HYPERTENSION

J.P. NORMAN · 2025 · Case ID: A25021919

DENIED

Summary

The veteran, who served from May 1986 to May 1990 and again from January 1991 to March 1991, appeals the denial of service connection for hypertension. The veteran claimed hypertension was secondary to service-connected insomnia disorder with generalized anxiety disorder and alcohol use disorder, and also claimed direct service connection due to toxic exposure risk activity during service. The Board adopted the favorable findings that the veteran has a current diagnosis of hypertension and service-connected insomnia disorder with alcohol use disorder. However, the Board reviewed three medical opinions regarding the nexus for secondary service connection. The first VA examiner's opinion was afforded minimal probative weight due to inadequate rationale, relying on an incomplete abstract of a medical study without applying it to the veteran's specific symptoms. The second and third VA examiners concluded that the veteran's hypertension was less likely than not related to his service-connected conditions or toxic exposure, citing other major risk factors like obesity and obstructive sleep apnea. These latter two opinions were given high probative weight. The Board also considered the veteran's lay statements but found him not competent to opine on the medical nexus. The Board found the evidence persuasively weighed against a nexus for both secondary and direct service connection. The benefit of the doubt doctrine was not applied as the evidence favored denial. Service connection for hypertension was denied.

Rationale

Secondary service connection requires current disability, service-connected disability, and nexus.; Veteran has current hypertension and service-connected insomnia/anxiety/alcohol use disorder.; Two VA opinions found less likely than not a nexus; one opinion was inadequate.; Evidence persuasively weighs against a nexus for secondary service connection.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

231128-395745

Full Decision Text

Citation Nr: A25021919
Decision Date: 03/11/25 Archive Date: 03/11/25

DOCKET NO. 231128-395745
DATE: March 11, 2025

ORDER

Entitlement to service connection for hypertension is denied.

FINDING OF FACT

The Veteran's hypertension is not secondary to service-connected insomnia disorder with generalized anxiety disorder and alcohol use disorder, and is not otherwise related to an in-service injury or disease.

CONCLUSION OF LAW

1. The criteria for service connection for hypertension due to service or insomnia disorder with generalized anxiety disorder and alcohol use disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active service from May 1986 to May 1990 and January 1991 to March 1991.

In the November 2023 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. On the NOD the Veteran listed an agency of original jurisdiction (AOJ) rating decision from March 2023, which had denied the claim on a lack of new and relevant evidence. This rating decision was subject to a higher-level review and resulted in a new adjudication of the Veteran's claim on the merits following the finding of a duty to assist error. The Veteran also listed on the NOD a subsequent November 2023 rating decision which followed the correction of the duty to assist error. The Board will use the November 2023 rating decision in determining the appropriate evidentiary window as it is most favorable to the Veteran. The Board will also proceed to the merits of the issue rather than analyze whether new and relevant evidence was submitted in March 2023, as that issue was already resolved in the Veteran's favor.

Therefore, the Board may only consider the evidence of record at the time of the November 2023 AOJ decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 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.

1. Entitlement to service connection for hypertension is denied.

The Veteran asserts that his diagnosed hypertension is the result of his service-connected insomnia disorder with generalized anxiety disorder and alcohol use disorder. The Board finds that the evidence of record is persuasive to a finding that Veteran's hypertension is not secondary to his service-connected disabilities or otherwise related to an in-service event or injury.

Secondary service connection is warranted if there is (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e. link) between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998).

As to the first element of secondary service connection, the AOJ made a favorable finding that the Veteran has a current diagnosis of hypertension, and that finding is adopted here.

As to the second element of secondary service connection, the AOJ made a favorable finding that the Veteran's insomnia disorder with generalized anxiety disorder and alcohol use disorder is a service-connected disability, and that element is similarly conceded.

There still must be found a nexus between the current disability and the service-connected disability. There are three medical opinions in the evidence of record which address the element of nexus between the Veteran's conditions.

The Veteran was afforded a VA examination July 2022. The examiner reviewed the Veteran's available health records as well as conducted an in-person interview. The examiner reached the conclusion that the Veteran's hypertension was at least as likely as not the result of the Veteran's insomnia and alcohol use disorder. The rationale offered to support this conclusion consisted in its entirety as a single note which states, "Insomnia is a prevalent sleep disorder that is associated with multitude of health consequences. Particularly, Insomnia has been associated with cardiovascular disease and it [sic] precursors, such as hypertension. Site [sic]: Insomnia and HTN:
three medical opinions in the evidence of record which address the element of nexus between the Veteran's conditions.

The Board finds this rationale to be inadequate to support the conclusion that the Veteran's current disability is secondary to his service-connected disability. The opinion mischaracterizes that the study purports that there is a determinative causal link between insomnia and hypertension. The examiner's note quotes the first two introductory sentences from the study's abstract, however, and said abstract goes on to conclude, "Based on a majority of case-control studies, no differences in BP were found between participants with and without insomnia. Further research is needed to identify putative pathophysiological mechanisms underlying the link between insomnia and hypertension." Jarrin et al., Insomnia and hypertension: A systematic review, Sleep Medicine Reviews 41 (2018). The abstract does purport that the article makes some correlation that, "when insomnia is frequent, chronic, and/or accompanied with short sleep duration or objective markers of arousal, there is a strong association with hypertension/BP." Id. (emphasis added). An "association" is not the same thing as causation. However, the examiner does not provide any analysis that discusses how the article can be relied on to reach this conclusion in the Veteran's specific case. No analysis of the Veteran's symptoms and nature of his insomnia are mentioned or analyzed in relation to this possible conclusion of the study. Thus, the Board finds that this bare recitation of a medical article's introductory material does not rise to the level of an adequate analysis that it can be relied upon to reach the examiner's affirmative opinion of a nexus. Accordingly, the examiner's opinion on a nexus between the Veteran's conditions is afforded minimal probative weight.

The Veteran was afforded a second VA examination in October 2022. The examiner concluded that the Veteran's hypertension was less likely than not a result of his insomnia disorder with alcohol use disorder. The rationale offered to support this conclusion was that there was not support among medical literature that there was a causal link between insomnia and hypertension. The examiner provided an overview of those conditions and medications which have been shown to cause an increase in blood pressure. Furthermore, the examiner provided a list of the most common risk factors such as age, race, family history, obesity, lack of exercise, and alcohol consumption, which are the main contributors to high blood pressure. The examiner is found to be competent to offer such an opinion and credible in their analysis. This opinion is therefore provided high probative weight.

The Veteran attended a third VA examination in July 2023. The examiner reviewed the Veteran's available health records as well as conducted an in-person interview. The examiner reached the conclusion that the Veteran's hypertension was less likely than not the result of the Veteran's insomnia and alcohol use disorder. The examiner stated their opinion was based on that the Veteran's hypertension was more likely to be caused by the other major risk factors contained in the Veteran's health records, including obstructive sleep apnea and obesity. The examiner is deemed to be competent to offer such an opinion and credible in their analysis. Thus, this opinion is also afforded high probative weight.

The Veteran also contended that his hypertension was the direct result of service and/or his service-connected disabilities in two statements. In an October 2022 statement the Veteran recounted multiple incidents during his active service which he felt lead to his conditions, including hypertension, for which he had been service connected or for which he was seeking service connection. The Veteran provided another statement in December 2022 specifically addressing his denial for secondary service connection for hypertension. This statement made reference to a previous Board decision from a different Veteran and noted three articles the Veteran had submitted in support of his claim.

Notably, it is well established that previous Board decisions in other appeals, unrelated to the Veteran at hand, are not binding on the Board and have no precedential value; as the Board's determinations are made based on the individual facts presented in each individual case. See 38 C.F.R. § 20.1303; see also Lynch v. Gober, 11 Vet
including hypertension, for which he had been service connected or for which he was seeking service connection. The Veteran provided another statement in December 2022 specifically addressing his denial for secondary service connection for hypertension. This statement made reference to a previous Board decision from a different Veteran and noted three articles the Veteran had submitted in support of his claim.

In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1377 (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board").

While the Veteran is competent and credible in describing his experiences during service, the Board does not find that the Veteran is competent to provide an opinion as to the nexus between in-service incidents or service-connected conditions and his current disability of hypertension. Both insomnia with alcohol use disorder and hypertension are complex medical issues with multiple etiologies. The record does not indicate that the Veteran, is either a trained medical professional, reporting a contemporaneous opinion from a medical professional, or describing a continuity of symptoms that is later established as explaining the etiology of hypertension. While the articles provided by the Veteran are relevant to his conditions, they similarly require a competent medical opinion to determine their applicability to the Veteran's specific circumstances. As such the Board is only able to provide minimal probative weight to this evidence in support of the element of nexus for secondary service connection.

In weighing the evidence presented for the third element of secondary service connection, two highly probative opinions from medical providers did not find a nexus between the Veteran's service-connected condition and his current disability. The evidence which does purport to find a nexus is found to be of only minimal probative value. Therefore, the evidence persuasively weighs against the finding of a nexus for secondary service connection. Without the finding of a nexus in satisfaction of the third element required, a claim for secondary service connection cannot be supported.

The Veteran was also evaluated for service connection for his current disability of hypertension on a direct basis. To establish service connection on a direct basis the following elements must be satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the medical "nexus" requirement). Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a).

As previously noted, the AOJ made a favorable finding that the Veteran has a current diagnosis of hypertension. Additionally, the AOJ made a favorable finding that the Veteran experienced toxic exposure risk activity during service. Thus, second element of an in-service incurrence is satisfied as well.

There still must be found a nexus between the Veteran's toxic exposure risk activity and his current diagnosis. There is one opinion in the evidence of record which addresses a nexus on a direct basis.

The Veteran attended a VA examination in July 2023. The examiner reviewed the
, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a).

The Veteran attended a VA examination in July 2023. The examiner reviewed the Veteran's available health records as well as conducted an in-person interview. The examiner reached the conclusion that the Veteran's hypertension was less likely than not the result of the Veteran's toxic exposure during service. The examiner stated even considering the combined and synergistic effect of toxic exposures throughout the Veteran's service period, it was more likely that the Veteran's hypertension was caused by the other major risk factors contained in the Veteran's health records, including obstructive sleep apnea and obesity. The examiner is deemed to be competent to offer such an opinion and credible in their analysis. Thus, this opinion is also afforded high probative weight.

The only medical opinion in the evidence of record concerning a nexus between toxic exposure risk activity and the current diagnosis of hypertension does not find a link between the two conditions. That opinion has been provided high probative weight and no countervailing evidence that supports a nexus is within the evidence of record. Therefore, the evidence persuasively weighs against the finding of a nexus for direct service connection. Without a finding of a nexus a claim for service connection on a direct basis cannot be supported.

For the above reasons, the Board finds that the evidence is neither evenly balanced nor approximately so with regard to whether entitlement to service connection for hypertension is warranted on either a secondary or direct basis. Rather, the evidence persuasively weighs against entitlement to service connection. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore 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). The appeal is hereby DENIED.

(This space intentionally left blank. VLJ signature on next page.)

J.P. Norman

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Arner, Jonathan T.

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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