VA Secondary Conditions to Hypertension and Disability Ratings

CCK Law: Our Vital Role in Veterans Law

Video Transcription

Maura Black: Hi everyone, welcome. Thank you for joining us today for our CCK Live discussion. My name is Maura Black. I’m the Managing Attorney at Chisholm Chisholm & Kilpatrick and I’m joined today by Kevin Medieros, an attorney at CCK, and Rachel Foster, an accredited claims agent who also works with us at CCK.

Today, we’re discussing conditions that can arise as secondary to hypertension. We’re first going to start by going over what hypertension is, which is a service-connectable disability. A lot of veterans experience hypertension and are also service-connected for it. And then we’re going to make our way into a list of conditions that could be related to hypertension, meaning that you might be able to obtain secondary service connection for those conditions if you are hypertension is service-connected.

We’ll also give you a brief overview about what secondary service connection is. We have other materials on that topic in particular, but it can be a little bit complicated. There are a number of steps that are involved in proving secondary service connection, so we’ll make sure that everyone has the same reference point that we’re working with as to how that works, and how it’s significant that you can get secondary service connection for conditions other than what you might already be service-connected for.

So to start, like I said, let’s start off with what hypertension is. Hypertension simply means high blood pressure, but it is a disability for VA benefits purposes. According to the CDC, blood pressure is the pressure of blood pushing against the walls of your arteries, so pretty basic. Hypertension places people at a higher risk for other health problems, and this is an important point as we talk about different secondary conditions today. The additional heart problems or additional disabilities include heart disease, heart attack, stroke, and other things that we’re going to be talking about later on.

Blood pressure is measured in two numbers, a systolic and diastolic number. You’ll notice this when you get your blood pressure reading through your doctor, they’re usually these two numbers side by side. And this is important because VA rates hypertension based on your systolic and diastolic readings, so the certain percentage evaluation that they will assign to a person with service-connected hypertension is usually very much rooted in what the blood pressure readings for that person are and whether they are or are not controlled by medication.

Generally speaking, a normal blood pressure level is less than 120 for the systolic number and 80 for the diastolic number. However, VA defines hypertension, specifically, as 90 or higher for the diastolic and 160 or higher for the systolic. It’s kind of a little bit, just think about those numbers though, 160 and 90 as benchmarks for high blood pressure because that’s what VA is going to be looking at in terms of figuring out whether someone has hypertension diagnosed.

Generally speaking, that is the nature of the disability that we’re talking about. Although we will be talking about other medical conditions later on as I said. Kevin, can you talk to us in a little bit more detail? I gave a little bit of this away, but can you talk to us about how hypertension is rated for VA benefits purposes.

Kevin Medieros: Yeah, like with many of the conditions contemplated by VA’s regulations, it’s rated from low to high depending on the severity of the condition. A 10% rating for hypertension is if the diastolic pressure is 100 or more or the systolic pressure is 160 or more. Then, as we move up in the ratings and severity of the condition, there’s a 20% rating with a diastolic pressure of 110 or more or systolic is 200 or more. A 40% rating contemplates diastolic pressure of 120 or more, and a 60% rating contemplates diastolic pressure of 130 or more.

As far as getting service-connected for the condition, if the veteran doesn’t have a hypertension diagnosis in service or isn’t found to be otherwise directly related to their service, we do commonly see that they’re able to get service connection for hypertension as secondary to another service-connected condition, which is called said secondary service connection.

And you can file a claim for secondary service connection just as you would for any other condition that you’re seeking service connection for. What you need is a diagnosis that aligns with the guidelines that are in the rating criteria and like Maura talked about earlier, that aligns with would be a considered the hypertension diagnosis for disability benefits purposes.

So, for veterans, blood pressure is only slightly elevated and doesn’t meet that threshold, they wouldn’t be able to receive service connection for hypertension. But if the veteran does have a diagnosis and can show that it’s due to another condition, they could receive secondary service connection. So, maybe medications that a veteran takes for another service-connected condition might impact their blood pressure. There’s a variety of ways that other conditions might affect either causing or aggravating the severity of hypertension that might warrant service connection.

As far as the causes, VA might assist veterans with obtaining a medical examination to determine if they’re related or veterans can go to their own doctors and have them write an opinion saying that the hypertension is either caused or related to a service-connected condition.

Maura: Great. And I think the secondary service connection element works both ways with hypertension. I think Kevin touched on the way in which you can have one service-connected condition that’s not hypertension, maybe it’s something else, maybe it’s something that you need medications for and those medications do cause hypertension or there’s some other way that you have a service-connected disability that leads to hypertension.

It is possible for hypertension to be medically linked to an already service-connected condition and in turn, hypertension itself, once service-connected, can lead to other secondary conditions, so both avenues of service connection are in play. It’s just that they are looking at different things. So, just because your hypertension may have arisen as secondary to another service-connected disability, doesn’t mean that you can’t also get a service connection for anything flowing from the hypertension.

There may be many links in the causal chain so to speak, you may have one starting disability that leads to hypertension that leads to two other things, but they’re still all service connectable. In other words, if you can link them back to an in-service event or a service-connected condition, then you can seek benefits for those disabilities.

So, we’re going to pivot now to talking about conditions that, typically speaking, and that we’ve seen in our practice, arise secondary to hypertension. Rachel, can you first talk to us about coronary artery disease and what that link might look like if a veteran is service-connected to hypertension but also develops coronary artery disease, or CAD?

Rachel Foster: Sure. So, exactly as you said CAD occurs when the arteries that supply blood to the heart muscle become hardened and narrow. CAD is usually due to the build-up of cholesterol and other material on the arteries and our walls. Coronary Artery Disease can also sometimes be known as ischemic heart disease. Some risk factors to keep in mind for CAD include being overweight, lack of physical activity, using tobacco, having a family history of heart disease, and of course, hypertension.

The way that VA rates the heart condition is under title 38 of the code of Federal Regulation, section 4.104, Schedule of Ratings for the cardiovascular system. The section was actually recently updated to include a general reading formula for diseases of the heart and this rating formula is primarily based on a series of metabolic equivalent tests, or METs.

So, a MET is defined as the energy you use when you’re resting or sitting still, so certain activities are expected to require a certain level of energy which can be quantified in METs.

For most heart conditions, VA will assign a 10, 30, 60, or 100% rating depending on the severity of the condition, and the energy that’s required to produce those symptoms. But at minimum, if a veteran continuously takes medication for their coronary artery disease, they should receive a 10% rating.

Maura: Thank you, Rachel, for, specifically among other great points that you made, pointing out the pertinent section of the code of federal regulations that were working with. Rachel mentioned that title 38 section 4.104 is where you will find the Schedule of Ratings for the cardiovascular system. That is important if you want to take a look at the way that VA assigns ratings for heart conditions, but you can also find the diagnostic code for hypertension in that same section, I believe. I believe it’s diagnostic code 7101.
So, that’s where you’ll see the breakdown of the different rating criteria that Kevin mentioned earlier, as to how VA rates hypertension. And then as Rachel mentioned, if you are seeking secondary service connection for a heart disability, then you can look to that same section 4.104, to see the way that VA would rate a heart disability, as Rachel had described, so that’s definitely an important section.

Other conditions are rated under different sections of the code of federal regulations, so you will need to hop around to different sections if you’re talking about a different type of disability. They’re usually grouped by bodily systems. So, orthopedic disabilities tend to have codes in the same section, same with gastrointestinal issues, heart issues, and psychiatric issues are all in one section.

Heart attack, Rachel, and I want to keep this with you, just for the next couple of conditions, a heart attack is another thing that can be related to hypertension and potentially a source of benefits if someone suffers from a heart attack but has service-connected hypertension. Can you talk to us a little bit about that potential medical possibility and the rating implications?

Rachel: Sure. If as a result of their hypertension a veteran experiences a heart attack, VA will rate them at the 100% level for three months following the incident. After that, they’ll be re-evaluated based on that general rating formula that I mentioned earlier, and their METs testing.

Maura: And strokes are another issue that we commonly see actually as arising secondary to hypertension or being “at least as likely as not” related, which is that standard that VA will be looking at for secondary service connection and nexus purposes. Can you talk to us about those implications, if someone does suffer a stroke and has service-connected hypertension?

Rachel: Yeah. For ratings, a veteran who experiences a service-connected stroke, they can be assigned a convalescent temporary and total 100% disability rating for six months following their final treatment, so it is meant to be temporary. Veterans are then reevaluated and assigned ratings based on their residual symptoms after the stroke. So, for example, if a veteran suffers from partial paralysis due to a stroke, then they would receive a rating based on that level of paralysis.

Maura: Great. Kevin, I’m going to move over to you to talk about kidney conditions. We’ve definitely seen these before but we did a little bit of research, the three of us, and I think we were interested to see that there’s a good amount of information about the interplay between hypertension and kidney conditions, so this is one we wanted to include because it’s not always the most well-known link. I think the heart conditions, logically follows that the high blood pressure can be an issue and cause those, but tell us about a potential link between hypertension and kidney disease.

Kevin: Sure. So, the kidneys help to filter the blood and bodily waste, but with uncontrolled high blood pressure or hypertension, especially those that are further up probably in the rating criteria, demonstrating they’re more severe. Hypertension can actually cause the kidneys, the arteries around the kidneys, to narrow, weaken, or harden. And when the kidneys are damaged they don’t deliver enough blood to the kidneys which, in turn, impairs their ability to work properly or filter the blood or dispose of waste in the body as they would normally be able to do.

This can lead to acute kidney failure, chronic kidney disease, and end-stage renal failure. And the way that this is detected is usually through blood and urine tests or CT scans or ultrasounds. VA does have particular ratings for kidney conditions under Section 4.115a. There are various ratings again based on the severity of the kidney condition, but we just, like Maura mentioned, want to note that if a veteran is service-connected for hypertension and has kidney issues, it might be something worth exploring to see whether they’re related and if the veteran could receive compensation for that.

Maura: And two other disabilities that could be linked to hypertension, that are separate, but one is eye conditions and another is erectile dysfunction. Kevin, can you talk about the potential links there to hypertension?

Kevin: Yeah. And it’s similar to the kidney conditions. With the eye conditions, what happens is the blood vessels behind the eye, or in the eye, specifically, the retina can become damaged due to the high blood pressure, and the most common complication is called hypertensive retinopathy. Again, VA has a section in their regulations 4.79 outlining various ratings for different eye conditions. But similar to the kidney conditions, the pressure that’s put on the blood vessels might be causing additional conditions in the eye.

And the same is true of erectile dysfunction. It’s a common condition for men when they reach the age of 50, but it also might be separately related to hypertension. Again, caused by the limited blood flow that prevents blood from flowing to the prostate. Unlike the other conditions, there’s no specific disability rating for erectile dysfunction. If a veteran does have erectile dysfunction related to hypertension, they’re unlikely to get a compensable rating. They will generally rate erectile dysfunction as service-connected with a non-compensable rating.

But there are benefits outside of the rating schedule, particularly called Special Monthly Compensation for the loss of use of the creative organ. That’s known as SMC at the K rate. That is paid out in addition to a veteran’s monthly compensation if they are diagnosed with erectile dysfunction related to service-connected hypertension.

Maura: And just a note about SMC, or Special Monthly Compensation. We do have separate materials on what special monthly compensation is, how you can obtain it, and the circumstances under which your disabilities might warrant additional compensation. SMC(k) is one of the smaller amounts of SMC that a veteran can receive, but as Kevin mentioned, it’s paid as an addition to the compensation that derives from your disability percentages, so the ratings that you have for your service-connected conditions.

If you think that you might be eligible for benefits above and beyond the percentage that you’re assigned and the monthly check that you receive, something that might be worth checking out is our information on SMC and how you might be entitled to those additional benefits.

One last condition will talk about before we go into a couple of other notes about ancillary benefits and also, just some practical tips that we thought would be important to include for you all.

The last condition that we have on our list, and this is not an exhaustive list, these are just the highlights based on our research, is Raynaud’s disease, which is a disability that occurs when the blood flow to the fingers is decreased. It can also happen in the toes, ears, nose, or knees if the blood vessels in those areas spasm. And spasms may be due to cold exposure, stress, or periods of heightened stress or emotional stress.

There are two forms of Raynaud’s disease. The primary form is where the condition simply develops on its own. But a secondary form of Raynaud’s disease occurs as a result of another condition. And one such condition that can cause that secondary form of Raynaud’s disease is pulmonary hypertension. And you can kind of understand the link that Raynaud’s disease is caused by decreased blood flow to a certain bodily area, then it might have a link to hypertension.

VA rates Raynaud’s syndrome or Raynaud’s disease, I think it’s listed as syndrome in VA’s rating criteria. So, if you’re going to be searching for it and trying to figure out where it’s contemplated in the ratings, you’ll want to use syndrome I believe, but you should be able to find it if you simply search for Raynaud’s. And you want to be looking again at section 4.104. That’s where the hypertension diagnostic code is listed and other heart condition codes are listed as Rachel and I had mentioned before.

And Raynaud’s disease can be rated at 10, 20, 40, 60, or 100% disabling. Barring any entitlement to ancillary benefits like Special Monthly Compensation, or other things that might entitle a veteran to compensation beyond just the standard ratings that VA contemplates in their diagnostic codes.

Rachel, I want to talk to you briefly about an ancillary benefit, sort of like Special Monthly Compensation, but specifically TDIU, or a total disability rating based on individual unemployability.

Hypertension is usually just one service-connected disability, but if a veteran has multiple service-connected disabilities – talk to us about how hypertension and TDIU could overlap or why a person with hypertension service-connected might also be thinking about TDIU.

Rachel: Yeah. So, first TDIU is a benefit that compensates veterans at the 100% monthly rate, even though their combined rating may be less than 100% scheduler.

Veterans can qualify for TDIU in two different ways. They can qualify for what’s called schedular TDIU, so that’s if they have a single disability, let’s say hypertension, and the situation that’s rated as 60% or higher. Or if they have multiple service-connected conditions, so maybe they have a single disability of hypertension and a combination of other disabilities, including kidney disease, and their combined rating is at least 70% with at least one condition rated at 40% or higher.

With those ratings, they would qualify under schedular TDIU. But even if a veteran does not meet those schedular requirements under section 4.16a, but their disability still prevents them from securing or following substantially gainful employment, they may still be able to obtain TDIU on an extraschedular basis. So, that’s section 4.16b.

Maura: Thank you. Super informative. This is again, one topic that we have lots of materials out there about, so please feel free to reference the TDIU blog posts and other videos that we have.

One of the things that I often see in cases is that hypertension is usually accompanied by pretty low ratings. A lot of veterans receive a 0% or non-compensable ratings for hypertension or 10% ratings. So, it’s a little bit tricky when it comes to TDIU because VA has a tendency to assume that if the number associated or the rating associated with your disability is low, it’s not that impactful.

So, definitely going about the secondary service connection route and trying to establish that your hypertension may have impact or be causing secondary disabilities beyond just the symptoms that it causes in isolation. Those are all important things for the VA to consider when trying to figure out what the appropriate rating for a veteran is, given the severity of their disabilities.

And I think hypertension having low ratings associated with it is also sometimes a sticking point, even though it shouldn’t be, with VA examiners who are assessing whether hypertension could have caused or aggravated a secondary condition that a veteran is seeking service connection for.

So, a couple of practical things. I know Kevin has some thoughts about this. We wanted to conclude with a couple of practical things that we see often, especially in the VA examination context when it comes to secondary service connection, because I think anyone who’s pursued a secondary service connection claim knows that VA tends to get exams on those issues. Sometimes in-person exams and sometimes simply medical opinions looking at nexus.

So Kevin, what can you tell us about things that we should keep our eye on if this is the type of claim that a veteran has pending and they’re running into some issues or common legal errors that VA makes with these?

Kevin: Yeah, like you mentioned Maura, hypertension is usually rated pretty low. And this makes sense because when a doctor diagnoses you with hypertension they’re going to want to treat it, and generally the medications in the treatment tend to keep it under control.

What we do see in a lot of VA exams with veterans seeking service connection secondary to hypertension is the VA examiner saying, “Well, his hypertension is really not that bad. It probably didn’t cause or it didn’t worsen this other condition.” When really, they might not be appreciating the full history of the condition, how long it might have gone undiagnosed and untreated, things like that. So, you want to be making sure that the examiner is taking into account everything. Especially if you feel like you might not have received the diagnosis because maybe you weren’t going to the doctor, maybe there are other more pressing medical issues going on.

So, when we see the VA examiners use the severity of the hypertension and we see that often, it sets off a red flag because the medications are generally going to control them, doesn’t necessarily mean that it couldn’t be causing or aggravating some other conditions. And in the reverse as well, we see a lot of times veterans claiming service connection for hypertension secondary to maybe diabetes or something like that and the examiner will say, “Well, the hypertension wasn’t worsened by the diabetes because it’s not that bad.”

Again, that goes back to the part where it’s not that bad because it’s being treated and maybe there’s some medical history that suggests that the two are related. So, those are some practical things that we generally like to keep an eye on.

Maura: Great. Thank you both so much. We did cover a lot of different little pockets of things in addition to just hypertension and related disabilities. So, please feel free to visit our website, our blog, our other videos for more information on service connection, secondary service connection, VA exams, inadequate VA exams, which are they one and the same? Sort of. That feels like that’s our experience. And the other types of disabilities that we discussed today.

We have several other videos, like I mentioned, on our YouTube page, so please feel free to visit our channel and subscribe to it if you find the information helpful.

We hope that today’s discussion was helpful. Thank you again, Kevin and Rachel, for joining me and we hope to see you all next time.