HYPERTENSION

Summary

The veteran, who served from September 1981 to April 1992, appeals the denial of service connection for hypertension. The veteran claims hypertension is secondary to his service-connected right lumbar abdominal spasms with chronic low back pain, asserting that the pain led to a sedentary lifestyle, weight gain, and subsequent hypertension. The AOJ had already granted service connection for the lumbar condition. The Board reviewed conflicting medical evidence. Two private medical opinions from clinicians C.M.B. and P.D. found a positive nexus, linking hypertension to the service-connected back condition with obesity as an intermediary step, citing medical literature and the veteran's weight gain. Conversely, multiple VA examiners provided negative nexus opinions. The September and October 2021 examiners found no correlation between lumbar spasms and hypertension or obesity. The April 2023 examiner erroneously stated the veteran had no hypertension diagnosis. The August 2023 examiner acknowledged risk factors but found hypertension unrelated to the back condition. The Board found the private opinions probative, despite minor flaws, and noted the VA opinions were also imperfect, with the April 2023 examiner incorrectly stating no hypertension diagnosis and the August 2023 examiner failing to fully address the link between the back condition and risk factors. Given the approximate balance of evidence, the Board applied the benefit of the doubt doctrine, resolving all reasonable doubt in the veteran's favor. Consequently, service connection for hypertension as secondary to the service-connected lumbar condition was granted.

Rationale

Conflicting medical opinions presented: private opinions found positive nexus, VA opinions were negative or flawed.; Private opinions from C.M.B. and P.D. linked hypertension to back condition and obesity, citing medical literature.; VA opinions were criticized for being conclusory, erroneous (no hypertension diagnosis), or failing to link back condition to risk factors.; Board found private opinions probative despite minor flaws, establishing a relationship between hypertension and service-connected disability.; Benefit of the doubt applied due to approximate balance of evidence.

Full Decision Text

Citation Nr: A25024422
Decision Date: 03/17/25	Archive Date: 03/17/25

DOCKET NO. 240401-430118
DATE: March 17, 2025

ORDER

Entitlement to service connection for hypertension as secondary to right lumbar abdominal spasms with chronic low back pain is granted.

FINDING OF FACT

The evidence is approximately balanced as to whether the Veteran's hypertension is related to a service-connected disability.

CONCLUSION OF LAW

Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for hypertension as secondary to right lumbar abdominal spasms with chronic low back pain have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from September 1981 to April 1992.  

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2023 rating decision of a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ).

In the April 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. 

Therefore, the Board may only consider the evidence of record at the time of the September 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. 

Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303.  The three-element test for service connection requires competent evidence of: (1) 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 in-service disease or injury.  Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009).  

Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability results from the service-connected disability. 38 U.S.C. §§ 1110, 1131; Spicer v. McDonough, 61 F.4th 1360, 1364, 1366 n.1 (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" and noting that, apart from distinguishing whether service was during a period of war, 38 U.S.C. §§ 1110 and 1131 are identical).

After careful consideration of the evidence, any reasonable doubt remaining is to be resolved in favor of the Veteran. ?38?U.S.C. §?5107;?38?C.F.R. §?3.102.  If the evidence is not in approximate balance or nearly equal, the claim is to be denied.  Lynch?v. McDonough,?999 F.3d 1391 (2021).

Entitlement to service connection for hypertension 

The Veteran is seeking service connection for his hypertension, which he asserts is caused by his service-connected right lumbar abdominal spasms with chronic low back pain, with obesity as an intermediary step. Specifically, he asserts that his service connected right lumbar abdominal spasms made it painful and completely hindered him from exercise. See August 2021 Correspondence. He contends that not being able to maintain an exercise routine over time caused him to gain "a significant amount of weight;" notably, "[w]hen [he] entered the military, [he] weighed about 149 lbs. at entrance, 195 lbs. at separation, and 255 lbs. now;" and "[a]long with the weight gain came health concerns" such as high blood pressure. Id. 

The AOJ has favorably found that the Veteran has a current diagnosis of hypertension and that the primary disability of right lumbar abdominal spasms with chronic low back pain is service connected. See September 2023 Rating Decision-Narrative. Thus, the remaining question is whether the Veteran's hypertension is related to his service-connected disability. The Board
 being able to maintain an exercise routine over time caused him to gain "a significant amount of weight;" notably, "[w]hen [he] entered the military, [he] weighed about 149 lbs. at entrance, 195 lbs. at separation, and 255 lbs. now;" and "[a]long with the weight gain came health concerns" such as high blood pressure. Id. 

The AOJ has favorably found that the Veteran has a current diagnosis of hypertension and that the primary disability of right lumbar abdominal spasms with chronic low back pain is service connected. See September 2023 Rating Decision-Narrative. Thus, the remaining question is whether the Veteran's hypertension is related to his service-connected disability. The Board finds that it is.

The Board notes that while obesity cannot be service-connected on a direct basis, it may serve as an "intermediate step" between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310(a). VAOGCPREC 1-2017; see also Walsh v. Wilkie, 32 Vet. App. 300 (2020).

Turning to the evidence, the Veteran has submitted two private positive nexus opinions for secondary service connection for hypertension. The first is a May 2022 private medical opinion from clinician C.M.B., who found that it is at least as likely as not that the Veteran's current hypertension is secondary to, related to, and/or aggravated by his service connected right lumbar abdominal spasms with chronic low back pain, with subsequent weight gain and obesity. In support of his opinion, C.M.B. explained that the Veteran "does suffer from an obese condition due to his service-connected right lumbar abdominal spasms with chronic low back pain." Based upon review of the Veteran's lay statement regarding his weight at military entrance, upon separation, and his current weight, the examiner found the Veteran to be "in the obese range," with a total weight gain of approximately 46 lbs. during active duty and an additional weight gain of 60 lbs. from his discharge from active duty to present, notably after his low back injury. The examiner cited to medical literature that attributes this weight gain to the Veteran's service-connected right lumbar abdominal spasms with chronic low back pain and opined that "[w]eight gain/obesity such that this [V]eteran suffers from is known to increase blood pressure and at the very least, aggravate pre-existing [h]ypertensive conditions." Given a review of the Veteran's medical history, and medical literature, C.M.B. concluded that the Veteran's hypertension was secondary to his lumbar disability, with obesity as an intermediary step. See May 2022 Medical Treatment Record-Non-Government Facility.

In the second private opinion submitted by the Veteran, private clinician P.D. also rendered a positive nexus opinion finding the Veteran's hypertension is at least as likely as not secondary to, related to, and/or aggravated by service-connected conditions to include right lumbar abdominal spasms with chronic low back pain with associated weight gain. P.D. explained that due to the chronic pain in the Veteran's low back, he has participated in fewer physical activities and has led a more sedentary lifestyle, which is a contributing factor to his weight gain. P.D.'s rationale also explained that medical literature supports the reasoning that overweight/obese individuals are more prone to several health issues to include hypertension. She concluded that, "medical literature supports the nexus based upon the musculoskeletal condition causing a decrease in physical activity and functional limitations related to chronic pain consequently promoting weight gain and an overweight/obesity condition which triggers a sympathetic nervous system activation, contributing to the development of hypertension." See January 2023 Medical Treatment Record -Non-Government Facility.

The Board finds the opinions of private clinicians C.M.B. and P.D. have probative value, as each considered the Veteran's specific contentions, the claims file, including the Veteran's service treatment records and VA treatment records, medical research, and clinical medical evidence, before providing a positive opinion. 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 opinions are not flawless. However, they do serve to establish a relationship between the Veteran's current hypertension and his service-connected disability, with related weight gain as an intermediate step. Id; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). 

In September 2021, October 2021, April 2023, and August 2023 VA examiners rendered negative nexus opinions for the Veteran's hypertension. 

In that regard, September 202
 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 opinions are not flawless. However, they do serve to establish a relationship between the Veteran's current hypertension and his service-connected disability, with related weight gain as an intermediate step. Id; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). 

In September 2021, October 2021, April 2023, and August 2023 VA examiners rendered negative nexus opinions for the Veteran's hypertension. 

In that regard, September 2021 examiner found the Veteran had a diagnosis of hypertension. She noted that the Veteran's blood pressure readings were elevated on the current examination, and that the Veteran's hypertension had never been medicated. The examiner concluded that the claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected condition. In support of that opinion, she stated that the Veteran's service connection for right lumbar abdominal spasms has "absolutely nothing to do with diagnosis of [hypertension]." See September 2021 DBQ; see also October 2021 DBQ.

In support of his negative opinion, the October 2021 examiner stated only that, "currently, there is no medical rationale correlating the diagnosis of lumbar spasms with the development of hypertension."

The October 2021 VA examiner then provided a clarifying opinion regarding obesity as an intermediate step, stating that "a review of the Veteran's available medical records does not provide any documentation indicating that his obesity has been attributed to his low back condition," nor is there "documentation or imaging available that demonstrates a correlation between the [V]eteran's low back condition and the [V]eteran becoming obese." He concluded that it was less likely than not that the Veteran's obesity is proximately due to or the result of the Veteran's low back condition. See October 2021 DBQ.

The April 2023 VA medical examiner found that the Veteran did not have a current diagnosis of hypertension. In support of his opinion, the examiner stated that a "search of the chart reveals no treatment," therefore "without currently diagnosed hypertension, the [V]eteran's medical records do not support that any currently diagnosed condition(s) related to the [V]eteran's claimed hypertension, is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) caused by (the) indicated toxic exposure risk activity(ies) 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 [V]eteran." See October 2021 DBQ.

The August 2023 examiner noted that the Veteran is overweight per the medical records and lives a sedentary lifestyle, both of which are risk factors that may have contributed to his hypertension diagnosis. However, he ultimately concluded that the conditions of hypertension and right lumbar abdominal spasms with chronic low back pain are not medically related and that hypertension is a separate entity entirely from the right lumbar abdominal spasms with chronic low back pain and unrelated to it. He concluded that Veteran's hypertension was less than likely caused by the Veteran's service-connected condition. See August 2023 Disability Benefits Questionnaire (DBQ).

Similar to the private opinions, none of the VA opinions are flawless. The 2021 opinions do not address obesity as an intermediate step or are conclusory. The April 2023 VA examiner erroneously stated that the Veteran does not have a diagnosis of hypertension. Finally, the August 2023 VA examiner acknowledged being overweight and living a sedentary lifestyle as risk factors for hypertension but did not address whether the Veteran's back disability caused those risk factors.

(Continued on the next page)

?

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary is required to give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. Additionally, VA is prohibited from developing additional evidence for the purpose of obtaining evidence against a claimant's case. See Mariano v. Principi, 17 Vet. App. 305 (2003). 

Here, the Board finds that the private medical opinions of C.M.B. and P.D. bring the evidence addressing whether the Veteran's hypertension is related to a service-connected disability at least into approximate balance. Thus, resolving all reasonable doubt in the Veteran's favor, the criteria for service connection are met, and service connection for hypertension is granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

 

 

L. STEP
 U.S.C. § 5107. Additionally, VA is prohibited from developing additional evidence for the purpose of obtaining evidence against a claimant's case. See Mariano v. Principi, 17 Vet. App. 305 (2003). 

Here, the Board finds that the private medical opinions of C.M.B. and P.D. bring the evidence addressing whether the Veteran's hypertension is related to a service-connected disability at least into approximate balance. Thus, resolving all reasonable doubt in the Veteran's favor, the criteria for service connection are met, and service connection for hypertension is granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

 

 

L. STEPANICK

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Hampl, Samantha

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.