toxic exposure risk activity and July 2023 opinions regarding entitlement to service connection as secondary to chronic low back pain and obstructive sleep apnea probative as they contain clear conclusions with supporting data and a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008).

The Board finds the Veteran's chronic hypertension did not manifest during service or within one year from separation from service such that entitlement to service connection may be granted on a presumptive basis under 38 C.F.R. § 3.309. The Veteran separated from service in October 2002. During the February 2023 examination, the Veteran reported onset of hypertension symptoms in 2010 and medical records document treatment as early as February 2011. See February 2023 examination and private medical record.

The Board has considered entitlement to service connection for hypertension due to the Veteran's participation in a toxic exposure risk activity (TERA). Here, the Board finds probative the May 2023 examiner's opinion finding the Veteran's hypertension is not due to TERA and is more likely the result of a sedentary lifestyle and hypercholesteremia which is not a service-connected disability.

The Board has also considered the Veteran's assertion of obesity as an intermediate step under 38 C.F.R. § 3.310 (a). VAOPGCPREC 1-2017 (Jan. 6, 2017). In order to establish service connection on this basis, three criteria must be met: (1) the service-connected disease or injury must have caused the veteran to become obese; (2) the obesity as a result of the service connected disability must be a substantial factor in causing the disability for which service connection is sought; and (3) whether the disability for which service connection is sought would not have occurred but for obesity caused by the service connected disease or injury.

Here, the Board finds the evidence of record weighs against a finding that any service-connected disability caused the Veteran to become obese. The Board affords probative weigh to the July 2023 medical opinion which found the Veteran's chronic lower back pain does not limit his ability to participate in non-weight bearing activity and an additional factor in the development of hypertension is calorie consumption unrelated to the physical limitations of chronic back pain.

The Board finds entitlement to service connection for hypertension is not warranted on a direct basis under the applicable presumptions for a chronic disability nor as the result of the Veteran's participation in a toxic exposure risk activity. Additionally, the evidence of record weights against a finding of entitlement to service connection due to chronic lower back pain and obstructive sleep apnea to include consideration of obesity as an intermediate step. The Board notes there is not a positive nexus medical opinion of record.

As the evidence is persuasively against a grant of service connection, the benefit of the doubt doctrine under 38 U.S.C. §5107(b), is not for application. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application).

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Accordingly, entitlement to service connection for hypertension is denied.

K. Parakkal

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Filsinger, Alexandra Q.

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.

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