Citation Nr: 1327661 Decision Date: 08/29/13 Archive Date: 09/05/13 DOCKET NO. 10-27 268 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to service connection for hypertension also claimed as secondary to the service connected diabetes mellitus type II. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD T. S. Willie, Counsel INTRODUCTION The Veteran served on active duty from May 1968 to May 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. The Board notes that in his June 2010 VA Form 9 Substantive Appeal the Veteran indicated that he wanted to appear for a Board hearing at the local RO. In May 2013, however, he expressed that he was unable to attend the hearing and did not wish to reschedule. As such, the request for the hearing is considered withdrawn. 38 C.F.R. § 20.702(e) (2012). Also, in his June 2010 VA Form 9 Substantive Appeal the Veteran appealed the denial of service connection for posttraumatic stress disorder (PTSD). He was, however, granted service connection for PTSD in the June 2012 rating decision. This issue is no longer before the Board as the benefit sought on appeal has been granted. 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 The Veteran appeals the denial of service connection for hypertension. He asserts that his hypertension is secondary to his service connected diabetes mellitus and/or his PTSD. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran has been afforded several VA examinations in relation to his claim. To that end, the April 2008 VA examiner opined that the Veteran's hypertension was not caused by the service connected diabetes mellitus type II since he had problems long before his diabetes was diagnosed. It is, she stated, most likely contributed to by his diabetes since he has neuropathy. The April 2008 examiner also found that concerning the Veteran's hypertension and PTSD, at times of stress the blood pressure may be elevated but this tends to be a transient change and the blood pressure normally returns to baseline. The literature does not support hypertension as being caused by PTSD she stated. The most likely cause in this Veteran is essential hypertension or primary hypertension that is as likely as not contributed to by the uncontrolled diabetes and not caused by the PTSD. After examination in February 2010, the VA examiner opined that the Veteran's elevated blood pressure was not related to his diabetes mellitus type II with nephropathy. He stated that the Veteran's nephropathy was mild and did not cause any kidney damage, and that he had been having elevated high blood pressure readings long before he had his nephropathy or even his diabetes diagnosis. The May 2012 VA examiner found that no evidence exists that the diabetes mellitus aggravated his hypertension beyond its natural progression. He has not needed more hypertension medication and that his available blood pressure readings are all in the same range without evidence of an upward trend the examiner stated. The examiner also found that the Veteran has not developed any hypertensive complications and his micro albuminuria had never been in clinically significant range (over 300mg/gm). The Board notes, however, the examiner also checked the box which stated that the claimed condition, clearly and unmistakably existed prior to service, and was clearly and unmistakably not aggravated beyond its natural progression by an in service event, injury or illness. The basis for this opinion is unclear as there are no elevated ratings in service and the pathology first showed up in later years. The Board notes that the opinions of record are inadequate to fully address the issue presented. To that end, the Board finds the April 2008 opinion is confusing at times. It is also noted that since that time studies have linked cardiovascular disease and PTSD contrary to the examiner's finding. Furthermore, the examiner did not adequately address whether the now service connected PTSD permanently aggravates the appellant's hypertension. Regarding the May 2012 examination, while the VA examiner found that no evidence exists that the diabetes mellitus aggravated the Veteran's hypertension beyond its natural progression, he also checked that the condition preexisted service and was not aggravated by an in service event, injury or illness. The Board notes that the etiology opinion and rationale are inconsistent and such should be reconciled on remand. The examination report should be returned to that examination for additional opinion/clarification. In light of the above, further development is now required. Simply put, once VA undertakes the effort to provide a medical opinion, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). Accordingly, a remand is warranted. Accordingly, the case is REMANDED for the following action: 1. The May 2012 examination report should be returned to the examiner who conducted that examination or a similarly situated examiner. The examiner is to be provided access to the Veteran's claims folders as well as the appellant's Virtual VA file. Following a review of all of those documents, the cardiologist is to opine whether it is at least as likely as not, i.e., is there a 50/50 chance, that the Veteran's hypertension was caused by service, or caused or permanently aggravated by the appellant's service connected PTSD or diabetes mellitus. When rendering the opinion, the examiner must address the Veteran's contentions. The cardiologist must offer a fully reasoned rationale for all opinions offered. 2. Upon completion of the above requested development and any additional development deemed appropriate, the RO should readjudicate the remanded issue. If any benefit sought on appeal remains denied, the appellant and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. 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 Supp. 2012). _________________________________________________ MICHAEL D. LYON 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).