LIVER DISEASE OF

JONATHAN B. KRAMER · 2026 · Case ID: 26001374

MIXED

Summary

The Veteran, who served in the Marine Corps from March 1970 to February 1973, appeals the denial of service connection for a liver disorder, including cancer, and the cause of death. The Veteran also sought an increased rating for hypertension and service connection for headaches and chest pain secondary to hypertension. The Board denied service connection for the liver disorder, finding no nexus to service or herbicide exposure, and that presumptive criteria were not met. The Board also denied service connection for the cause of death, finding the Veteran's service-connected conditions did not substantially or materially contribute to his death, and that the private medical opinion was inadequate. The Board denied an increased rating for hypertension, as the Veteran's blood pressure readings did not meet the criteria for a higher rating, and the symptoms of headaches and chest pain were not contemplated under the hypertension rating schedule. However, the Board granted service connection for headaches and chest pain as secondary to hypertension, finding the evidence in approximate balance and resolving doubt in the Veteran's favor.

Rationale

No nexus to service for liver disorder.; Presumptive criteria for herbicide exposure not met.; Evidence weighed against direct service connection.; Private medical opinion found inadequate.

Service Branch

MARINE CORPS

Special Benefit

ACCRUED BENEFITS; DIC / CAUSE OF DEATH

Docket No.

16-54 168

Full Decision Text

Citation Nr: 26001374
Decision Date: 01/30/26 Archive Date: 01/30/26

DOCKET NO. 16-54 168
DATE: January 30, 2026

ORDER

Entitlement to service connection for a liver disorder, to include as due to herbicide agent exposure, is denied.

Entitlement to service connection for cause of death is denied.

Entitlement to a disability rating in excess of 10 percent for service-connected vascular hypertension is denied.

Entitlement to service connection for a disability manifested by headaches, as secondary to service connected hypertension, on a causation basis, for the purpose of accrued benefits, is granted.

Entitlement to service connection for a disability manifested by chest pain, as secondary to service connected hypertension, on a causation basis, for the purpose of accrued benefits, is granted.

FINDINGS OF FACT

1. The evidence of record persuasively weighs against finding the Veteran's liver disorder was etiologically related to service or secondary to his service-connected diabetes.

2. The evidence of record persuasively weighs against finding that the Veteran's service-connected disabilities caused or contributed substantially or materially to his death.

3. During the period on appeal, the Veteran's hypertension was not manifested by systolic pressure predominantly 200 or more or diastolic pressure predominantly 100 or more.

4. Resolving reasonable doubt in favor of the Veteran, his disability manifested by headaches was caused by service-connected hypertension.

5. Resolving reasonable doubt in favor of the Veteran, his disability manifested by chest pain was caused by service-connected hypertension.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for a liver disorder are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310.

2. The criteria for entitlement to Dependency and Indemnity Compensation based on entitlement to service connection for the cause of the Veteran's death are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 1310, 1312, 5103, 5103A, 5107; 38 C.F.R. §§ 3.5, 3.102, 3.159, 3.303, 3.307, 3.309, 3.310, 3.312.

3. The criteria for a disability rating in excess of 10 percent for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.104, Diagnostic Criteria (DC) 7101.

4. The criteria for entitlement to service connection for a disability manifested by headaches, as secondary to hypertension have been met. 38 U.S.C. §§ 1110, 5103, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.310.

5. The criteria for entitlement to service connection for a disability manifested by chest pain, as secondary to hypertension have been met. 38 U.S.C. §§ 1110, 5103, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The appellant is the surviving spouse of the Veteran who served on active duty from March 1970 to February 1973. Unfortunately, the Veteran died in [REDACTED] 2010.

These matters initially come before the Board of Veterans' Appeals (Board) on appeal of a February 2013 rating decision of the Department of Veterans Affairs (VA).

In July 2022, the appellant appeared at a Board hearing before the undersigned Veterans Law Judge. Due to technical difficulties, her testimony could not be received. She agreed to submit her arguments in writing in lieu of hearing. See September 2022 Third Party Correspondence.

These matters were before the Board in April 2023, at which time these claims were denied. The appellant appealed the April 2023 decision to the United States Court of Appeals for Veterans Claims (the Court or CAVC). In a December 2023 Joint Motion for a Partial Remand (JMPR), the interested parties agreed the Board erred in failing to provide adequate reasons and bases.

These matters were
Department of Veterans Affairs (VA).

These matters were most recently before the Board in June 2024 at which time the appeals were remanded to obtain new medical opinions. VA obtained supplemental medical opinions in July 2024 and December 2024. Initially, the Board finds the VA examinations are in substantial compliance with its remand directives. Stegall v. West, 11 Vet. App. 268 (1998) (a remand confers upon the claimant, as a matter of law, the right to compliance with the remand directives).

Following issuance of a February 2025 Supplemental Statement of the Case (SSOC), the appellant's representative submitted a request for hearing. See February 2025 Hearing Request. In September 2025, the appellant's representative elected to submit a memorandum in lieu of a hearing. See BVA Hearing Withdrawal Letter. Thereafter, the appellant's representative submitted written argument in support of the appellant's contentions. See September 2025 Third Party Correspondence.

Service Connection Laws and Regulations

Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection requires evidence showing: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the current disability and the disease or injury incurred or aggravated in service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a presumptive basis due to herbicide agent exposure for certain diseases. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a)(6)(ii), 3.309(e); Blue Water Navy Vietnam Veterans Act of 2019, Pub. L. No. 116-23, 133 Stat 966 (2019) (Blue Water Navy Act of 2019); William M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021, Pub. L. No. 116-283, 134 Stat. 3388 (2021); Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act (PACT Act of 2022), Pub. L. No. 117-168, 136 Stat. 1759 (2022).

For the purposes of this section, the term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, specifically: 2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram. 38 C.F.R. § 3.307(a)(6)(i). A veteran is presumed to have been exposed to an herbicide agent in service if they served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 U.S.C. § 1116(d); 38 C.F.R. § 3.307(a)(6)(iii).

Certain chronic diseases, including cirrhosis of the liver and malignant tumors, are subject to presumptive service connection if manifested 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; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). A nexus to service may also be established by
and ending on May 7, 1975. 38 U.S.C. § 1116(d); 38 C.F.R. § 3.307(a)(6)(iii).

Certain chronic diseases, including cirrhosis of the liver and malignant tumors, are subject to presumptive service connection if manifested 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; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). A nexus to service may also be established by showing continuity of symptomatology following service. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013).

Service connection on a secondary basis requires (1) evidence of a current nonservice-connected disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability either (a) caused, or (b) aggravated, the nonservice-connected disability. 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); see also Spicer v. McDonough, No. 2022-1239 (Fed. Cir. March 8, 2023) (invalidating the requirement of "proximate cause" and instead held a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

A lay person is competent to report symptoms and experiences observable by their senses; however, usually, they are not competent to prove a matter requiring medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 470 (1994).

After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall resolve all reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); 38 C.F.R. § 3.102. This standard does not require the evidence to be exactly equal; rather, it includes "scenarios where the evidence is not in equipoise but nevertheless is in approximate balance. Put differently, if the positive and negative evidence is in approximate balance (which includes but is not limited to equipoise), the claimant receives the benefit of the doubt." Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

1. Entitlement to service connection for a liver disorder.

The appellant seeks service connection for liver cancer. As there are multiple diagnoses of liver disorders of record, the Board has recharacterized this as a claim for a liver disorder, to include liver cancer, to permit the broadest possible scope of review. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a claim pursued by a claimant includes any diagnosis that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). Previously, the appellant's representative asserted the Veteran's liver cancer was secondary to his service connected diabetes and/or secondary to herbicide agent exposure in service. See November 2022 and February 2024 Submissions. In a more recent submission, the appellant's representative asserted that STRs and post-service medical records reflected "risk factors tied to service, including possible in-service inoculation under unsterile conditions, as well as his history of hepatitis C, which is medically linked to cirrhosis and liver cancer." See September 2025 Submission. A private medical opinion from Dr. T. was cited in support of liver cancer being related to service. Id.

Turning to the evidence, STRs do not reflect inoculations taking place in unsterile conditions, nor evidence of liver problems in service. The Veteran underwent drug abuse treatment in service with a noted history of heroin dependence and other drug abuse. See November 1972 Clinical Record. He was recommended for discharge over concerns of likely return to drug abuse and resultant disciplinary processes. Id. In November 1973, the Veteran reported a history of using intravenous heroine. See Narrative Summary.

Post service, the
as his history of hepatitis C, which is medically linked to cirrhosis and liver cancer." See September 2025 Submission. A private medical opinion from Dr. T. was cited in support of liver cancer being related to service. Id.

Post service, the Veteran was diagnosed with hepatitis C, although the reported date of diagnosis varies. See e.g., VA treatment records June 1994 (history of hepatitis C); May 1999 (history of hepatitis C by blood transfusion in 1980); September 2002 (10 year history of hepatitic C); May 2005 (Veteran reported using drugs from 1971 to 1980, having a blood transfusion in 1980 after knee surgery and being diagnosed as HCV positive in 2003).

A mass was detected on the left lobe of the Veteran's liver by a computed tomography (CT) scan in June 2008. An October 2009 CT showed a liver mass suggestive of a hemangioma, as well as cirrhosis with portal venous hypertension. Following diagnostic testing in May 2010, the Veteran was assessed with hepatocellular carcinoma (HCC) and cirrhosis, "consistent with a clinical history of hepatitic C." See VA treatment record. In a June 2010 Oncology Note, it was noted the Veteran had "newly discovered HCC in setting of cirrhosis and chronic hepatitis C." In August 2010, the Veteran's primary problem was listed as hepatic encephalopathy with a secondary problem of liver cancer. Multiple etiologies were noted for encephalopathy including Hepatitic C, and portal vein thrombosis. Id. The Veteran passed away in [REDACTED] 2010. The immediate causes of death were hepatic encephalopathy, cirrhosis, and hepatitis C due to unknown etiology. See December 2010 Death Certificate.

A VA examination in February 2004 determined the Veteran's Hepatitis C was more likely of post-service origin, noting the Veteran's report of visiting prostitutes, getting tattoos, and periods of alcoholism with altercations, head injuries and legal problems.

A November 2022 private medical opinion from Dr. T. found the Veteran's liver cancer was secondary to service-connected diabetes mellitus. As explained in the June 2024 Board decision:

However, the Board finds that the November 2022 opinion is inadequate to support a grant of service connection without additional development. The opinion refers to "Medical studies" showing that diabetes is one of the main risk factors for the development of liver cancer but does not provide or even cite such studies. While the Board is not competent to offer an opinion on the cause of the Veteran's liver cancer, a review of research from the Centers for Disease Control regarding the risk factors for liver cancer does not mention diabetes. https://www.cdc.gov/liver- cancer/about/index.html. However, it does mention hepatitis C. Strangely, the private opinion does not discuss the Veteran's hepatitis C as a risk factor for his liver cancer. At the time of his death, the Veteran had been diagnosed with hepatitis C for at least 10 years. The opinion is therefore inadequate.

The Board remanded the claim for a new medical opinion regarding the relationship between diabetes and liver cancer. A VA medical opinion was obtained in July 2024, concluding in relevant part:

Veteran has HCC secondary to hepatitis C thus has an underlying factor. Even though DM can cause non-alcoholic fatty liver, it's not known for DM to aggravate HCC. Therefore, in my opinion, the claimed condition of liver disease is less likely than not (likelihood is less than approximately or nearly equal) aggravated beyond its natural progression by his service connected diabetes mellitus type II ...

There is no pathological or etiological correlation or evidence in the medical records provided establishing a nexus between the Veteran's claimed condition of liver [disorder] and DM2. Therefore, in my opinion, the claimed condition of liver [disorder] is less likely than not ... proximately due to or the result of diabetes mellitus type II.

The VA medical opinion also rejected a nexus between the Veteran's liver conditions of HCC and hepatic encephalopathy and service, or service-connected diabetes and hypertension, finding the medical evidence did not support such nexus.

A February 2025 VA medical
likely than not (likelihood is less than approximately or nearly equal) aggravated beyond its natural progression by his service connected diabetes mellitus type II ...

A February 2025 VA medical opinion from a different VA examiner explained the etiology of the Veteran's various liver diagnoses of record as follows:

Veteran served 3/19/1970-2/8/1973. After reviewing medical records, Veteran died on [REDACTED]2010. Cause of death was listed as Hepatic encephalopathy, Cirrhosis, Hepatitis C and contributing diabetes and hypertensive vascular disease. There was a liver mass seen on CT from 6/6/2008. Veterans hepatic encephalopathy in the records is attributed to the history of cirrhosis of the liver from Hepatitis C. There was a diagnosis of cirrhosis of the liver on 7/6/2004. It was worsening towards death which led to the Hepatic encephalopathy. Veteran developed Varices from this condition as well. There is also a diagnosis of Hepatitis C from 9/22/2006. This was still active at the time of death.

According to the Cleveland clinic, Cirrhosis of the liver is a chronic liver disease characterized by the formation of scar tissue (fibrosis) that replaces healthy liver cells. This scarring impairs the liver's ability to function properly. (https://my.clevelandclinic.org/health/ diseases/15572-cirrhosis-of-the-liver. According to the Mayo clinic, Hepatitis C is a liver infection caused by the hepatitis C virus (HCV). It is primarily transmitted through contact with infected blood, such as through sharing needles, receiving unscreened blood transfusions, or getting tattoos or piercings with unsterilized equipment. (https://www.mayoclinic.org/diseases-conditions/hepatitis-c/ symptoms-causes/syc-20354278). All tabbed and relevant records were reviewed and considered in relation to the claimed condition.

In September 2025, the appellant re-submitted the November 2022 medical opinion from Dr. T.

The Board has reviewed the evidence of record in conjunction with the applicable laws and regulations and finds that service connection for a liver disorder is not warranted.

Initially the Board notes that diseases presumed to be associated with herbicide agent exposure do not include liver cancer, hepatitis or cirrhosis. Nor is there any medical opinion of record linking the Veteran's diagnosed liver disorders to herbicide exposure. Thus, this presumption is not for application.

The Board recognizes that service connection may be awarded on a presumptive basis for certain chronic diseases, including cirrhosis of the liver and malignant tumors that manifest to a degree of 10 percent within one year of service separation. 38 C.F.R. §§ 3.303(b), 3.307, 38 C.F.R. § 3.309(a). In this case, the Veteran's liver condition(s) were not diagnosed in service, nor in the year after discharge. Nor is there continuity of symptomatology demonstrated where, by the Veteran's own accounts to his medical providers, his hepatitis C was the result of a blood transfusion in 1980, years after service. His other liver disorders were not diagnosed until years later. Thus, the chronic disease presumption if also not for application.

Regarding direct service connection, the appellant contends there were "risk factors tied to service, including possible in-service inoculation under unsterile conditions." See September 2025 Submission:

Before his death, [the Veteran] personally reported to his wife that during service inoculations, needles were reused between service members without sterilization. This practice is well-documented in his era and is recognized by medical experts as a direct vector for hepatitis C transmission. Hepatitis C was the underlying cause of his cirrhosis and hepatic encephalopathy. Therefore, we maintain it is at least as likely as not that [the Veteran] contracted hepatitic C from unsanitary inoculation practices while in the Marine Corps.

There is no substantiating evidence that the Veteran was exposed to reused needles in service during inoculations. Despite reference to such practice being "well-documented," no such documentation or support for this theory has been submitted. Personal factors putting the Veteran at risk for liver disorders, however, do consistently appear in the evidence of record. See e.g., November 1973 STR (used intravenous heroin); January 1978 clinical record (released from prison, referred to alcohol counseling); VA treatment records dated May 1999 (history of hepatitis C by blood transfusion in 1980); May 2000 (interested in treatment for hepatitis C but not able to sustain from alcohol long enough to be evaluated); September 2002 (history of intravenous drug use); October 2002 (patient of intravenous drug use, stage 4 cirrhosis, still drinking EOH so not candidate for treatment, elevated liver enzymes); December 2003 (history of blood transfusions in the late 1970's and early 1980s, drug use and high risk sexual behavior); November 2009 (hepatitis C and liver cirrhosis from ETOH abuse); February 2009 (assessed with alcoholic liver disease).

The Board finds the evidence of record weighs against direct service connection where the alleged event of unsanitary inoculations in service is not substantiated, where other personal risk factors for liver disorders are demonstrated by the evidence of record, and the February 2004 and July 2024 VA medical opinions specifically rejected a medical nexus between the Veteran's liver disorder(s) and service.

Finally, turning to secondary service, there is medical evidence for and against the claim. However, the November 2022 private medical opinion suggesting the Veteran's diabetes worsened his liver cancer has been found inadequate as explained above. The Board finds the July 2024 VA medical opinion, on the other hand, highly probative based on the comprehensive analysis offered and in addressing both causation and aggravation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (noting that the probative value of a medical opinion derives from the factually accurate, fully articulated, sound reasoning for the conclusion).

Based on the foregoing, the Board finds the evidence of record is persuasively against the claim. See Lynch, 21 F.4th at 776. Thus, the evidence is not in approximate balance. Accordingly, service connection for a liver disorder to include as secondary to service connected diabetes, or secondary to herbicide agent exposure, is denied.

General Provisions Applicable to Cause of Death

Dependency and Indemnity Compensation (DIC) benefits are payable to the surviving spouse of a veteran if the veteran died from a service-connected disability. 38 U.S.C. § 1310; 38 C.F.R. § 3.5. To establish a service-connected cause of death, it must be shown that a service-connected disability either caused death or substantially or materially contributed to cause death. A service-connected disability is one which was incurred in or aggravated by active service, one which may be presumed to have been incurred during active service, or one which was proximately due to or the result of, or aggravated by, a service-connected disability.

The death of a veteran will be considered as having been due to a service-connected disability when the evidence establishes that such disability was either the principal or a contributory cause of death. The issue involved will be determined by exercise of sound judgment, without recourse to speculation, after a careful analysis has been made of all the facts and circumstances surrounding the death of the veteran, including, particularly, autopsy reports. 38 C.F.R. § 3.312(a).

The service-connected disability will be considered as the principal (primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related hereto. 38 C.F.R. § 3.312(b).

A contributory cause of death is inherently one not related to the principal cause. In determining whether the service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. It is not sufficient to show that
circumstances surrounding the death of the veteran, including, particularly, autopsy reports. 38 C.F.R. § 3.312(a).

A contributory cause of death is inherently one not related to the principal cause. In determining whether the service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c)(1); see also Gabrielson v. Brown, 7 Vet. App. 36, 39 (1994).

Generally, minor service-connected disabilities, particularly those of a static nature or not materially affecting a vital organ, would not be held to have contributed to death primarily due to unrelated disability. In the same category there would be included service-connected disease or injuries of any evaluation (even though evaluated as 100 percent disabling) but of a quiescent or static nature involving muscular or skeletal functions and not materially affecting other vital body functions. 38 C.F.R. § 3.312(c)(2).

Service-connected diseases or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. Where the service-connected condition affects vital organs as distinguished from muscular or skeletal functions and is evaluated as 100 percent disabling, debilitation may be assumed. 38 C.F.R. § 3.312(c)(3). There are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of coexisting conditions, but, even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. In this situation, however, it would not generally be reasonable to hold that a service-connected condition accelerated death unless such condition affected a vital organ and was of itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c)(4).

2. Entitlement to service connection for cause of the death.

The appellant contends that the Veteran's service-connected diabetes mellitus type 2 and hypertension were "contributing factors to his death, materially lessening his ability to resist the fatal progression of liver failure." See September 2025 Submission. Further, assertions were made that his "death was directly related to conditions incurred during service, as well as systemic failures in timely medical care by the VA." The Board notes that, to the extent the appellant statement may be construed as raising a new 1151 claim related to treatment for cause of the Veteran's death, this issue has not been adjudicated before the RO, and the Board does not have jurisdiction over it. Thus, the Board will limit its review to those issues before the RO.

Turning to the evidence, as previously noted, the Veteran's death certificate indicates that the cause of death was hepatic encephalopathy, which was due to or as a consequence of cirrhosis, which was due to or a consequence of hepatitis C, which was of unknown etiology. The certificate further indicates that the service-connected diabetes and hypertension "could have contributed." See December 2010 Death Certificate. VA treatment records reflect that, in [REDACTED] 2010, the appellant requested "medical conditions that may be service connected that possibly contributed to his death be listed on his death certificate." See Geriatric Medicine Note.

A VA examination in May 2012 contained a review of the full VA hospital discharge summary in [REDACTED] 2010, which stated that the contribution from service-connected conditions, such as hypertension and diabetes, is unknown definitively and indicated as such on the summary. The May 2012 VA medical opinion concluded that, based on the discharge summary, it was far less likely than not that the Veteran's death was in any way related to his service connected diabetes or hypertension.

In July 2022, a private medical opinion from Dr. T. concluded that hepatic encephalopathy is caused by a chronic liver disease such as liver cancer and is worsened by diabetes. Dr. T. indicated that, as the Veteran was service connected for diabetes, and should be granted service connection for liver cancer,
summary in [REDACTED] 2010, which stated that the contribution from service-connected conditions, such as hypertension and diabetes, is unknown definitively and indicated as such on the summary. The May 2012 VA medical opinion concluded that, based on the discharge summary, it was far less likely than not that the Veteran's death was in any way related to his service connected diabetes or hypertension.

The July 2024 VA medical opinion concluded that there was no pathological or etiological correlation or evidence in the medical records establishing a nexus between the Veteran's liver disorders and his diabetes mellitus type 2. Nor was diabetes determined to aggravate HCC. The Veteran's HCC was noted as secondary to hepatitis C.

The Board has reviewed the evidence of record in conjunction with the applicable laws and regulations and finds that service connection for the cause of the Veteran's death is not warranted.

Here, while the death certificate mentions the Veteran's service-connected disabilities, apparently at the appellant's request, it does so inconclusively in stating such disabilities "could have" contributed. It is well established VA law that speculative medical opinions are insufficient to establish service connection. See Obert v. Brown, 5 Vet. App. 30 (1993) (medical opinion expressed in terms of "may" [can] also implies "may or may not" [can or cannot] and is too speculative to establish medical nexus); McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006) (stating that speculative medical opinion as to causation cannot establish medical nexus to service); Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009) (holding that doctor's statement that veteran's brain tumor "may well be" connected to Agent Orange exposure was speculative"); Bloom v. West, 12 Vet. App. 185, 187 (1999) (noting that the use of the term "could," without additional rationale or supporting data, is speculative).

The speculative statement that the Veteran's diabetes and hypertension "could have" contributed do not demonstrate substantial or material contribution, nor that such disabilities combined to cause death nor aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c)(1); see also Gabrielson v. Brown, 7 Vet. App. 36, 39 (1994). Nor is there a reasonable basis for concluding that the Veteran's service connected conditions accelerated death. 38 C.F.R. § 3.312(c)(4).

While the private medical opinion of Dr. T. suggests the Veteran's cause of death should be service connected, this opinion has been found inadequate as previously explained. Further, Dr. T's conclusions were premised on a determination that the Veteran's liver cancer should be a service connected disability. Herein, the Board has found that the evidence of record persuasively weighs against entitlement to service connection for a liver disorder to include liver cancer.

The Board finds the July 2024 VA medical opinion on the other hand, in conjunction with the May 2012 VA medical opinion, to be competent and probative medical evidence weighing against a grant of service connection for cause of death.

While the appellant may believe the Veteran's cause of death should be service connected, she has not demonstrated the necessary medical expertise to render an etiology opinion. The issue is medically complex as it requires specialized medical education. Jandreau, 492 F.3d at 1377.

Based on the foregoing, the evidence of record persuasively weighs against the claim. See Lynch, 21 F.4th at 781-82. Accordingly, service connection for the Veteran's cause of death is denied.

Increased Rating

Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1.

Increased Rating

If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. Where the schedular criteria does not provide for a noncompensable rating, such a rating is assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31.

A disability rating may require re-evaluation in accordance with changes in condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994).

When an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). The rating must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007).

3. Entitlement to a disability rating in excess of 10 percent for vascular hypertension.

The appellant seeks an increased rating for the Veteran's service-connected vascular hypertension, asserting VA treatment records and lay statements reflect functional decline and increased impairment beyond the assigned rating. See September 2025 Submission. The appellant's representative further argues in their submission that the appellant is entitled to increased ratings for diabetes mellitus, peripheral neuropathy and hearing loss; however, these matters were adjudicated in the unappealed June 2024 Board decision which became final and are therefore not before the Board at present. Finally, the appellant's representative asserts entitlement to total disability rating based on individual unemployability (TDIU) prior to the Veteran's death. However, the appellant was previously granted a TDIU effective August 4, 2003, for accrued purposes. See April 2023 Board Decision and April 2023 rating decision. Thus, this issue is not before the Board on appeal.

By way of procedural background, a September 2002 rating decision granted service connection for hypertension and assigned an initial disability rating of 10 percent effective July 9, 2001. An earlier effective date of May 8, 2001, for service connection of hypertension was granted in a January 2003 rating decision. The Veteran did not appeal that rating decision nor submit new and material evidence within one year of its issuance. See 38 C.F.R. §§ 3.156(b), 19.21, 19.52. As such, the January 2003 rating decision became final. The current appeal stems from an increased rating claim submitted in July 2010. See VA 21-0820 Report of General Information.

Consequently, the period on review before the Board is from July 16, 2010, to the present, with consideration of the one-year lookback period. See Gaston, 605 F.3d at 984. Further, as in this case, where an increase in the level of a previously service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1999).

The Veteran's hypertension is evaluated under Diagnostic Code 7101. 38 C.F.R. § 4.104. Under Diagnostic Code 7101, a 10 percent rating is assigned for diastolic pressure predominately 100 or more, or systolic pressure predominantly 160 or more, or is the minimum rating for an individual with a history of diastolic pressure predominantly
back period. See Gaston, 605 F.3d at 984. Further, as in this case, where an increase in the level of a previously service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1999).

The Veteran's hypertension is evaluated under Diagnostic Code 7101. 38 C.F.R. § 4.104. Under Diagnostic Code 7101, a 10 percent rating is assigned for diastolic pressure predominately 100 or more, or systolic pressure predominantly 160 or more, or is the minimum rating for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. Id. In order for a 20 percent disability rating to be warranted, the evidence must show diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. Id. Higher ratings require diastolic pressure of predominantly 120 or more. Id.

Although the schedular criteria do not specifically outline any criteria for a noncompensable (0 percent) rating, the Board notes that a 0 percent rating is assigned when the requirements for a compensable evaluation are not met pursuant to 38 C.F.R. § 4.3.

The term "predominant" is not defined in the rating criteria. However, Merriam-Webster defines "predominant" to mean "being most frequent or common." Merriam-Webster, https://www.merriam-webster.com/dictionary/predominant (last visited January 2026).

As DC 7101 clearly contemplates the effects of medication, the Board may consider the ameliorative effects of any medication in determining the disability rating to be assigned. See McCarroll v. McDonald, 28 Vet. App. 267, 271-72 (2016). Put another way, the Board cannot consider the hypothetical level of impairment the Veteran might experience if he were not using the prescribed medication. Id.

Turning to the evidence, VA treatment record reveal that the Veteran had the following blood pressure readings during the period on appeal: October 2009 (112/68, with home BP readings noted to be in the 120-low 130's over 70 both am and pm); December 2009 (140/93); March 2010 (138/84); April 2010 (127/84); May 2010 (128/85 and 116/70); June 2010 (102/60, 96/58, 107/69, 110/72, 136/62, 103-133/74-95), July 2010 (132/62, 100/62, 107/62), August 2010 (123/82 and 135/91). See also August 2010 (his previously low BP has been asymptomatic and tolerant of change of narcotic therapy).

In a November 2022 private medical opinion, Dr. T. concluded the Veteran suffered from additional symptoms due to the severity of his hypertension, including frequent headaches and chest pain that were so severe he was prescribed nitro pills. Dr. T. concluded a 20 percent rating was warranted for the foregoing symptoms.

A July 2024 VA medical opinion concluded that the Veteran's service connected hypertension diagnosis remains the same without additional diagnoses rendered. February 2025 VA medical opinions determined that the Veteran's headaches and his chest pain were both symptoms of his hypertension.

The Board has reviewed the evidence of record in conjunction with the applicable laws and regulations and finds that a disability rating in excess of 10 percent for the Veteran's hypertension is not warranted.

Prior to his death, the Veteran did not demonstrate diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more as required by regulation to warrant a higher disability rating under DC 7101.

Based on the foregoing, the evidence of record persuasively weighs against the claim. See Lynch, 21 F.4th at 781-82. Accordingly, a disability rating in excess of 10 percent for the Veteran's service-connected vascular hypertension is denied.

In doing so, the Board acknowledges the June 2024 Board decision remanded the increased rating claim for hypertension on the basis that the Veteran's hypertension may result in impairments not contemplated under the rating schedule for hypertension. Because the disability rating criteria for the cardiovascular system under 38 C.F.R. § 4.104 (including DC 7101) does not contemplate symptoms of headaches and chest pain, such symptoms are addressed as secondary service connection claims below.

4. Entitlement to service connection for a disability manifested by headaches, as secondary to service connected hypertension.

5. Entitlement to service
at 781-82. Accordingly, a disability rating in excess of 10 percent for the Veteran's service-connected vascular hypertension is denied.

4. Entitlement to service connection for a disability manifested by headaches, as secondary to service connected hypertension.

5. Entitlement to service connection for a disability manifested by chest pain, as secondary to service connected hypertension.

The appellant has not explicitly asserted entitlement to service connection for disabilities manifested by headaches or chest pain; however, the Board finds that these issues have been reasonably raised by the medical evidence of record. See Bailey v. Wilkie, 33 Vet. App. 188, 203 (2021) (when entitlement to service connection on a secondary basis is raised during the appeal of the rating assigned for the underlying primary disability, the claimant need not file a separate, formal claim for secondary service connection); see also Morgan v. Wilkie, 31 Vet. App. 162 (2019).

As outlined above, the private opinion of Dr. T., as well as the February 2025 VA medical opinions have attributed the Veteran's headaches and chest pain to his service connected hypertension, as outlined above.

Turning to the other medical evidence of record, the Veteran underwent a VA ophthalmology consultation in November 2009 for headaches and diplopia for the past six months. He reported experienced intermittent bitemporal aching sensation and eye pain. The clinician indicated the intermittent ptosis and bitemporal and retro-orbital pains were associated with V-pattern strabismus suggestive of thyroid eye disease versus temporal arteritis, and that myasthenia should be ruled out. See also August 2009 Eye Report (six month history of flashes and floaters in both eyes associated with headaches).

With regard to chest pain, during a June 2010 VA examination for another claim, the Veteran reported a history of dyspnea and non-anginal chest pain. During the examination, he complained of left arm, shoulder and left chest muscle pain and reported being told the pain was radiating from his cervical spine condition. See also October 2009 Emergency Department Note (atypical chest pain with a history liver failure as a possible cause).

Based on the foregoing, there is evidence for and against these claims. The Board finds such evidence is in approximate balance as to whether the Veteran's disability manifested by headaches and chest pain is secondary to his service connection hypertension.

Based on the foregoing and resolving all reasonable doubt in favor of the appellant, the Board finds service connection is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection for a disability manifested by chest pain and a disability manifested by headaches, as secondary to hypertension, on a causation basis, is granted.

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JONATHAN B. KRAMER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Long, Kindra F.

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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