Citation Nr: 1309454 Decision Date: 03/20/13 Archive Date: 04/01/13 DOCKET NO. 07-31 202 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to service connection for hypertension, to include as secondary to posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1978 to May 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana, which denied service connection for hypertension on a direct-incurrence basis. A January 2009 rating decision denied service connection for hypertension as secondary to PTSD. In May 2010, the Veteran testified before the undersigned Veterans Law Judge, and a transcript of that hearing is associated with the claims file. The appeal is REMANDED to the RO via the Appeals Management Center in Washington, DC. VA will notify the Veteran if further action is required. REMAND In September 2010, the Board remanded the Veteran's claim for further development. Specifically, the Board requested that a VA examiner review the Veteran's claims file and provide a medical opinion as to whether it was at least as likely as not that the Veteran's current hypertension was related to any findings of elevated blood pressure as reflected in the service treatment records. In addition, the VA examiner was to address whether the Veteran's current hypertension was caused or aggravated by his service-connected PTSD or his medication for his PTSD. Finally, the VA examiner was asked to provide an opinion as to whether it was at least as likely as not that the Veteran's service-connected PTSD caused or aggravated his weight gain, and if so, whether the weight gain caused or aggravated his hypertension. Accordingly, the record shows the Veteran underwent VA examination in October 2010. The VA examiner reviewed the Veteran's service treatment records and VA treatment records and diagnosed essential hypertension. With respect to the findings of elevated blood pressure in the service treatment records, the VA examiner opined that the Veteran's hypertension was less likely as not caused by or the result of any findings of elevated blood pressure in service because one reading of elevated blood pressure did not make a diagnosis of hypertension. The VA examiner focused on the fact that hypertension had not been diagnosed until 2004. With respect to a nexus between the Veteran's hypertension and his service-connected PTSD, the VA examiner opined that the Veteran's hypertension was not caused by or a result of PTSD because the Veteran had essential hypertension, which was not caused by PTSD. The VA examiner also found that it was at least as likely as not that the Veteran's hypertension was permanently aggravated by weight gain. The VA examiner reported that obesity was a well-known factor for the development of essential hypertension. However, because essential hypertension was a multifactorial disease with many established and unknown contributing factors, the VA examiner could not state to what extent the Veteran's obesity had aggravated his hypertension. Here, the Board finds the October 2010 VA opinion inadequate for purposes of determining service connection. "Once VA undertakes the effort to provide an examination, it must provide an adequate one or, at a minimum, notify the veteran why one will not or cannot be provided." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). First, the VA examiner did not provide an adequate opinion as to whether the Veteran's hypertension was caused or aggravated by his PTSD. The report shows that the VA examiner merely stated that essential hypertension was not caused by PTSD and did not address the issue of aggravation. In addition, the VA examiner did not comment upon whether the Veteran's current hypertension was caused or aggravated by his medication for PTSD. Finally, although the VA examiner opined that it was at least as likely as not that the Veteran's hypertension was permanently aggravated by weight gain, the VA examiner did not provide an opinion as to a nexus between the Veteran's weight gain and his service-connected PTSD. In this respect, the Board notes that obesity is a manifestation and not a disability warranting service connection, and as such, service connection is warranted on the basis of a relationship between hypertension and weight gain only if the Veteran's weight gain is found to be caused or aggravated by his service-connected PTSD. Therefore, in order to satisfy VA's duty to assist, the Board finds a remand is warranted in order to afford the Veteran an additional VA examination. 38 U.S.C.A. §§ 5103A, 5107(a) (West 2002); 38 C.F.R. § 3.159 (2012). Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for an additional VA examination to determine the nature and etiology of his currently diagnosed hypertension, to include as secondary to posttraumatic stress disorder. The claims file should be made available to the examiner in conjunction with the examination. Any medically indicated tests should be accomplished, and all pertinent symptomatology and findings must be reported in detail. Following a review of the Veteran's claims file, to include his service treatment records and VA examination reports, and with consideration of the Veteran's lay testimony regarding a relationship between his hypertension, PTSD symptoms, and weight gain, the examiner should provide an opinion as to the relationship, if any, between the Veteran's hypertension and his active duty service, and/or PTSD. Specifically, the examiner is requested to provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran's hypertension is related to any findings of elevated blood pressure during active duty service, to include the finding of 140/94 in May 1981. The examiner must state whether or not the elevated blood pressure reading during service may be clinically distinguished from his current hypertension. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that hypertension was caused or aggravated by the Veteran's PTSD, to include medication taken for PTSD. Finally, the VA examiner should opine as to whether it is at least as likely as not (50 percent probability or more) that PTSD caused or aggravated the Veteran's weight gain, and if so, whether the weight gain caused or aggravated the Veteran's hypertension. In providing the opinion, the examiner is advised that the term at least as likely as not does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. A complete rationale for any opinion expressed should be included in the examination report. 2. Thereafter, re-adjudicate the Veteran's claim of entitlement to service connection for hypertension, to include as secondary to PTSD. If the benefit sought on appeal remains denied, issue the Veteran and his representative a Supplemental Statement of the Case and provide a reasonable opportunity to respond before the case is returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter 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 Supp. 2012). _________________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), 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).