HYPERTENSION

Summary

The Veteran served in the Marine Corps from March 1972 to March 1986. He appeals the denial of service connection for several conditions, including cardiac autonomic neuropathy (CAN), GERD, hypertension, sleep apnea, an acquired psychiatric disability, exercise/heat/cold intolerance, gastritis, headaches, and fatigue. The Veteran contends that his CAN is service-connected due to exposure to contaminated water at Camp Lejeune and toxic chemicals related to his MOS. He also claims the other conditions are secondary to his CAN. The Board found the Veteran's lay statements regarding his exposures and symptoms credible and noted the AOJ's favorable finding that he served at Camp Lejeune. While a VA examiner opined negatively on the nexus for CAN, private medical opinions from FNP D.T. and Dr. M.R. provided positive nexus opinions linking CAN to Camp Lejeune and toxic chemical exposure. The Board found the evidence in approximate balance and granted service connection for CAN, applying the benefit of the doubt. The claims for GERD, hypertension, sleep apnea, acquired psychiatric disability, intolerance, gastritis, headaches, and fatigue, as secondary to CAN, were remanded. The remand instructions require VA to obtain examinations to determine the nature and etiology of these conditions and to provide opinions on their secondary service connection to CAN, including baseline severity if aggravated.

Rationale

AOJ favorable finding of current CAN; Credible lay statements regarding exposure and symptoms; Positive private medical opinions; Approximate balance of evidence; Benefit of the doubt applied

Full Decision Text

Citation Nr: A26037809
Decision Date: 04/22/26	Archive Date: 04/22/26

DOCKET NO. 200918-111749
DATE: April 22, 2026

ORDER

Entitlement to service connection for cardiac autonomic neuropathy (to include angina, palpitations, arrhythmias, tachycardia) ("CAN" or "heart disability") is granted.

REMANDED

Entitlement to service connection for gastroesophageal reflux disease (GERD), as secondary to service-connected CAN, is remanded.

Entitlement to service connection for high blood pressure (hypertension), as secondary to service-connected CAN, is remanded.

Entitlement to service connection for sleep apnea, as secondary to service-connected CAD, is remanded.

Entitlement to an acquired psychiatric disability, as secondary to service-connected CAD, is remanded.

Entitlement to service connection for exercise/heat/cold intolerance (to include nausea), as secondary to service-connected CAN, is remanded.

Entitlement to service connection for gastritis, as secondary to service-connected CAN, is remanded.

Entitlement to service connection for headaches, as secondary to service-connected CAN, is remanded.

Entitlement to service connection for fatigue (to include shortness of breath and sweating abnormalities), as secondary to service-connected CAN, is remanded.

FINDINGS OF FACT

The Veteran's cardiac autonomic neuropathy had its onset in, or is otherwise related to, his military service.

CONCLUSIONS OF LAW

The criteria for entitlement to service connection for cardiac autonomic neuropathy are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the Marine Corps from March 1972 to March 1975, from April 1975 to April 1977, and from February 1978 to March 1986.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2020 higher-level review rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), also known as the Agency of Original Jurisdiction (AOJ), which adjudicated the Veteran's request for higher-level review of a prior December 2019 rating decision.

In the September 2020 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held in December 2024 before the undersigned Veterans Law Judge. A transcript of the hearing is of record.

Therefore, the Board may only consider the evidence of record at the time of the December 2019 AOJ decision, which was subsequently subject to higher-level review, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the December 2024 hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision, which was subsequently subject to higher-level review and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 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[s], considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Service Connection

Entitlement to service connection for cardiac autonomic neuropathy (CAN) (to include angina, palpitations, arrhythmias, tachycardia) ("heart disability") is granted.

The Veteran contends that he suffers from a heart disability that had its onset in service and continued to the present.  See September 2020 NOD; December 2024 Hearing Transcript.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303.  The three-element test for service-connection requires 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
ias, tachycardia) ("heart disability") is granted.

The Veteran contends that he suffers from a heart disability that had its onset in service and continued to the present.  See September 2020 NOD; December 2024 Hearing Transcript.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303.  The three-element test for service-connection requires 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.  See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

Service connection for a disability may also be granted on a secondary basis if a Veteran has: (1) a current disability; and (2) the current disability was either (a) caused or (b) aggravated beyond its natural progression by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995).

When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the evidence is persuasively against the claim, in which case the claim is denied. Id.

In its July 2020 rating decision, the AOJ favorably found that the Veteran has a current disability of cardiac autonomic neuropathy to include angina, palpitations, arrhythmias, tachycardia.  The Board is bound by favorable findings by the AOJ in the absence of evidence of clear and unmistakable error. 38 C.F.R. § 3.104 (c).  See 38 C.F.R. § 3.104.  The Board, therefore, finds that the first element of service connection has been met.  38 U.S.C. §§ 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a).

The Veteran contends that he was stationed at Camp Lejeune and exposed to contaminated water.  See December 2024 Hearing Transcript.  In its July 2020 rating decision, the AOJ favorably found that the Veteran served at Camp Lejeune.  The Board is bound by favorable findings by the AOJ in the absence of evidence of clear and unmistakable error. 38 C.F.R. § 3.104 (c).  The Veteran further avers that he was also exposed to toxic chemicals as a result of his military occupational specialty (MOS).  See December 2024 Hearing Transcript.  The Board is bound by favorable findings by the AOJ in the absence of evidence of clear and unmistakable error. 38 C.F.R. § 3.104 (c).  The Board has considered the Veteran's statements.  A lay person is competent to report the onset and recurrence of his or her symptoms. See Layno v. Brown, 6 Vet. App. 465 (1994). Here, the Board finds the Veteran is competent to report to the onset of his exposures during his military service and his present symptoms.  In light of these credible lay statements, and the AOJ's favorable finding that the Veteran served at Camp Lejeune, the Board finds that the second element of service connection has also been met.

Turning to the issue of evidence addressing a nexus between the in-service incident and the current diagnosis, in August 2016 (and again in November 2019) the Veteran submitted a June 2016 (and October 2019) letter from his private neurologist FNP D.T., who opined that the Veteran's CAN is likely related to his exposure to chemicals at Camp Lejeune.  She reasoned that the chemicals at Camp Lejeune have been found to cause the symptoms that the Veteran suffers from. 

The Veteran was afforded a VA medical opinion regarding his heart disability in January 2018.  The VA examiner opined that the Veteran's current heart disability is less likely than not connected to his military service.  The examiner reasoned
 issue of evidence addressing a nexus between the in-service incident and the current diagnosis, in August 2016 (and again in November 2019) the Veteran submitted a June 2016 (and October 2019) letter from his private neurologist FNP D.T., who opined that the Veteran's CAN is likely related to his exposure to chemicals at Camp Lejeune.  She reasoned that the chemicals at Camp Lejeune have been found to cause the symptoms that the Veteran suffers from. 

The Veteran was afforded a VA medical opinion regarding his heart disability in January 2018.  The VA examiner opined that the Veteran's current heart disability is less likely than not connected to his military service.  The examiner reasoned that the Veteran's service treatment records (STRs) indicate that the Veteran had little to no exposure to contaminated water in Camp Lejeune, and that the medical literature indicates that neurologic deficits from solvent exposure to do not begin 10 years after the exposure ceases.  As such, a negative nexus was opined.

In December 2024, the Veteran submitted an October 2024 private medical opinion from Dr. M.R., who opined that it is at least as likely as not that the Veteran's CAN is a result of his exposure to contaminated water at Camp Lejeune, as well as his exposure to numerous other toxic chemicals.  He reasons that the peer-reviewed medical literature corroborates that the Veteran's current symptoms and diagnoses are likely a result of his exposure to these toxins while in the military.

In light of the foregoing, the Board finds that the record is in at least approximate balance as to whether the Veteran's heart disability is a result of his military service.  While the Board acknowledges the negative nexus opinion of the January 2018 VA examiner, the Board finds that the Veteran's credible hearing testimony and the positive nexus opinions of his private neurologist and Dr. M.R., whose opinion is based on numerous citations to peer-reviewed medical literature, are sufficiently probative to place the record in at least approximate balance.

Generally, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. An approximate balance of the evidence includes, but is not limited to, equipoise. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). 

Accordingly, the Board finds that the Veteran's heart disability (CAN) is connected to his time in military service.  Therefore, the claim for entitlement to service connection for a heart disability is granted.

REASONS FOR REMAND

GERD, Hypertension, Sleep Apnea

The Veteran contends that he suffers from GERD, hypertension, and sleep apnea as a secondary result of his (now) service-connected CAN.  See September 2020 NOD; December 2024 Hearing Transcript.

Here, the AOJ did not afford the Veteran a VA examination for his GERD, hypertension, or sleep apnea.  In Dr. M.R.'s October 2024 private medical opinion, however, he opined that it is at least as likely as not that the Veteran's GERD, hypertension, and sleep apnea are secondarily related to his service-connected CAN.  

The Board notes, however, that Dr. M.R.'s opinion regarding secondary service connection is predicated upon aggravation of the Veteran's GERD, hypertension, and sleep apnea by his service-connected CAN, but does not establish a baseline severity for the Veteran's GERD, hypertension, and/or sleep apnea prior to aggravation by the Veteran's service-connected CAN.  As such, this opinion cannot be used to establish service connection on that basis.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("Most of the probative value of a medical opinion comes from its reasoning" and a medical opinion is not "entitled to any weight....if it contains only data and conclusions.").

As noted above, the Veteran has not been afforded a VA examination to determine the nature and etiology of his GERD, hypertension, and sleep apnea during the period on appeal. See McLendon v. Nicholson, 20 Vet. App. 79 (2006).  The Board finds, based on McLendon, the low threshold of obtaining a VA examination and medical opinion for these conditions was met prior to the issuance of the July 2020 rating decision on appeal, as the record indicates that the Veteran received diagnoses for GERD, high blood pressure, and sleep apnea prior to July 2020.

Under the AMA, the Board's rem
 not "entitled to any weight....if it contains only data and conclusions.").

As noted above, the Veteran has not been afforded a VA examination to determine the nature and etiology of his GERD, hypertension, and sleep apnea during the period on appeal. See McLendon v. Nicholson, 20 Vet. App. 79 (2006).  The Board finds, based on McLendon, the low threshold of obtaining a VA examination and medical opinion for these conditions was met prior to the issuance of the July 2020 rating decision on appeal, as the record indicates that the Veteran received diagnoses for GERD, high blood pressure, and sleep apnea prior to July 2020.

Under the AMA, the Board's remand authority is generally limited to correcting predecisional duty to assist errors or to correct any other error in satisfying a regulatory or statutory duty. See 38 C.F.R. § 20.802(a). Here, the Board finds the evidence of record met the low threshold of obtaining a VA examination and medical opinion prior to the issuance of the July 2020 rating decision on appeal, and, therefore, remand is required to correct this predecisional duty to assist error. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 8 (2006).

Acquired Psychiatric Disability, Intolerance to exercise/heat/cold, Gastritis, Headaches, & Fatigue

The Veteran contends that he suffers from difficulty concentrating, intolerance to exercise/heat/cold, gastritis, headaches, and fatigue as a secondary result of his (now) service-connected CAN.  See September 2020 NOD; December 2024 Hearing Transcript.

Initially, the Board notes that while the Veteran filed a claim for difficulty concentrating, the Board notes that the record contains references to anxiety, depression, and other mental health symptoms.  Symptoms such as difficulty concentrating, anxiety, and depression all fall under the General Rating Formula for Mental Disorders, and the practice of assigning multiple disability ratings for duplicative or overlapping symptomology under various diagnoses, also known as pyramiding, is to be avoided. 38 C.F.R. § 4.14.  Therefore, the Board consolidates and recharacterizes the claim for entitlement to service connection for difficulty concentrating as a claim for entitlement to service connection for an acquired psychiatric disability.  Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009).

The Board has granted the claim for entitlement to service connection for CAN. Thus, the issues of entitlement to service connection for an acquired psychiatric disability, intolerance to exercise/heat/cold, gastritis, headaches, and fatigue, as secondary to service-connected CAN, are inextricably intertwined with the AOJ's implementation of the award of service connection for CAN.  Accordingly, the claims for entitlement to service connection for an acquired psychiatric disability, intolerance to exercise/heat/cold, gastritis, headaches, and fatigue are remanded as intertwined with the implementation of the Board's grant of service connection for CAN, decided above. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1990) (issues are inextricably intertwined when they are so closely tied together that a final Board decision cannot be rendered unless all are adjudicated).

The matters are REMANDED for the following action:

1. Schedule the Veteran for VA examinations to determine the nature and etiology of the Veteran's GERD, hypertension, and sleep apnea.  The clinician must review the entire claims file, including a copy of this Remand. 

Following a review of the Veteran's claims file, the clinician must provide an opinion as to:

(a)	Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's diagnosed GERD, hypertension, and/or sleep apnea are related to his active duty service.

(b)	Whether it is at least as likely as not (the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's GERD, hypertension, and/or sleep apnea were caused by or aggravated by the Veteran's service-connected CAN.  If the examiner finds that the Veteran's GERD, hypertension, and/or sleep apnea were aggravated by the CAN, the examiner must identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred.

A complete rationale for all opinions must be provided.  If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation.  The
)	Whether it is at least as likely as not (the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's GERD, hypertension, and/or sleep apnea were caused by or aggravated by the Veteran's service-connected CAN.  If the examiner finds that the Veteran's GERD, hypertension, and/or sleep apnea were aggravated by the CAN, the examiner must identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred.

A complete rationale for all opinions must be provided.  If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation.  The clinician must indicate whether there was any further need for information or testing necessary to make a determination.  Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner.

2. Implement the Board's decision awarding service connection for the Veteran's CAN, and ater all proper implementation of the Board's decision awarding service connection for CAN, readjudicate the claims for entitlement to service connection for an acquired psychiatric disability, intolerance to exercise/heat/cold, gastritis, headaches, and fatigue, as secondary to service-connected CAN.

 

 

M. MILLS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	B. Hillman, Counsel

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.