Citation Nr: 1332800 Decision Date: 10/21/13 Archive Date: 10/24/13 DOCKET NO. 03-26 563 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to service connection for hypertension. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD T. Blake, Associate Counsel INTRODUCTION The Veteran had active service from October 1978 to April 1985 and from October 1990 to May 1991. He served in the Persian Gulf during the Persian Gulf War. 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 North Little Rock, Arkansas. In September 2009, the Board denied the claim on the merits. The Veteran appealed to the Veterans Claims Court. In August 2010, the Court Clerk vacated the Board's September 2009 decision and remanded the matter for further consideration pursuant to a Joint Motion for Remand (JMR). In July 2011, the Board remanded this matter for additional development. Thereafter, in July 2012, the Board again denied the claim. The Veteran again appealed to the Court Clerk vacated the Board's July 2012 decision and remanded the matter for further consideration pursuant to another JMR. The case has been returned to the Board for further appellate review. The appeal is REMANDED to the RO, via the Appeals Management Center (AMC), in Washington, DC. REMAND The most recent JMR found that the medical opinion was inadequate for failing to provide a sufficient rationale and the opinion was inconclusive because of the examiner's use of the word "thinks" in the opinion. Therefore, pursuant to the Order of the Court Clerk, additional development is necessary under the duty to assist. Accordingly, the case is REMANDED for the following actions: 1. Direct the claims file to the January 2009 and August 2011 VA examiner (Dr. H. P.) and provide him with an opportunity to clarify his opinion. Dr. H. P. is asked to address the following: * provide a rationale (fully explain) for (1) why he "thinks" it is less likely than not that the Veteran's service-connected PTSD caused hypertension, and (2) why he "thinks" the Veteran's hypertension is "essential," i.e., idiopathic or relating to unknown causes (as provided in the August 2011 VA medical opinion report). * provide a rationale (fully explain) for (1) why he does not "think" there is any medical evidence that PTSD will permanently aggravate hypertension (as provided in the August 2011 VA medical opinion report), and (2) whether that conclusion was based on the Veteran's treatment records or in reference to medical literature. If Dr. H. P. is not available, please direct the claims file to another health care professional to address the following: * Is it at least as likely as not that service-connected PTSD caused hypertension? This question is meant to address whether PTSD caused hypertension (not the other way around). * Is it at least as likely as not that service-connected PTSD aggravated hypertension? This question is meant to address whether PTSD increased or worsened hypertension. The reviewer is informed that "aggravation" is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. If aggravation is present, the reviewer should indicate, to the extent possible, the approximate level of hypertension present (i.e., a baseline) before the onset of the aggravation. The claims file should be made available to the reviewer. If the reviewer cannot render an opinion without an examination, one should be ordered. A complete rationale for all opinions expressed would be most helpful to the Board. This is critical to the Board's ability to adjudicate the claim. In this regard, if the reviewer concludes that there is insufficient information to provide an etiologic opinion without result to mere speculation, the examiner should state whether the inability to provide an opinion was due to a need for further information (with said needed information identified) or because the limits of medical knowledge had been exhausted regarding the etiology of the disorder. 2. Thereafter, the issue on appeal should be readjudicated. If the benefit sought on appeal is not granted, the Veteran and his representative should be provided with a supplemental statement of the case (SSOC) and afforded the appropriate time period within which to respond thereto. The Veteran and representative have 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 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. 2013). _________________________________________________ L. HOWELL 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) (2013).