Citation Nr: 1319440 Decision Date: 06/14/13 Archive Date: 06/21/13 DOCKET NO. 09-30 776 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey THE ISSUE Entitlement to service connection for hypertension, including as secondary to service-connected posttraumatic stress disorder (PTSD) or due to exposure to herbicides or Agent Orange. REPRESENTATION Appellant represented by: New Jersey Department of Military and Veterans' Affairs ATTORNEY FOR THE BOARD D. Bredehorst INTRODUCTION The Veteran served on active duty from January 1968 to July 1969, which includes Vietnam service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision of the Newark RO. In April 2011, September 2011, and January 2013, the matter was remanded for additional development. 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, the matter must be remanded again due to noncompliance with the Board's directive. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders). In previous remands, the Veteran was to undergo VA examinations to obtain an opinion regarding whether his hypertension was caused or aggravated by his service-connected PTSD. The examiner was specifically asked to identify and explain the medical basis or bases for this opinion, with identification of any evidence of record. In formulating the opinion the examiner was also referred to an article from VA National Center for PTSD entitled, "PTSD and Physical Health." See www.ptsd.va.gov/professional/pages/ptsd-physical-health.asp. The Board noted pertinent passages in the article and those excerpts can be found in the prior remands. The January 2013 remand stated that the examiner who conducted the October 2011 VA examination provided an opinion regarding the etiology of the hypertension, which was that hypertension was not caused or aggravated by the Veteran's PTSD. The examiner noted that PTSD does not cause hypertension nor does it aggravate hypertension and that the Veteran's hypertension was well-controlled. The deficiency pointed out in the January 3013 remand was that the examiner did not specifically identify and explain the medical basis or bases for his or her opinion, which was needed since the article suggested that PTSD may cause or aggravate hypertension. The AMC was directed to return the claims file to the October 2011 VA examiner for an addendum opinion to determine whether the Veteran's current hypertension is caused or aggravated by his PTSD in light of a review of the claims file, the Veteran's medical history, and the article "PTSD and Physical Health", and any other pertinent information. Another opinion is shown in the record from the October 2011 VA examiner that is dated in July 2012, which is prior to the January 2013 remand, but it is shown to have been entered into the system and signed in March 2013. Because of the initial date shown, it is unclear whether the opinion was offered in response to the Board's remand. Regardless, the examiner essentially provided the same opinion and rationale that was offered in October 2011. The examiner opined the hypertension was less likely than not proximately due to or the result of the service-connected PTSD. Although noting the claims file and the article were reviewed, the comment was that the Veteran had essential hypertension that was mild and well-controlled. The examiner also stated that PTSD is not known to cause or aggravate essential hypertension and that the hypertension is not caused or aggravated beyond the natural progression of the disease by PTSD. Thus, the examiner again failed to explain the medical basis or bases for the opinion. Therefore, it is not responsive to the remand directives and Board has no choice to remand the matter again. Accordingly, the case is REMANDED for the following action: 1. Arrange for the Veteran's claims file to be reviewed by a different clinician for a medical opinion. If the clinician decides that an examination is necessary, then schedule the Veteran for an examination. The purpose of the addendum opinion is to determine whether the Veteran's current hypertension is caused or aggravated by his military service. The claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must also specifically review the VA national center for PTSD article, "PTSD and physical health" (found at www.ptsd.va.gov/professional/pages/ptsd-physical-health.asp), along with any other information deemed pertinent. The reviewing examiner must respond to the following: * Was the veteran's hypertension caused by his PTSD? * Please provide a detailed explanation of the underlying medical reasoning behind your answer to above question with specific consideration of the veteran's medical history, the information contained in the article "PTSD and physical health" and any other information deemed pertinent. * Has the veteran's hypertension been aggravated (i.e. increased in severity beyond the natural progression of the disease) by his PTSD? * Please provide a detailed explaination of the underlying medical reasoning behind your answer to above question regarding aggravation with specific consideration of the veteran's medical history, the information contained in the article "PTSD and physical health" and any other information deemed pertinent. 2. After the above has been completed, the AMC/RO must review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 3. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The appellant 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). _________________________________________________ JOHN Z. JONES 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).