Citation Nr: 1308079 Decision Date: 03/11/13 Archive Date: 03/20/13 DOCKET NO. 05-29 637 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for hypertension, including as secondary to post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESSES AT HEARING ON APPEAL Veteran and S.B. ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served on active duty from September 1970 to August 1974. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2005 decision of the Waco, Texas, Regional Office (RO) of the Department of Veterans Affairs (VA). In October 2008, the Veteran and S.B. testified at a Travel Board hearing before the undersigned. In February 2009 and October 2011, the Board remanded this case. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND Unfortunately, a remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that the Veteran is afforded every possible consideration. In the Board's recent remand, it was determined that a medical opinion was needed to determine if the Veteran's hypertension is as likely as not aggravated by the Veteran's PTSD as the prior examinations/opinions were flawed or incomplete. In April 2012, an opinion was obtained. The VA examiner indicated that before the Veteran was diagnosed with PTSD, in 2002 his blood pressure was 163/105. However, after the Veteran was diagnosed with PTSD, in December 2004, his blood pressure was 139/91. Recently, in 2011, the examiner stated that the Veteran's blood pressure reading were all normal, i.e., below 140/90. The examiner concluded that there was no current clinical data in the medical literature that supported PTSD as a causative or aggravating agent in the development or worsening of hypertension. Also, the examiner indicated that his current level of severity of the blood pressure readings was not greater than the baseline. The Veteran's representative has requested a new VA examination because the VA opinion was not supported by adequate reasons and bases. He noted that at the time that the Veteran was first given medication for hypertension, he was already taking medication for PTSD and the examiner did not discuss the import, if any, of the Veteran's medical regimen over the years. Second, the representative pointed out that the examiner stated that the Veteran did not currently suffer from elevated blood pressure levels, but did not discuss if he had suffered from elevated blood pressure levels during the appeal period; moreover, as noted, there was no discussion of the effect of his medications. The Board further notes that in reviewing the Veteran's hearing testimony, he also asserted that hypertension was initially manifest in the initial post-service year. There is no medical assessment regarding whether hypertension is directly related to service or that its onset was within the first post-service year. Once VA undertakes the effort to provide an examination for a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). In light of the claimed inadequacies with the prior VA examinations and opinions, the Board finds that a new examination, rather than an addendum opinion is warranted in this case. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA hypertension examination to determine the nature and etiology of any current hypertension disability. Any indicated tests, should be accomplished. The examiner should review the claims folder prior to examination. The examiner should provide an opinion as to (a) whether it is more likely than not (50 percent probability or more), less likely than not, or at least as likely as not, that any current hypertension disability had its clinical onset during service, was manifest in the initial post-service year, or is related to any in-service disease, event, or injury. (b) whether it is more likely than not, less likely than not, or at least as likely as not, that any current hypertension disability is proximately due to, or the result of, the service-connected PTSD (c) whether it is more likely than not, less likely than not, or at least as likely as not, that any current hypertension disability is permanently aggravated by the Veteran's service-connected PTSD. If such aggravation is found present, the examiner should address the following medical issues: (1) The baseline manifestations of the Veteran's hypertension disability found present prior to aggravation; (2) The increased manifestations which, in the examiner's opinion, are proximately due to the service-connected PTSD based on medical considerations. The examiner should comment on the effect, if any of both the Veteran's psychiatric and hypertensive medications on his/her conclusions, including as to whether there is a current disability, and the time period for when those medications began should be noted. The aforementioned questions (a), (b), and (c), apply to the entire appeal period, not just the Veteran's current status at this time. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 2. The AMC should review the medical opinion obtained above to ensure that the remand directives have been accomplished. If all questions posed are not answered or sufficiently answered, AMC should return the case to the examiner for completion of the inquiry. 3. The AMC should then readjudicate the claim on appeal in light of all of the evidence of record. If the issue remains denied, the Veteran should be provided with a supplemental statement of the case as to the issue on appeal, and afforded a reasonable period of time within which to respond thereto. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). _________________________________________________ ROBERT E. O'BRIEN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002 & Supp. 2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).